Norwalk Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Norwalk, Connecticut.
- Location
- 23 Prospect Avenue, Norwalk, Connecticut 06850
- CMS Provider Number
- 075159
- Inspections on file
- 24
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Norwalk Care Center during CMS and state inspections, most recent first.
Two residents with dementia and impaired cognition engaged in a sexual encounter when staff failed to maintain required supervision during an overnight shift. Due to improper break scheduling, only one staff member was present and unable to monitor the unit, allowing the incident to occur. A subsequent psychiatric evaluation determined that one resident lacked capacity to consent.
The facility failed to document the clinical criteria for placing residents in a secured unit, which is meant for those with specific needs related to dementia and wandering. Observations and interviews revealed a lack of clear criteria and incomplete assessments for residents placed on the unit. Some residents, including those with intact cognition, expressed feeling imprisoned and unable to make independent choices about leaving the unit.
The facility failed to ensure that care plans for residents on a secured unit accurately reflected their placement and criteria for such placement. Observations and reviews revealed that care plans did not identify the residents' residence on a secured unit, nor did they specify the criteria for placement or confirm that it was the least restrictive setting. This deficiency was noted for residents with various diagnoses, including dementia and schizoaffective disorder.
The facility's kitchen was found to be unsanitary, with sticky floors, dusty vent covers, and buildup on equipment. Interviews revealed unclear cleaning responsibilities and a lack of documentation for cleaning schedules, despite policy requirements for regular cleaning.
The facility failed to review its infection control policies annually, complete monthly and quarterly infection surveillance reports, and report positive Legionella water test results to the State Agency. The Infection Preventionist Nurse, new to the role, was unable to locate necessary documentation, and the facility's consultant incorrectly advised that reporting was unnecessary.
Two residents in the facility did not receive the pneumococcal and influenza vaccines as required. One resident, admitted with anemia and end-stage renal disease, did not receive the pneumococcal vaccine, and another resident with COPD and hypertension did not receive both the pneumococcal and influenza vaccines despite giving consent. The facility's policies required these vaccinations, but there was no documentation of their administration.
The facility failed to administer and document COVID-19 vaccinations for two residents upon admission. One resident, with impaired cognition and multiple diagnoses, consented to the vaccine but did not receive it, and the facility could not provide documentation of refusal. Another resident, also with impaired cognition, was not offered the vaccine, and the facility lacked documentation of an offer or refusal. The facility's policy required offering the vaccine within 14 days of admission and updating records accordingly.
The facility failed to maintain kitchen equipment, with a non-functional dishwasher and two ovens, and a leaking sink. Disposable items were used for meals due to the broken dishwasher, which had been out of order for months. The Maintenance Director was unaware of some issues and the facility had not paid a deposit for a new dishwasher despite obtaining a quote.
A facility failed to refer a resident with a new diagnosis of major depressive disorder for a level II PASARR assessment. The resident, who required assistance with daily activities and was at risk for psychotropic drug complications, had a new diagnosis documented by a social worker. However, the responsible social worker was not informed, and the referral was not made, highlighting a breakdown in communication and procedure.
A resident readmitted with a surgical wound from a hip replacement did not have a physician's order for wound care documented. The facility failed to follow the surgeon's instructions, resulting in the dressing falling off prematurely and no record of physician notification. The wound later showed signs of infection, prompting a delayed physician's order.
The facility failed to ensure accurate controlled medication counts and proper documentation for one of the medication carts reviewed. Discrepancies were found in the medication counts for three residents, with the actual number of tablets not matching the control drug receipt and disposition records. Interviews with an RN and the DNS highlighted the responsibility of nurses to ensure expired medications are not stored and that controlled medications are secured and documented correctly. The facility's policies require controlled substances to be stored in a double-locked container and accurately recorded, which was not adhered to in this case.
A facility failed to store medications appropriately, as observed in a medication cart review. Expired medications were found, and a bottle of Lantus lacked an open date and discard date. The narcotic box was not locked, although the cart was secured. Interviews with staff revealed that it was everyone's responsibility to ensure expired medications were not stored and that controlled medications should be secured behind two locks. The facility's guidelines require controlled substances to be stored in a double door, double locked container.
The facility failed to document and assess a secured unit, as observed during a survey. The East 1 Unit required a code for entry and exit, but the facility's assessment did not acknowledge its existence or include criteria for resident placement. The assessment was outdated, signed by current staff without their participation, and a new assessment still failed to identify the secured unit. Interviews revealed a lack of awareness and participation in the assessment process by the DNS, Administrator, and medical staff.
Failure to Provide Adequate Supervision Resulting in Sexual Abuse
Penalty
Summary
The facility failed to provide adequate supervision to prevent sexual abuse between two residents, both of whom had dementia and impaired cognitive function. One resident, with a history of vascular dementia, psychotic and mood disturbances, and aphasia, was identified as having sexual expression behaviors and was care planned to discuss feelings and receive psychology consults as needed. The other resident, with anxiety, depression, and dementia, was care planned as being at risk for abuse and sexual risk due to congregate living, with interventions to seek staff assistance and avoid contact with aggressors. On the night of the incident, staff scheduling and supervision were not properly managed. During the overnight shift, two staff members went on break at the same time, leaving only one staff member on the unit, who was seated in a location without visibility of the resident hallway. This lapse in supervision allowed one resident to enter another resident's room, where a sexual encounter occurred. The incident was discovered when the remaining staff member began rounds and found the two residents together, with clothing and briefs displaced, indicating sexual activity. Subsequent interviews and documentation revealed that both residents initially stated the encounter was consensual. However, a psychiatrist later determined that the resident who was the victim of the incident lacked the capacity to consent to sexual activity. The facility's policy required that two staff be present on the unit at all times, and the Director of Nursing confirmed that this protocol was not followed, contributing to the failure to prevent the incident.
Failure to Document Criteria for Secured Unit Placement
Penalty
Summary
The facility failed to ensure proper documentation and assessment for the placement of residents in a secured unit, which is intended for individuals with specific needs related to dementia and wandering. Observations and interviews revealed that the secured unit required a code for entry and exit, and was equipped with wanderguard alarm sensors. However, the facility did not have clear criteria for placement on this unit, as evidenced by interviews with the Director of Nursing Services, the Administrator, and the Corporate Social Worker, who were unable to specify the criteria for placement. For several residents, including those with diagnoses such as dementia, schizoaffective disorder, and muscular dystrophy, the clinical records lacked documentation by the physician of the clinical criteria met for placement on the secured unit. Additionally, the records did not demonstrate that the secured unit was the least restrictive setting for these residents. For instance, one resident with severely impaired cognition and behavioral disturbances was placed on the unit without the required signatures from nursing, psychiatric providers, or the attending physician on the assessment form. Another resident, who was cognitively intact and did not exhibit wandering behaviors, expressed feeling imprisoned on the unit and was not allowed to make independent choices about leaving the unit. The facility's policy for the secured unit indicated that the interdisciplinary team, along with the resident or their representative, should identify those who need placement on the unit based on diagnoses, cognitive status, functional status, and behavioral health needs. However, the policy was not followed, as evidenced by the lack of physician documentation and interdisciplinary team assessments that were incomplete or missing required signatures. Interviews with staff, including LPNs and social workers, further highlighted the lack of a structured process for assessing and documenting the appropriateness of placement on the secured unit.
Care Plan Deficiencies for Residents on Secured Unit
Penalty
Summary
The facility failed to ensure that the care plans for five residents residing on a secured unit accurately reflected their placement and the criteria for such placement. Observations and reviews of clinical records revealed that the care plans did not identify the residents' residence on a secured unit, nor did they specify the criteria for their placement or confirm that the secured unit was the least restrictive setting. This deficiency was noted for residents with various diagnoses, including dementia, schizoaffective disorder, and muscular dystrophy, among others. For Resident #1, the care plan did not reflect the resident's placement on a secured unit despite the resident having severe cognitive impairment and behavioral disturbances. The care plan lacked details on the criteria for the resident's placement on the secured unit and did not confirm that it was the least restrictive environment. Similarly, Resident #9's care plan failed to document the resident's placement on a secured unit, and there was no mention of a physician's review for such placement, despite the resident expressing feelings of being in a prison-like environment. Residents #21, #33, and #82 also had care plans that did not reflect their secured unit placement. Resident #21, who had moderately impaired cognition, was noted to have difficulty with decision-making but was otherwise alert and oriented. Resident #33, who was cognitively intact, had no documented physician's order for placement on a secured unit. Resident #82, with severely impaired cognition, had no abnormal behaviors observed, yet the care plan did not document the secured unit placement. Interviews with the Director of Nursing Services and the Medical Director confirmed that care plans should reflect special circumstances, including secured unit placement, but this was not evident in the reviewed care plans.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour with the Corporate Food Service Director. The kitchen floor was sticky with scattered food debris and water was present under the 3-bay sink near the cooking area. Additionally, a ceiling vent cover and the ceiling in the 3-bay sink area had a moderate amount of black dusty buildup, and multiple vent covers near the coffee station were similarly affected. The side and front of the stove oven had a buildup of brownish/grey matter, and the ice machine had metal pieces inside that were covered with brown stains resembling rust. The ice cream freezer's plastic covering inside was cracked with a black stain noted inside the plastic cover. The prep counter was cluttered with scattered food debris, white stains, papers, and pens. Interviews with the kitchen staff revealed a lack of clarity regarding cleaning responsibilities and schedules. Dietary Aide #1 stated that the kitchen staff is responsible for cleanliness, with the floor cleaned after each meal and equipment cleaned after each use, but was unsure about who was responsible for cleaning the ceiling and vents. The Corporate Food Service Director was also uncertain about the cleaning schedule and could not provide documentation of a cleaning log during the survey. The facility's policy indicated that vents and ceilings should be cleaned monthly, the oven weekly and as needed, and floors and counters after each use and as needed. However, there was no evidence that these cleaning schedules were being followed, contributing to the unsanitary conditions observed during the survey.
Infection Control Program Deficiencies and Unreported Legionella
Penalty
Summary
The facility failed to ensure that its infection prevention and control program policies and procedures were reviewed annually. The Infection Control Program Policies and Procedure manual was last reviewed and approved in July 2023, but there was no documentation of a review for 2024. The newly hired Infection Preventionist Nurse, who started in July 2024, was unable to locate the signature page for the 2024 review. The Director of Nursing Services also confirmed the lack of documentation for the 2024 review. The facility did not complete monthly infection surveillance reports and analysis of infection trends from April 2022 through September 2024. The Infection Preventionist Nurse, responsible for these reports, had only started in July 2024 and was unable to provide documentation of the reports. The facility's policy requires monthly surveillance forms to be maintained and a monthly report compiled to identify areas of high infection incidence. Additionally, quarterly infection statistical reports were not completed for several specified periods, and the Infection Preventionist Nurse was unable to locate these reports. The facility also failed to report positive Legionella water sampling test results to the State Agency. Several water samples collected between March 2023 and March 2024 tested positive for Legionella, but the facility did not report these results. The Director of Maintenance and the Administrator were unaware of the requirement to notify the State Agency, and the facility's consultant had incorrectly informed them that reporting was not necessary. The facility's policy requires reporting any positive Legionella testing results to the Connecticut Department of Public Health.
Failure to Administer Vaccines to Residents
Penalty
Summary
The facility failed to administer the pneumococcal and influenza vaccines to two residents as required by their policies. Resident #26, who was admitted in September 2023 with diagnoses including anemia, end-stage renal disease, and major depressive disorder, did not receive the pneumococcal vaccine upon admission. The facility's electronic medical record system indicated that Resident #26 required the pneumococcal vaccine, but there was no documentation of its administration. The Infection Preventionist (IP) nurse, who started in July 2024, noted that the admitting supervisor was responsible for obtaining vaccination consent and status, but this was not completed for Resident #26. Resident #87, admitted in November 2022 with chronic obstructive pulmonary disease, hypertension, and a pulmonary nodule, also did not receive the pneumococcal vaccine despite giving consent on November 7, 2022. The electronic medical record system showed that Resident #87 required the vaccine, but there was no record of its administration. The IP nurse indicated that the infection control nurse should have followed up on the vaccine consent documentation and obtained a physician's order to administer the vaccine, but this was not done. Additionally, Resident #87 consented to receive the influenza vaccine on November 7, 2022, but there was no documentation of its administration in the clinical records. The facility's policy required that all residents receive the influenza vaccine annually unless contraindicated or refused, and that new admissions during the influenza season be offered the vaccine. The IP nurse was in the process of reviewing the resident's vaccination information, but the deficiency in administering the vaccines was evident.
Failure to Administer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was administered as requested by two residents upon admission and did not offer or assess for COVID-19 immunizations upon admission. Resident #26, admitted in September 2023 with diagnoses including anemia, end-stage renal disease, and major depressive disorder, had moderately impaired cognition. Despite giving consent for the COVID-19 vaccine on 9/20/23, the clinical records did not show that the vaccine was administered. The electronic medical record indicated a refusal, but the facility could not provide a consent form showing the resident's refusal. The Infection Preventionist Nurse (RN #1) confirmed the resident had declined the vaccine on 6/7/24 but could not locate the consent form. The facility's policy required that new residents be offered the vaccine within 14 days of admission, and the care plan and immunization tab should be updated accordingly. Resident #52, admitted in October 2022 with chronic kidney disease, type 2 diabetes mellitus, and legal blindness, also had moderately impaired cognition. The immunization records did not show that the COVID-19 vaccine was offered or assessed for past immunization. The facility failed to provide documentation that the resident was offered the vaccine or had declined it. RN #1 stated that the supervisor at the time of admission was responsible for assessing and obtaining vaccination consent and status, and the infection control nurse would follow up on the documentation. The facility's policy required that new residents be offered the vaccine within 14 days of admission, and the care plan and immunization tab should be updated to reflect the vaccine administration.
Kitchen Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to maintain kitchen equipment in a safe and functional manner, as observed during a survey. On the morning of October 7, 2024, it was noted that the facility was using disposable plates and cups for serving breakfast to all residents due to a non-functional dishwasher. A tour of the kitchen revealed that the dishwasher had been broken for months and could not be repaired, necessitating a replacement. Additionally, two out of four ovens were not operational, and there was a continuous water leak from the 3-bay sink near the oven area. Dietary Aide #1 confirmed the prolonged dysfunction of the dishwasher and the use of disposable items for meals, indicating that both the Maintenance Director and the Administrator were aware of these issues. The Maintenance Director, who had recently started his position, acknowledged the non-functional dishwasher and mentioned that a new one was supposedly being ordered, although he was unaware of the order's status or installation timeline. He was also unaware of the non-functional ovens and the sink leak until the survey. Further interviews revealed that the facility had obtained a price quote for a new dishwasher on October 2, 2024, but had not yet paid the deposit required to process the order. This lack of action and communication among the facility's staff contributed to the ongoing equipment deficiencies in the kitchen.
Failure to Refer Resident for Level II PASARR Assessment
Penalty
Summary
The facility failed to ensure that a resident with a qualifying diagnosis was referred to the state-designated authority for a level II PASARR assessment. Resident #62, who had diagnoses including major depressive disorder, unspecified psychosis, and generalized anxiety disorder, was identified as cognitively intact and required various levels of assistance for daily activities. The care plan noted the risk of complications from psychotropic drug use, with interventions to monitor behavior and medication side effects. However, a new diagnosis of major depressive disorder was documented, which should have triggered a referral for a level II assessment. Interviews revealed a breakdown in communication and procedure. Social Worker #2 documented the new diagnosis but failed to notify Social Worker #1, who was responsible for submitting the referral. Social Worker #1 was unaware of the new diagnosis and thus did not make the necessary referral. The Regional MDS Coordinator noted that the Social Worker attends weekly meetings with psychiatric providers to be informed of new diagnoses requiring referrals, but this process was not followed in this instance, leading to the deficiency.
Failure to Obtain Physician's Order for Surgical Wound Care
Penalty
Summary
The facility failed to obtain a physician's order for the treatment of a surgical wound for a resident who was readmitted with a right femur fracture, polyneuropathy, and type 2 diabetes mellitus. Upon readmission, the resident had undergone a partial hip replacement and had specific instructions to keep the surgical dressing in place for seven days. However, the facility did not document a treatment order for the surgical wound from the time of readmission until several days later. The nursing staff did not follow the surgeon's instructions for the surgical wound care, as evidenced by the lack of documentation in the treatment administration record (TAR) and the absence of a physician's order for the wound care. The dressing fell off prematurely, and although it was replaced, there was no record of the type of dressing used or whether the physician was notified. This oversight continued until the wound showed signs of infection, at which point a physician's order was finally obtained. Interviews with the facility's wound nurse and the Director of Nursing Services (DNS) revealed that the responsibility for ensuring proper wound care orders were in place was not fulfilled. The facility's policy required that dressing changes and wound cleaning be conducted according to the surgeon's orders, which was not adhered to in this case. The lack of communication and documentation led to a delay in appropriate wound care management for the resident.
Controlled Medication Count and Documentation Discrepancies
Penalty
Summary
The facility failed to ensure the accuracy of controlled medication counts and proper documentation on the control disposition record for one of the three medication administration carts reviewed. Specifically, discrepancies were found in the controlled medication counts for three residents. A blister pack of Alprazolam 0.5mg for one resident contained 11 tablets, while the record indicated 12. Another resident's Tramadol 50mg blister pack had 3 tablets, but the record stated 4. Additionally, a blister pack of Alprazolam 0.25mg for a third resident contained 1 tablet, whereas the record showed 2. These discrepancies indicate a failure to maintain accurate records and accountability for controlled substances. Interviews with RN #4 and the Director of Nursing Services (DNS) revealed that it was the responsibility of all nurses to ensure expired medications were not stored in the cart and that controlled medications should be secured behind two locks. RN #4 acknowledged that she should have signed the control drug receipt and disposition record when administering medication. The facility's Medication Administration Guidelines and Control Substances policy require that controlled substances be stored in a double-locked container and that the administration of these medications be accurately recorded. The failure to adhere to these guidelines and policies resulted in the identified discrepancies in medication counts and documentation.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications appropriately as observed during a review of the 2 East medication administration cart. Two bottles of Oyster Shell Calcium with Vitamin D were found with an expiration date of 9/2024, indicating they were expired. Additionally, a bottle of Lantus 100 units/ml was found without an open date, approximately one-quarter full, in a plastic sandwich bag with the last name of a resident written in black marker that was worn away and barely visible. There was no open date or discard date written on the bottle. Furthermore, the narcotic box located in the medication administration cart was not locked, although the cart itself was secured and located behind the nurses' station. Interviews with RN #4 and the Director of Nursing Services (DNS) revealed that it was the responsibility of all nurses to ensure expired medications were not stored in the medication cart and that controlled medications should be secured behind two locks. RN #4 acknowledged that insulin should be labeled with the opened date and discard date, and that she should have signed the control drug receipt and disposition record when administering the medication. The facility's Medication Administration Guidelines and Control Substances policy require that controlled substances be stored in a double door, double locked container, and that accountability and security must be maintained at all times.
Failure to Document and Assess Secured Unit
Penalty
Summary
The facility failed to properly document and assess the presence of a secured unit within its premises, as observed during a survey. The East 1 Unit was identified as a secured unit requiring a code for entry and exit, with additional security features such as wanderguard alarm sensors on fire exits. However, the facility's assessment did not acknowledge the existence of this secured unit, nor did it include criteria for resident placement or the physical and environmental characteristics of the unit. The assessment was outdated, containing signatures from former staff and information from the previous year, and was signed by the current administrator and DNS without their participation in its completion. Interviews with the DNS and Administrator revealed that they were unaware of the details of the facility assessment they signed, and the secured unit was not included in the assessment. The Corporate Administrator later provided a new assessment, which still failed to identify the secured unit. The facility policy for the secured unit outlined criteria for placement and quarterly assessments, but the facility could not provide policies or procedures for ongoing assessments or physician input. Interviews with medical staff indicated a lack of participation in the facility assessment process, highlighting a disconnect between the facility's documentation and its operational practices.
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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