Pendleton Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mystic, Connecticut.
- Location
- 44 Maritime Drive, Mystic, Connecticut 06355
- CMS Provider Number
- 075341
- Inspections on file
- 24
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pendleton Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Two residents who reported abuse did not have timely nursing assessments documented in their clinical records as required by facility policy. Although assessments were reportedly performed and incidents were investigated, the necessary documentation was either missing or entered late, resulting in incomplete records of the events and the facility's response.
A resident with a history of subdural hematoma and on anticoagulation experienced multiple unwitnessed falls. After the initial fall, neurological checks were performed as required, but following a subsequent unwitnessed fall, staff did not restart neurological checks at the mandated intervals according to facility policy. Documentation and staff interviews confirmed that the required neurological assessments were not completed after each fall.
A resident with multiple diagnoses experienced swelling and pain in the left hand, but the facility failed to notify the physician as required by policy. Despite the symptoms being documented in nursing notes, staff interviews revealed that the physician was not informed, which was a deviation from the facility's procedures for handling changes in a resident's condition.
A facility failed to include necessary monitoring and emergency actions in the care plan for a resident receiving anticoagulant medication. Despite daily administration of Coumadin, the care plan lacked interventions for monitoring side effects, contrary to facility policy. The DNS confirmed the care plan should have addressed these needs.
Two residents were found with medications at their bedside without proper authorization or assessments for self-administration. One resident with COPD had respiratory medications left by nurses for convenience, while another resident with kidney disease had a red liquid and ointment left in their room. The facility's policy requires an interdisciplinary team assessment and a physician's order for self-administration, which were not in place for these residents.
A resident with cognitive impairment and mobility issues did not receive scheduled showers over a three-month period, despite being scheduled for twice-weekly showers. Facility documentation lacked reasons for missed showers, and staff interviews revealed confusion about documentation protocols. The facility's policy requires necessary services for residents unable to perform ADLs, which was not followed.
A resident with COPD did not receive medications as prescribed due to discrepancies in administration and documentation. The resident's medications were left in their room for convenience, and the MAR showed inconsistencies with the pharmacy's dispensed quantities. Nursing staff failed to reorder medications appropriately, leading to a shortage and non-compliance with the facility's medication administration policy.
A resident, admitted with conditions including dementia and COPD, requested a pneumococcal vaccine upon admission. Despite consent from the resident's legal representative, the facility failed to administer the PCV 20 vaccine and did not communicate the request to the primary physician. The facility's policy required offering immunizations unless contraindicated, but the oversight in communication led to the deficiency.
A resident with multiple diagnoses had a nebulizer mask and tubing improperly stored in their room, despite not having received a treatment in several months. The prescribed Albuterol Sulfate solution was not administered from November 2024 to January 2025, and an LPN confirmed no treatments since July 2023. The facility's policy required equipment to be stored in a zip lock bag when not in use, which was not followed.
A facility failed to accurately code MDS assessments for a resident with end-stage kidney disease, heart failure, and diabetes, omitting the resident's hemodialysis treatments. Despite having a physician's order for dialysis three times a week, four MDS assessments did not reflect this treatment. The MDS Coordinator acknowledged the oversight but could not explain the reason for the error, despite the facility's comprehensive assessment process.
A resident with a fractured tibia, diabetes, and morbid obesity developed pressure ulcers that were not promptly reported to the physician. Despite initial skin checks showing no issues, subsequent checks identified abrasions. The facility failed to document and treat the pressure ulcers as per recommendations, and staff were unaware of the worsening condition. The DNS was not informed of medical appointments and consultation reports, leading to a failure in notifying the physician and the resident's family.
A facility failed to properly assess, monitor, and treat a resident's pressure ulcer, leading to the development of new pressure ulcers. Despite physician orders and documented skin checks, new abrasions and pressure ulcers were later identified, indicating inconsistent and inadequate monitoring and documentation.
Failure to Timely Document Nursing Assessments Following Abuse Allegations
Penalty
Summary
The facility failed to ensure that nursing assessments were completed and documented in the clinical records at the time allegations of abuse were reported for two of three sampled residents. In the first case, a resident with cognitive impairment and a history of non-compliance reported to a family member that a nurse aide had physically abused them, resulting in visible bruising on both forearms. Although the incident was reported and an assessment was said to have been performed, there was no contemporaneous nurse's note or documentation of the assessment in the clinical record. A late entry was created by the DON two weeks after the incident, but the original assessment and documentation were missing at the time of the event. In the second case, another resident with psychiatric diagnoses reported to a social worker that a nurse aide had physically and verbally abused them. The facility's incident report indicated that there were no injuries and that appropriate notifications and an investigation were initiated. However, a review of the clinical record revealed that no nurse's note or assessment was documented following the allegation. The DON later acknowledged that, despite personally assessing the resident and completing paperwork, she did not document the assessment or the allegation in the clinical record at the time of the incident. Facility policy requires that each resident's medical record contain accurate, complete, and timely documentation of all assessments, observations, and services provided, to be completed no later than the shift in which the event occurred. In both cases, the required documentation was not entered into the clinical record as stipulated by policy, resulting in incomplete records regarding the residents' experiences and the facility's response to the abuse allegations.
Failure to Complete Neurological Checks After Multiple Unwitnessed Falls
Penalty
Summary
The facility failed to follow its own policy regarding neurological checks after unwitnessed falls for a resident with significant risk factors, including a history of subdural hematoma, atrial fibrillation, and use of anticoagulation. The resident was identified as being at risk for falls due to confusion and disorientation, and the care plan included interventions for fall prevention. On the day in question, the resident experienced multiple unwitnessed falls, each requiring neurological assessments as per facility protocol. After the first unwitnessed fall, neurological checks were initiated and documented at the required intervals. However, following a second unwitnessed fall, the neurological checks were not restarted as required by facility policy. Instead, the checks continued at the previous schedule, resulting in missed assessments at the mandated half-hour intervals after the second fall. Staff interviews confirmed that the expectation was to initiate a new set of neurological checks after each unwitnessed fall, but this was not done after the second incident. Documentation review and staff interviews further revealed that the neurological assessment protocol was not consistently followed after subsequent falls. The Director of Nursing confirmed that the facility policy required neurological checks to be restarted after each unwitnessed fall, but this was not adhered to in this case. The medical record lacked evidence of the required frequency of neurological checks after the second fall, and staff were not aware that the protocol had not been followed as outlined in the facility's neurological assessment form.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician when a resident experienced symptoms of pain and swelling in the left hand. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, gout, and atrial fibrillation, was cognitively intact and required maximum assistance with certain activities of daily living. Despite the resident's left hand showing signs of edema, redness, and impaired range of motion, there was no documentation that the physician was informed of these changes. Interviews with staff confirmed that the physician should have been notified, especially since the symptoms were significant enough to be noted in nursing records. The deficiency was identified through observations, clinical record reviews, and staff interviews. The facility's policy mandates prompt consultation with the resident's physician when there is a change in condition that requires notification. However, the policy was not followed in this case, as the physician was not informed of the resident's persistent swelling and pain, which could have necessitated a reevaluation of interventions and treatments. The lack of communication with the physician was a clear deviation from the facility's established procedures for handling changes in a resident's condition.
Care Plan Deficiency for Anticoagulant Monitoring
Penalty
Summary
The facility failed to ensure that the care plan for a resident receiving anticoagulant medication included necessary monitoring for possible side effects and actions to take in case of an emergency. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, gout, and atrial fibrillation, was cognitively intact and required maximum assistance with certain activities of daily living. Despite being administered Coumadin daily, the care plan did not reflect the resident's use of anticoagulant medication or include interventions to monitor for adverse effects such as bleeding, hemorrhage, or changes in hematocrit or blood pressure. The facility's policy for high-risk medications, including anticoagulants, mandates that the care plan should alert staff to monitor for adverse consequences and include interventions to minimize risks. However, the care plan dated 10/31/24 for the resident did not comply with this policy. The Director of Nursing Services confirmed that the care plan should have acknowledged the use of anticoagulant medication and included necessary precautions. This oversight was identified during a review of the clinical record, facility policies, and interviews conducted as part of the survey process.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered according to acceptable standards of practice for two residents. Resident #22, who has diagnoses including respiratory failure and COPD, was found with medications at the bedside without a physician's order for self-administration or a completed self-administration assessment. The medications included Advair Diskus and Fluticasone Propionate, which were supposed to be administered by the nursing staff. The resident reported that the medications were left by the nurses for convenience, and the LPN confirmed that she assumed the resident had an order for self-administration. However, the Nursing Unit Manager and the DNS confirmed that there was no such order or assessment in place. Resident #101, who has diagnoses including kidney disease and high blood pressure, was also found with medications at the bedside without proper authorization. A medication cup containing a red liquid and mupirocin ointment were left in the resident's room. The resident was moderately cognitively impaired and did not want to self-administer medications, as noted in the nurse's quarterly assessment. The DNS confirmed that self-administration assessments are required, and medications should be stored in a lock box if a resident is authorized to self-administer. The facility's policy on self-administration of medications requires an interdisciplinary team assessment and a physician's order before a resident can self-administer medications. Both residents were found with medications at their bedside without these requirements being met, indicating a failure to adhere to the facility's policy and professional standards of quality care.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #44, received showers as scheduled, which is a deficiency in providing necessary care for activities of daily living (ADLs). Resident #44, who has diagnoses including muscle weakness and difficulty walking, was identified as moderately cognitively impaired and required assistance with bathing. The care plan specified that the resident should receive showers on certain days and shifts. However, interviews and documentation reviews revealed that Resident #44 only received two showers over a three-month period, despite being scheduled for showers twice weekly. The nurse aide documentation did not provide reasons for the missed showers, and the resident did not refuse showers according to staff interviews. Interviews with staff, including a nurse aide and the Director of Nursing Services (DNS), highlighted a lack of clarity and adherence to documentation protocols. The nurse aide indicated that the care tasks prompt them to document if a shower is given, refused, or not applicable, but there was confusion about what 'N/A' meant in the documentation. The DNS acknowledged that if a resident does not receive a shower as scheduled, it should be documented, and the resident should be reapproached. The facility's policy on ADLs states that residents unable to perform these activities should receive necessary services to maintain hygiene, which was not adhered to in this case.
Medication Administration Deficiency for a Resident with COPD
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed by the physician for Resident #22, who had diagnoses including respiratory failure, COPD, asthma, and dependence on supplemental oxygen. The resident was cognitively intact and required moderate assistance for certain activities but was independent with toileting hygiene and bed mobility. The care plan included administering medications as ordered and monitoring for respiratory distress. However, observations and interviews revealed discrepancies in medication administration and documentation. During an observation, it was found that Resident #22 had medications in a plastic bag on the nightstand, which included Advair Diskus and Fluticasone Propionate, with some medications not being administered as prescribed. The resident reported last using these medications about a month ago, and it was noted that the nurses left the medication there for convenience. The medication cart and storage room did not contain the required medications for the resident, and the Medication Administration Record (MAR) showed inconsistencies with the actual dispensed quantities from the pharmacy. Interviews with nursing staff and the pharmacy technician revealed that the resident's medications were not reordered appropriately, and the MAR was signed without proper administration. The pharmacy had not received a refill order for the medications since the last dispense date, leading to a shortage. The facility's policy required medications to be administered by licensed nurses and observed, but this was not followed, resulting in the resident not receiving medications as ordered, potentially affecting their health condition.
Failure to Administer Requested Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to a resident who had requested it upon admission. The resident, who was cognitively intact and had a history of cervical disc disorder with myelopathy, unspecified dementia, and COPD with exacerbation, was admitted in June 2024. Despite having received previous pneumococcal vaccinations (PCV 13 in 2015 and PPV23 in 2017), the resident's legal representative consented to the administration of the PCV 20 vaccine in June 2024. However, the facility did not administer the vaccine, nor did they document any change in the resident's decision. Interviews with the Infection Preventionist Nurse and the Regional Clinical Manager revealed that the responsibility for reviewing immunization consent forms and obtaining physician orders for vaccines lay with the Infection Preventionist Nurse. Despite this, the resident's request for the PCV 20 vaccine was not communicated to the primary physician, who confirmed he would have approved the vaccine if informed. The facility's policy stated that residents should be offered pneumococcal immunizations unless contraindicated or already immunized, and that immunizations could be administered under physician-approved standing orders. The oversight in communication and failure to follow through with the resident's vaccination request led to the deficiency.
Improper Storage of Nebulizer Equipment
Penalty
Summary
The facility failed to ensure proper storage and labeling of nebulizer equipment for a resident diagnosed with high blood pressure, obesity, and depression. The resident, who was cognitively intact and required maximum assistance with daily activities, had a nebulizer mask and tubing hanging from a light fixture above their bed, attached to a nebulizer machine in the bedside table. The resident reported not having received a breathing treatment in several months and could not recall the last time the nebulizer was used. A review of the Medication Administration Records revealed that the prescribed Albuterol Sulfate solution for nebulizer use had not been administered from November 2024 to January 2025. An LPN confirmed that the resident had not received a nebulizer treatment since July 2023. Despite the lack of use, the nebulizer equipment remained in the resident's room, contrary to the facility's Nebulizer Therapy policy, which required equipment to be stored in a zip lock bag when not in use. The order for the nebulizer medication was eventually discontinued, but no explanation was provided for the oversight in equipment management.
Inaccurate MDS Coding for Dialysis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments for a resident with end-stage kidney disease, heart failure, and diabetes were accurately coded to reflect the resident's hemodialysis treatments. The resident had a physician's order for hemodialysis three times a week from February 2024 through January 2025. However, four MDS assessments, including two admission and two quarterly assessments, did not indicate that the resident was receiving hemodialysis treatments. An interview with the MDS Coordinator (RN #3) revealed that dialysis should have been coded on the MDS assessments, but RN #3 could not provide a reason for the omission. The MDS assessment process, as described by RN #3, involves reviewing various sources of information, including nurses' notes, physician orders, and documentation from the hospital, as well as interviewing the resident. The facility's policy on MDS 3.0 Completion emphasizes a comprehensive assessment process to identify care needs and develop an interdisciplinary care plan. Despite this, the assessments failed to document the resident's dialysis needs, as required by RAI guidance.
Failure to Notify Physician of Pressure Injuries
Penalty
Summary
The facility failed to notify the physician of pressure injuries for a resident who was admitted with a fracture of the left tibia, diabetes type II, and morbid obesity. The resident's care plan included monitoring skin integrity and circulation around the cast every shift. Initial skin checks showed no skin alterations, but subsequent checks identified new skin impairments, including abrasions on the left heel and toes. Despite these findings, the facility did not notify the physician promptly, and the resident's condition worsened, leading to pressure ulcers that were later identified by an outpatient orthopedic surgeon and wound clinic. The resident's medical record lacked documentation of the pressure ulcers identified by the orthopedic surgeon and wound clinic. The facility's wound care nurse and other staff members failed to monitor and treat the pressure ulcers as per the outpatient wound clinic's recommendations. Interviews with staff revealed that they were unaware of the resident's worsening condition and did not follow proper procedures for notifying the physician and documenting the resident's skin impairments. The facility's Director of Nursing Services (DNS) was not aware of the resident's medical appointments and consultation reports. The process for handling post-visit reports was not followed, resulting in the physician not being notified of the resident's pressure ulcers. The facility's policy on notification of changes was not adhered to, leading to a failure in consulting with the resident's physician and notifying the resident's family member or legal representative when there was a significant change in the resident's condition.
Failure to Properly Monitor and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess, monitor, and treat a resident's pressure ulcer, leading to the development of new pressure ulcers. The resident, who had a history of diabetes, venous insufficiency, and morbid obesity, was admitted with a fractured left tibia and had a cast placed on the left lower extremity. Despite physician orders to monitor skin integrity under and around the cast every shift, the facility's documentation showed inconsistent and inadequate skin checks, with some staff unable to recall specific details of their assessments. On multiple occasions, skin checks were documented as showing no new issues, but on 7/5/23, new abrasions were noted on the resident's left heel, toes, and dorsal foot. These areas were treated with skin prep as ordered by the physician. However, subsequent documentation failed to identify any further skin impairments until an outpatient orthopedic consultation on 7/13/23 revealed pressure ulcers on the resident's dorsal midfoot and posterior heel, with the latter showing eschar. This discrepancy indicates a failure in the facility's monitoring and documentation processes. Interviews with various staff members revealed a lack of consistent practice in removing the cam boot to check the resident's skin thoroughly. The wound RN and other nursing staff were not aware of the severity of the pressure ulcers until much later, and the facility's documentation did not reflect the outpatient wound clinic's recommendations for treatment. The Director of Nursing Services (DNS) was also unaware of the resident's medical appointments and consultation reports, highlighting a breakdown in communication and follow-up within the facility.
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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