Pomperaug Woods Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Southbury, Connecticut.
- Location
- 80 Heritage Rd, Southbury, Connecticut 06488
- CMS Provider Number
- 075318
- Inspections on file
- 20
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pomperaug Woods Health Center during CMS and state inspections, most recent first.
A resident with dementia and other medical conditions had an iPad taken from the facility. The missing device was reported by the family, and after an internal search, it was tracked to a location outside the facility. Investigation revealed that a staff member was involved in the misappropriation of the resident's property, violating the facility's policy on protecting residents' belongings.
A resident with chronic pain conditions was prescribed Oxycodone, which was delivered, signed in by two nurses, and stored in the locked narcotic drawer. During a routine audit, the DON discovered that both the medication and its disposition sheet were missing. Despite searching all medication storage areas and interviewing staff, the items could not be located, resulting in a failure to protect the resident from misappropriation of property.
A facility failed to adhere to care plans for three residents, resulting in falls and injuries. One resident, identified as a high fall risk, was not provided with scheduled toileting or gripper socks, leading to a fall with major injuries. Another resident, requiring a two-person assist for transfers, was improperly transferred by a single aide, resulting in a fall. A third resident, also a high fall risk, was not toileted as per the care plan, leading to self-transfer attempts and falls.
The facility failed to maintain accurate temperature logs for kitchen equipment and did not ensure cleanliness of storage containers. Temperature logs were not kept from October 1 to October 10, and when produced, they were postdated. Storage containers for food items were found unclean, and there was no cleaning schedule in place. The facility did not provide policies for temperature maintenance and cleaning.
The facility did not implement appropriate plans of action to correct quality deficiencies identified through its QAPI program. A bed safety program and a mechanical lift sling quality control project were initiated and reported as completed, but facility documentation lacked measurable goals, detailed interventions, or a monitoring process. The DON could not explain the absence of documentation related to these initiatives.
The facility failed to provide PPE gowns to staff handling soiled linens, as observed during an interview with a laundry aide and the Director of Laundry, who was unaware of PPE usage requirements. No PPE gowns were stored in the laundry area, leading to contamination of the aide's clothing while handling soiled and clean linens. Facility policy required gowns and gloves for sorting and washing linen.
A facility failed to maintain a clean and sanitary environment for personal care items in shared bathrooms. Unlabeled items, such as toothbrushes and razors, were found on countertops, leading to confusion among staff and residents. Nursing staff acknowledged the need for labeling and proper storage, as per facility policy.
A resident with type II diabetes and chronic kidney disease, who was cognitively intact, expressed a preference for fresh potatoes over instant ones. Despite this, the resident was repeatedly served instant potatoes, contrary to their documented preference. Staff interviews revealed awareness of the preference but cited oversight as the reason for the error. The facility failed to adhere to the resident's right to self-determination and choice in meal preferences.
A resident with dementia and osteoarthritis, who was cognitively intact, was found with a bruise on the left upper thigh. The DNS did not report the injury to the state agency, believing it did not meet reporting criteria, despite the facility's policy requiring immediate reporting of such injuries.
A resident with a history of falls and cognitive intactness was prescribed Risperdal 0.25 mg every evening for delusions and hallucinations. However, the handwritten order was incorrectly transcribed into the EMAR as every 8 hours, leading to overmedication for 13 days. The error was discovered by an RN who failed to clarify the order, and the prescribing MD confirmed the original order. No adverse effects were reported.
A resident with limited mobility and cognitive impairment was improperly transferred by staff, leading to a fall and femur fracture. The resident required assistance from two staff members for transfers, as per the care plan, but was transferred by one NA alone. The wheelchair was not locked, and the resident was not positioned safely, resulting in the fall. The facility lacked a policy on transferring residents.
A resident with impaired cognition and a history of falls was not transferred according to physician orders, requiring two staff members and a Maximove lift. Instead, a nursing assistant transferred the resident alone, allegedly using rough handling and verbal abuse. The incident led to the assistant's termination after an investigation confirmed the violation of transfer protocols.
A resident with osteoarthritis, dementia, and muscle weakness fell and fractured their femur due to improper transfer procedures and incomplete clinical records. The resident required substantial assistance with transfers, but physician orders for transfer status were unavailable. Two NAs attempted to transfer the resident without locking the wheelchair, and one NA had previously transferred the resident alone, contrary to the care plan.
Resident's Personal Property Misappropriated by Staff
Penalty
Summary
A deficiency occurred when a resident's personal property, specifically an iPad with a blue cover, was taken from the facility. The resident, who had diagnoses including dementia, anxiety, generalized muscle weakness, and chronic obstructive pulmonary disease, was identified as having moderately impaired cognition and required substantial assistance with activities of daily living. The missing iPad was reported by the resident's family when they arrived to collect the resident's belongings. Facility staff conducted a search and notified all departments, but the iPad was not found. The family later used the iCloud account to track the device, which was located at a middle school outside the facility. An internal investigation was initiated, and the police were notified. The facility provided the police with a list of staff who had cared for the resident, as well as other relevant information. The police instructed the facility to allow them to handle the investigation as a criminal matter. During the investigation, a staff member was placed on administrative leave, and it was later identified that the iPad was returned to the family and the suspect was a nursing assistant. The facility's policy states that residents have the right to be free from misappropriation of property, but in this instance, the resident's property was not protected from wrongful use.
Failure to Account for Controlled Medication and Documentation
Penalty
Summary
A deficiency occurred when a controlled medication, Oxycodone, and its corresponding controlled substance disposition sheet for a resident with chronic pain conditions were found to be missing from the facility. The resident, who had diagnoses including osteoporosis, spondylosis, cervicalgia, and polyosteoarthritis, was receiving scheduled pain medication and had no memory recall deficits. The medication was delivered by the pharmacy, signed in by two nurses, and placed in the locked narcotic drawer of the medication cart as per facility protocol. However, when the resident required a dose two days later, the medication could not be located in the cart and had to be obtained from the emergency box. A routine bimonthly narcotic audit conducted by the DON revealed that both the blister pack of Oxycodone and the corresponding disposition sheet were unaccounted for. Despite searching all medication storage areas and interviewing staff who worked during the relevant period, the medication and documentation could not be found. Facility policies required proper accounting and documentation of all controlled drugs and defined misappropriation as the wrongful use or misplacement of a resident's belongings or money. The failure to account for the controlled medication and its documentation constituted a failure to protect the resident from misappropriation of property.
Failure to Follow Care Plans Leads to Resident Falls
Penalty
Summary
The facility failed to follow the care plan for Resident #26, who had a history of falls and was identified as a high fall risk. Despite the care plan's directives to apply gripper socks and offer toileting every 2 hours, Resident #26 was found barefoot and had not been toileted according to the schedule. This oversight resulted in a fall with major injuries, including multiple subarachnoid hemorrhages and a nondisplaced occipital bone fracture, requiring a 5-day hospital admission. Resident #2, who required a two-person assist for transfers, was improperly transferred by a single nurse aide, leading to a fall. The care plan and physician orders specified the need for a two-person assist during certain shifts and the use of a Hoyer lift during others. However, the nurse aide attempted to transfer Resident #2 alone, resulting in the resident panicking and being eased to the floor. This incident occurred despite the staff's awareness of the resident's transfer requirements. Resident #10, identified as a high fall risk with a history of falls, was not toileted according to the care plan, which required frequent checks and assistance. The resident was found on the bathroom floor after attempting to self-transfer, having not been toileted as scheduled. The staff failed to adhere to the care plan's directives to offer toileting every hour and to remain with the resident during bathroom visits, contributing to the fall incidents.
Deficiencies in Kitchen Documentation and Cleanliness
Penalty
Summary
The facility failed to maintain proper documentation and cleanliness standards in the kitchen, as observed during a survey. Temperature logs for refrigerators, freezers, and the dishwasher were not maintained from October 1 to October 10, 2024. When questioned, the Culinary Director produced logs that were postdated with temperatures through October 10, 2024, at 5 PM, indicating that the logs were not accurately maintained. Additionally, four 50-pound storage containers used for flour, sugar, oatmeal, and rice were found with a brown sticky substance around the tops, indicating they were not clean. The Culinary Director admitted there was no cleaning schedule or log for these containers. Despite requests, the facility did not provide policies for temperature maintenance and cleaning equipment.
Failure to Document and Monitor QAPI Initiatives
Penalty
Summary
The facility failed to implement appropriate plans of action to correct quality deficiencies identified through its Quality Assurance and Performance Improvement (QAPI) program. The QAPI Committee Minutes from March 2024 indicated the initiation of a bed safety program for entrapment checks before bed changes for residents using bed rails as mobility enablers. By June 2024, the program was reported as completed, with maintenance performing bed checks. However, the facility documentation did not include measurable goals, step-by-step interventions to address the problem, or a method to monitor progress over time. Additionally, the QAPI Meeting Minutes from March 2024 outlined a plan for mechanical lifts and sling quality control to ensure all slings were safe and appropriately sized according to manufacturer guidelines. By July 2024, the project was reported as completed, with all residents having two slings in rotation and inspection as part of daily practice. Despite this, the facility documentation again lacked measurable goals, detailed interventions, or a monitoring process. The Director of Nursing was unable to explain the absence of documentation related to these QAPI initiatives.
Failure to Provide PPE Gowns in Laundry
Penalty
Summary
The facility failed to ensure that staff were provided with Personal Protective Equipment (PPE) gowns while sorting and washing soiled linens. During an observation and interview with a laundry aide, it was identified that PPE gowns had never been used to handle soiled linen. The Director of Laundry, who was new to the position, was unaware of when PPE gowns should be utilized during laundry processing. Further observations revealed that no PPE gowns were stored in the laundry area, and there was contamination of the laundry aide's clothing while handling soiled linens, which was followed by handling clean linens. The facility's policy indicated that employees sorting and washing linen must wear a gown and gloves, and a mask may be worn if aerosolization is expected.
Failure to Maintain Sanitary Storage of Personal Care Items
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for personal care items in shared bathrooms, as observed during a survey. Unlabeled personal care items, including hairbrushes, combs, razors, shampoo bottles, soap dishes, toothbrushes, and denture cups, were found on the countertops in bathrooms shared by residents. These items were not labeled with resident identifiers, leading to confusion among staff about ownership. Nursing assistants interviewed during the survey indicated that they would discard items if they were unsure of ownership, and noted that some residents, who were confused, would use any items available on the countertop. Further observations confirmed that the issue persisted, with unlabeled items remaining on the countertops in shared bathrooms. Interviews with nursing staff, including a registered nurse, revealed that personal care items should be labeled and stored in designated shelving units provided by the facility. The Director of Nursing acknowledged the lack of staff competencies or in-services related to the storage and labeling of personal care items and recognized the need for improvement in this area. The facility's policy emphasizes maintaining a clean, sanitary, and orderly environment, which was not adhered to in this instance.
Failure to Honor Resident's Food Preference
Penalty
Summary
The facility failed to honor a resident's food preference, specifically for fresh potatoes instead of instant potatoes, which was a significant aspect of the resident's self-determination and choice. The resident, who was cognitively intact and independent with eating, had a care plan that emphasized involvement in daily decision-making. Despite this, the resident repeatedly received instant potatoes, contrary to their expressed preference for fresh potatoes. This issue was brought to the attention of the Director of Nursing, who assured the resident it would not happen again. Interviews with staff revealed a lack of adherence to the resident's documented food preferences. A nurse aide confirmed that the resident was initially served instant potatoes and had to replace them with fresh ones. Dietary aides acknowledged awareness of the resident's preference but failed to ensure the correct meal was served due to oversight. The Food Service Director confirmed that staff should have checked meal tickets to ensure the resident received fresh potatoes as per their preference. This oversight indicates a failure in the facility's processes to accommodate the resident's dietary choices as outlined in the Resident Rights policy.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with dementia and osteoarthritis to the overseeing state agency. The resident was cognitively intact and required a two-person assist for bed mobility, transfers, and toileting. On a specific date, a bruise measuring 6.5cm by 4cm was observed on the resident's left upper thigh during care. Despite the bruise's location, the Director of Nursing (DNS) did not report the injury, as he did not believe it met the criteria for reporting. The facility's Abuse Prevention Policy mandates that all alleged violations of abuse, including injuries of unknown source, must be reported immediately, within two hours of discovery. The policy defines injuries of unknown source as those where the source was not observed or explained by the resident, and the injury is suspicious due to its extent, location, or frequency. The DNS's decision not to report the injury was contrary to this policy, as the injury's source was not observed, and the resident could not explain it.
Medication Transcription Error for Psychotropic Drug
Penalty
Summary
The facility failed to ensure accurate transcription of a physician's order for a newly prescribed psychotropic medication for Resident #16. The resident, who was cognitively intact and had no prior behaviors directed toward others, was admitted with a history of fainting, falls, and a cervical fracture. A psychiatrist prescribed Risperdal 0.25 mg to be administered every evening at 8:00 PM to address delusions, hallucinations, and yelling behaviors. However, the handwritten order was incorrectly transcribed into the electronic medication administration record (EMAR) as Risperdal 0.25 mg every 8 hours, leading to the resident receiving the medication more frequently than prescribed from October 3 to October 15. The error was discovered when RN #2, who was responsible for transcribing the order, noted the discrepancy but did not seek clarification from other staff or the prescribing physician. The Director of Nursing (DNS) was informed of the issue on October 15, and an investigation was initiated. The prescribing physician, MD #2, confirmed the original order and noted potential adverse effects of the incorrect dosage, although no adverse effects were reported for Resident #16. The facility's policy requires verification of handwritten orders by a licensed nurse before entry into the electronic health record, which was not adequately followed in this case.
Failure to Follow Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was transferred with the assistance of two staff members as required by the Resident Care Plan. The resident, who had diagnoses including osteoarthritis, dementia, and muscle weakness, required substantial assistance with transfers. On the day of the incident, two nursing assistants (NAs) were preparing to transfer the resident from a wheelchair to a bed. However, the resident was not seated properly in the wheelchair, and when instructed to reposition, the resident slid out of the wheelchair and sustained a femur fracture. The incident report noted that the wheelchair was not locked, and the resident was not positioned safely, leading to the fall. Interviews and record reviews revealed that the resident had an order for assistance of two staff members via a Hoyer lift for transfers, which was not followed. One NA transferred the resident from the toilet to the wheelchair alone, contrary to the care plan, and the resident was not properly positioned in the wheelchair. The Director of Nursing confirmed that the resident required two staff for transfers and acknowledged that the transfer was conducted improperly. The facility did not have a policy on transferring residents, which contributed to the incident.
Failure to Follow Transfer Orders Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident was transferred in accordance with physician orders, leading to a deficiency. The resident, who had diagnoses including difficulty in walking and muscle weakness with a history of falls, required partial/moderate assistance with transfers as per the Minimum Data Set. The Resident Care Plan indicated the need for assistance of two staff members during transfers to mitigate fall risk. A physician's order further specified the use of a Maximove lift with two staff members for toileting and transferring. An incident occurred where a nursing assistant (NA) allegedly transferred the resident alone, without the required second staff member, and was reported to have been rough and verbally abusive. The Director of Nursing confirmed that the NA performed the transfer alone, contrary to the physician's orders. The NA was suspended and subsequently terminated following the investigation, which revealed that the resident had a history of directing staff to perform unsafe transfers.
Incomplete Clinical Record and Improper Transfer Lead to Resident Fall
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate, specifically regarding transfer status orders. The resident, who had diagnoses including osteoarthritis, dementia, and muscle weakness, required substantial assistance with transfers as per the Minimum Data Set (MDS) and Resident Care Plan (RCP). However, the facility was unable to provide physician orders for the resident's transfer status prior to a fall incident, despite requests for these records. The incident occurred when two nursing assistants (NAs) were preparing to transfer the resident from a wheelchair to bed. The resident was not properly positioned in the wheelchair, and when instructed to move back, the resident leaned forward and fell, resulting in a left femur fracture. The NAs did not lock the wheelchair before attempting to reposition the resident, and one NA had previously transferred the resident from the toilet to the wheelchair without assistance, contrary to the care plan's directive for two-person assistance. The Director of Nursing confirmed the absence of physician orders for the resident's transfer status.
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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