Villa At Stamford, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Stamford, Connecticut.
- Location
- 88 Rockrimmon Road, Stamford, Connecticut 06903
- CMS Provider Number
- 075153
- Inspections on file
- 26
- Latest survey
- June 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Villa At Stamford, The during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and severe cognitive impairment, who required maximum assistance with eating, had multiple instances of missing meal intake documentation over nearly a month. Despite facility policy and expectations for accurate recordkeeping, several breakfasts, lunches, and dinners were not recorded in the EMR, as confirmed by interviews with the dietician and DON.
A resident with a history of aggressive behaviors, including verbal and physical gestures, repeatedly directed negative actions toward another cognitively impaired resident. Despite staff awareness of these ongoing behaviors, care plans did not address the escalating conflict, resulting in a physical altercation where one resident struck the other. The lack of specific interventions and care plan updates contributed to the incident of resident-to-resident abuse.
A resident with hemiplegia/hemiparesis was involved in an abuse allegation where a family member reported a nursing assistant slapped the resident. The facility's investigation found no injuries and could not substantiate the claim. However, the social worker failed to document a follow-up visit with the resident, violating the facility's documentation policy.
The facility failed to follow dental orders for a resident needing a tooth extraction, resulting in multiple cancellations due to not discontinuing aspirin and lacking an Ativan order. Additionally, another resident with a surgical incision did not receive prescribed sulfadiazine cream treatment as ordered. Staff interviews revealed a breakdown in transcribing and administering physician orders, with the DNS acknowledging the failure to follow expected procedures.
A resident with COPD, dementia, and a psychotic disorder was found smoking in their room, but the responsible party was not notified until five days later. The facility's policy requires prompt notification of incidents, which was not followed in this case.
A resident with multiple mental health diagnoses did not receive a timely Level II PASRR screening after their short-term approval expired. The facility's social worker failed to submit the necessary screening, which was completed seven months late, despite the facility's policy requiring timely assessments for residents with short-term PASRR approvals.
The facility failed to update care plans for two residents after significant incidents. One resident, with a history of smoking, was found smoking in their room, but the care plan was not revised to include new interventions like a nicotine patch. Another resident, admitted for rehabilitation with a cervical fracture and an implanted loop recorder, did not have their care plan updated to include necessary interventions for the neck collar and surgical incision monitoring. Staff interviews revealed that care plans were not revised due to time constraints, despite facility policy requiring comprehensive care plans.
A resident with hemiplegia and other conditions did not have splints applied as per physician orders, leading to contracted limbs. Despite a care plan and orders for specific splints, observations showed they were not consistently used. Interviews with staff and the resident confirmed the inconsistency, and the facility's policy on orthotics was not followed, resulting in a deficiency in care.
A resident with a history of COPD and dementia was found smoking in their room, violating the facility's no-smoking policy. The resident accessed smoking materials brought by their spouse, highlighting lapses in supervision and documentation. Staff interviews revealed missing admission paperwork and incomplete incident reporting, contributing to the deficiency.
A facility failed to implement contact precautions for a resident with a multi-drug resistant organism (MDRO) infection, despite heavy wound drainage and treatment with intravenous antibiotics. The resident, who had lymphedema, sepsis, MRSA infection, and schizoaffective disorder, was only placed on enhanced barrier precautions (EBP). Staff interviews revealed a lack of communication and oversight in updating the resident's precautionary status, and a misunderstanding of the difference between EBP and contact precautions.
The facility did not complete annual performance evaluations for three nurse aides, as required by policy. Personnel files lacked documentation of 2023 evaluations. The DNS acknowledged the oversight, confirming it was her responsibility to ensure reviews on anniversary dates. Facility policy mandates annual written reviews by department supervisors, which were not conducted.
Incomplete Meal Intake Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure complete and accurate clinical record documentation for a resident with Alzheimer's disease and anxiety who was at risk for weight loss. The resident was identified as being severely cognitively impaired and required maximum assistance with eating. Review of the resident's care plan directed staff to feed the resident meals. However, meal intake documentation was missing for multiple breakfasts, lunches, and dinners over a period of nearly one month. Specifically, several dates were identified where meal intakes were not recorded in the electronic medical record. Interviews with the dietician and the DON confirmed that it was the expectation for staff to document meal intakes accurately after each meal, and that the facility's policy required records to be accurate and based on resident information. The DON was unable to provide an explanation for the missing documentation. The deficiency was identified through clinical record review, facility documentation review, policy review, and staff interviews.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with a history of behavioral issues, including verbal and physical aggression, was not adequately protected from physical abuse by another resident. The resident, who had diagnoses such as impulse disorder, intellectual disabilities, schizophrenia, and delusional disorder, frequently directed negative comments, gestures, and spitting toward another resident with severe cognitive impairment. Multiple staff members, including LPNs, a social worker, and a psychiatric APRN, confirmed that the resident regularly expressed dislike and made threatening gestures toward the other resident, who typically did not react to these provocations. On the day of the incident, staff heard yelling in the hallway and observed both residents with raised arms. An LPN witnessed the cognitively impaired resident strike the resident with behavioral issues on the cheek after the latter had reportedly hit the former first. The resident who was struck exhibited distress, repeatedly hitting their own cheek and stating they had been hit. Documentation and interviews confirmed that the resident with behavioral issues admitted to hitting the other resident first because of personal dislike. Prior to this incident, the care plans for both residents did not specifically address the ongoing negative interactions and behaviors between them. Although staff were aware of the frequent verbal and non-verbal aggression, interventions to keep the residents separated or to address the specific conflict were not implemented in the care plans until after the physical altercation occurred. The lack of targeted interventions and failure to update care plans contributed to the occurrence of resident-to-resident physical abuse.
Incomplete Documentation Following Abuse Allegation
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate following an allegation of abuse. The resident, who was admitted with hemiplegia/hemiparesis after a cerebral infarction, was reported by family to have been slapped by a nursing assistant. An assessment was conducted with no injuries noted, and the facility's investigation could not substantiate the allegation. However, the clinical record did not include documentation of a follow-up visit by social services after the incident. The social worker admitted to seeing the resident for a follow-up support visit but failed to document the encounter, stating she forgot to write a note. The Director of Nursing Services confirmed that the social worker should have documented the visit. The facility's Charting and Documentation Policy requires all observations and services performed to be documented in the resident's clinical record, which was not adhered to in this case.
Failure to Follow Dental and Medical Orders
Penalty
Summary
The facility failed to follow dental orders for a resident requiring a tooth extraction. The resident, who had a history of dysphagia and other conditions, was scheduled for a tooth extraction to facilitate the fitting of dentures. However, the facility did not discontinue the resident's aspirin as ordered by the dentist, nor did they have an order in place for Ativan to manage the resident's anxiety prior to the procedure. This oversight led to multiple cancellations of the dental procedure, delaying the resident's dental care and denture fitting. Another deficiency involved a resident with a surgical incision who required treatment with 1 percent sulfadiazine cream. The physician's order specified that the cream should be applied twice daily to the resident's left chest. However, the treatment administration record did not reflect that the cream was administered as ordered, indicating a failure to follow the physician's directive. This lapse in care was identified during a review of the treatment records and confirmed through staff interviews. Interviews with facility staff, including LPNs and the DNS, revealed that there was a breakdown in the process of transcribing and administering physician orders. The DNS acknowledged that the orders were not followed as expected, and the facility's policies required that all medications be administered according to written orders from licensed prescribers. These deficiencies highlight a failure in the facility's processes to ensure that residents receive the prescribed care and treatment.
Failure to Notify Responsible Party of Smoking Incident
Penalty
Summary
The facility failed to notify the responsible party of a resident who was found smoking in their room, which is a violation of the facility's policy on reporting incidents. The resident, who has diagnoses including chronic obstructive pulmonary disease, dementia, and a psychotic disorder with delusions, was found smoking in their room with their spouse present. The nursing note documented that the resident was educated on the smoking policy, a room search was conducted, and a new order for a Nicotine patch was obtained. However, the reportable event report did not indicate that the resident's responsible party was notified of the incident. Interviews revealed that the responsible party was not informed of the incident until five days later, via an email from a social worker. The Director of Nursing Services (DNS) acknowledged that the responsible party should have been notified at the time of the incident and that the reportable event report was not completed until two days after the incident due to her being busy. The facility's policy requires that all incidents be promptly investigated and reported, with the family being notified and the date/time of notification documented on the reportable event form.
Failure to Complete Timely PASRR Screening for Resident
Penalty
Summary
The facility failed to complete a necessary Preadmission Screening and Resident Review (PASRR) for a resident with multiple mental health diagnoses, including paranoid personality disorder, delusional disorder, post-traumatic stress disorder, and major depressive disorder. The resident, who had intact cognition and was dependent on a wheelchair for mobility and all activities of daily living, was initially given a short-term approval without specialized services, which required a follow-up Level II screening. However, this screening was not completed until seven months after the short-term approval had expired. The deficiency was identified during a review of the resident's clinical records and interviews with facility staff. The social worker responsible for the PASRR process acknowledged that she should have submitted the resident for a Level II screening following the expiration of the short-term approval. The facility's policy required the social worker to complete a new level screen and level of care assessment if a resident was admitted with a short-term or time-sensitive PASRR. Despite this policy, the necessary screening was delayed, resulting in a failure to comply with the required procedures for residents with mental health needs.
Failure to Update Care Plans for Residents After Incidents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents following significant incidents. Resident #23, diagnosed with chronic obstructive pulmonary disease, dementia, and a psychotic disorder, was found smoking in their room, which violated the facility's smoking policy. Despite the incident, the care plan was not updated to reflect the new interventions, such as the use of a nicotine patch, to address the unauthorized smoking behavior. Interviews with staff, including the Director of Nursing and a Social Worker, revealed that the care plan had not been revised due to time constraints, despite the facility's policy requiring an interdisciplinary team to develop individualized care plans. Resident #45, admitted for short-term rehabilitation following a cervical vertebrae fracture, required the use of an Aspen neck collar and had an implanted loop recorder. The care plan failed to include necessary interventions for the use of the neck collar and the monitoring of the surgical incision related to the loop recorder. Nursing notes did not reflect monitoring for signs of infection at the incision site. Interviews with an LPN and the Director of Nursing Services indicated that the care plan should have addressed these needs, but it was not updated to include the physician's instructions for care and monitoring. The facility's policy mandates that the interdisciplinary team is responsible for creating comprehensive care plans for each resident. However, in both cases, the care plans were not updated to reflect the residents' current needs and interventions following significant incidents, highlighting a deficiency in the facility's care planning process.
Failure to Apply Splints as Ordered for Resident
Penalty
Summary
The facility failed to ensure that a resident, who had specific physician orders for splint use, had the splints in place daily as required. The resident, diagnosed with hemiplegia, hemiparesis, legal blindness, rheumatoid arthritis, and vascular dementia, was observed multiple times without the necessary splints on their upper extremities. Despite the care plan and physician's orders specifying the use of various splints, including a left elbow splint, right resting hand splint, and left-hand carrot splint, these were not consistently applied during morning care. Interviews with the resident revealed that the splints had not been placed for some time, and the resident had not refused their use. Observations confirmed the absence of splints on several occasions, and staff interviews indicated a lack of consistent application of the splints. Nursing staff and nursing assistants were both responsible for ensuring the splints were applied, yet there was a failure to do so, as evidenced by the resident's contracted limbs and the absence of splints during observations. The facility's policy on the use of orthotics for contracture management was not adhered to, as splints were not applied according to the individualized wearing schedule. The policy required splints to be removed every two hours for skin inspection and reapplication, but this was not consistently followed. The therapy director and other staff interviews highlighted a lack of adherence to the care plan and physician's orders, contributing to the deficiency in care for the resident.
Inadequate Supervision Leads to Resident Smoking Incident
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident from smoking in their room, which posed a significant safety hazard. The resident, who had a history of chronic obstructive pulmonary disease, dementia, and a psychotic disorder, was found smoking in their room despite the facility's no-smoking policy. The resident's care plan indicated they required supervision for personal care, but the incident revealed a lapse in monitoring. The resident's spouse had brought smoking materials, which the resident accessed, leading to the incident. Interviews with staff highlighted several procedural lapses. The Nursing Supervisor noted the incident but did not complete the Accident and Incident report promptly. The Director of Nursing acknowledged that the resident should have been treated as a new admission due to their extended absence from the facility, which would have required updated admission paperwork, including acknowledgment of the no-smoking policy. However, the necessary documentation was missing, and the care plan was not updated following the incident. The facility's policies on reportable events and smoking were not adequately enforced. The Admissions Director could not locate the signed no-smoking agreement for the resident, and the Social Worker failed to document discussions with the resident and their spouse about the dangers of smoking. The facility's failure to implement and document preventive measures and update care plans contributed to the deficiency, as did the lack of a timely investigation into the incident.
Failure to Implement Contact Precautions for Resident with MDRO
Penalty
Summary
The facility failed to implement appropriate transmission-based precautions for a resident actively infected with a multi-drug resistant organism (MDRO). The resident, identified as having lymphedema, sepsis, Methicillin Resistant Staphylococcus Aureus (MRSA) infection, and schizoaffective disorder, was not placed on contact precautions despite having a wound with heavy drainage. The resident's care plan included enhanced barrier precautions (EBP) due to a lower extremity wound, but the facility did not update the precautions to contact precautions as recommended by the Centers for Disease Control and Prevention (CDC) for residents with active infections and uncontained drainage. The resident's clinical records showed a wound culture with heavy growth of pseudomonas aeruginosa and moderate growth of MRSA, and the resident was treated with intravenous antibiotics. Despite this, the facility's infection control tracking sheet and physician's orders for April 2024 only indicated EBP, not contact precautions. Interviews with staff, including the Infection Preventionist and Director of Nursing Services, revealed a lack of communication and oversight in updating the resident's precautionary status, even though the resident exhibited behaviors such as refusing dressing changes and having copious wound drainage. The facility's policies on multidrug-resistant organisms and contact precautions were not followed, as the resident's condition warranted contact precautions due to the inability to contain wound drainage and the resident's non-compliance with care. Staff interviews confirmed that the resident was never placed on contact precautions, and there was a misunderstanding among staff regarding the difference between EBP and contact precautions. This oversight in implementing the correct precautions contributed to the deficiency identified by the surveyors.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance evaluations for three nurse aides, as required by their policy. The personnel files of the nurse aides, hired on various dates, did not contain documentation of a performance evaluation for the year 2023. During an interview, the Director of Nursing Services (DNS) acknowledged the oversight and confirmed that it was her responsibility to ensure that annual performance reviews were conducted on each employee's anniversary date. The facility's policy mandates that all employees undergo a written annual review by their department supervisor on their anniversary date, which was not adhered to in these cases.
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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