Village Crest Center For Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in New Milford, Connecticut.
- Location
- 19 Poplar Street, New Milford, Connecticut 06776
- CMS Provider Number
- 075208
- Inspections on file
- 18
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Village Crest Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident who required a mechanical lift and two-person assistance for transfers was instead transferred by a single nurse aide without the lift, resulting in a fall and ankle fractures. Additionally, several doors on the locked memory care unit, including those to rooms containing hazardous materials, were found unsecured, contrary to facility policy requiring a secure environment for resident safety.
Surveyors found that the facility failed to properly label and date opened food items, did not discard expired foods, and did not maintain sanitary conditions in nourishment room refrigerators, freezers, and ice makers. Multiple opened and undated food items, expired products, and unsanitary equipment were observed throughout the dietary department and nourishment rooms. The Dietary Director was unaware of proper labeling and inventory procedures, and cleaning rounds were not conducted frequently enough to ensure compliance.
A resident with a history of stroke, dementia, and poor dentition experienced significant delays in receiving necessary dental care, including extractions and denture fabrication, despite repeated referrals and documented need. Communication lapses among nursing staff, dental providers, and the receptionist, as well as missed transportation and lack of documentation of barriers, led to the resident continuing to experience dental pain and difficulty eating.
Staff did not consistently wear required PPE, such as N95 masks, gowns, gloves, and eye protection, when entering rooms under droplet/contact precautions for residents with COVID-19 or other infections. Documentation of isolation precautions was inconsistent, and PPE was not always readily available, leading to lapses in infection prevention. Staff interviews confirmed knowledge of the requirements but revealed non-compliance due to rushing or missing equipment.
A resident admitted with chronic venous hypertension, bilateral lower extremity cellulitis, and a surgical wound did not have comprehensive wound treatment or dressing change orders in place upon admission. Although hospital discharge records indicated the need for daily dressing changes and topical treatments, the facility's physician orders and documentation failed to specify wound care for all affected areas. Nursing staff applied dressings without proper orders, and staff interviews confirmed that necessary wound care directives were not obtained or clarified at the time of admission.
A resident with multiple chronic conditions was admitted and identified as wishing to be DNR, but the care plan incorrectly listed the individual as full code, and no physician order for code status was present on admission. The discrepancy was confirmed during review, and facility policy requiring written documentation and physician order for code status was not followed.
A resident with orthostatic hypotension and a history of falls did not receive daily orthostatic blood pressure monitoring as ordered by the physician. The order was not correctly transcribed into the EHR, resulting in its omission from the MAR and TAR, and nursing staff were unaware of the requirement. This failure was not detected during routine audits, leading to the deficiency.
Two residents receiving IV antibiotics did not have appropriate physician orders or maintenance protocols in place for peripheral IV site care, including timely site rotation and dressing changes. The required batch order set for IV maintenance was not implemented at the time of IV initiation, resulting in IV sites remaining in place longer than recommended and without proper documentation or monitoring.
Expired medications and supplies were found in two medication rooms, including hemoccult cards, developer, and COVID-19 test kits. A Schedule IV controlled medication, Lorazepam, was stored in a refrigerator without being secured in a locked, affixed box, and staff were unaware of the lock box's status. The DNS was not aware of these issues, and facility policy for controlled substance storage was not followed.
A resident with a history of stroke and dementia received two doses of the Pfizer COVID-19 vaccine only nine days apart due to a failure in communication and documentation review by nursing staff. The nurse administering the second dose was unaware of the prior administration, as vaccine documentation was only entered in the EMR's vaccination section and not in progress notes, and information was relayed through shift reports.
A heavy accumulation of various debris, including furniture and equipment, was observed alongside the dumpsters, with staff confirming the items had been left for over a week and the area was not kept clean. The responsible staff delayed arranging for removal and was unfamiliar with the facility's policy requiring regular inspection and maintenance of disposal areas.
State survey results were not accessible to residents on the secured unit, as confirmed by resident interviews and facility observations. While the latest survey results were available in the lobby, the secured unit only had outdated information, and staff were unsure about the location or requirement for survey postings on each floor.
Medication storage rooms were found unclean and poorly maintained, with dirty floors, expired hemoccult supplies, broken tiles, and a soiled sink. An LPN and the Director of Facilities Housekeeping confirmed that cleaning and maintenance responsibilities were not consistently fulfilled, and required issues were not documented or reported as per facility policy.
A resident with severe cognitive impairment and mobility deficits was not provided adequate assistance during a bed linen change, resulting in the resident rolling out of bed and sustaining a left femur fracture. The resident was dependent on staff for bed mobility and had side rails in use as enablers. During the linen change, a nurse aide released their hold on the resident to secure the sheets, at which point the resident rolled off the bed despite the side rails being up. The resident was later found to have an acute hip fracture and was transferred to the hospital.
A resident with Alzheimer's disease and severe anxiety, known for frequent wandering and agitation, was not adequately supervised or redirected, leading to an incident where the resident entered another resident's room and engaged in inappropriate sexual contact. Staff and clinical notes documented the resident's behaviors, but interventions were insufficient to prevent the event, resulting in a failure to protect residents from abuse.
A resident with significant mobility impairments and high risk for pressure injuries did not have a comprehensive care plan developed or implemented to prevent skin breakdown upon admission. Documentation shows that interventions were only formally established after the resident developed a heel blister, which progressed to a deep tissue injury, despite facility policy requiring early care planning for high-risk individuals.
A resident with Alzheimer's and anxiety was repeatedly observed by staff wandering into other residents' rooms, displaying agitation and anxiety, and at times could not be redirected. Despite multiple nursing notes and staff awareness of these behaviors, the care plan was not updated to address the specific issue of wandering into others' rooms until after an incident involving inappropriate contact occurred. The DON was unaware of the extent of the wandering prior to this event, and the care plan did not reflect the resident's actual behaviors as required.
Failure to Follow Transfer Orders and Secure Memory Care Unit
Penalty
Summary
A deficiency occurred when a resident with a history of transient cerebral ischemic attack, morbid obesity, and difficulty walking was not transferred according to physician orders. The resident was assessed as moderately cognitively impaired, non-ambulatory, and required the use of a mechanical lift (Sarita) with the assistance of two staff members for transfers. However, the nurse aide care card contained conflicting instructions, and a nurse aide attempted to transfer the resident alone without the mechanical lift. During the transfer, the resident's legs buckled, resulting in a fall and subsequent fractures to the right ankle, confirmed by x-ray. The nurse aide reported confusion regarding the care card instructions and did not seek clarification before proceeding with the transfer. Additionally, the facility failed to ensure that all appropriate doors were secured on the locked memory care unit. Observations revealed that the shower room contained potentially hazardous items and was not secured, the dentist office door was propped open, and the soiled utility room door with a keypad lock had been bypassed and was not locked. The soiled utility room contained bottles of cleaning solution, and staff were unaware that these doors were unsecured. The maintenance director demonstrated how the keypad could be bypassed and acknowledged the need for a more secure lock. Interviews with staff confirmed that the unsecured doors and access to hazardous materials were not in accordance with facility policy, which required all doors on the secured memory care unit to be locked for resident safety. The facility's policy for the memory care unit emphasized maintaining a secure environment to ensure the safety and well-being of residents, but this was not followed at the time of the survey.
Deficient Food Storage, Labeling, and Sanitation in Dietary and Nourishment Areas
Penalty
Summary
Surveyors identified multiple failures in the facility's dietary department and nourishment rooms regarding food storage, labeling, and sanitation. During a tour, numerous food items were found opened and not labeled or dated, including hot dog buns, French bread, French toast, donuts, egg noodles, honey, peas, elbow macaroni, rice, and pinto beans. Some items were also found to be expired, such as egg noodles and pinto beans, yet had not been discarded. Additionally, prepared foods in the walk-in refrigerator, such as meatloaf, cheese, tomato juice, soup, sliced beef with gravy, and egg noodles, were either undated, not labeled, or held beyond the recommended time frame for safe consumption. Further observations in the nourishment rooms on multiple floors revealed unsanitary conditions and improper food handling. The 2nd floor nourishment room had a soiled coffee maker, expired cereal, uncovered and undated food items, and a refrigerator with visible brownish drip marks. The 3rd floor nourishment room had an ice maker with a brown substance in the scoop container, debris behind the ice maker, opened and undated brown sugar, an unidentified foil-wrapped item, and a refrigerator with a tacky, brown substance. The 4th floor nourishment room also had an ice maker with heavy accumulation of brown and white substances, an ice scoop container with a brown substance, and opened, undated containers of mayo and salsa. Interviews with the Dietary Director revealed a lack of awareness regarding the facility's policy on labeling and dating opened food items and the process for discarding expired food. The director acknowledged that the nourishment room refrigerators, freezers, and ice makers required cleaning and that the dietary department was responsible for maintaining their cleanliness. However, rounds to check cleanliness were not conducted frequently enough to ensure compliance with facility policy and food safety standards.
Failure to Provide Timely Dental Services for Resident with Non-Restorable Teeth
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely dental services were provided to a resident with multiple non-restorable teeth. The resident, who had a history of stroke with partial paralysis, dementia, and depression, was identified as having poor dentition and expressed ongoing concerns about dental pain and the desire for dental repairs. Despite repeated assessments by dental staff and clear documentation of the need for dental intervention, including referrals for full mouth rehabilitation and later for removal of all remaining teeth and denture fabrication, there were significant delays in arranging the necessary dental appointments. The clinical record and interviews revealed that although referral letters and recommendations were uploaded into the electronic medical record (EMR) and communicated to nursing staff, the process for scheduling outside dental appointments was not effectively followed. The receptionist responsible for making appointments did not recall receiving earlier referrals and only scheduled appointments after significant delays. Missed transportation and a lack of follow-up further contributed to the postponement of dental care. Nursing staff and the Director of Nursing Services were unaware of the earlier referrals and did not document barriers or reasons for the delays in the EMR, as required by facility policy. Observations confirmed the resident continued to experience dental pain, had visible tooth fragments, and required modified meals due to the condition of their teeth. The resident expressed dissatisfaction with the facility's assistance in obtaining timely dental care and was unclear about when the necessary dental procedures would occur. The facility's policy required documentation of delays and assistance with transportation, but these steps were not consistently implemented, resulting in a prolonged period without appropriate dental intervention for the resident.
Failure to Ensure Proper PPE Use and Consistent Infection Control Documentation
Penalty
Summary
Nursing staff failed to consistently don the required Personal Protective Equipment (PPE) when entering rooms under transmission-based precautions for droplet/contact isolation, as observed in multiple instances involving residents with COVID-19 or other infectious conditions. In several cases, staff entered rooms with posted signage indicating the need for gown, N95 mask, eye protection, and gloves, but were observed wearing only a surgical mask or missing other required PPE. Staff interviews confirmed awareness of the PPE requirements but cited reasons such as being in a rush or lack of available equipment for non-compliance. Documentation related to infection control precautions was also found to be inconsistent. For one resident who tested positive for COVID-19, nursing notes alternated between documenting transmission-based precautions and enhanced barrier precautions across different shifts and days, despite a physician's order specifying the type and duration of isolation. This inconsistency in documentation could lead to confusion among staff regarding the appropriate level of precautions to implement. Additionally, there were instances where staff failed to ensure PPE was readily available outside isolation rooms, particularly eye protection, resulting in staff entering rooms without full PPE. Interviews with the Infection Preventionist and Director of Nursing confirmed that facility policy required full PPE for all staff entering rooms under transmission-based precautions, regardless of which resident was being attended to. The facility's own policies and posted signage were not consistently followed, leading to lapses in infection prevention and control practices.
Failure to Obtain Comprehensive Wound Care Orders Upon Admission
Penalty
Summary
The facility failed to obtain and document comprehensive wound treatment and dressing change orders upon admission for a resident with significant skin conditions, including a surgical wound and a venous stasis ulcer. The resident was admitted with chronic venous hypertension, cellulitis of the lower limbs, and a left foot abscess that had undergone surgical debridement. Hospital discharge records indicated the need for daily dressing changes and specific topical treatments, but did not provide clear or complete instructions for all affected areas. Upon admission, the nursing assessment and skin assessment identified multiple wounds, but the physician's orders only addressed topical application of Sodium Hypochlorite to foot ulcers, omitting detailed wound care and dressing instructions for the bilateral lower extremities and the surgical site. Nursing documentation showed that the resident required assistance with activities of daily living and had visible dressings on both lower extremities, with evidence of drainage on the left side. Despite this, the Treatment Administration Record and care plan interventions referenced wound care in general terms without specifying the type, frequency, or method of dressing changes for each wound. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing Services, confirmed that wound treatment orders were incomplete and that nursing staff had been applying dressings without proper physician orders since admission. Staff acknowledged that the hospital discharge instructions were unclear and that clarification should have been sought immediately upon admission. Further review revealed that the admitting nurse did not clarify or obtain the necessary wound care orders, and subsequent provider notes also failed to specify comprehensive wound care directives. The lack of clear, site-specific, and physician-authorized wound treatment orders resulted in nursing staff performing dressing changes without appropriate guidance. This deficiency was identified through observation, record review, and staff interviews, all of which confirmed that the required wound care orders were not in place at the time of admission.
Failure to Accurately Reflect Code Status in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan accurately reflected a resident's code status. A resident admitted with chronic obstructive pulmonary disease, diabetes, and a history of falls was identified in the social service assessment as a full code, but the signed advanced directive consent form indicated the resident's wishes were for Do Not Resuscitate (DNR). Despite this, the care plan listed the resident as a full code, and there were no physician orders on admission specifying the code status. The admission Minimum Data Set (MDS) assessment documented that the resident was moderately cognitively impaired and required varying levels of assistance with daily activities. During an interview and review of the care plan, it was confirmed that the care plan was incorrect and should have reflected the resident's DNR status. Facility policy required that code status be documented in writing after consent and that a physician's order be obtained, but these steps were not completed at the time of admission, resulting in the care plan not matching the resident's documented wishes.
Failure to Monitor Orthostatic Blood Pressures Due to Transcription Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure that orthostatic blood pressures were monitored daily as ordered by the physician for a resident with a history of orthostatic hypotension and repeated falls. The resident, who was cognitively intact and required some assistance with transfers and toileting, had a care plan that included monitoring for signs and symptoms of orthostatic hypotension. Despite a physician's order for daily orthostatic blood pressures, the order was not transcribed onto the Medication Administration Record (MAR) or Treatment Administration Record (TAR), and as a result, the blood pressures were not taken or documented. Interviews with nursing staff and review of the clinical record revealed that the order was incorrectly entered into the electronic health record (EHR) and was not carried over to the MAR or TAR. This transcription error was not identified during routine order audits, and nursing staff were unaware of the order or its requirements. The facility's policy required accurate transcription and verification of orders, but this process was not followed, leading to the omission of the required monitoring for the resident.
Failure to Ensure Proper Physician Orders and Maintenance for Peripheral IV Administration
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for two residents by not having proper physician orders in place for the maintenance and rotation of peripheral IV sites. For one resident with diagnoses including COVID-19, myocardial infarction, and hyponatremia, the clinical record showed that IV Ceftriaxone was started for a urinary tract infection. However, there was no corresponding physician order for the IV medication or for the required site maintenance, such as rotating the access site every 96 hours. The resident’s IV site dressing was observed to be 11 days old, and the site was not rotated or removed as per protocol, with the batch order set for IV maintenance not implemented until several days after IV initiation. Another resident, diagnosed with sepsis, a right femur fracture, and chronic obstructive pulmonary disease, was started on IV Ceftriaxone for cellulitis. Similarly, there was no physician order corresponding to the medication administration record, and the batch order set for IV site maintenance was not in place when the IV was started. The IV site was not discontinued within the recommended 96-hour period, and the facility did not provide a written policy for peripheral IV site maintenance when requested. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the required batch order set, which includes parameters for site rotation, flushing, and monitoring, was not implemented at the time of IV initiation for either resident. The DNS acknowledged that the oversight resulted in IV sites remaining in place longer than recommended and that appropriate orders were not obtained for each resident started on a peripheral IV.
Expired Medications and Improper Storage of Controlled Substances
Penalty
Summary
Surveyors identified that expired medications and supplies were not properly disposed of in two of three medication storage rooms. On the 4th floor, expired hemoccult cards and developer were found in a cabinet drawer, along with unopened tubes of Collagen Hydrogel and an indwelling catheter, some of which were expired. On the 3rd floor, an unopened box of Lorazepam, a Schedule IV controlled medication, was stored in a medication refrigerator without being secured in a locked, affixed box as required. The lock box present in the refrigerator was marked 'DO NOT USE,' and staff were unaware of the reason or unable to access it. The Director of Nursing Services (DNS) was not aware that the lock box was not being used for controlled medications or that it was marked as unusable. A review of the maintenance log did not show any entry regarding the lock box being broken. Additionally, expired COVID-19 test kits and a partially used gallon of distilled vinegar with a past use-by date were found in the 3rd floor medication room. The pharmacy consultant confirmed that non-medication items would not typically be reviewed during monthly inspections and could not confirm if the Lorazepam was present during the last inspection, as it was not noted in the summary report. Facility policy requires Schedule II-V medications to be kept in a separately locked, permanently affixed compartment, with a different access system from non-scheduled medications, which was not followed in this instance.
Improper COVID-19 Vaccine Administration Interval
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, dementia, and prior COVID-19 infection received two doses of the Pfizer COVID-19 2024-2025 vaccine only nine days apart, rather than the recommended interval. The resident was documented as cognitively intact and required varying levels of assistance for daily activities. The immunization report showed that the first dose was administered on 10/9/24 and the second on 10/18/24, both in the left deltoid, while the resident was in the facility. The registered nurse responsible for vaccine administration stated that her process included obtaining consent, providing the Vaccination Information Sheet, and documenting the vaccination in the electronic medical record (EMR). She was unaware that the resident had already received the vaccine earlier in the month and indicated that she would not have administered the second dose had she seen the prior documentation. The nurse also noted that vaccine administration was communicated during shift reports and only documented in the vaccination section of the EMR, not in progress notes. Facility policy required documentation of immunizations in the medical record, including specific details, but did not specify documentation in progress notes.
Improper Disposal and Accumulation of Debris in Dumpster Area
Penalty
Summary
Surveyors observed a significant accumulation of debris, including a discarded mattress, bedside tables, wheelchairs, a leg rest, large cloth garbage containers, a blanket, curtains, window blinds, and a piece of therapy equipment, alongside the dumpsters in the facility's designated disposal area. The Dietary Director acknowledged that the area was not well maintained or cleaned and clarified that the items originated from maintenance, not dietary services. The Maintenance Director confirmed that the debris had been present for over a week and admitted to delaying pickup until the pile became larger, also stating unfamiliarity with the facility's policy and recognizing that the area was not clean or tidy. Review of the facility's Environmental Management policy revealed that there was an established process and schedule for inspecting, maintaining, and cleaning grounds, including areas around dumpsters, to keep them free of debris.
Survey Results Not Accessible on Secured Unit
Penalty
Summary
The facility failed to ensure that state survey results were available and accessible to residents residing on the secured unit. During a resident council interview, five residents on the secured unit reported they were unaware of where to find the state survey results. Observations confirmed that while the most recent survey results from 2023 were available in the facility lobby, they were not present on the locked unit. An orange binder labeled 'State Survey' behind the nurse's desk on the secured unit was found to be dusty and only contained outdated results from 2019, missing the 2021 and 2023 re-certification surveys. Multiple staff interviews, including with the Administrator, Recreation Director, DON, and Scheduler, revealed uncertainty and lack of knowledge regarding the location and requirement for survey results on each floor, with none able to confirm their presence on the secured unit.
Medication Room Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in two of three medication storage rooms, as observed during interviews and inspections. On the 4th floor, the medication room floor was found dirty with dried spilled liquids and debris, and expired hemoccult cards and developer were present in a cabinet drawer. The LPN interviewed stated that housekeeping was responsible for cleaning the medication room floor, but acknowledged that it was not cleaned frequently. The Director of Facilities Housekeeping confirmed that housekeeping staff were responsible for daily cleaning, including dusting, mopping, and cleaning fixtures in the medication rooms. On the 3rd floor, the medication room had a soiled tile floor with a build-up of dust and debris, and several tiles near the medication cart were broken, crumbling, and cracked. The sink and faucet had white build-up and the base of the sink was dirty with splashes of liquid and debris. The Director of Facilities Housekeeping was aware of the broken tiles and the condition of the sink but could not specify how long these issues had existed. The unit maintenance book did not show that these problems had been reported, and the LPN was unable to confirm when or if they had been reported. Facility policies required daily cleaning and maintenance of medication rooms and their fixtures, which was not followed.
Resident Fracture Due to Inadequate Assistance During Bed Linen Change
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, generalized muscle weakness, and difficulty walking was not provided adequate assistance during a bed linen change, resulting in the resident rolling out of bed and sustaining a left hip fracture. The resident was assessed as having severely impaired cognition, was non-ambulatory, always incontinent, and required maximal assistance with bed mobility and total care for activities of daily living. The care plan specified the use of two upper quarter side rails for bed mobility and directed total care with the assistance of one staff member for bed mobility and incontinent care. On the night of the incident, a nurse aide was performing a bed change with the resident lying on their right side, gripping the side rails. The bed was in a high position, and the aide was standing on the left side of the bed. While tucking in the clean sheets, the aide released their hold on the resident's waist to secure the sheets, at which point the resident rolled out of bed onto the floor. Both upper quarter side rails were up, and the resident had their hands on them, but the aide believed the resident could grip the rails. The aide reported that the resident's left leg's weight contributed to the fall when the sheets were pulled. Following the fall, the resident initially showed no signs of injury or pain, but later began to complain of left hip pain and exhibited guarding of the hip and pelvic area. An x-ray revealed an acute fracture of the left femur with mild displacement, and the resident was subsequently transferred to the hospital for evaluation. The incident was documented as unwitnessed by some staff, but the nurse aide involved reported witnessing the fall during care.
Failure to Supervise Wandering Resident Results in Sexual Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise a resident with known wandering behaviors, resulting in an incident of sexual abuse involving another resident. The resident with Alzheimer's disease and generalized anxiety disorder exhibited ongoing agitation, anxiety, and frequent wandering into other residents' rooms, as documented in multiple clinical notes and staff interviews. Despite these behaviors being well-documented, the resident was not consistently redirected or supervised to prevent entry into other residents' rooms. The care plan for the resident identified interventions such as redirection and removal from overstimulating environments, but staff notes repeatedly described the resident as being unable to be redirected at times and requiring frequent intervention. On the day of the incident, staff observed the resident pacing the hallways and entering other residents' rooms. At one point, the resident was not visible in the hallway, prompting a staff member to search for them. The resident was found in another resident's room, engaging in inappropriate sexual contact with a resident who was dependent for activities of daily living and had severely impaired cognition. Interviews with staff confirmed that the resident's wandering and entry into other rooms were known behaviors, and that frequent redirection was required. The Director of Nursing stated she was unaware of the extent of the wandering behavior prior to the incident and that no care plan was in place specifically addressing this risk. The facility's policy required prevention of harm from resident-to-resident contact, but the lack of supervision and specific interventions for the wandering resident led to the incident of sexual abuse.
Failure to Develop and Implement Pressure Injury Prevention Care Plan for High-Risk Resident
Penalty
Summary
A resident with multiple sclerosis, Guillain-Barre syndrome, and generalized muscle weakness was identified as being at high risk for developing pressure injuries upon admission, as documented in the nursing assessment and Braden Scale. Despite this high-risk status, there was no evidence that a comprehensive care plan with specific interventions to prevent skin breakdown was developed and implemented at the time of admission. The care plan addressing the risk for pressure injuries was not created until after the resident developed a blister on the left heel, which was later assessed as a deep tissue injury. Facility documentation and interviews confirmed that while standard practices such as offloading heels and turning every two hours were reportedly in place, there was no documentation to support that a comprehensive care plan had been developed or implemented prior to the identification of the pressure injury. The facility's policy requires the interdisciplinary team to create a person-centered care plan addressing high-risk factors upon admission, but this was not done for the resident until after the injury occurred.
Failure to Revise Care Plan for Resident Wandering and Behavioral Issues
Penalty
Summary
The facility failed to review and revise the care plan for a resident with Alzheimer's disease and generalized anxiety disorder who was repeatedly observed wandering into other residents' rooms. Multiple nursing notes documented the resident's behaviors, including pacing, agitation, anxiety, and entering other residents' rooms, with some instances where the resident could not be redirected and required multiple interventions, including PRN medication and 1:1 observation. Staff interviews confirmed that the resident's baseline behaviors included frequent pacing and wandering into other rooms, requiring frequent redirection. Despite these ongoing behaviors, the resident's care plan did not address the specific issue of wandering into other residents' rooms until after a significant incident occurred, where the resident was found in another resident's room engaging in inappropriate physical contact. The Director of Nursing was unaware of the extent of the resident's wandering behaviors prior to this incident, and the care plan was not updated to reflect these behaviors as required by facility policy. The deficiency was identified due to the lack of timely care plan review and revision in response to the resident's documented behaviors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
