Whispering Pines Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in East Haven, Connecticut.
- Location
- 38 Talmadge Avenue, East Haven, Connecticut 06512
- CMS Provider Number
- 075294
- Inspections on file
- 26
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Whispering Pines Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A dependent resident with hemiplegia, aphasia, and severely impaired cognition, who required staff assistance for bed mobility and transfers, was found by an LPN with multiple unexplained injuries, including a lip laceration, forehead abrasion with swelling, and bruising to the right hand and wrist. Earlier in the shift, the NA assigned to the resident had been upset, stated she should not be working, and left early. Another NA later found the resident incontinent of stool with stool on the floor and confirmed the resident required two-person assistance for care. The DON reported the resident could not get up independently and there were no wandering or aggressive residents on the unit. In a subsequent interview, the resident, using limited verbal communication and gestures, indicated that the NA had struck him, while also acknowledging a fall but without details, leaving the injuries as an injury of unknown origin that met the facility’s criteria for potential abuse.
A resident with a seizure disorder received both 100 mg and 125 mg doses of Lamotrigine on two days due to a failure to discontinue the previous order when a new dosage was prescribed. The error occurred because the previous order was not properly discontinued in the MAR, resulting in the resident receiving an excessive dose.
A resident with a history of dementia, depression, and behavioral symptoms was not permitted to return to the facility after hospitalization, even though hospital psychiatric staff determined the resident was not a risk to self or others. The facility refused re-admission following repeated incidents of inappropriate touching, did not consult with the hospital, and lacked a specific emergency discharge policy.
A resident with severe cognitive impairment and osteoporosis developed a bruised and discolored right pinky finger and hand, which was first identified by staff during the night shift. The nurse supervisor assessed the injury but did not promptly notify the physician, becoming distracted by other duties. The injury was only reported to the provider several hours later after further assessment revealed swelling and abnormal positioning, leading to the discovery of a fracture and transfer to the emergency department.
A resident with severe cognitive impairment and mobility deficits, who required total assistance for transfers, was found with a significant bruise on the chest. Investigation determined the injury likely resulted from contact with the Hoyer lift bar during a transfer, indicating a failure to ensure the area was free from accident hazards and to provide adequate supervision to prevent accidents.
A resident with diabetes and mobility issues did not receive necessary podiatry services for nearly nine months, resulting in excessively long and uncomfortable toenails. Despite a physician's order for podiatry services as needed, the facility's staff failed to identify and address the issue during routine care and audits. The deficiency was discovered during a surveyor inquiry.
A resident with heart failure, hypertension, and COPD was not weighed for four consecutive days due to a broken scale, and the physician was not notified as required by the care plan. Despite the availability of another scale, the facility failed to adhere to the physician's order for daily weight monitoring, which was crucial for assessing the resident's nutritional status.
A facility failed to develop a comprehensive care plan for a resident with major depressive disorder and alcohol dependence, who exhibited behaviors such as agitation, cursing, sexual inappropriateness, and refusal of care. Despite these behaviors being documented in nurse's notes, the Resident Care Plan did not address these issues. Staff interviews revealed that the behaviors were discussed but not formally documented or planned for, leading to a deficiency in care.
Two residents experienced a decline in bowel and bladder function due to the facility's failure to assess and implement continence care. One resident, admitted with various diagnoses, was not assessed for continence and was not provided with preferred toileting options, leading to frequent incontinence. Another resident, with a history of urinary issues, was identified as a candidate for retraining but did not receive appropriate programs, resulting in frequent incontinence. Staff interviews revealed a lack of communication and understanding of continence care policies.
The facility failed to monitor and address significant weight changes for two residents. One resident experienced a significant weight loss over two months without timely identification or intervention, while another was not weighed for four days due to a broken scale, despite physician orders. The facility's weight policy was not followed, and staff failed to utilize alternative weighing options.
A resident with COPD and other conditions was observed receiving oxygen at 3.0 LPM, contrary to the physician's order of 2.0 LPM. An LPN, unfamiliar with the unit, had not checked the oxygen settings, leading to a failure in following the facility's Oxygen Therapy policy.
A facility failed to monitor and document targeted behaviors for a resident receiving psychotropic medications, as required by a physician's order. The resident, diagnosed with major depressive disorder and alcohol dependence, was not monitored for increased anxiety, yelling, or agitation due to an incorrect entry by a previous APRN. This lack of monitoring from November 2023 through May 2024 was confirmed by facility staff, resulting in a deficiency.
The facility failed to maintain proper temperature controls for medications in one of its medication rooms. The refrigerator used for storing medications such as lispro, Levemir, and lorazepam had recorded out-of-range temperatures on multiple occasions, with no corrective actions taken. The Infection Preventionist and an LPN were unable to explain the lack of rechecking or reporting of these temperatures, which violated the facility's Medication Storage policy.
The facility failed to ensure a clean environment in the laundry room's drying and folding areas. Observations revealed lint on fan blades blowing onto clean laundry and debris on dryer tops. Interviews indicated that laundry staff were responsible for cleaning, but no cleaning schedule or checklist was in place, contrary to the facility's policy.
A facility failed to refer a resident for a level II PASRR evaluation after a new diagnosis of schizoaffective disorder. Initially admitted with other diagnoses, the resident's care plan included psychotropic medications and mood disorders. Despite a progress note identifying the new psychiatric condition, no level II PASRR was conducted, as confirmed by a social worker.
Failure to Protect Dependent Resident From Possible Physical Abuse and Unexplained Injuries
Penalty
Summary
The deficiency involves the facility’s failure to protect a dependent resident from physical abuse and to ensure the resident remained free from injuries of unknown origin. The resident had hemiplegia and hemiparesis affecting the left side, aphasia, depression, and anxiety, with a BIMS score of 3 indicating severely impaired cognition. The care plan documented that the resident was dependent on staff for bed mobility and transfers and required assistance of one staff member for activities of daily living and transfers in and out of bed and chair. The resident was also identified as at risk for falls due to decreased functional mobility and hemiplegia/hemiparesis. On the evening in question, an LPN reported that the NA assigned to the resident approached him in an upset and erratic manner, stating she should not be working because it was her mother’s birthday, and then left the shift early. When the LPN entered the resident’s room to administer medications, he discovered the resident with multiple injuries, including a swollen right lip with a laceration, an abrasion and quarter-sized bump on the forehead, and bruises on the back of the right wrist and thumb area. The resident, who communicated primarily through yes/no responses due to aphasia, initially nodded no when asked if he had fallen or bumped his head and was unable to explain how the injuries occurred. The facility documented this as an injury of unknown origin. Subsequent interviews and observations further highlighted the unexplained nature of the injuries and the possibility of abuse. Another NA who came on after the first NA left reported that the resident was incontinent of stool, required assistance of two staff for personal care, and that stool was found on the floor near the bed when she later provided care and observed the injuries. The DON stated the resident would not have had the ability to get up independently and would likely require two staff to assist if a fall had occurred, and there were no residents on the unit who wandered or had a history of aggression. In a later interview, the resident, with a family member present, verbally identified that the NA who had left the shift early had struck him, and demonstrated this by forming a fist and touching his forehead, while also acknowledging a fall but without being able to provide details. The facility’s own abuse policy required that injuries of unknown origin be investigated as potential abuse when the source is not observed or cannot be explained, or when the injury is suspicious due to its extent, location, or number, conditions that were present in this case.
Medication Order Transcription Error Led to Overdose
Penalty
Summary
A deficiency occurred when a resident with a seizure disorder received incorrect dosages of Lamotrigine due to a failure in accurately transcribing medication orders. The resident had physician orders for Lamotrigine that required a dosage adjustment, with the previous 100 mg dose to be discontinued and a new 125 mg dose to be started. However, the previous order for 100 mg was not discontinued in the medication administration record, resulting in the resident receiving both the 100 mg and 125 mg doses on two consecutive days. This error was identified through clinical record review, facility documentation, and interviews with facility staff. The resident's care plan included interventions to medicate as ordered and monitor for effectiveness, and the facility's medication orders policy required discontinuation of previous entries when a dosage change occurred. Despite this, the transcription error led to the administration of an excessive dose of Lamotrigine. The facility did not have a specific medication order transcription policy, and the error was attributed to the failure to discontinue the previous order when entering the new one.
Failure to Re-Admit Hospitalized Resident After Psychiatric Clearance
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, despite the hospital psychiatric team determining the resident was not a risk to self or others. The resident, who had diagnoses including alcohol abuse with alcohol-induced Korsakoff's psychosis, depression, and dementia, had previously exhibited inappropriate behavioral symptoms, including inappropriately touching staff. After a second incident of inappropriate touching, the resident was placed on one-to-one observation and transferred to the emergency department for psychiatric evaluation. The hospital records indicated the facility required psychiatric clearance for the resident's return, and after clearance was provided, the facility refused to re-admit the resident. Interviews and documentation revealed that the facility informed the resident's conservator and the hospital that the resident would not be allowed to return, citing repeated behavioral incidents. The facility did not initiate a consultative process with the hospital and did not have a specific policy for emergency discharges. The facility's own policy stated that involuntary transfer or discharge is permitted when the health and safety of individuals in the facility is endangered, but there was no evidence of a formal process or documentation supporting the emergency discharge in this case.
Failure to Timely Notify Physician of Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to timely notify a physician of a resident's change in condition. The resident, who had Alzheimer's Disease, anxiety disorder, and osteoporosis, was found to have a bruise and discoloration on the right pinky finger and hand during the night shift. The nurse supervisor assessed the resident but did not immediately report the change to the physician, intending to review previous notes first. The nurse became distracted by a re-admission and routine duties, ultimately forgetting to notify the physician until the morning shift, when another nurse aide reported the injury again. Further assessment in the morning revealed swelling and abnormal positioning of the resident's right pinky finger, prompting immediate notification to the next nurse on duty, who then contacted the APRN. An x-ray confirmed a displaced fracture, and the resident was sent to the emergency department. Facility policy required prompt notification of the physician and responsible party for any significant change in condition or injury, which was not followed in this instance, as the injury was identified several hours before the physician was notified.
Failure to Prevent Injury During Hoyer Lift Transfer
Penalty
Summary
A resident with Alzheimer's disease and severe cognitive impairment, who was dependent on staff for activities of daily living including transfers, was found to have a large bruise on the left chest during morning care. The resident's care plan required the use of a Hoyer lift for transfers due to impaired mobility and cognition. Clinical documentation indicated that the bruise measured 6.5 cm in length and 10.5 cm in width, and an X-ray of the left ribs was negative for fracture. The bruise was determined to be of unknown origin at the time of discovery. Facility investigation revealed that the bruise aligned with the Hoyer lift bar, suggesting that the bar may have swung and struck the resident's chest during a transfer. Staff interviews conducted for the 24 hours prior to the incident did not identify any specific event or issue that could have caused the injury. The facility's policy required safe handling and transfers to minimize risk of injury, but the incident indicated a failure to ensure the resident remained free from injury during a Hoyer lift transfer.
Failure to Provide Podiatry Services to Diabetic Resident
Penalty
Summary
The facility failed to provide necessary podiatry services to a long-term resident with type II diabetes mellitus, muscle weakness, difficulty in walking, and repeated falls. The resident, who was admitted in August 2023, had a physician's order for podiatry services as needed. Despite this, observations in May 2024 revealed that the resident had excessively long toenails, which were uncomfortable and jagged, causing them to get caught on sheets. The resident reported that their toenails had not been cut since before their admission to the facility, nearly nine months prior, despite having complained to nursing assistants multiple times. Interviews and record reviews indicated that the facility's policy required diabetic residents to be seen by a podiatrist. However, there was no record of podiatry consent or services for the resident. Nursing staff, including an RN and an LPN, failed to identify the issue during weekly body audits, and the social worker, who was the podiatry liaison, was unaware of the resident's need for podiatry services. The deficiency was identified when surveyors inquired about the resident's toenail care, leading to the discovery of the oversight.
Failure to Notify Physician of Missed Weights
Penalty
Summary
The facility failed to notify the physician when weights were not obtained for a resident as per the physician's order. Resident #62, who had diagnoses including heart failure, hypertension, and COPD, was identified as being at risk for nutritional deficit. The care plan required monitoring of weights and notifying the physician of any significant weight changes. A physician's order specified that the resident should be weighed every night shift, with notification to the physician if there was an increase of 2-3 pounds per day or 5 pounds per week. However, the clinical record revealed that Resident #62 was not weighed for four consecutive days due to a broken scale, and there was no documentation indicating that the physician was informed of this lapse. Interviews with RN #6 and an Advanced Practice Registered Nurse confirmed that the physician was not notified, despite the availability of another scale in the facility. This oversight was contrary to the facility's policy, which emphasized the importance of regular weight monitoring as an indicator of the resident's nutritional status and medical condition.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #67, who was diagnosed with major depressive disorder and alcohol dependence. The resident exhibited behaviors such as agitation, cursing, sexual inappropriateness, and refusal of care, which were documented in nurse's notes over several months. Despite these documented behaviors, the Resident Care Plan (RCP) did not include a plan addressing these issues. Interviews with staff, including an LPN and the Director of Nursing Services (DNS), revealed that although the behaviors were discussed in morning reports, there was no formal documentation or care plan in place to address the resident's noncompliance and behaviors. The facility's Comprehensive Care Plan policy requires documentation of refusals and behaviors in the resident's clinical records, which was not adhered to in this case. The DNS acknowledged awareness of the resident's behaviors but was unaware that a care plan had not been developed. The MDS nurse, responsible for the noncompliance care plan, also did not ensure that a care plan was created. This lack of documentation and formal planning led to the deficiency in addressing Resident #67's needs and behaviors effectively.
Failure to Implement Bowel and Bladder Continence Care
Penalty
Summary
The facility failed to assess and implement a plan for bowel and bladder continence for two residents. Resident #53 was admitted with diagnoses including fall, aspiration pneumonia, and acute kidney injury. Despite being cognitively intact and using a walker, the nursing admission assessment did not address bowel and bladder continence. The resident was incontinent of bladder and bowel multiple times and expressed a preference for using a toilet, which was not accommodated. The DNS acknowledged the lack of a bowel and bladder assessment and the oversight during the facility's weekly Standards of Care meeting. Resident #67, with a history of urinary tract infections and urogenital implants, was frequently incontinent of urine and bowel. Despite being identified as a candidate for retraining and toileting schedules, no such programs were implemented. The resident experienced incontinence due to delayed assistance and was unaware of the urge to use the bathroom. Interviews with staff revealed a lack of communication and understanding of the facility's bowel and bladder retraining policies, with no clear process for initiating or documenting toileting programs. The facility's policies directed the completion of bowel and bladder assessments and retraining programs, but these were not followed. The DNS and staff interviews highlighted a lack of documentation, communication, and follow-up on residents' bowel and bladder functioning. The facility's failure to implement appropriate continence care and retraining programs contributed to the residents' decline in bowel and bladder function.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to ensure timely identification and response to significant weight changes for two residents. Resident #14, who was admitted with diagnoses including dementia, congestive heart failure, and diabetes, experienced a significant weight loss of 23.2 pounds over two months. Despite physician orders for daily weights, there were no recorded weights from December 21, 2023, to February 16, 2024. The dietician, responsible for monitoring weight changes, was unavailable for part of this period and was not informed by staff about the weight loss. It was only on her third visit, 24 days after the weight loss, that the dietician recognized the issue. Resident #62, with diagnoses including heart failure and COPD, was not weighed for four consecutive days due to a broken scale, despite physician orders to weigh the resident nightly and report any significant weight changes. The facility's weight policy requires re-weighing within 24 hours for any weight gain or loss of 5 pounds or more. However, the resident was not weighed during this period, and RN #6 could not provide an explanation, although alternative weighing options were available.
Failure to Follow Physician's Oxygen Order
Penalty
Summary
The facility failed to follow the physician's order for oxygen administration for a resident diagnosed with pneumonia, chronic obstructive pulmonary disease (COPD), anxiety disorder, and dementia. The resident was severely cognitively impaired and dependent on staff for various activities of daily living. Observations on two separate occasions revealed that the resident was receiving oxygen at a rate of 3.0 liters per minute (LPM) via nasal cannula, despite the physician's order specifying 2.0 LPM. This discrepancy was noted during an observation on 5/10/24 and again on 5/13/24. An interview with an LPN revealed that she was unaware of the mismatch between the oxygen concentrator settings and the physician's order, as she did not typically work on the resident's unit and had not yet checked the oxygen settings during her shift. The facility's Oxygen Therapy policy requires that oxygen administration follow a physician's order and that the flow meter be set to the prescribed rate, which was not adhered to in this case.
Failure to Monitor and Document Targeted Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor and document targeted behaviors for a resident receiving psychotropic medications, as per the physician's order. The resident, who was diagnosed with major depressive disorder and alcohol dependence, was cognitively intact and required assistance with personal hygiene and mobility. The care plan required monitoring and documentation of signs and symptoms of depression, but the facility did not comply with these requirements. A physician's order specifically directed monitoring for increased anxiety, yelling, agitation, or unusual behaviors, but the Medication Administration Record and Treatment Administration Record from December 2023 through May 2024 did not include documentation of such monitoring. Interviews with facility staff revealed that behavior monitoring was not conducted due to an incorrect entry by a previous APRN. The RN responsible for the resident's care was unable to locate behavior monitoring documentation in the clinical record, and the ADNS confirmed that the orders for behavior monitoring had been incorrectly entered, leading to a lack of monitoring from November 2023 through May 2024. The facility's policy on psychotropic medications required behavioral monitoring to record specified target behaviors, but this was not adhered to, resulting in a deficiency.
Improper Temperature Control for Medication Storage
Penalty
Summary
The facility failed to maintain proper temperature controls for drugs and biologicals in one of the two medication rooms reviewed. During an observation and interview with the Infection Preventionist, it was identified that the Windsor Court medication refrigerator had recorded out-of-range temperatures on 13 out of 16 days in May 2024, with temperatures ranging from 49 F to 60 F, and on 3 out of 30 days in April 2024, with temperatures between 47 F and 54 F. The medications stored in this refrigerator included carboxymethyl cellulose sodium, lispro, Levemir, Trulicity, Aranesp syringes, and lorazepam oral concentrate. The Infection Preventionist was unable to explain why the temperatures were not rechecked or how long the medications had been exposed to these unacceptable temperatures. An interview with an LPN revealed that the responsibility for checking the refrigerator temperature fell to the 11:00 PM to 7:00 AM nurse, who should report any out-of-range temperatures to maintenance. The facility's Medication Storage policy, aligned with the United States Pharmacopeia and the Centers for Disease Control, mandates that refrigerated medications be kept between 35 F to 46 F. However, the facility did not adhere to this policy, leading to the deficiency in maintaining proper storage conditions for medications.
Failure to Maintain Clean Laundry Environment
Penalty
Summary
The facility failed to maintain a clean environment in the laundry room's drying and folding areas. During an observation with the Infection Preventionist, a moderate coating of white/gray debris, identified as lint, was found on the protective covering over the blades of two wall-mounted fans. These fans were blowing directly onto clean, uncovered laundry on the clean linen cart. Additionally, a moderate amount of similar debris was observed on the tops of the dryers. Interviews with the Maintenance worker and the Laundry Attendant revealed that the dryer tops and fans required cleaning, and it was the responsibility of the laundry staff to clean them as needed. However, there was no cleaning schedule implemented for the fans. The Director of Environmental Services confirmed that the laundry staff were responsible for cleaning the laundry area but was unable to locate a cleaning schedule or a checklist for cleaning the fans or dryer tops. The facility's Laundry Service policy, dated 8/19/22, directed that the cleaning schedule must be posted and up to date.
Failure to Conduct PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated authority for a level II PASRR evaluation following a new psychiatric diagnosis. The resident, admitted in June 2020, had diagnoses including chronic obstructive pulmonary disease, anxiety, and lung neoplasm. Initially, a negative PASRR level I was recorded with no diagnosis of Alzheimer's dementia or mental illness. However, a progress note dated September 29, 2022, identified a new diagnosis of schizoaffective disorder. Despite this, the clinical record did not show that a PASRR level II was conducted. The resident's care plan noted the use of psychotropic medications and mood and behavior disorders, with interventions to assist in expressing feelings and de-escalation. During an interview, a social worker confirmed that the state agency should have been notified for a level II PASRR assessment following the new diagnosis.
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.
