Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wilton Meadows Health Care Center during CMS and state inspections, most recent first.
A resident with dementia and multiple care needs was subjected to verbal abuse by a NA during incontinent care, where the NA yelled and used profane language in response to the resident's incontinence. The incident was witnessed by another NA and reported to facility leadership. Facility documentation and staff interviews confirmed the occurrence of verbal abuse, representing a failure to ensure the resident was free from such treatment as required by facility policy.
A resident with severe cognitive impairment and behavioral issues became physically aggressive during personal care and later assaulted another resident, causing a nasal fracture. Despite staff awareness of escalating behaviors and a combative episode earlier in the day, no updates were made to the care plan or interventions, leading to a failure to protect a resident from abuse.
The facility failed to ensure nursing staff had completed required annual skill competencies, as identified through the facility assessment. A resident with a feeding tube had their tube dislodged, and an agency nurse reinserted it without documented competency. The facility's policy requires licensed nurses to perform G-tube replacements and document the procedure, but this was not done. The DNS later found that the agency employing the nurse did not have documentation of the nurse's competency in feeding tube replacement.
The facility failed to conduct and document annual performance evaluations for its nurse aides, as required by policy. A review of personnel files for several nurse aides showed no evaluations for 2023 or 2024. Interviews with the DNS and Payroll Manager confirmed the absence of these evaluations, indicating a systemic issue in maintaining and storing performance records.
The facility failed to manage chemical sanitizing solutions properly, using expired test strips and not maintaining recommended concentration levels. Additionally, nourishment refrigerators lacked proper temperature logging and labeling, with many food items unlabeled and temperature logs incomplete. Staff interviews revealed confusion about responsibilities for maintaining and logging refrigerator temperatures and labeling food items.
The facility failed to have a qualified infection preventionist (IP) after the previous IP left. A new RN was hired but had not completed the necessary IP certification. The DNS and ADNS were also not certified, and the DNS assumed the new RN was qualified. The facility's job description requires specific qualifications for the IP role.
The facility failed to notify physicians and resident representatives of new wounds and medication unavailability for three residents. One resident developed a heel ulcer, another missed glaucoma medications and had an unreported cardiac device, and a third had new wounds without proper notification. The facility's policies required immediate notification, which was not followed.
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving resident-to-resident altercations and neglect of wound care. A resident with a history of aggression was involved in altercations with two other residents, leading to physical confrontations and threats. Additionally, another resident experienced neglect when staff failed to perform daily dressing changes on a pressure ulcer for four consecutive days, resulting in worsened wound conditions.
A resident with dementia, acid reflux, and diabetes was transferred to the hospital due to abnormal labs and refusal of IV insertion. The facility failed to provide specific lab results, leading to multiple calls from the hospital for clarification. The charge nurse did not document or send the necessary information, and the DNS confirmed the inadequacy of the discharge paperwork.
A facility failed to complete a baseline care plan for a resident with an implanted cardiac defibrillator upon admission. The resident, admitted with cardiomyopathy and ventricular tachycardia, had a defibrillator monitor in use, but the care plan was left blank. The charge nurse or supervisor was responsible for starting the care plan, and the MDS coordinator was to complete it, but this was not done. No facility policy for baseline care plans was provided.
Two residents in the facility did not receive scheduled showers due to staff shortages and lack of documentation. One resident, with heart failure and anxiety disorder, was not given showers on scheduled days, and staff cited being short-staffed. Another resident, with severe morbid obesity and COPD, also missed scheduled showers, with staff claiming they were too busy with other residents requiring Hoyer lifts. Facility staff were unaware of these issues, and documentation and reporting policies were not followed.
The facility failed to provide appropriate care and documentation for several residents, including not walking a resident as ordered, not obtaining daily weights for a resident with CHF, failing to restart Eliquis for a resident post-procedure, and not administering glaucoma medications due to unavailability. Additionally, an implanted cardiac defibrillator was not documented or communicated to the necessary medical professionals.
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their care. One resident did not receive weekly skin audits, and a new skin issue was not assessed or reported in a timely manner. Another resident was at high risk for pressure ulcers, yet the facility failed to complete weekly body audits and Braden scales, and a new pressure ulcer was not assessed by an RN for 16 days. A third resident did not receive an initial skin assessment upon admission or readmission, and weekly body audits and Braden scales were not completed as ordered.
A resident experienced significant weight loss due to the facility's failure to monitor and document weights as ordered by the physician. The dietitian was unaware of the weight loss due to a lack of communication from nursing staff, and no dietary interventions were implemented. The facility's policies on weight monitoring and physician notification were not followed, leading to unaddressed nutritional risks.
The facility failed to ensure pharmacy recommendations were addressed for two residents. One resident was at risk for adverse effects from medications, and recommendations to reevaluate these were not acknowledged. Another resident was on Seroquel without a gradual dose reduction trial, and recommendations for this were not addressed. The facility's policy requires physician action on pharmacy recommendations, but this was not documented, leading to a deficiency.
The facility failed to conduct required environmental rounds, leading to lapses in infection control. A resident with a pressure ulcer received improper wound care, with supplies placed on the bed and inadequate hand hygiene by an LPN. Another resident on contact precautions for C. Diff was not properly managed, as an agency nurse did not use the required PPE. Additionally, the resident nourishment area was unsanitary, with personal items and moldy food present.
A resident under palliative care was administered morphine at ten times the prescribed dose due to nurses failing to verify the medication concentration. The error occurred on three occasions, leading to the resident's hospitalization. The facility's failure to follow the five rights of medication administration resulted in Immediate Jeopardy.
A resident under palliative care received morphine at ten times the prescribed dose due to nurses failing to verify the medication concentration. The resident, with serious health conditions, was supposed to receive 5 mg of morphine but was given 50 mg on three occasions. The error was discovered during a narcotics count, and the resident experienced adverse effects, leading to hospitalization. The facility's failure to follow medication administration protocols resulted in Immediate Jeopardy.
A resident admitted for palliative care received a morphine dose ten times higher than prescribed on three occasions. The error was identified by an RN, but the physician was not notified until three hours later, contrary to facility policy requiring prompt notification. Interviews with the Medical Director and DON confirmed that immediate notification was expected.
A resident in palliative care received incorrect doses of morphine, prompting a physician's order for vital signs to be monitored every two hours. However, the facility failed to consistently document these vital signs, as confirmed by interviews with staff and a review of the clinical record. The facility's policy requires accurate medical records, which was not maintained in this case.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with diagnoses including dementia, depression, anxiety, dysphagia, difficulty walking, and generalized muscle weakness required complete assistance with activities of daily living (ADLs) and was incontinent of bowel and bladder. During the 11 P.M. to 7 A.M. shift, a nursing assistant (NA) was witnessed by another NA yelling and swearing at the resident while providing incontinent care. The NA directed derogatory and profane language at the resident, specifically calling the resident 'f***ing nasty' due to incontinence of stool. The incident was reported by the witnessing NA to the Director of Human Resources, and the resident was noted to have reported that a staff member was very mean to them. Facility documentation, including a reportable event form and nurse's notes, confirmed the occurrence of verbal abuse. Interviews with facility leadership and staff corroborated that the NA engaged in verbally abusive behavior towards the resident during care. The facility's abuse prevention policy states that residents have the right to be free from all forms of abuse, including verbal abuse, and the incident constituted a failure to protect the resident from such abuse as required by policy.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment, dementia, depression, and anxiety required moderate assistance with transfers and supervision with ambulation. The resident's care plan included monitoring for behavioral disturbances and the use of antipsychotic medication, with interventions to observe mood, behavior, and interactions. Another resident, also with severe cognitive impairment and behavioral issues such as restlessness, agitation, and anxiety, had a history of rejection of care and required moderate assistance with transfers. This second resident had ongoing behavioral concerns, including aggression and restlessness, which were documented in clinical notes and addressed with psychotropic medication adjustments. On the day of the incident, the second resident became combative during personal care in the morning, striking out at a nurse aide, but there was no update to the care plan or additional interventions implemented following this event. Later that day, the same resident was witnessed leaving the first resident's room, after which the first resident was found on the floor with a facial abrasion and minor nasal bleeding. The first resident reported being punched in the face and pushed to the floor by the second resident, resulting in a nasal fracture confirmed by X-ray. The incident was unwitnessed, but staff responded immediately upon hearing calls for help. Interviews with staff revealed that the behavioral escalation and aggression of the second resident were known prior to the incident, and that the combative episode earlier in the day was reported to nursing staff but not escalated or addressed in the care plan. The facility's abuse prevention policy requires protection of residents from abuse by anyone, including other residents. The failure to update the care plan or implement further interventions after the morning aggression contributed to the subsequent resident-to-resident abuse resulting in injury.
Failure to Ensure Nursing Staff Competency in Feeding Tube Replacement
Penalty
Summary
The facility failed to ensure that nursing staff had completed the required annual skill competencies as identified through the facility assessment. The review of the Competency Book 2023 revealed that only a portion of the nursing staff had completed hand hygiene and medication administration competencies. The Staff Development Nurse, who began her role in March 2024, acknowledged that the annual in-service conducted in July 2024 did not include skill competencies. The Director of Nursing Services (DNS), who had been at the facility for seven weeks, was unaware that the annual skill competencies for licensed nurses and nurse aides had not been evaluated in 2023. In the case of Resident #77, who was admitted with diagnoses including tracheostomy and gastrostomy status, the facility failed to ensure that an agency nurse had the required competencies to replace a feeding tube. On a specific date, the resident's feeding tube was found dislodged, and an agency nurse reinserted it without documented evidence of competency in the procedure. The DNS later discovered that the agency employing the nurse did not have documentation of the nurse's education or competency in feeding tube replacement. The facility's policy requires that a licensed nurse perform G-tube replacements and document the procedure's time, date, and condition of the treatment area. However, the nurse's notes failed to include this documentation. The DNS indicated that in the future, all agency nurses and nurse aides must arrive with a competency checklist before starting their shift, highlighting a gap in ensuring agency staff's competencies were verified before performing critical procedures.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for certified nurse aides, as required by their policy. The review of personnel files for five nurse aides revealed that none had documented performance evaluations for the years 2023 or 2024. This included nurse aides hired as early as 2004 and as recently as 2023. Interviews with the Payroll Manager and the Director of Nursing Services (DNS) confirmed the absence of these evaluations, with both unable to locate any relevant documentation. The DNS, who had been in the position for seven weeks, noted that she expected these evaluations to be completed annually and stored appropriately. The facility's policy mandates a standardized process for annual evaluations to ensure employee performance aligns with facility goals and regulatory requirements. However, the lack of documentation indicates a failure to adhere to this policy. Interviews with staff, including a nurse aide who could not recall her last evaluation, further highlighted this deficiency. The DNS and Payroll Manager's inability to find records suggests a systemic issue in maintaining and storing performance evaluations, which are supposed to be kept in personnel files and retained by both the DNS and Human Resources.
Deficiencies in Kitchen Sanitation and Refrigerator Management
Penalty
Summary
The facility failed to ensure proper management and testing of chemical sanitizing solutions in the kitchen, leading to deficiencies in maintaining sanitation standards. During a kitchen tour, it was observed that the test strips used to check the chemical sanitizing solution were expired, and the solution itself was not maintained at the recommended concentration levels. The Dietary Supervisor and Director were unaware of the correct sanitizing ranges for the solution being used, and there was no policy in place regarding the testing and changing of the chemical sanitizing solution. The facility had recently changed the chemical sanitizer provider, but the Dietary Director did not verify the expiration date of the test strips, leading to the use of expired strips. Additionally, the facility failed to maintain proper temperatures and labeling in the unit nourishment refrigerators. Observations revealed that the refrigerators lacked proper temperature logging, and many food items were not labeled with dates or resident information. The logs for the Deerfield unit showed numerous instances of missing temperature documentation, and the refrigerators contained unlabeled food items, including juices, milk, and other perishables. Interviews with staff indicated confusion about responsibilities for maintaining and logging refrigerator temperatures, as well as labeling food items. The facility's policies on food brought by family and preventing foodborne illness were not adhered to, as evidenced by the lack of labeling and temperature control in the nourishment refrigerators. The DNS acknowledged the issues with the logs and labeling but was unable to identify who was responsible for cleaning the refrigerators. The facility's failure to maintain proper sanitation and food storage practices posed a risk of cross-contamination and foodborne illness, as the policies in place were not effectively implemented or followed.
Facility Lacks Qualified Infection Preventionist
Penalty
Summary
The facility failed to have a qualified infection preventionist (IP) in place, as required for their infection prevention and control program. The previous IP, RN #13, was no longer employed by the facility as of 8/5/24. Subsequently, RN #1 was hired on 9/3/24 to fill the IP role. However, RN #1 had not completed the necessary IP course, having only finished 92% of the coursework and not passing the post-test required for certification. An interview with the Director of Nursing Services (DNS) revealed that neither she nor the Assistant Director of Nursing Services (ADNS) were certified as IPs, and the DNS had assumed RN #1 was certified. The facility's infection control nurse job description requires a graduate of an accredited school of nursing, a bachelor's degree as a plus, current licensure as a registered nurse in Connecticut, and working knowledge of applicable regulations and standards.
Failure to Notify Physicians and Representatives of Resident Conditions
Penalty
Summary
The facility failed to notify the physician and resident representative when new open areas were identified for two residents reviewed for pressure ulcers. Resident #87, who was admitted with dementia and osteoporosis, developed a new wound on the right heel. Despite the nurse's aide informing LPN #7 of the wound, the physician and resident representative were not notified until two days later. The facility's policy required immediate notification, but LPN #7 only placed a note in the physician's book, which was not an acceptable practice. Resident #274 was admitted with cardiomyopathy, ventricular tachycardia, and glaucoma. The facility failed to notify the physician when two glaucoma medications were unavailable for several days. Additionally, the facility did not inform the physician about the resident's implanted cardiac defibrillator, which required a bedside monitor. The resident and their representative were upset about the lack of medication and the facility's refusal to use the resident's personal medication. The DNS indicated that the physician should have been notified immediately about the medication unavailability and the cardiac device. Resident #378, admitted with chronic kidney disease, edema, and gout, had new wounds identified during a wound follow-up. The facility failed to notify the RN supervisor or the resident representative about the new wounds. LPN #4 documented the wounds but did not assess them further or notify the appropriate parties. The facility's policy required direct notification for newly identified wounds, but the nurse only entered a request in the wound care communication book, which was insufficient.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving resident-to-resident altercations and neglect of wound care. Resident #24, who had a history of physical aggression, was involved in an altercation with Resident #19, where water was thrown, leading to a physical confrontation. Despite interventions in place to monitor and report aggressive behavior, the altercation occurred, and Resident #24 was not protected from potential harm. Additionally, Resident #24 was involved in another incident where they hit Resident #39 on the head and threatened them, indicating a failure to manage and prevent aggressive behavior effectively. Resident #39, who had intact cognition, reported being hit and threatened by Resident #24 after their wheelchairs became entangled. Despite being seen by psychiatric services and reporting feeling safe afterward, the incident highlights a lapse in the facility's ability to prevent resident-to-resident aggression. The facility's abuse policy emphasizes the right of residents to be free from abuse, yet these incidents demonstrate a failure to uphold this standard. Resident #87 experienced neglect when staff failed to perform daily dressing changes on a pressure ulcer for four consecutive days, despite documentation indicating the changes had been completed. The wound was found to have worsened, with an odor and increased slough, indicating a lack of proper wound care management. The facility's neglect of this resident's wound care needs resulted in physical harm, as defined by the facility's abuse policy, which mandates the provision of necessary goods and services to avoid harm and distress.
Inadequate Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to convey appropriate information when a resident was transferred to the hospital. The resident, admitted in June 2023 with dementia, acid reflux, and diabetes, was sent to the emergency room due to abnormal lab results and refusal of IV insertion. However, the facility's transfer form only mentioned 'abnormal labs' without specifying which labs were abnormal. The hospital had to contact the facility multiple times to obtain the lab results, which were not available in the resident's medical record. The facility's documentation did not include the specific abnormal lab results, and there was no record of a verbal report from the lab. Interviews with facility staff revealed that the charge nurse and supervisor were responsible for providing the hospital with the exact reason for the transfer. However, the nurse involved did not recall the specific abnormal labs and failed to document or send the necessary information with the transfer paperwork. The Director of Nursing Services (DNS) confirmed that the discharge paperwork was inadequate and that the hospital should not have had to repeatedly contact the facility for information. The facility was unable to provide a policy for hospital transfer documentation, further highlighting the deficiency in communication and documentation during the transfer process.
Failure to Complete Baseline Care Plan for Resident with Cardiac Defibrillator
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed upon admission for a resident with an implanted cardiac defibrillator. The resident was admitted with diagnoses including cardiomyopathy and ventricular tachycardia, and the hospital discharge summary noted the presence of the implanted cardiac defibrillator. However, the baseline care plan was left blank and did not include necessary interventions related to the defibrillator. Observations revealed that the resident had a defibrillator monitor plugged in and transmitting data, with the owner's manual placed in the nightstand. Despite this, the baseline care plan remained incomplete. Interviews indicated that the charge nurse or supervisor on the admission shift was responsible for initiating the care plan, while the MDS coordinator was to complete it the next business day. The DNS confirmed the care plan was blank and did not reflect the defibrillator, and no facility policy for baseline care plans was provided upon request.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to provide scheduled showers to two residents, leading to a deficiency in the care provided. Resident #30, admitted with diagnoses including heart failure and anxiety disorder, was supposed to receive showers on Tuesdays during the 7:00 AM - 3:00 PM shift. However, documentation from nurse aide flowsheets and nurse's notes from September and October 2024 showed no evidence that Resident #30 received showers on the scheduled days. The resident confirmed not having received a shower since admission, except for one refusal due to feeling unwell, and reported that staff cited being short-staffed as a reason for not providing showers. Similarly, Resident #100, with diagnoses including severe morbid obesity and chronic obstructive pulmonary disease, was scheduled for showers on Tuesdays and Fridays during the 3:00 PM - 11:00 PM shift. Documentation from nurse's notes and nurse aide flowsheets for August and September 2024 also failed to show that Resident #100 received showers on the scheduled days. The resident reported not having a shower since moving floors in October 2023 and mentioned that staff claimed they were too busy with other residents requiring Hoyer lifts. Interviews with facility staff, including the Administrator, RN, and DNS, revealed a lack of awareness regarding the residents not receiving showers. The DNS acknowledged that nurse aides should have reported and documented if showers were not given. The facility's policy requires documentation of showers and reporting refusals to supervisors, which was not adhered to in these cases.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for several residents. One resident, who had a physician's order to be walked daily, was not walked as required. Despite documentation indicating the resident was walked, interviews revealed that staff did not walk the resident due to fear of falls, and the resident expressed concern about losing the ability to walk. The facility's documentation did not reflect any refusals or reasons for not walking the resident, and the social worker did not document the resident's complaints. Another resident with congestive heart failure had a physician's order for daily weights, which were not consistently obtained or documented. The resident frequently refused to be weighed, but there was a lack of documentation regarding these refusals and no communication with the physician or APRN about the missed weights. The facility's documentation guidelines were not followed, and the DNS acknowledged the need for improvement in weight monitoring. Additionally, a resident who required Eliquis for atrial fibrillation did not have the medication restarted after a medical procedure, despite a consultation report indicating it should be resumed. The facility's staff did not communicate effectively with the APRN or MD regarding the need to restart the medication, and the resident missed several doses. Furthermore, a new admission with glaucoma did not receive prescribed eye drops due to unavailability, and the facility failed to document or notify the physician about the missed doses. The resident also had an implanted cardiac defibrillator that was not documented in the nursing admission assessment, and the facility did not notify the cardiologist or primary physician about the device.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their care. Resident #26 did not receive weekly skin audits as ordered by the physician, and a new skin issue was not assessed or reported in a timely manner. The Wound Specialist identified moisture-associated skin damage and a stage 2 pressure wound on the resident, but the facility's documentation and communication were lacking, as evidenced by the Wound Nurse and Nurse Supervisor being unaware of the resident's condition. Resident #87 was at high risk for pressure ulcers, yet the facility failed to complete weekly body audits and Braden scales as ordered. A new unstageable pressure ulcer on the resident's right heel was not assessed by an RN for 16 days, and treatment was delayed by two days. The dietitian was not notified of the new pressure ulcer until 15 days later, and daily treatments were not consistently documented or completed, as evidenced by the dressing being unchanged for five days. Resident #378 did not receive an initial skin assessment upon admission or readmission, and weekly body audits and Braden scales were not completed as ordered. The resident developed new stage 3 pressure ulcers, but there was a lack of timely assessment and intervention. The dietitian was not notified of the new pressure ulcers, and documentation of body audits was incomplete. The facility's communication and documentation processes were insufficient, leading to delays in care and treatment for the residents.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper nutritional monitoring and intervention for a resident who experienced significant weight loss. The resident, admitted with conditions including a spinal fracture and prostate cancer, was ordered by the physician to be weighed weekly for four weeks and then monthly. However, the resident's weight was not consistently recorded, and refusals to be weighed were not documented or communicated to the physician. The resident lost 19.8 lbs, or 7.2% of their body weight, over 20 days, but there was no documentation of physician notification or implementation of dietary interventions. The dietitian, who was responsible for tracking resident weights, was unaware of the resident's weight loss until an interview conducted during the survey. The dietitian worked part-time and manually reviewed weights twice a month, relying on nursing staff to notify her of significant changes. The facility had recently undergone administrative changes, resulting in the discontinuation of weekly at-risk meetings that previously addressed issues like weight loss. The Director of Nursing Services (DNS) confirmed that weights should be obtained as per physician orders and that any issues, such as refusals, should be documented and communicated to the physician and dietitian. Facility policies required that significant weight changes be reported to the physician and that care plans be updated accordingly. However, the clinical record lacked documentation of any communication regarding the resident's weight loss, and the communication book on the unit did not contain any relevant entries. The facility's failure to adhere to its policies and procedures resulted in the resident's significant weight loss going unaddressed, highlighting a breakdown in communication and documentation processes.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were responded to by the physician or APRN for two residents reviewed for unnecessary medications. Resident #28, who had diagnoses including chronic kidney disease, type 2 diabetes mellitus, and bipolar disorder, was identified in a Pharmacy Medication Regimen Monthly Review as being at risk for adverse effects from certain medications. Recommendations were made to reevaluate the use of these medications, but there were no signatures from the DNS or physician/APRN acknowledging the review of these recommendations. Additionally, a PRN order for an anxiolytic had been in place for more than 14 days without a stop date, and recommendations to reevaluate this order were not addressed in the physician or APRN progress notes. Resident #66, admitted with dementia and psychotic and mood disturbances, was receiving Seroquel without a gradual dose reduction trial since admission. The Pharmacy Medication Regimen Monthly Review recommended a gradual dose reduction, but this was not addressed by the APRN or MD. The ADNS confirmed that the recommendations had not been addressed, and there was no signed and dated copy of the review in the clinical record. The DNS indicated that the pharmacy recommendations are received via email, printed, and placed in specific books for review, but the APRN/MD had not completed the necessary actions within the expected timeframe. The facility's policy directs that the physician or prescriber should act upon the recommendations in the Medication Regimen Review, either accepting or rejecting them with an explanation. The policy also states that the medical director should be alerted if recommendations are not addressed in a timely manner. However, in these cases, the recommendations were not documented as reviewed or acted upon, leading to a deficiency in the facility's compliance with its own policies and procedures.
Infection Control Deficiencies in Environmental Rounds and Resident Care
Penalty
Summary
The facility failed to ensure that the infection preventionist conducted environmental rounds at least quarterly, as required by the facility policy. Interviews with RN #1 and LPN #19 revealed that environmental rounds were not documented for 2023 and 2024, and corrective action forms were missing for the rounds that were found. The Director of Nursing Services (DNS) confirmed the lack of documentation and indicated that environmental rounds had not been completed for September or October 2024 until the surveyor's inquiry prompted action. In the case of Resident #87, the facility did not adhere to proper infection control practices during wound care. The resident, who had a severely impaired cognition and an unstageable pressure ulcer, received wound care from LPN #14, who placed dressing supplies on the resident's bed and did not wash her hands before putting on gloves. LPN #14 also wore multiple layers of gloves, contrary to the facility's policy, and did not follow the clean dressing change procedure, which required washing hands before and after glove use and using a clean field for supplies. For Resident #374, the facility failed to maintain proper infection control techniques for a resident on contact precautions due to a C. Diff infection. LPN #3, an agency nurse, was unaware of the resident's contact precautions and did not don the required personal protective equipment (PPE) when entering the resident's room. The facility's policy required gloves and gowns for contact precautions, but LPN #3 only used gloves and hand sanitizer after exiting the room. The DNS acknowledged the oversight and noted that the facility did not provide infection control training to agency staff, assuming the agency handled it. Additionally, the resident nourishment area was found to be unsanitary, with personal items and moldy food present, which the DNS confirmed should not have been there.
Medication Administration Error Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that multiple nurses adhered to the five rights of medication administration, resulting in a significant medication error for a resident under palliative care. The resident, who was admitted with conditions including cirrhosis, heart failure, chronic kidney disease, and severe sepsis with septic shock, was prescribed morphine at a specific concentration. However, the nurses administered morphine at ten times the prescribed dose on three separate occasions. The error occurred because the nurses did not verify the concentration of the morphine solution before administration. The morphine retrieved from the Omnicell was at a concentration of 100 mg/5 ml, but the nurses administered it as if it were the prescribed 2 mg/1 ml concentration. This resulted in the resident receiving 50 mg of morphine per dose instead of the intended 5 mg. The error was identified after the resident exhibited symptoms such as low oxygen saturation, nausea, and vomiting, leading to hospitalization. Interviews with the involved staff revealed that the nurses failed to check the medication label properly, and the facility's Director of Nurses confirmed that the error was due to not following the five rights of medication administration. The Medical Director emphasized the importance of verifying medication labels to ensure correct dosing, highlighting a critical lapse in the facility's medication administration process.
Significant Medication Error with Morphine Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the administration of morphine at ten times the prescribed dose on three separate occasions. The resident, who was under palliative care with multiple serious health conditions, was supposed to receive a morphine solution of 2 mg/1 ml, with a total dose of 5 mg every four hours. However, due to a failure to check the concentration of the morphine solution, two nurses administered a much higher concentration of 100 mg/5 ml, resulting in a dose of 50 mg each time. The error occurred because the nurses did not verify the concentration of the morphine solution before administration. The first nurse, an LPN, reported not having the scheduled dose and received a bottle from the nursing supervisor, which she failed to check properly. She administered the incorrect concentration at 4:00 AM. The second nurse, an RN, also failed to verify the concentration and administered the incorrect dose at 8:00 AM and 12:00 PM. The error was discovered later when another LPN noticed the discrepancy during a narcotics count. The resident experienced adverse effects, including low oxygen saturation, nausea, and vomiting, and was eventually sent to the hospital. Interviews with the medical director and the director of nursing revealed that the nurses did not follow the facility's medication administration policy, which requires checking the medication label three times to ensure the correct dose is given. The facility's failure to adhere to these protocols resulted in a finding of Immediate Jeopardy.
Delayed Notification of Medication Error
Penalty
Summary
The facility failed to ensure timely reporting of a significant medication error involving a resident who was admitted for palliative care with diagnoses including cirrhosis, heart failure, chronic kidney disease, and severe sepsis with septic shock. The resident was ordered to receive morphine solution 2 mg per 1 ml, with a dose of 2.5 ml every 4 hours. However, on three separate occasions, the resident received 2.5 ml of a higher concentration morphine solution (100 mg/5 ml), resulting in a dose of 50 mg, which was ten times the ordered dose. The error was identified by RN #1 at approximately 4:00 PM, but the physician was not notified until 7:00 PM, three hours after the error was discovered. The facility's policy requires prompt notification of the physician in the event of a significant medication error. Interviews with the Medical Director and the Director of Nurses confirmed that immediate notification was expected. The delay in notifying the physician was attributed to RN #1's attempt to understand the circumstances of the error before making the call.
Incomplete Documentation of Vital Signs After Medication Error
Penalty
Summary
The facility failed to ensure the clinical record for Resident #1 was complete and accurate, particularly concerning the documentation of vital signs following a medication error. Resident #1, admitted for palliative care with multiple serious diagnoses, received erroneous doses of morphine on three occasions. Following the medication error, the physician ordered that the resident's vital signs be monitored every two hours. However, the clinical record did not consistently reflect this monitoring, as vital signs were not documented at 9:00 P.M. on 4/20/24 and at 1:00 A.M. on 4/21/24. Interviews with facility staff revealed that although vital signs were reportedly taken, they were not documented as required. LPNs involved in the care of Resident #1 admitted to possibly forgetting to document the vital signs. The Medical Director and the Director of Nursing Services both confirmed that the expectation was for vital signs to be recorded every two hours following the medication error, which was not adhered to. The facility's policy mandates maintaining accurate medical records, which was not followed in this instance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 381 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridge Crest At Meadow Ridge | 4.1 mi | ★★★★★ | 3 | 0 |
| Autumn Lake Healthcare At Norwalk | 4.4 mi | ★★★★★ | 25 | 0 |
| Notre Dame Health And Rehabilitation Center | 5 mi | ★★★★★ | 1 | 0 |
| Waveny Care Center | 6 mi | ★★★★★ | 12 | 0 |
| Norwalk Care Center | 6.3 mi | ★★★★★ | 4 | 0 |
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