Wilton Meadows Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilton, Connecticut.
- Location
- 439 Danbury Rd, Route 7, Wilton, Connecticut 06897
- CMS Provider Number
- 075317
- Inspections on file
- 25
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 1
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.
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.
