Advanced Center For Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in New Haven, Connecticut.
- Location
- 169 Davenport Avenue, New Haven, Connecticut 06519
- CMS Provider Number
- 075348
- Inspections on file
- 38
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Advanced Center For Nursing & Rehabilitation during CMS and state inspections, most recent first.
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.
Two residents did not receive adequate nail and bathing care, and staff failed to effectively address and report ongoing care issues. One dependent resident with a contracted hand and multiple comorbidities resisted nail care, and NAs and an LPN reported persistent difficulty cleaning and trimming the nails on the affected hand. Despite foul odor, visible overgrown nails, and repeated resistance, the problem was not escalated to the supervisor or provider, and the APRN was not informed of specific nail care concerns until after the resident was hospitalized with a finger infection requiring nail removal and incision and drainage. Another cognitively impaired resident, care planned for assisted showers, went multiple weeks without a documented shower or complete bed bath, with no refusals noted, and was later found with feces under the fingernails requiring prolonged soaking to remove, contrary to facility policy requiring at least weekly bathing and routine nail care with grooming.
The facility failed to consistently obtain and document ordered and policy-required weights and meal intakes for three residents at risk for or experiencing significant weight loss and malnutrition. One resident with dementia and adult failure to thrive had long gaps without weights after admission and multiple readmissions, delayed post-readmission weights, and no timely re-weights after large weight changes, while meal intake was documented for only a small fraction of meals. Another resident with severe protein-calorie malnutrition, diabetes, and a stage 3 pressure ulcer had only three weights recorded over several months, with one month missing entirely and minimal meal intake documentation. A third resident with cancer, right heart failure, and HIV had a physician order for weekly weights that was not followed for multiple extended periods, including after readmission, and had incomplete meal percentage documentation. The RD and DON acknowledged expectations for timely admission/readmission weights, monthly and weekly weights per orders, re-weights after significant changes, and complete meal percentage recording, but weights, re-weights, and intake documentation were not consistently obtained or followed up.
Two residents experienced deficiencies in care planning and implementation. One cognitively intact resident with multiple medical conditions and a history of substance abuse had a physician order for an independent LOA, but the care plan was not updated to include goals or interventions related to the LOA, despite facility policy requiring LOAs to align with the care plan. Another resident with diabetes, a left hand contracture, and schizoaffective disorder had documented refusal-of-care behaviors and was to receive nail care on bath days, yet staff reported ongoing difficulty providing nail care due to the contracture and resistance. An LPN was unable to fully assess the nails and did not notify supervisors or the provider, and the DON was unaware of the problem, resulting in no alternative nail care interventions being arranged.
Two residents did not receive necessary assistance with personal hygiene and bathing. A resident with diabetes, a contracted hand, and behavioral symptoms was dependent for ADLs and repeatedly resisted left hand care, leading staff to perform only limited cleaning of the contracted hand; despite ongoing difficulty, nurses did not escalate the issue to supervisors or the provider, and the DNS was unaware of the problem until after the resident developed a severe finger infection requiring hospitalization and nail removal. Another cognitively impaired resident with vascular dementia and failure to thrive, care planned for weekly showers, went multiple weeks without a documented shower or complete bed bath, and there were no recorded refusals; this resident was later found with feces under the fingernails requiring prolonged soaking to remove. These failures occurred despite a facility policy requiring assistance with ADLs to maintain grooming and hygiene and specific guidance on managing care resistance in cognitively impaired residents.
The facility failed to maintain complete and accurate clinical records showing that required weekly hygiene care was provided to two residents who were dependent on staff for ADLs and had significant cognitive impairment and medical conditions, including severe protein calorie malnutrition, adult failure to thrive, type II DM, vascular dementia, and a stage 3 pressure ulcer. Point of Care records over several months showed only sporadic showers or bed baths with multiple weeks lacking any documented bathing, and there was no documentation of refusals. In one instance, a resident was found with feces under the nails requiring soaking to remove. The DON confirmed that residents are expected to receive at least weekly showers or complete bed baths with documentation each shift, and the facility’s bathing and grooming policy required at least weekly showers and associated grooming.
The facility failed to provide timely notification to the State LTC Ombudsman when several residents with complex medical and behavioral conditions were discharged or planned for discharge. Although 30‑day Notices of Intent to Discharge were issued and discharge planning meetings were documented, the facility did not upload the required discharge notices to the Aging and Disability Services portal at the same time notices were given to residents and their representatives. In one case, a resident on an independent LOA later died in the ED, and no discharge notice was uploaded because staff considered it a transfer. For the other residents, uploads to the portal occurred days to over a month after the written discharge notices, and interviews with facility staff revealed they were unaware of a specific timeframe for notifying the ombudsman, contrary to CMS requirements and the facility’s own transfer/discharge policy.
A resident with vascular dementia and adult failure to thrive experienced a documented weight decrease from 122.0 lbs to 108.6 lbs over six months, exceeding a 10% loss, and was care planned as at risk for malnutrition with interventions to monitor weights and intakes. However, the quarterly MDS did not code a 5% or greater one-month or 10% or greater six-month weight loss. The RD, responsible for Section K, acknowledged using an incorrect baseline weight and not applying the correct six-month look-back period, resulting in inaccurate coding of swallowing and nutritional status, and the DON confirmed the MDS did not accurately reflect the resident’s significant weight loss.
A resident dependent on supplemental oxygen experienced acute respiratory distress and death after staff failed to assess, monitor, and report the resident's worsening condition, did not ensure the availability of functioning oxygen equipment, and did not communicate critical changes to supervisors or providers. Multiple staff members did not follow facility policies for change of condition and oxygen management, resulting in Immediate Jeopardy.
A resident with a history of respiratory issues reported shortness of breath to staff, but the LPN did not assess the resident or notify the provider and nursing supervisor for several hours, despite repeated reports from nurse aides. The situation escalated to a medical emergency, with the provider only being notified after the resident became unresponsive. This delay was contrary to the facility's policy and the resident's care plan.
Three residents requiring supplemental oxygen did not have their oxygen tubing changed every seven days as required by facility policy. Observations and record reviews showed that tubing was left in place beyond the scheduled change date, and documentation did not match actual practice. Interviews with the DON and an LPN confirmed that staff were expected to change and document tubing weekly, but this was not consistently done.
A resident with acute respiratory failure, COPD, and anxiety disorder was receiving supplemental oxygen as ordered by a physician, but the facility did not develop a care plan to address the resident's respiratory diagnoses and oxygen use. This deficiency was identified through record review, observation, and staff interviews, revealing that the required care plan was not in place at the time of assessment.
A resident with a history of respiratory failure, COPD, and CHF, who was dependent on supplemental oxygen, experienced shortness of breath that was reported multiple times by nurse aides to an LPN. The LPN did not assess the resident, take vital signs, or notify the nursing supervisor or provider, despite facility policy requiring prompt intervention for changes in condition. The resident later became unresponsive and died despite emergency intervention.
A medication cart was found unlocked and unattended in a hallway, with the keys left on top and various items including medications, a glucometer, and personal items left exposed. A resident walked by the cart while the assigned LPN was inside a resident's room, and the LPN later acknowledged leaving the cart unsecured without requesting staff assistance. Facility policy requires medication carts to be locked and secured at all times when unattended.
Two residents did not have physician-ordered blood work obtained or documented, and there was no record of refusal or provider notification. Staff interviews confirmed the lack of documentation, and the NP was unaware the orders were not followed. Facility policy requires lab services to be provided and documented per physician orders, which was not done in these cases.
Two residents with significant respiratory conditions were found using oxygen concentrators that were five months overdue for annual inspection, and one unit had a thick layer of dust on its filter. The vendor was not given a full list or locations of concentrators, and staff did not consistently monitor or clean the equipment as required.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident was not protected from the wrongful use of their belongings or money, as facility staff failed to safeguard the resident's property or funds, resulting in unauthorized or improper use.
The facility did not maintain proper controls or documentation for narcotic medications, as staff signed out controlled substances without corresponding entries in the MAR or physician orders, and required monthly audits were not documented or available. The DON and Administrator could not provide evidence of completed audits or explain the audit process, and completed CSDR sheets were found stored without audit records, in violation of facility policy.
Three residents did not receive ordered medications, including IV antibiotics and Methadone, due to unavailability and lack of communication among staff. Missed doses occurred when residents were out of the facility or when medications were not obtained from the clinic, and responsible staff did not notify supervisors or providers as required by facility policy.
A resident with severe cognitive impairment and depression was physically assaulted by another resident who entered their room and struck them with a telephone, resulting in facial and hand injuries. Staff responded after hearing calls for help, but the abuse had already occurred, indicating a failure to protect the resident from physical harm as required by facility policy.
A resident with multiple chronic conditions and a history of hypotension had a blood pressure medication discontinued, with a provider order to obtain vital signs every shift. Vital signs were not recorded for several shifts, and staff interviews revealed uncertainty about why this occurred. The facility did not provide a policy for obtaining vital signs when requested.
A resident with dementia and COPD experienced a significant change in mental status, including confusion and hallucinations, along with decreased oxygen saturation. Although these changes were documented by an LPN, the supervising nurse and on-call provider were not notified as required by facility policy. Interviews confirmed that the supervisor was unaware of the incident, and leadership acknowledged that proper notification procedures were not followed.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall, but the care plan was not updated with new interventions to prevent recurrence. Staff interviews and documentation review confirmed that required care plan revisions were not made following the incident, despite facility policies mandating such updates.
A resident with severe cognitive impairment and a history of brain injury experienced an unwitnessed fall. Although initial assessments were performed and no injuries were found, required neurological checks were not consistently completed or documented every shift for 72 hours as per facility policy. Interviews with nursing staff and the DON confirmed the monitoring was not carried out as required.
A resident with dementia and COPD experienced shortness of breath and low oxygen saturation. Although a breathing treatment was given and an APRN assessment was reportedly performed with new oxygen orders obtained, there was no documentation of the APRN's assessment in the medical record, resulting in an incomplete and inaccurate record.
A resident with multiple complex medical conditions did not receive a prescribed antineoplastic medication for two days due to supply issues, and the nursing staff failed to notify the physician or APRN as required. Although the pharmacy and family were contacted about the medication, there was no documentation or evidence that the provider was informed of the missed doses, and interviews confirmed the provider was unaware of the situation.
A resident with severe cognitive impairment and multiple medical conditions received a specialty medication brought in by family members, but facility staff failed to document verification of the medication as ordered by the physician or ensure its contents were checked by a licensed pharmacist, contrary to facility policy.
A resident with multiple risk factors for skin breakdown did not receive timely implementation of wound care physician recommendations, including specific wound treatments and use of a specialized air mattress and pressure-relieving boots. Documentation showed delays in both entering and carrying out orders, as well as incomplete skin assessments, resulting in the resident being transferred to the hospital for wound evaluation and later developing a viral skin eruption.
A resident with chronic conditions and alert mental status was involved in an incident where a recreational aide cursed during a verbal altercation. The aide admitted to cursing about the incident, which the resident overheard, violating the facility's policy on treating residents with dignity and respect.
A facility failed to provide a safe smoking environment for a resident with dementia and schizophrenia, as their smoking apron was not properly secured, and necessary safety equipment was unavailable. Additionally, another resident with visual hallucinations and insomnia posed a fire risk by placing paper over their overbed light, a behavior known to the maintenance director but not reported to the administration. These deficiencies highlight lapses in supervision and communication, resulting in unsafe conditions.
A resident with chronic kidney disease and atrial fibrillation did not receive timely physician visits as required by facility policy. Despite being cognitively intact and requesting to see their primary care physician, the last documented physician note was from over two years ago. Interviews revealed that the Medical Director and DNS could not account for the lack of documentation, indicating a failure to adhere to the policy of regular physician visits.
The facility did not complete annual performance evaluations for four nurse aides, as discovered during a review of employee files and interviews with HR and the DNS. No evaluations had been conducted since April 2022, and despite efforts to locate them, none were found.
The facility failed to maintain proper recordkeeping and chain of custody for methadone, affecting 28 residents. Methadone was self-administered by residents without signing a chain of custody, and the medication nurse was solely responsible for signing off on the MAR. The facility did not maintain accurate records for methadone destruction, with only one nursing signature on destruction worksheets. Interviews revealed a lack of adherence to standard procedures and facility policies for controlled substance handling.
The facility failed to serve food at appropriate temperatures, as observed during a dietary department tour. Scrambled eggs and hot cereal were initially at high temperatures but cooled significantly by the time they reached the third floor, unit D3. The food cart door was left open during transport, contributing to the temperature drop. The Food Service Director acknowledged the issue, citing timing and container limitations as factors.
The facility failed to maintain sanitary conditions in the dietary department. During a test tray observation, a black, thin, hair-like object was found in the vegetables. The Food Service Director suggested it might be a string from the vegetable bag lining and noted that defrosting and spreading out vegetables could prevent this issue.
The facility failed to maintain proper documentation and review of antibiotic use as part of its Infection Control Program. The IP, in the role for two months, was unable to provide evidence of ongoing infection surveillance and had not utilized McGeer's forms. The DNS confirmed that the previous IP had left with the infection tracking information, leaving the facility unable to provide evidence of infection control reviews since April 2022. The facility's policy required regular reviews and educational activities, which were not being conducted.
A resident with multiple health conditions reported feeling disrespected by a nurse aide who suggested they could clean up urine independently. The incident was investigated, and the aide confirmed the comment, leading to a deficiency in maintaining the resident's dignity.
A resident's furniture was not maintained properly, with closet cabinet doors ajar and peeling, and dresser drawers that would not stay closed. The Director of Maintenance acknowledged these issues, which posed a potential safety concern, but they persisted, indicating a deficiency in timely maintenance.
A resident with severe cognitive impairment had $50.00 given by a family member to a staff member, which was not deposited into the personal fund account as per policy. Instead, it was kept in the medication cart, and most of it was spent without proper documentation. The facility's policy required funds to be secured in a locked box in the resident's room, which was not done, leading to a deficiency in managing resident funds.
A facility failed to ensure the advanced directive paperwork for a resident with multiple chronic conditions was present in the medical record, as required by a physician's order and facility policy. Despite a Full Code status order, the advanced directive was missing from both paper and electronic records. An LPN and RN acknowledged the absence, with the RN suggesting the documents might have been misplaced, contrary to the facility's policy requiring documentation within 24 hours of admission.
A resident's medication was found missing, with staff unaware and lacking proper documentation. Two residents shared a room with a non-functioning sink for 20 days, requiring staff to use other bathrooms. Another resident's furniture was in disrepair, posing safety concerns. Maintenance and nursing staff were aware but had not resolved these issues.
The facility failed to implement its abuse prevention policies, resulting in two residents being inadequately protected following allegations of abuse. One resident continued to work with an LPN accused of inappropriate conduct, while another resident's concerns about a roommate's aggressive behavior were not promptly addressed. The facility did not ensure timely psychiatric evaluation or monitoring to confirm the safety of the residents involved.
A facility failed to develop a comprehensive care plan for a resident with end-stage renal disease, omitting specific interventions for dialysis access. Additionally, another resident's sensory needs were neglected, as their care plan did not address the need for corrective lenses, despite the resident having broken glasses and informing staff. These deficiencies highlight a lack of adherence to the facility's policy for comprehensive, person-centered care plans.
The facility failed to update care plans for two residents, one with urinary retention and another with incontinence. The first resident's care plan lacked interventions for urinary retention after a hospital stay, while the second resident's care plan did not reflect their preference for independence or include an evaluation for a bowel and bladder retraining program. Staff interviews revealed a lack of awareness and documentation of the residents' care needs and preferences.
A resident who required assistance with toileting was not provided incontinent care during the night shift, resulting in the resident being soaked with urine. The assigned nursing assistant did not wake the resident for care, contrary to the care plan and facility policy. The interim DNS confirmed the deficiency and provided education to the staff member involved.
A facility failed to manage a resident's pain effectively, as the resident refused acetaminophen and was not assessed further, leading to inadequate pain management. Additionally, another resident missed a cardiologist appointment due to the absence of a staff escort, with no alternative arrangements made. These incidents highlight lapses in communication and coordination among staff.
The facility failed to follow physician orders for a resident with urinary retention, lacking documentation of required bladder scans and catheterizations due to the absence of a bladder scanner. Additionally, another resident frequently incontinent of bowel and bladder was not assessed for a bowel and bladder retraining program, despite facility policy requirements. Staff interviews revealed a lack of awareness and documentation regarding the residents' incontinence management needs.
A facility failed to monitor a resident's weight accurately, leading to a deficiency in maintaining the resident's health. The resident, at nutritional risk, did not have a timely readmission weight recorded, and subsequent weights were inconsistently documented, with invalid entries noted. Despite dietician requests for reweights, the nursing staff did not obtain them promptly, contributing to the deficiency.
A resident with respiratory needs was left without power for their suction machine due to a tripped breaker. Despite reporting the issue, staff were unaware, and the problem persisted over the weekend. The facility lacked a power outage policy and battery-powered equipment, compromising the resident's care.
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 Provide Nail and Bathing Care Resulting in Infection and Poor Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care and to respond effectively to care refusals for a dependent resident with a contracted hand, resulting in an infected finger that required surgical intervention. Resident #2, who had Type 2 diabetes, a chronic left hand contracture, and schizoaffective disorder, was care planned as dependent for toileting, bathing, and lower body dressing and known to refuse care at times. Nursing assistants reported ongoing difficulty opening the resident’s contracted left hand, with the resident expressing pain, pulling away, and allowing only limited cleaning and nail trimming on some digits. Staff described being able only occasionally to slide a thin washcloth under the contracted fingers, noting a strong foul odor afterward, and reported that nail care to the left hand was an ongoing issue. Despite these persistent difficulties, nursing staff did not escalate the problem according to facility practice. One LPN stated that nail care had been an ongoing issue since the resident’s transfer to her unit prior to January 2026, that she could not adequately visualize the nails due to the contracture, and that she did not inform the nursing supervisor or provider because she believed the issue was common knowledge. The APRN reported being aware that the resident resisted staff touching or opening the left hand but was not informed of specific nail care issues until after the resident’s hospitalization for septic shock, during which a left fourth finger paronychial infection was identified and treated with nail removal and incision and drainage. Photographs from the hospitalization showed overgrown, unkempt fingernails on the contracted hand. The DNS stated he/she was unaware of any difficulties performing nail care for this resident and therefore no alternative nail care interventions were implemented. The deficiency also includes the facility’s failure to provide regular bathing and grooming care, including nail care, for a cognitively impaired resident, resulting in poor hygiene and fecal matter under the fingernails. Resident #14, who had vascular dementia with severely impaired cognition and required assistance with ADLs, was care planned to receive assistance with showering on a scheduled shift. Point of Care documentation showed multiple weeks in December, January, and March during which the resident did not receive a shower or complete bed bath at least weekly, and the clinical record contained no documentation of refusals. A grievance documented that the resident was found with feces under the nails requiring hand soaks in warm soapy water to remove. The DNS confirmed that each resident should receive at least a weekly shower or complete bed bath and that the record did not show such care in the week leading up to the grievance, despite facility policies requiring weekly bathing and routine nail care as part of standard grooming.
Failure to Monitor Weights and Meal Intake Leading to Ongoing Weight Loss and Malnutrition
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional monitoring and intervention to prevent significant weight loss and malnutrition for three residents by not following its own weight and intake monitoring policies and physician orders. For one resident with vascular dementia and adult failure to thrive, the care plan identified risk for malnutrition and called for assessing intakes, bloodwork, and weights, and monitoring for significant changes. However, no weights were obtained between early June and early July, and there was no weight order in the physician’s orders over several months. After multiple hospitalizations and readmissions, weights were not obtained within 24 hours of readmission as required by policy, and there were long gaps before weights were recorded. A readmission nutrition assessment documented poor to fair intake and requested an updated weight, but the next weight was not obtained until 19 days after readmission. Subsequent weights showed significant unplanned weight loss, including a loss of over 10% in six months and an 11.694% loss in one month, and the resident met criteria for severe malnutrition related to inadequate oral intake. Despite these significant changes, re-weights were not obtained within two days of the large loss and subsequent large gain, and the record did not show refusals of readmission weights or re-weights. For a second resident with severe protein-calorie malnutrition, adult failure to thrive, diabetes, and a stage 3 pressure ulcer, the MDS identified significant weight loss not associated with a prescribed weight-loss regimen, and the care plan called for monitoring weight for significant changes and encouraging and monitoring oral intake. Physician orders over several months did not include an order to obtain weights. The clinical record showed only three weights over a three-month period, with no weight obtained in one of those months, and there was no documentation that the resident refused the missing monthly weight. Meal percentage documentation for this resident was also sparse, with only 42 of 270 meals having recorded intake percentages. For a third resident with malignant neoplasm of the gallbladder, acute on chronic right heart failure, and HIV, there was a physician’s order for weekly weights on Mondays. The MDS identified significant weight loss not associated with a prescribed weight-loss regimen, and the care plan included monitoring weight for significant changes and encouraging and monitoring oral intake. The clinical record showed weights obtained on scattered dates, but there were multiple extended periods where weekly weights were not documented, and there was no documentation that the resident refused weights during those gaps. After a hospitalization and readmission, weekly weights were again not obtained for several weeks despite the standing order, and the first post-readmission weight was not recorded until 25 days after return. Across all three residents, meal intake documentation was incomplete: only 74 of 459 meals were recorded for the first resident and 269 of 453 meals for the third resident, which the RD stated prevented her from obtaining a clear picture of intake when assessing significant weight loss. Interviews and policy review further described the actions and inactions contributing to the deficiency. The RD stated that all non-hospice residents should have weight orders and be weighed at least monthly, that readmission weights should be obtained within 24–48 hours, and that residents with a 5% or more weight change should be reweighed within two days and she should be notified. She acknowledged that she ordered weights and re-weights for residents with significant weight loss but was inconsistent with follow-up when weights were not obtained, and that incomplete meal documentation limited her ability to assess intake; she also stated she did not report the documentation issues to the DNS or provider and did not recommend more frequent weight monitoring for the resident who met criteria for severe malnutrition. The DON reported that residents with weight loss or gain should have physician orders directing weight frequency, that she was unaware residents were missing weight orders, and that nursing staff were responsible for entering weight orders on admission/readmission. She stated that residents should have weights at least monthly or per orders, on readmission, and with any significant change, and that admission/readmission weights and re-weights should be obtained within 24 hours and documented before the end of the shift. She also stated that meal percentages should be recorded for every resident and refusals documented, and she was unaware that meal percentages were not being documented consistently. The facility’s weight policy required admission and readmission weights within 24 hours, weekly weights for four weeks, monthly weights by the 10th of each month, re-weighing and RD notification for significant weight changes, and RD review and dietary interventions for significant changes, but the facility did not provide additional policies for significant weight loss and re-weights despite request.
Failure to Update Care Plans for Leave of Absence and Contracture-Related Nail Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables that addressed all identified needs for two residents. For one resident with Type 2 diabetes mellitus, chronic osteomyelitis of the right foot and ankle, cellulitis of the right lower limb, and a history or active diagnosis of substance abuse, the resident was cognitively intact and had a physician’s order for an independent leave of absence (LOA). Although the facility’s LOA policy required that temporary LOAs be in accordance with the resident’s care plan and physician orders, the resident’s care plan did not include goals of care or interventions related to the independent LOA. The DNS confirmed that goals and interventions for residents with active LOA orders should be implemented into the care plan once the LOA order was approved, but this was not done for this resident. For a second resident with Type 2 diabetes mellitus with diabetic autonomic neuropathy, a contracture of the left hand, and schizoaffective disorder, bipolar type, the care plan identified refusal of care behaviors and included interventions such as re-approaching the resident, monitoring mood/behavior changes, and reporting to the medical doctor. Nail care was to be performed on bath days, but staff interviews revealed ongoing difficulty performing nail care due to the resident’s left hand contracture and resistance to having the hand cleaned or opened. An LPN reported being unable to adequately visualize or assess the nails and did not inform the nursing supervisor or provider, believing the issue was common knowledge. The DNS stated being unaware of the difficulties performing nail care, so no alternative nail care treatments were offered, despite facility practice requiring escalation to nursing supervisors or the provider when care tasks such as nail care could not be completed. This reflects a failure to implement care plan interventions related to physician notification for refusal of contracture-related care.
Failure to Provide Adequate Nail Care and Regular Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with personal hygiene and nail care for a dependent resident with a contracted hand. Resident #2, who had Type 2 diabetes, a left hand contracture, and schizoaffective disorder, was care planned as dependent for toileting, bathing, and lower body dressing and known to sometimes refuse care. Staff interviews revealed that nail care was typically done on shower days by NAs, and multiple staff members reported ongoing difficulty accessing and cleaning the resident’s contracted left hand due to pain responses and resistance. Despite these persistent issues, nursing staff did not notify the nursing supervisor, DNS, or provider that nail care could not be adequately performed, and no alternative interventions or referrals were initiated. The DNS stated he/she was unaware of the difficulties and therefore no alternative nail care treatments were offered. Resident #2 was later hospitalized with septic shock due to MSSA, pneumonia, UTI, and respiratory failure, and was found to have a left fourth finger paronychial infection and chronic contracture requiring nail removal and incision and drainage, with cultures growing MSSA and Staphylococcus lugdunensis. Photographs documented overgrown, unkempt fingernails on the contracted hand, and the APRN reported not being informed of nail care issues until after the hospitalization, although he/she was aware of the resident’s resistance to staff touching/opening the left hand. The APRN indicated that regular nail care could have prevented the nail infection identified during the hospitalization. Staff interviews confirmed that resistance to left hand care was longstanding, that only limited cleaning (such as sliding a thin washcloth under the fingers) was sometimes possible, and that foul odor was present after cleaning, yet this problem was not escalated as required by facility practice. The deficiency also includes failure to provide regular bathing and nail hygiene for a cognitively impaired resident. Resident #14, diagnosed with vascular dementia and adult failure to thrive, required assistance with ADLs and was care planned to receive a shower every Monday on the 3:00 PM–11:00 PM shift. Point of Care documentation showed that this resident did not receive at least weekly showers or complete bed baths during multiple date ranges in December, January, and March, and the clinical record contained no documentation of refusals of showers or bed baths during those periods. A grievance documented that the resident was found with feces under the nails, requiring hand soaks in warm soapy water to remove, and noted that staff were educated regarding daily nail/foot care. The facility’s ADL policy required that residents unable to perform ADLs independently receive services to maintain grooming and personal hygiene and directed staff caring for cognitively impaired residents who resisted care to identify underlying causes and re-approach or use different staff, but the record did not show that such approaches were implemented for this resident during the identified periods of missed bathing care.
Incomplete Documentation of Required Bathing and Grooming Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records reflecting the provision of required hygiene care, including weekly showers or bed baths, for two residents. For one resident with severe protein calorie malnutrition, adult failure to thrive, type II diabetes mellitus, and a stage 3 pressure ulcer, the MDS showed moderately impaired cognition and dependence on staff for most ADLs, with the care plan calling for total care for showering and grooming. Point of Care (POC) documentation for December and January showed only one shower and a few partial bed baths, with multiple week-long gaps where no shower or bed bath was recorded, and the clinical record contained no documentation of refusals during those periods. For another resident with vascular dementia without behavioral disturbances and adult failure to thrive, the MDS showed severely impaired cognition and a need for assistance with ADLs, and the care plan specified assistance with showering on a set weekly schedule. POC records for December, January, and March showed only sporadic showers or bed baths, with several weeks lacking any documented shower or bed bath, and no refusals recorded in the clinical record. A grievance documented that this resident was found with feces under the nails requiring soaking to remove. The DON stated that residents should receive at least a weekly shower or complete bed bath and that care should be documented before the end of the shift, and acknowledged that the record did not show a shower or bed bath for the week preceding the grievance. The facility’s Bathing and Grooming Care policy required at least weekly showers and associated grooming, but requested policies for nurse aide documentation or Kardex/Care Card were not available.
Failure to Timely Notify Ombudsman of Resident Discharges
Penalty
Summary
The deficiency involves the facility’s failure to provide timely notification to the State LTC Ombudsman via the Aging and Disability Services application portal when residents were discharged or planned for discharge. For one resident with type 2 DM with foot ulcer, chronic osteomyelitis, and cellulitis, the facility granted an independent leave of absence, documented the expected return time, and later documented that the resident would return the following morning and would miss medications. The resident was subsequently found intoxicated, hypothermic, and later expired in the ED, and the facility could not provide evidence that a discharge notice was uploaded to the portal. Interviews with the social worker and DNS confirmed that this resident’s situation was considered a transfer rather than a discharge and that no ombudsman notification was made. For multiple other residents with complex medical conditions, including osteomyelitis, peripheral vascular disease, gas gangrene, coronary artery disease, renal insufficiency, COPD, heart failure, respiratory failure, depression, multiple sclerosis, schizoaffective and anxiety disorders, the facility issued written Notices of Intent to Discharge, generally providing 30‑day notices due to improved health, acceptance into Money Follows the Person programs, or family choice to return home. Social service notes documented discharge planning meetings with residents, families, therapy, and MFP representatives, as well as the actual discharge dates. However, the corresponding discharge notices were not uploaded to the Aging and Disability Services application portal at the time the notices were given to the residents. Instead, the discharge notifications for these residents were uploaded days to more than a month after the Notices of Intent to Discharge were issued, with delays ranging from 1 to 37 days. Interviews with the social worker and DNS showed that facility staff were unable to identify a specific timeframe for when discharge notices must be created and uploaded to the portal and believed there was no defined deadline. This practice conflicted with the facility’s Transfer/Discharge policy and the CMS regulation requiring that a copy of the discharge notice be sent to the State LTC Ombudsman at least 30 days prior to discharge or as soon as possible, and at the same time the notice is provided to the resident and resident representative.
Inaccurate MDS Coding of Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s comprehensive assessment accurately reflected a significant weight loss of more than 10% over six months. The resident had diagnoses including vascular dementia without behavioral disturbances and adult failure to thrive. A weight of 122.0 lbs was recorded on 5/13/25, and the resident’s care plan dated 6/10/25 identified risk for malnutrition related to adult failure to thrive, altered nutrition-related bloodwork, a BMI less than 23, and significant weight changes, with interventions to assess intakes, bloodwork, and weights, and to monitor for significant changes. A subsequent weight of 108.6 lbs on 11/16/25 represented a 13.4 lb (10.984%) loss over six months compared to the 5/13/25 weight. Despite this documented weight loss, the quarterly MDS assessment dated [DATE] did not identify that the resident had experienced a weight loss of 5% or more in the last month or 10% or more in the last six months. The RD, who was responsible for completing Section K (Swallowing and Nutritional Status) of the MDS, acknowledged that Section K of the 12/4/25 MDS was coded incorrectly, explaining that she used an incorrect baseline weight and failed to calculate the weight change using the appropriate six-month look-back period from the Assessment Reference Date. The DON stated that the MDS should accurately reflect a resident’s care for all sections, including swallowing and nutritional status, and acknowledged that this MDS did not accurately reflect the resident’s significant weight loss. When requested, the facility did not provide a policy on comprehensive assessments.
Failure to Provide Safe and Timely Respiratory Care Resulting in Resident Death
Penalty
Summary
A resident with a history of acute respiratory failure with hypercapnia, COPD, CHF, and dependence on supplemental oxygen experienced a critical event due to the facility's failure to provide safe and appropriate respiratory care. The resident had a physician's order for continuous oxygen at 3.0 liters per minute via nasal cannula. Over the course of several shifts, the resident's oxygen concentrator was not functioning, and staff relied on portable oxygen tanks, some of which were empty or unavailable. Multiple staff members, including LPNs and nurse aides, failed to assess the resident's respiratory status, obtain vital signs or oxygen saturation levels, or notify the nursing supervisor and provider of the resident's ongoing shortness of breath and equipment issues. Communication breakdowns occurred between shifts and among staff. Nurse aides reported the resident's shortness of breath to the charge nurse, but the charge nurse did not assess the resident or escalate the issue to the supervisor or provider. The nursing supervisor and nurse practitioner were not made aware of the resident's deteriorating condition until the resident was in acute distress. Staff also failed to ensure the availability of functioning oxygen equipment, as all portable tanks on the unit and the emergency cart were found empty when urgently needed, requiring staff to retrieve tanks from another floor. The lack of timely assessment, failure to monitor and document the resident's condition, and inadequate communication and escalation of the resident's change in status resulted in the resident's condition deteriorating to acute respiratory arrest and ultimately death. The facility did not follow its own policies regarding change of condition and oxygen supply management, which required immediate assessment, documentation, and notification of the provider and supervisor in the event of respiratory distress or equipment malfunction. These failures led to a finding of Immediate Jeopardy.
Failure to Timely Notify Provider of Resident's Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure, COPD, CHF, and dependence on supplemental oxygen reported shortness of breath to staff, but the provider was not notified until approximately three hours later. The resident's care plan required staff to monitor for signs of respiratory distress, check oxygen saturation as needed, and report abnormal findings to the provider. Despite these directives, nurse aides reported the resident's shortness of breath to the charge nurse shortly after the start of the shift and again later in the morning, but the charge nurse did not assess the resident, take vital signs, or notify the provider or nursing supervisor at that time. The charge nurse was informed by the previous shift that the resident's oxygen concentrator was not functioning and that portable oxygen was being used. Although the nurse aides followed protocol by reporting the resident's symptoms, the charge nurse only instructed them to bring additional portable oxygen tanks and did not perform a respiratory assessment or further evaluate the resident's condition. The nursing supervisor was on the unit during this period but was not made aware of the resident's complaints or the issues with the oxygen equipment until a critical event occurred. The situation escalated when the resident began calling out for help, stating they could not breathe. At this point, the nursing supervisor and a nurse practitioner responded immediately, assessed the resident, and initiated emergency interventions, including calling 911 and performing CPR. Despite these efforts, the resident was pronounced deceased. Interviews confirmed that the provider and nursing supervisor were not notified of the resident's change in condition in a timely manner, contrary to facility policy and the resident's care plan.
Failure to Change Oxygen Tubing per Policy
Penalty
Summary
The facility failed to ensure that oxygen tubing for residents requiring supplemental oxygen was changed every seven days as per facility policy. For three of seven sampled residents, clinical record reviews and direct observations revealed that the oxygen tubing was not changed within the required timeframe. One resident with acute respiratory failure, COPD, and anxiety disorder was observed using oxygen tubing labeled with a date ten days prior, despite documentation indicating it had been changed more recently. Another resident with pneumonia, heart failure, and COPD was found with oxygen tubing labeled with a date seven days past the scheduled change, and there was no active physician's order to change the tubing weekly. A third resident with acute and chronic respiratory failure, CHF, and COPD was observed with oxygen tubing that had not been changed for over two weeks, and similarly lacked an active physician's order for weekly tubing changes. Interviews with the DON and a regional nurse confirmed that the facility's policy required weekly tubing changes on the 11PM-7AM shift, and that staff were expected to document these changes accurately. However, the observations and record reviews indicated that the tubing was not changed as required, and documentation did not reflect actual practice. The facility's policy, dated 01/19/18, directed that standard nasal cannula/tubing be changed every seven days or sooner if soiled, and that change dates be documented in the medical record, but these procedures were not consistently followed for the residents reviewed.
Failure to Develop Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a care plan addressing the need for supplemental oxygen use for one resident with significant respiratory diagnoses. The resident had acute respiratory failure with hypoxia, COPD, and an anxiety disorder, and a physician's order directed the use of oxygen via nasal cannula or non-rebreather at two to three liters per minute as needed to maintain oxygen saturation above 92%. Despite these orders and the resident's ongoing use of oxygen therapy, clinical record reviews and observations revealed that there was no care plan in place to address the resident's respiratory conditions and oxygen utilization at the time of review. The deficiency was identified through clinical record reviews, direct observation of the resident using oxygen, and interviews with facility staff. The facility's own policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and interventions based on thorough assessment. However, the care plan for this resident was not developed until several days after the deficiency was noted, and staff interviews confirmed that a care plan should have been in place to address the resident's respiratory needs and oxygen use.
Failure to Assess and Intervene for Resident with Acute Respiratory Distress
Penalty
Summary
A deficiency occurred when a resident with a history of acute respiratory failure with hypercapnia, COPD, CHF, and dependence on supplemental oxygen experienced shortness of breath and did not receive timely assessment or intervention from nursing staff. The resident had a physician's order for continuous oxygen and a care plan directing staff to monitor for respiratory distress, check oxygen saturation as needed, and report abnormal findings to the provider. On the day of the incident, nurse aides reported the resident's shortness of breath to the charge nurse shortly after the start of the shift and again later in the morning, but did not observe the nurse assess the resident at either time. The charge nurse acknowledged being notified by the nurse aides about the resident's symptoms and directed them to bring portable oxygen tanks due to a malfunctioning concentrator, but did not personally check on or assess the resident, nor did she take vital signs or oxygen saturation levels. The nursing supervisor was not informed of the resident's condition until later in the morning, at which point the resident was found in severe respiratory distress. The nurse practitioner and supervisor responded immediately, but the resident became unresponsive and, despite CPR and emergency services intervention, was pronounced deceased. Facility policy required that any change in a resident's condition be identified and addressed promptly, with the LPN responsible for collecting data and administering treatments, and the RN/supervisor to be notified for further assessment and provider notification. In this case, the failure of the charge nurse to assess the resident and notify the supervisor or provider in a timely manner led to a lack of appropriate intervention for the resident's acute respiratory symptoms.
Unattended Unlocked Medication Cart with Keys Left Exposed
Penalty
Summary
A medication cart was observed unlocked and unattended in the hallway near the nurse's station, with the cart keys left on top of the cart. Items found on the cart included an open bottle of docusate sodium, a glucometer, glucometer test strips, several empty blister packs of medication, six pre-poured cups of water without covers, an insulin syringe cover, and a cell phone. During this time, a resident was seen walking by the cart while the assigned nurse was inside a resident's room with the door closed. The nurse later confirmed that she left the cart unlocked and unattended, with the keys on top, because she needed to attend to a resident quickly and did not request assistance from other staff. The nursing supervisor stated that the medication cart should be locked at all times when unattended and that items, including keys, should not be left on top of the cart. Facility policy requires medication carts to be locked and secured at all times when unattended, with keys kept in the possession of the assigned nurse, and prohibits storage of unrelated items on the cart.
Failure to Obtain and Document Physician-Ordered Blood Work
Penalty
Summary
The facility failed to ensure that blood work was obtained as ordered by physicians for two residents. For one resident with diagnoses including pneumonia, respiratory failure, CHF, anemia, generalized edema, and hypocalcemia, a physician's order directed that a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) with differential be obtained on a specific date. Review of the clinical record did not show that the blood work was completed or that the resident refused the procedure. A subsequent order for different blood work was later carried out, but the initial order was not addressed. For another resident with alcohol abuse, hypothyroidism, and peripheral vascular disease, a physician's order directed that a BMP and CBC with differential be obtained on a specific date. The clinical record did not indicate that the blood work was completed or refused. Interviews with facility staff confirmed that documentation was lacking for both residents, and the nurse practitioner was unaware that the blood work had not been obtained. Facility policy requires that laboratory services be provided per physician orders, with results documented and communicated appropriately, but this was not followed in these cases.
Failure to Ensure Timely Inspection and Maintenance of Oxygen Concentrators
Penalty
Summary
The facility failed to ensure that oxygen concentrators used by two residents were inspected annually for function and safety, as required. Both residents had significant respiratory diagnoses, including COPD, CHF, and chronic respiratory failure, and were receiving supplemental oxygen via concentrators. Observations revealed that the inspection stickers on both concentrators indicated the last inspection occurred over a year ago, making them five months overdue for their required annual inspection. Additionally, one concentrator was observed to have a thick covering of dust on its filter. Interviews with facility staff and the oxygen concentrator servicing vendor revealed that the vendor was not provided with a complete list or locations of all concentrators, resulting in some units not being inspected during their visit. The Director of Environmental Services did not accompany the vendor during the inspection, which contributed to the oversight. Maintenance staff were responsible for weekly filter checks, and housekeeping was to monitor filters daily, but the presence of thick dust on one unit indicated this process was not consistently followed. Requested policies on servicing and cleaning oxygen concentrators were not provided by the facility.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or improper use. Specific actions or omissions by facility staff led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Maintain Proper Controls and Documentation for Narcotic Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality regarding the control and documentation of narcotic medications for three residents reviewed for medication administration. Clinical record and facility documentation reviews revealed that staff signed out Hydromorphone on the Controlled Substance Distribution Record (CSDR) for multiple dates, but there was no corresponding documentation in the residents' medical records or Medication Administration Records (MAR) to confirm that the medication was actually administered. In some instances, narcotic medications were signed out on the CSDR when there were no physician orders, and there was a lack of required witness signatures for medication wastage. The Director of Nursing (DON) was unable to explain these discrepancies or provide documentation of the required monthly or bi-monthly audits of controlled substances for the relevant months, as stipulated by facility policy. Further investigation found that completed CSDR sheets were stored in the medical records office, but there was no evidence of audit results or documentation of audits being completed. Interviews with the DON and Administrator indicated that there was no established process or tracking system for current audits of controlled medications, and the DON could not explain how previous audits were conducted or why issues were not identified. The facility's Controlled Substance Handling Policy required monthly audits to monitor for discrepancies, unexplained wastage, and patterns of high usage, as well as the retention of accountability and audit records for at least five years, but these requirements were not met.
Failure to Ensure Medication Availability and Administration per Physician Orders
Penalty
Summary
The facility failed to ensure that medications were available and administered in accordance with physician orders for three residents. One resident with chronic pain syndrome, opioid dependence, osteomyelitis, and bacteremia was ordered to receive IV Cefazolin every eight hours. On two occasions, the resident did not receive the scheduled 2 PM dose because they were out of the facility at the hospital for another medication. The LPN responsible did not notify the nursing supervisor, physician, or APRN about the missed doses, and the supervisor was unaware of the omission. The APRN and DON both stated they would have expected to be notified of the missed antibiotic doses. Another resident with a history of substance use disorder was ordered to receive Methadone 115 mg daily. The medication was not available in the facility for four consecutive days, and the resident missed multiple doses. The resident was subsequently transferred to the hospital for Methadone administration after experiencing withdrawal. Facility staff interviews revealed that the Methadone nurse, responsible for obtaining the medication from the clinic, was not aware of the unavailability, and the RN supervisor was not notified of the missed doses until after several had been omitted. The APRN was also not notified of the missed doses until after the resident was transferred to the hospital. A third resident, also with opioid abuse, was ordered Methadone 75 mg daily. The medication was not available for administration on one occasion, and the reason for the unavailability could not be identified. The RN supervisor was not aware of the missed dose, and the DNS could not explain why the medication was not available. Facility policy directed that Methadone should be retrieved and administered as ordered, but this was not followed in these cases.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment, major depression, and significant physical care needs was physically abused by another resident who entered the victim's room and struck them multiple times with a telephone. The incident resulted in visible injuries, including bruising and lacerations to the face, mouth, and hand, as well as swelling of the left thumb and index finger. The injured resident was on a blood thinner and was alert and oriented at the time of the event. The attack was unprovoked, and the resident reported not recognizing the assailant. Staff became aware of the incident when they heard the resident calling for help and observed the aggressor exiting the room. Immediate observations and interviews confirmed the sequence of events, and medical evaluation documented the extent of the injuries. Facility documentation and camera footage corroborated that staff responded after the resident called for help, but the abuse had already occurred. The facility's policies require residents to be free from abuse, but in this case, the resident was not protected from physical harm inflicted by another resident.
Failure to Monitor and Document Vital Signs After Medication Discontinuation
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document vital signs according to a provider order for a resident who required monitoring after the discontinuation of a blood pressure medication. The resident, who had multiple sclerosis, functional quadriplegia, neurogenic bladder, and a pressure ulcer, was identified as having intermittent hypotension and had their metoprolol succinate discontinued. The provider ordered that vital signs be obtained every shift following this change. However, review of the medical record revealed that vital signs were not recorded for several specified shifts. Interviews with staff indicated that nursing assistants were responsible for obtaining vital signs, which were then to be reviewed and entered into the electronic medical record by the assigned nurse. The LPN assigned to the resident during the missed shifts could not recall if she had reviewed the vital signs and did not know why they were not recorded. The APRN confirmed the importance of monitoring vital signs after discontinuing the medication, and the DNS stated that nurses are expected to follow provider orders. The facility did not provide a policy for obtaining vital signs when requested.
Failure to Notify Provider of Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely notification of a medical provider following a significant change in condition for a resident with dementia and chronic obstructive pulmonary disease (COPD). The resident, who was alert and oriented with a history of stable oxygen saturation, experienced episodes of shortness of breath and a drop in oxygen saturation, which were managed with breathing treatments and supplemental oxygen. However, on one occasion, the resident exhibited a change in mental status, including confusion and hallucinations, along with a further decrease in oxygen saturation. Despite these significant changes, there was no documentation that the supervising nurse or the on-call provider was notified as required by facility policy. Interviews with facility staff confirmed that the LPN who observed the change in mental status did not notify the nursing supervisor, and the supervisor was unaware of the resident's altered condition. The DON and Medical Director both acknowledged that the change in mental status constituted a significant change in condition and that the supervisor and provider should have been contacted. Facility policy directs that every resident's change in condition must be reported to the physician, but this protocol was not followed in this instance.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to revise a resident's care plan in a timely manner following a fall. The resident, who had a history of traumatic brain hemorrhage, Schizophrenia, severely impaired cognition, and required extensive assistance for mobility and transfers, was identified as being at risk for falls. The care plan in place included interventions such as reminding the resident to use the call bell and to toilet promptly. However, after the resident experienced an unwitnessed fall, which was documented in an incident report and nursing note, no new interventions were added to the care plan to address the circumstances of the fall or to prevent recurrence. Interviews with facility staff, including the charge nurse and the Director of Nursing (DON), confirmed that the care plan was not updated after the incident, despite facility policies requiring care plan revisions when a resident's condition changes or when desired outcomes are not met. The DON was unable to provide documentation of any care plan update following the fall, and the charge nurse could not recall if any changes were made. The facility's Fall Prevention Policy and Comprehensive Care-Planning Policy both direct staff to implement and revise interventions as needed, but these procedures were not followed in this case.
Failure to Complete Timely Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure that neurological assessments were completed in a timely manner following an unwitnessed fall, as required by facility policy. A resident with a history of traumatic brain hemorrhage, severe cognitive impairment, and a high risk for falls experienced an unwitnessed fall and was found on the floor by housekeeping staff. Initial assessments were performed, and the resident was found to have no injuries or pain. However, documentation revealed that neurological checks were not consistently completed every shift for 72 hours post-fall, as directed by the facility's Post Accident & Incident Monitoring Sheet. Only a few assessments were documented, leaving several required checks unaccounted for during the monitoring period. Interviews with nursing staff and the Director of Nursing confirmed that neurological assessments should have been performed and documented every shift for 72 hours following the fall. The Director of Nursing was unable to provide documentation that these assessments were completed according to policy and acknowledged that the required monitoring was not carried out. The deficiency was identified through clinical record review, facility documentation, and staff interviews, which collectively demonstrated a failure to meet professional standards of quality in post-fall monitoring.
Failure to Document APRN Assessment Following Respiratory Event
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate, specifically lacking timely documentation of a medical evaluation. The resident, who had diagnoses including dementia and COPD, was noted to be alert, oriented, and independent with mobility. The care plan directed staff to assess for changes in respiratory status and notify the physician as needed. On the date in question, the resident was observed with shortness of breath and a low oxygen saturation of 88% on room air, compared to a baseline of 92-95%. A breathing treatment was administered, oxygen was applied, and the resident's oxygen saturation improved to 90%. It was documented that the resident was assessed by an APRN and new orders for nasal oxygen were obtained. However, upon review, there was no documentation of the APRN's assessment in the medical record for that date. The facility's policy required that a progress note be written, signed, and dated for each visit. The Medical Director confirmed that if the APRN had assessed the resident, this should have been documented. The absence of this documentation resulted in an incomplete and inaccurate medical record for the resident.
Failure to Notify Physician of Missed Medication Doses
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician or APRN after a resident did not receive a prescribed medication, Abiraterone, for two consecutive days. The resident, who had diagnoses including dementia, prostate cancer, schizophrenia, diabetes mellitus, seizures, and encephalopathy, was dependent on staff for activities of daily living and had severely impaired cognition. The physician's order required daily administration of Abiraterone, but documentation showed the medication was not given on two days because the supply was not available, as it was being delivered to the family rather than the facility. Nursing notes indicated that the pharmacy and the resident's family were contacted regarding the medication supply, and the nursing supervisor was updated about the situation. However, there was no evidence in the clinical record that the physician or APRN was notified about the missed doses. Interviews confirmed that the APRN was not informed and would have taken further action if notified. The LPN involved stated that he did not notify the physician/APRN, believing it was the supervisor's responsibility, but the facility could not provide information on who the supervisor was during the relevant period. The DON confirmed that the expectation was for the nursing team to notify the provider when a resident does not receive scheduled medication, but could not explain why this did not occur.
Failure to Verify Family-Provided Medication Prior to Administration
Penalty
Summary
The facility failed to ensure that a medication provided by a resident's family for administration by facility staff was properly verified as the drug ordered by the physician, and did not ensure that the contents of the medication container were verified by a licensed pharmacist, as required by facility policy. Specifically, a resident with multiple complex diagnoses, including dementia, prostate cancer, schizophrenia, diabetes, seizures, and encephalopathy, was ordered to receive Abiraterone 1000 mg daily. Due to the facility pharmacy not supplying the medication, the resident's family brought the medication to the facility. There was no documentation or evidence that nursing staff verified the medication prior to administration, nor was there a record of the process followed when the medication was delivered by the family. Interviews with facility staff, including the DON and pharmacy personnel, confirmed that the medication was dispensed by an outside pharmacy and brought in by the family, but could not provide documentation of verification by a licensed pharmacist or details on how the medication was checked before administration. The facility's policy requires that medications brought in from outside be verified by the nursing staff, the attending physician, and the consultant pharmacist, but this process was not documented or followed in this case. The medication in question was also not available for review, as it had been destroyed after the resident's discharge.
Failure to Implement Timely Pressure Ulcer Interventions
Penalty
Summary
The facility failed to ensure that the treatment plans recommended by the wound care physician for a resident with multiple risk factors, including pressure ulcer, diabetes mellitus, malnutrition, peripheral vascular disease, and dementia, were promptly entered into the clinical record and implemented. Although the resident's care plan included interventions such as applying barrier cream, turning and repositioning every two hours, and weekly skin checks, documentation revealed lapses in weekly skin assessments and incomplete records regarding the resident's skin condition. After re-admission from an acute care facility, the resident was found to have a non-stageable sacral pressure ulcer and a deep tissue injury to the right heel, with the wound care physician recommending specific treatments and preventative measures, including a specialized air mattress and pressure-relieving boots. Despite these recommendations, the clinical record and Treatment Administration Records showed that the recommended sacral wound treatment was not initiated until five days after the physician's order, and the specialized air mattress and boots were never applied. Interviews with facility staff, including the wound nurse and DON, confirmed delays in entering orders and implementing the recommended interventions, with no clear explanation for the lapses. The resident was subsequently transferred to the hospital for evaluation and treatment of the sacral wound, and later developed a viral skin eruption involving the groin, perineum, and sacrum. Facility policy required timely implementation of interventions consistent with residents' needs, but this was not followed in this case.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as required by the Resident Rights policy. The incident involved a resident with diagnoses including chronic pulmonary edema, depression, anxiety, and chronic pain, who was alert and oriented with a BIMS score of 15. During a recreational activity, the resident was verbally disruptive, leading to an altercation with a recreational aide. The aide, in frustration, cursed about the incident, which the resident overheard. This behavior was contrary to the facility's policy that mandates treating all residents with dignity and respect. The incident was reported by the resident to the social worker the following day, prompting an investigation. The recreation aide admitted to cursing during the incident, although she claimed it was not directed at the resident. The Director of Nursing confirmed the aide's admission and the violation of the facility's policy. The facility's policy, last revised in 2018, emphasizes the importance of treating residents with consideration, respect, and full recognition of their dignity and individuality, which was not upheld in this situation.
Failure to Ensure Safe Smoking Environment and Address Fire Hazard
Penalty
Summary
The facility failed to provide a safe smoking environment for Resident #21, who was identified as a smoker with diagnoses of dementia and schizophrenia. During a smoking break, Resident #21 was observed with a smoking apron that was not properly secured, leaving their legs uncovered. The security staff responsible for supervision was distracted with other tasks and did not maintain a direct line of sight on the residents. Additionally, the facility's smoking policy was not adhered to, as the last smoking safety assessment for Resident #21 was conducted several months prior, and necessary smoking safety equipment, such as a cigarette filter, was not available. The facility also failed to address a fire hazard involving Resident #187, who had diagnoses of visual hallucinations and insomnia. Resident #187 was observed placing thin pink paper over their overbed light to dim the room, which posed a fire risk. The Director of Maintenance was aware of this behavior but did not report it to the Administrator or the Director of Nursing Services. Consequently, the facility was unaware of the safety concern and had not implemented any interventions to mitigate the risk. Both deficiencies highlight lapses in supervision and communication within the facility. The staff failed to adhere to established policies for smoking safety assessments and did not report hazardous behaviors that could compromise resident safety. These oversights resulted in unsafe conditions for the residents involved, with potential risks that were not addressed in a timely manner.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure timely physician visits for a resident with chronic kidney disease and atrial fibrillation. The resident, who was cognitively intact and had clear speech, expressed a desire to see their primary care physician to coordinate care. However, the clinical record review revealed that the last note by a physician was an admission history and physical dated over two years ago. Subsequent notes categorized as physician notes were written by non-physician providers, indicating a lack of direct physician involvement in the resident's ongoing care. Interviews with the Medical Director and the Director of Nursing Services (DNS) highlighted discrepancies in the facility's process for physician visits. The Medical Director mentioned that he examines residents every sixty days and signs orders, but there was no documentation of such visits for the resident in question. The DNS confirmed the absence of physician notes since the resident's admission and could not explain the lack of documentation. The facility's policy requires a physician to see a resident at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter, which was not adhered to in this case.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for four nurse aides, identified as Nurse Aides #5, #6, #7, and #8. This deficiency was discovered during a review of employee files and interviews with the Human Resource Director and the Director of Nursing Services. The review revealed that no performance evaluations had been conducted for these nurse aides since April 4, 2022. Despite the Director of Nursing Services indicating a willingness to search for the missing evaluations in the nursing offices, no evaluations were found or provided.
Deficiencies in Methadone Management and Recordkeeping
Penalty
Summary
The facility failed to develop and implement adequate policies for the recordkeeping and chain of custody of controlled substances, specifically methadone, for 28 residents. The report highlights that the facility did not maintain an unbroken chain of custody for controlled medications once received and distributed to nursing units. There was a lack of documentation for inventory across shifts, and the facility did not maintain an accurate disposition log for the destruction and return of unused controlled medication. Observations revealed that residents self-administered methadone without signing a chain of custody, and the medication nurse was solely responsible for signing off on the Medication Administration Record (MAR). Interviews with staff, including LPNs and the interim Director of Nursing Services (DNS), revealed that the facility's practice did not align with standard procedures followed in other facilities. The methadone nurse, LPN #5, was responsible for acquiring and maintaining the chain of custody of methadone but did not require a second nurse to sign off after the medication was received by the facility. Additionally, there was no documented chain of custody when methadone was brought to nursing units for weekend dispensing, and no accounting between shifts by nursing staff. The facility's policy for methadone maintenance failed to include resident participation in self-medication administration and individual recordkeeping of tapering doses. The facility also failed to maintain complete and accurate recordkeeping for methadone destruction. A review of Methadone Destruction Worksheets showed only one nursing signature, belonging to LPN #5, without a second licensed staff signature or the resident's signature when able. Interviews with the DNS and nursing staff indicated a lack of awareness and adherence to facility policies regarding controlled substance handling. The facility's policy directed that methadone be stored and counted like any other controlled substance, but the revised policy did not include this requirement, leading to deficiencies in the management of methadone within the facility.
Food Temperature Deficiency in Dietary Department
Penalty
Summary
The facility failed to ensure that food was served at an appropriate temperature to maintain palatable taste. During a tour of the dietary department, it was observed that scrambled eggs and hot cereal were initially at temperatures of 196 and 195 degrees Fahrenheit, respectively, when placed in a heating tray. However, by the time the food cart reached the third floor, unit D3, the scrambled eggs had cooled to 88.2 degrees, and the oatmeal was at 131.2 degrees. The food cart door was left open during transport, contributing to the temperature drop. The Food Service Director acknowledged that the food was not served at the correct temperature due to the timing of service and the containers' inability to maintain temperature during transport.
Sanitation Deficiency in Dietary Department
Penalty
Summary
The facility failed to serve food under sanitary conditions, as identified during a tour of the dietary department. On one occasion, a test tray containing baked chicken, rice, and assorted vegetables was ordered. During an observation, a black, thin, hair-like object was found in the assorted vegetables. The Food Service Director suggested that the object might be a string from the lining of the vegetable bag and acknowledged that defrosting and spreading out the vegetables could help prevent such occurrences in the future.
Failure in Antibiotic Stewardship and Infection Control Documentation
Penalty
Summary
The facility failed to ensure proper documentation and ongoing review of antibiotic use as part of its Infection Control Program, in accordance with Antibiotic Stewardship guidelines. During an interview and document review, the Infection Preventionist (IP), who had been in the role for two months, was unable to provide evidence of ongoing infection surveillance. The only documentation available was a binder containing a list of antibiotics used in 2023 and 2024, provided by the pharmacy. The IP had not utilized McGeer's forms for antibiotic surveillance and had been frequently pulled away from infection control duties to provide resident care. The IP was unaware of the need to track infections, check antibiotic appropriateness, and review trends with medical staff. Additionally, the IP was not aware of an infection control or pharmacy committee. The Director of Nursing Services (DNS) confirmed that the previous IP had left the position and taken the infection tracking information, leaving the facility unable to provide evidence of infection control reviews at medical staff meetings since April 2022. The facility's policy on Antibiotic Stewardship indicated that the Medical Director, IP, DNS, and consultant pharmacist should lead antibiotic stewardship activities, coordinated through the Pharmacy and Infection Control Committees. These activities were to include regular reviews of antibiotic utilization and sensitivity patterns, distribution of educational materials, and reports on potential mis-prescribing. However, these activities were not being conducted as required.
Failure to Ensure Respectful Interaction with Resident
Penalty
Summary
The facility failed to ensure respectful interaction with a resident, leading to a deficiency in maintaining the resident's dignity. Resident #70, who has diagnoses including chronic congestive heart failure, back pain, diabetes mellitus, anxiety, and depression, was found to be cognitively intact and independent with toileting hygiene. The resident reported an incident where urine was on the bedside floor, and while attempting to clean it, called for staff assistance. Nurse Aide (NA #8) responded by bringing an open bag for the soiled linens and suggested that the resident could have completed the task independently, which the resident found disrespectful. The incident was reported to the state agency, and an investigation was initiated. During the investigation, NA #8 confirmed telling the resident they could have cleaned the urine without assistance, based on previous observations of the resident's independence. The resident expressed feeling disrespected by NA #8's comment, although not abused, and agreed that further training in customer service was necessary. The Director of Nursing Services conducted an interview with NA #8, who was subsequently removed from the resident's assignment and received a discussion on customer service and respectful treatment of residents.
Deficiency in Resident Furniture Maintenance
Penalty
Summary
The facility failed to maintain resident furniture in proper working order for a resident, leading to a deficiency. During an observation, the resident's closet cabinet doors were found ajar with the wood at the edges peeling apart, and the doors did not stay closed due to missing magnets. Additionally, a 3-drawer dresser had drawers that would not stay closed, posing a potential safety concern. The Director of Maintenance confirmed these issues during an interview and attempted to address them, but the problems persisted, indicating a lack of timely maintenance and repair of the resident's furniture.
Failure to Secure Resident's Personal Funds
Penalty
Summary
The facility failed to ensure the security of personal funds for a resident diagnosed with cerebral palsy, mood disorder, and delusional disorder, who was identified as severely cognitively impaired and dependent on staff for personal care. The resident's family member provided $50.00 to a staff member for the resident's use, but the money was not deposited into the resident's personal fund account as per facility policy. Instead, the family member requested the money be left on the nursing medication cart for the resident's access, which was against the facility's policy. The Business Office Manager was aware of the situation but did not ensure the money was secured according to policy. The money was later found in the narcotics box in the medication cart, with only $1.25 remaining, indicating it had been spent without proper documentation or oversight. The facility's policy required that any funds not deposited into a personal account should be secured in a locked box in the resident's room, which was not done. The Administrator and Social Worker were initially unaware of the situation, highlighting a breakdown in communication and adherence to policy regarding the management of resident funds.
Missing Advanced Directive Documentation for Resident
Penalty
Summary
The facility failed to ensure that the advanced directive paperwork for Resident #89 was present in the medical record, as required by the physician's order and facility policy. Resident #89, who was diagnosed with chronic congestive heart failure, acute respiratory failure, chronic kidney disease, and type 2 diabetes mellitus, had a physician's order dated 6/28/2024 indicating a Full Code status with instructions to have the resident sign the advanced directives form and place a copy in the medical record. However, during a clinical record review and interviews, it was found that the advanced directive paperwork was missing from both the paper and electronic medical records. An interview with an LPN on 1/29/25 revealed that the advanced directive sheets were not found in the medical record, and the LPN was unsure of the reason for their absence. The LPN indicated they would contact the nursing supervisor for further clarification. The nursing supervisor, an RN, was interviewed on 1/30/2025 and suggested that the papers might have been misplaced but assured that they would look for them when time allowed. The facility's policy on advanced directives requires that residents without advanced directives be provided with a handout upon admission, and the completed form should be filed in the medical record within 24 hours, which was not adhered to in this case.
Medication Mismanagement and Environmental Deficiencies
Penalty
Summary
The facility failed to ensure the safety and proper management of a resident's personal medication. Resident #173, who has a diagnosis of carcinoma in situ of the prostate and Type 2 diabetes mellitus, was found to have missing doses of Revlimid, a medication prescribed for myeloma. Despite being cognitively intact and independent in some activities, the resident's medication was not properly accounted for, leading to a discrepancy in the medication count. Interviews with staff revealed a lack of awareness and documentation regarding the missing medication, and the facility's policy on handling medications brought in by family members was not adequately followed. The facility also failed to maintain a safe and functional environment for two residents sharing a room. Residents #164 and #181 were found to have a non-functioning bathroom sink for 20 days, with a sign indicating it was leaking. The maintenance staff was unaware of the sign and the issue persisted due to a delay in obtaining necessary parts for repair. This resulted in staff having to use other residents' bathrooms to provide care, which was acknowledged as unacceptable by the Director of Nursing Services. Additionally, the facility did not ensure that resident furniture was maintained in proper working order. Resident #118's closet cabinet doors were observed to be peeling and unable to stay closed, and the dresser drawers were malfunctioning, posing a potential safety concern. The Director of Maintenance acknowledged the issues and indicated that repairs or replacements were necessary, but the deficiencies had not been addressed at the time of observation.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies to ensure the protection of residents following allegations of abuse. In the case of Resident #144, who was cognitively intact and required assistance with ambulation and toileting, an allegation was made against LPN #6 for inappropriate conduct. Despite the facility's policy requiring the removal of staff members named in abuse allegations from the schedule pending investigation, LPN #6 continued to work during the investigation period. The interim Director of Nursing Services (DNS) acknowledged the oversight but could not explain why the policy was not followed. In another incident, Resident #214 expressed concerns about the behavior of Resident #1, who had a history of dementia with behavioral disturbances and was known to exhibit aggression and combative behavior towards staff. Despite these concerns, the facility did not adequately monitor Resident #1's behavior to ensure they were not a danger to themselves or others. The facility's documentation failed to show that Resident #1 was evaluated by psychiatry until several days after the concerns were raised, leaving Resident #214 feeling threatened and requesting a room change. The facility's documentation and interviews revealed a lack of timely follow-up and monitoring of the residents involved, particularly in ensuring the safety and well-being of Resident #214. The facility did not provide evidence of consistent monitoring or psychiatric evaluation of Resident #1 to address the concerns raised by Resident #214, resulting in a deficiency in the facility's handling of abuse allegations and resident safety concerns.
Deficiencies in Care Planning for Dialysis and Sensory Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #111, who has end-stage renal disease and is dependent on dialysis. The care plan dated 12/20/2024 did not include specific interventions related to the resident's dialysis access site, which is crucial for their treatment. This oversight was identified during an interview and record review with a nursing supervisor, who acknowledged the absence of a specific care plan addressing the resident's dialysis needs. The facility's policy requires a comprehensive, person-centered care plan that meets the resident's physical, psychosocial, and functional needs, which was not adhered to in this case. Additionally, the facility did not address the sensory needs of Resident #109, who requires corrective lenses. The care plan dated 11/28/2024 failed to include interventions for the resident's eyeglasses, despite the resident being identified as needing them. Observations revealed that the resident had broken glasses, and despite informing the facility staff and the Ombudsman Office, no action was taken to address the issue. Interviews with social workers and nursing staff indicated a lack of communication and oversight, as the broken glasses were not documented or addressed in the resident's care plan.
Failure to Revise Care Plans for Urinary Retention and Incontinence
Penalty
Summary
The facility failed to revise the care plan for a resident with urinary retention after returning from an inpatient stay. The resident, who was cognitively intact, had a physician's order to begin voiding trials and perform bladder scans with intermittent catheterization if necessary. However, the care plan was not updated to include these interventions, and the nursing supervisor confirmed that all physician's orders and nursing interventions should be documented in the care plan. Another resident, who was cognitively intact and had diagnoses including diabetes mellitus and sepsis, was frequently incontinent of bowel and bladder. Despite being noted as frequently incontinent on assessments, there was no evidence of an evaluation for participation in a bowel and bladder retraining program. The resident expressed a preference for independence and did not use the bathroom or commode, instead using an adult incontinent brief. The care plan did not reflect the resident's preferences or include an evaluation for a retraining program. Interviews with staff revealed a lack of awareness and documentation regarding the residents' care needs and preferences. The facility's policy required a comprehensive, person-centered care plan to meet each resident's needs, but this was not adhered to in these cases. The nursing supervisor acknowledged the deficiencies and the need to revise the care plans to reflect the residents' current conditions and preferences.
Failure to Provide Required ADL Care for Resident
Penalty
Summary
The facility failed to provide necessary Activities of Daily Living (ADL) care to a resident who required assistance with toileting. The resident, who was cognitively intact and frequently incontinent of urine, was not offered incontinent care during the 11:00 PM to 7:00 AM shift. The resident reported that they were last provided care at 9:00 PM and were not checked on until 6:00 AM the following morning, resulting in the resident being soaked with urine. The Point of Care History confirmed that incontinent care did not occur during the night shift. The nursing assistant (NA #3) assigned to the resident during the night shift stated that they did not wake the resident for care unless the resident was awake and calling. This practice was contrary to the resident's care plan, which required assistance with transfers and toileting. The facility's policy directed that residents should be provided care to maintain their ability to carry out ADLs, including elimination and toileting needs. The interim Director of Nursing Services (DNS) confirmed that the resident was not offered toileting as required and provided education to the staff member involved.
Deficiencies in Pain Management and Appointment Coordination
Penalty
Summary
The facility failed to adequately address the pain management needs of a resident with a history of dysuria and bipolar disorder. The resident, who was cognitively intact, reported increasing pain and refused the offered acetaminophen, stating it would not alleviate the pain. Despite the resident's complaints of significant pain and refusal of the medication, the nursing staff did not conduct a thorough assessment or notify the appropriate medical personnel for further evaluation and potential adjustment of the pain management plan. The lack of communication and assessment led to the resident being told that the only alternative was to go to the hospital. In another incident, the facility failed to ensure a resident with cardiac issues attended a scheduled cardiologist appointment. The resident, who was dependent on staff for wheelchair mobility, missed the appointment due to the absence of a staff escort. Although the transport van arrived, the resident was unable to attend the appointment because the assigned escort was not present, and no alternative arrangements were made. The facility's policy did not provide a clear process for handling situations where an escort was unavailable, leading to the resident missing a critical medical appointment. These deficiencies highlight a lack of proper communication and coordination among the facility's staff, resulting in inadequate care and support for the residents. The failure to assess and address the resident's pain and the oversight in ensuring the resident's attendance at a medical appointment demonstrate significant lapses in the facility's operational procedures.
Failure to Follow Physician Orders and Assess Incontinence
Penalty
Summary
The facility failed to follow the discharge summary physician's order for a resident diagnosed with urinary retention. The resident, who was cognitively intact and required maximum assistance with personal hygiene, returned from the hospital with a diagnosis of urinary retention. The physician's order required bladder scans every six hours while awake and intermittent catheterization for post-void residual urine greater than 600. However, the facility did not have a bladder scanner, and there was no documentation of voiding trials, bladder scans, or intermittent catheterizations in the Treatment Administration Record. The nursing supervisor and unit secretary were unaware of the order, and the care plan did not include revised interventions for urinary retention. Another resident, who was frequently incontinent of bowel and bladder, was not assessed for participation in a bowel and bladder retraining program. The resident was cognitively intact, required substantial assistance for toileting, and was frequently incontinent. Despite being noted as frequently incontinent on the Minimum Data Set assessments, there was no evidence of an evaluation for a bowel and bladder program. The care plan included interventions for incontinence care but did not address retraining. Interviews with staff revealed a lack of documentation and awareness of the resident's incontinence management needs. The facility's policies for managing urinary retention and bowel and bladder programs were not followed. The policy for urinary retention included catheterization as appropriate, but this was not implemented due to the lack of a bladder scanner. The bowel and bladder program policy required assessment for participation in a program for residents with frequent incontinence, but this was not conducted for the resident in question. The deficiencies highlight a failure to adhere to physician orders and facility policies, resulting in inadequate care for residents with urinary and bowel incontinence issues.
Failure to Monitor Resident's Weight Accurately
Penalty
Summary
The facility failed to ensure timely and accurate weight monitoring for a resident at nutritional risk, leading to a deficiency in maintaining the resident's health. Resident #105, who had diagnoses including diabetes mellitus and abnormal weight loss, was readmitted to the facility on 9/11/2024. However, the facility did not obtain a readmission weight within the required 24 hours, as per their policy. Subsequent weights were not consistently recorded or verified, with invalid entries noted in November 2024, leaving no accurate monthly weight for that month. This lack of timely and accurate weight monitoring was critical for Resident #105, who was identified as being at nutritional risk. The facility's policy required reweights for any resident displaying a significant weight change, but this was not consistently followed. Despite the dietician's requests for reweights and discussions during at-risk meetings, the nursing staff did not obtain the necessary reweights promptly. The weight book lacked documentation for November 2024, and the computer system showed invalid weights that were not reverified. This failure to adhere to the facility's weight policy and ensure accurate weight monitoring contributed to the deficiency, as Resident #105 experienced significant weight fluctuations without appropriate intervention or documentation.
Failure to Maintain Respiratory Equipment Due to Power Outage
Penalty
Summary
The facility failed to ensure that respiratory equipment was in working condition for a resident with significant respiratory needs. Resident #78, who had a history of malignant neoplasm of the larynx, acute respiratory failure with hypoxia, and pulmonary hypertension, was left without power in their room, rendering their suction machine inoperable. The resident reported the power outage to staff on Friday, but the issue was not addressed until Monday. The resident's care plan required regular suctioning of the laryngectomy tube, which was compromised due to the lack of power. Interviews with various staff members revealed a lack of awareness and communication regarding the power outage. The maintenance staff identified the issue as a tripped breaker but did not ensure immediate resolution or communicate effectively with nursing staff. The Director of Maintenance and the DNS were unaware of the outage until it was brought to their attention by the surveyor. The facility lacked a policy on power outages, and there were no battery-powered suction machines available, leaving the resident at risk without a backup plan in place.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
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