Apple Rehab Laurel Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in East Haven, Connecticut.
- Location
- 451 North High Street, East Haven, Connecticut 06512
- CMS Provider Number
- 075389
- Inspections on file
- 37
- Latest survey
- April 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Apple Rehab Laurel Woods during CMS and state inspections, most recent first.
The facility did not consistently monitor or document the mood, behavior, or physical condition of residents involved in resident-to-resident abuse incidents, despite care plans and policy requiring such actions. Multiple residents with cognitive and psychiatric conditions were not assessed or documented for injuries or emotional distress on several shifts following altercations, and required monitoring orders were absent from physician directives and MARs.
A resident with cognitive and respiratory conditions was transferred to the hospital, leaving personal belongings at the facility. During the resident's absence and after their passing, a staff member accessed the resident's phone and PayPal account, transferring over $1,700 to themselves and attempting to change account details. The misappropriation was discovered by the resident's financial POA, and the facility's investigation confirmed the staff member's involvement.
A resident with cognitive and respiratory conditions was transferred to the hospital and later passed away. After the transfer, the resident's family discovered unauthorized financial transactions linked to a staff member. The facility initiated an internal investigation and suspended the implicated staff member, but failed to conduct a comprehensive investigation as required by policy, including obtaining statements from the accused, other staff, and residents.
A resident with multiple chronic conditions and significant ADL needs did not have complete nurse aide documentation in the electronic health record for several care areas, including elimination, eating, hygiene, and fluid intake, across multiple shifts. This occurred despite facility policy requiring CNAs to document care every shift, and the issue was acknowledged by the DNS as an ongoing compliance problem.
A resident with cognitive and mental health diagnoses, dependent on staff for toileting, was verbally abused by a nurse aide who became argumentative, raised her voice, and refused to leave the room or call a supervisor when requested. Audio evidence and witness accounts confirmed the aide's unprofessional conduct, resulting in fear and distress for the resident and roommate.
A resident with cognitive and psychiatric diagnoses reported an upsetting interaction with a nurse aide, providing a recording of the incident to an LPN. The LPN did not report the allegation to the Nursing Supervisor within the required timeframe and allowed the accused aide to continue working with other residents, contrary to facility policy requiring immediate reporting and suspension pending investigation.
A resident with severe cognitive impairment and total dependence for ADLs and transfers was sent alone by transportation to a medical appointment, despite care plan and facility policy requiring accompaniment. Due to a miscommunication about the appointment location and lack of staff or family presence, the resident was dropped off at the wrong address and later brought to the emergency department by an unknown individual, before being returned to the facility by family.
The report details several incidents of abuse and inadequate supervision within the facility. A resident with dementia and traumatic brain injury experienced staff abuse when an LPN forcefully administered medication, causing a cut on the resident's lip and using profanity. Another resident with hemiplegia and hemiparesis was involved in a physical altercation with a resident diagnosed with vascular dementia, who exhibited wandering behavior and struck the former in the face. Additionally, a resident with congestive heart failure was struck on the hand and hip during a confrontation initiated by the same resident with vascular dementia. These incidents highlight the need for adequate supervision and effective management of residents with behavioral disturbances.
The facility failed to conduct required background checks for newly hired licensed nurses and certified nurse aides, resulting in several employees starting work without completed ABCMS background checks, fingerprinting, and reference checks. The HR Coordinator confirmed the absence of these documents, and the Administrator expected all pre-hiring screenings to be completed per the facility's checklist.
The facility failed to properly label and date food items in the walk-in refrigerator and did not maintain the required concentration levels for sanitizing solutions used in the kitchen. Observations revealed unlabeled and outdated food, and sanitizing solutions tested below the required ppm levels due to a clogged metering tip.
The facility failed to conduct quarterly interdisciplinary care conferences with the resident representative for a resident with Alzheimer's and dementia. The resident representative only received phone updates from the social worker, and no progress notes were entered into the medical record. The MDS coordinator confirmed that attendance sheets often lacked signatures, indicating that required meetings were not held as per facility policy.
The facility failed to accurately document life support choices for a resident and did not review advance directives with another resident upon admission. One resident's code status was changed without proper consent, and another resident did not have any advance directive documentation reviewed or signed.
A resident with severe cognitive impairment and at risk for pressure ulcers developed a skin blister that was not promptly communicated to the APRN/physician or the resident's representative. Facility policies requiring immediate notification were not followed, leading to a delay in medical response and family notification.
A resident's Morphine Sulfate medication was misappropriated when it was borrowed for another resident on multiple occasions, contrary to facility policy. Staff interviews revealed a lack of awareness and adherence to the policy prohibiting the borrowing of controlled substances, leading to the misappropriation.
A facility failed to notify law enforcement of a staff-to-resident abuse incident involving a resident with dementia and other conditions. Multiple staff members witnessed an LPN forcefully administering medication, causing a cut on the resident's lip. Despite reporting the incident internally, the LPN continued to work for 2.5 hours, and the police were not notified, violating the facility's abuse policy.
A resident with dementia and other conditions was allegedly mistreated by an LPN, who forcefully administered medication and used profanity. Multiple staff members witnessed the incident and reported it, but the initial response from the RN was inadequate, and the LPN continued to work for 2.5 hours after the incident. The facility failed to follow its abuse policy, resulting in a deficiency.
The facility failed to complete timely social worker assessments for three residents, resulting in missed quarterly and annual assessments. Staff shortages and personal leave were cited as reasons for the delays.
The facility failed to update the PASARR for a resident with a new diagnosis of dementia. Despite multiple indications of the diagnosis in medical records and physician's orders, the Social Worker missed updating the PASARR, and the facility lacked a policy to ensure such updates. This oversight led to a deficiency in compliance with PASARR requirements.
The facility failed to complete required neurological assessments after multiple falls for two residents, did not ensure a physician's order for hospice services for a resident, and neglected to perform an RN assessment for a newly identified skin blister. Additionally, the facility did not follow physician's orders for repeated labs and failed to obtain weights according to policy for two residents.
The facility failed to monitor a resident's weight per physician's order, leading to significant weight loss over several months. Despite a history of stroke, hypertension, and diabetes, the resident's weights were not consistently documented weekly as required, resulting in an 11.1% weight loss over six months.
The facility failed to ensure proper labeling, dating, and storage of respiratory equipment for two residents. One resident's oxygen and nebulizer equipment were not labeled, dated, or bagged, while another resident's BiPaP tubing was not dated or bagged. Staff interviews confirmed that the facility's policies were not followed.
The facility failed to complete annual performance reviews for certified nurse aides, as evidenced by a personnel file showing no review for 2023. The DNS, who started in July 2023, acknowledged the backlog and developed a plan to address it.
The facility failed to document and monitor specific behaviors with the use of antipsychotic medication for two residents. One resident with paranoid schizophrenia and other diagnoses was prescribed Zyprexa, but behavior monitoring was not documented. Another resident with vascular dementia and other diagnoses was prescribed Seroquel, but behavior monitoring was inconsistently documented. The DNS and MD were unaware of these lapses, which violated the facility's policy requiring behavior monitoring every shift.
The facility failed to ensure complete and accurate documentation of neurological checks and RN assessments following unwitnessed falls for a resident with dementia and repeated falls. The clinical records did not reflect the initiation of neurological checks or vital sign monitoring after multiple falls, as required by the facility's policy. Interviews with the DNS revealed concerns about the clinical documentation and confirmed that comprehensive RN assessments and updated vital signs should have been completed following each fall.
A resident with Alzheimer's and dementia receiving hospice care had an incomplete medical record, missing the hospice election form and physician certification of terminal illness. Interviews revealed confusion and lack of communication regarding responsibility for obtaining these documents, and the facility lacked a policy for required hospice documentation.
The facility failed to ensure timely completion and transmission of MDS assessments for three residents, leading to significant delays. The Director of MDS coordinators cited increased workload and insufficient staffing as primary reasons for the delays. The Administrator was aware of the issue and was in the process of hiring additional MDS coordinators.
Observations revealed missing signatures on narcotic count sheets for multiple shifts across various units. Staff interviews indicated a lack of awareness and adherence to the protocol of counting and signing off on controlled substances at the beginning and end of each shift. The DON acknowledged awareness of the issue.
Failure to Monitor and Document Resident Status After Abuse Incidents
Penalty
Summary
The facility failed to ensure that residents involved in resident-to-resident abuse incidents were properly monitored for injuries, mood, and behaviors as required by facility policy and care plans. For four residents with varying degrees of cognitive impairment and psychiatric diagnoses, documentation and monitoring were not consistently completed following altercations. Specifically, after incidents where residents were struck or involved in altercations, there was a lack of documented assessments regarding their mood, behavior, and physical condition on multiple shifts over several days. For example, one resident with vascular dementia and a history of traumatic brain injury was involved in an altercation and subsequently had interventions listed in the care plan, including RN assessment and monitoring for mental distress. However, there were no physician orders or MAR entries for mood or behavior monitoring, and nurses' notes lacked documentation of these assessments on several shifts following the incident. Similar deficiencies were observed for other residents involved in altercations, including those with severe cognitive impairment and mood disorders, where care plans called for monitoring and support, but documentation and orders for such monitoring were absent. Interviews with facility leadership confirmed that nursing staff were expected to monitor and document mood, behavior, and skin condition for all residents involved in such incidents every shift for 72 hours. Despite this expectation, the Director of Nursing was unaware that monitoring and documentation were not completed consistently and acknowledged that education and audits regarding this requirement were lacking. Review of facility policy also indicated that staff should observe, intervene, and monitor residents following abuse incidents, but these actions were not consistently documented or carried out.
Misappropriation of Resident Property and Funds by Staff Member
Penalty
Summary
A deficiency occurred when a staff member misappropriated a resident's personal belongings and funds. The resident, who had acute respiratory failure with hypercapnia and a cognitive communication deficit, was admitted with personal items including an iPhone and iPad. After experiencing a medical emergency, the resident was transferred to the hospital and did not return, ultimately passing away. The resident's belongings, including the cell phone, remained at the facility following the transfer. Subsequently, the resident's financial Power of Attorney discovered unauthorized financial transactions from the resident's PayPal account, which was accessed via the resident's cell phone. These transactions, totaling approximately $1,735, were traced to a staff member whose contact information matched the PayPal account receiving the funds. The facility's internal investigation confirmed that the staff member had access to the resident's belongings during the period in question. Additionally, there were attempts to change the billing address and request a credit card in the resident's name, further indicating misuse of the resident's property and financial information. The facility's review of staff schedules and interviews revealed that the implicated staff member worked multiple shifts during the relevant period and that another staff member with a matching address was also employed, though no direct involvement was established for the second individual. The facility's abuse policy defined misappropriation as the deliberate misuse or theft of a resident's belongings or money without consent, and the events described met this definition. The deficiency was further compounded by the lack of interviews with other staff, residents, or representatives to determine if additional residents were affected.
Failure to Fully Investigate Allegation of Misappropriation of Resident Property
Penalty
Summary
The facility failed to fully investigate an allegation of misappropriation of money involving a resident who was admitted with acute respiratory failure and cognitive communication deficit. The resident was alert and oriented at admission, required assistance with activities of daily living, and brought personal electronic devices to the facility. After being transferred to the hospital for an acute change in condition, the resident did not return and subsequently passed away. The resident's family later reported unauthorized financial transactions from the resident's PayPal account, which were linked to a staff member's contact information. The facility initiated an internal investigation, notified the police, and suspended the implicated staff member. Despite these initial actions, the investigation was incomplete. The facility did not obtain statements from the accused staff member, other staff, other residents, or resident representatives. Key personnel, such as the social workers, were not involved in the investigation and were not instructed to conduct interviews or assist in gathering information. The investigation did not include interviews with other staff or residents to determine if additional individuals were affected by misappropriation, and there was no evidence that the facility attempted to contact all relevant parties. The facility's abuse policy required a thorough investigation, including interviews with all witnesses and individuals with relevant information, but this was not followed. Interviews with facility leadership confirmed that a full investigation should have been conducted, including interviews with other staff, residents, and their representatives. However, these steps were not taken, and the investigation was limited to the initial report and suspension of the accused staff member. The failure to conduct a comprehensive investigation as outlined in facility policy resulted in a deficiency related to the facility's response to an allegation of misappropriation of resident property.
Incomplete Documentation of Resident Care by Nurse Aides
Penalty
Summary
The facility failed to ensure complete and consistent documentation in the clinical record for a resident with multiple complex medical conditions, including type 2 diabetes mellitus with hyperglycemia, congestive heart failure, obesity, and muscle weakness. The resident required significant assistance with activities of daily living (ADLs) such as eating, toileting hygiene, showering, personal hygiene, bed mobility, and transfers, as identified in the admission MDS and care plan. Despite these needs, a review of the March 2025 documentation survey report revealed multiple instances where nurse aide documentation was missing for key care areas, including bladder and bowel elimination, eating, personal hygiene, showering, toileting hygiene, amount eaten, bowel and bladder diary, fluid intake, and output across several dates and shifts. The facility's policy required CNAs to complete flow sheets in the electronic health record for each resident every shift, documenting all care provided. However, interviews with the DNS confirmed that nurse aide compliance with documentation was inconsistent and ongoing education was being provided to address missing entries. The lack of complete documentation was observed despite the resident's complex care needs and the facility's established procedures for record-keeping. The resident in question was ultimately transferred to the emergency department following a change in condition and did not return to the facility.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A resident with schizoaffective disorder, cognitive communication deficit, and anxiety, who was dependent on staff for toileting, experienced verbal abuse from a nurse aide during an overnight shift. The resident had requested assistance for incontinence care and, after a significant delay, questioned the aide about the wait. The interaction escalated, with the aide becoming argumentative and raising her voice. Audio evidence confirmed that the aide refused to leave the room when repeatedly asked by the resident, declined to summon a supervisor as requested, and continued to provide care despite the resident's objections. The resident and their roommate both reported feeling fearful during the incident, and the roommate described the aide as rude and was concerned for the resident's safety. Facility documentation and interviews corroborated the resident's account, including a statement from the aide admitting to raising her voice and failing to excuse herself or seek a nurse's intervention. The facility's abuse policy strictly prohibits any mistreatment of residents, yet the aide's actions did not align with expected standards of professionalism and resident care. The incident was reported, investigated, and substantiated as a failure to protect the resident from verbal abuse by staff.
Failure to Timely Report and Respond to Alleged Verbal Abuse
Penalty
Summary
A deficiency occurred when an allegation of staff-to-resident verbal abuse was not reported to the facility Administrator or designee within two hours as required. A resident with schizoaffective disorder, cognitive communication deficit, and anxiety reported an upsetting interaction with a nurse aide during the overnight shift. The resident played a recorded audio of the incident for the charge nurse (LPN), who then provided care to the resident for the remainder of the shift and instructed the nurse aide not to care for that resident further. However, the nurse aide was allowed to continue caring for other residents, and the charge nurse did not report the incident to the Nursing Supervisor. The facility's abuse policy requires immediate reporting of any abuse or mistreatment to a supervisor and immediate suspension of the accused individual pending investigation. Despite this, the charge nurse did not escalate the allegation as required, citing the resident's preference not to report the incident. The incident was only brought to the attention of facility leadership later, after another staff member became aware of the recording and reported it. The delay in reporting and failure to immediately remove the accused staff member from duty with all residents constituted noncompliance with facility policy and regulatory requirements.
Resident Sent Unaccompanied to Medical Appointment, Resulting in Drop-Off at Wrong Location and Emergency Department
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependent on staff for activities of daily living (ADLs) and transfers, was sent unaccompanied to a medical appointment in the community. The resident had diagnoses including mild cognitive impairment, seizures, diabetes mellitus, peripheral vascular disease, and bipolar disorder, and was identified as having a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The care plan specified that the resident should be accompanied to medical appointments as necessary, but there was no leave of absence (LOA) order documented in the clinical record for this outing. On the day of the incident, the resident was picked up by a transportation company and sent out alone for a vascular appointment. The appointment location had been changed, but this information was not communicated to the facility prior to the resident's departure. Facility staff attempted to contact the resident's family before the resident left but were unsuccessful. The resident's family was not present at the facility at the time of departure, and no staff member was assigned to accompany the resident, contrary to facility policy and care plan directives. As a result, the resident was dropped off at the wrong location and subsequently transported by an unknown person to the emergency department. The emergency department noted that the resident arrived alone, was unable to provide history due to cognitive impairment, and only had paperwork indicating their medical history and facility of origin. The resident was later returned to the facility by a family member. Interviews with facility staff and the medical director confirmed that the resident should not have been sent out unaccompanied and that established procedures for ensuring supervision during offsite appointments were not followed.
Instances of Resident Abuse and Inadequate Supervision Leading to Physical Altercations
Penalty
Summary
The report details instances of abuse and inadequate supervision leading to physical altercations involving several residents at the facility. Resident #31, diagnosed with dementia and traumatic brain injury, was subjected to staff abuse when LPN #8 forcefully administered medication, resulting in a cut on the resident's lip. LPN #8 was reported to have used profanity during the incident. Resident #62, with hemiplegia and hemiparesis, engaged in a resident-to-resident altercation with Resident #74, resulting in physical contact between the two residents. Resident #74, diagnosed with vascular dementia, exhibited wandering behavior and engaged in altercations with other residents, including striking Resident #62 in the face. Resident #76, admitted with congestive heart failure, was involved in an incident with Resident #74, where Resident #76 was struck on the hand and hip during a confrontation initiated by Resident #74's delusions. The facility's failure to ensure adequate supervision and prevent abuse is evident in the detailed accounts of the altercations. LPN #8's actions towards Resident #31, including forcefully administering medication and using inappropriate language, highlight a lack of proper care and respect for the resident. The altercation between Resident #62 and Resident #74 underscores the need for enhanced supervision and interventions to prevent resident-to-resident conflicts. Resident #74's behaviors, including wandering and engaging in altercations, point to a lack of effective monitoring and management of residents with behavioral disturbances, leading to incidents of physical harm.
Failure to Conduct Required Background Checks for New Hires
Penalty
Summary
The facility failed to conduct required background checks for newly hired licensed nurses and certified nurse aides prior to hire. Specifically, the personnel files for several employees, including two nurse aides, two registered nurses, and one licensed practical nurse, lacked documentation of completed background checks. This includes missing ABCMS background checks, fingerprinting, and reference checks. The HR Coordinator, who started at the facility three months prior to the survey, confirmed the absence of these required documents in the personnel files and acknowledged that employees should not have started working without these checks being completed first. The HR Coordinator identified that the facility's pre-hire checklist mandates several screenings and verifications, including license/certification copies, sex offender registry checks, exclusion screening verification, ABCMS background checks, third-party background checks, and reference checks. However, these requirements were not met for the employees in question. The HR Coordinator also noted that he has begun auditing employee files to ensure compliance with these pre-hire requirements moving forward. The Administrator, who began her employment at the facility a few months prior to the survey, expressed that her expectation was for all pre-hiring screenings, including background checks, to be completed in accordance with the facility's pre-hire checklist. Despite this expectation, the facility's failure to adhere to its own policies and procedures resulted in the hiring of staff without the necessary background checks, potentially compromising the safety and well-being of the residents.
Food Storage and Sanitization Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, several food items in the walk-in refrigerator were found not labeled or dated, including pancakes, salad mix, puree pancake mix, puree eggs, a brown liquid, diced fruit, cookies, and a pie. Cook #1 acknowledged that all prepared foods must be labeled and dated and discarded after three days, but this was not adhered to in practice. Additionally, the facility's policy for prepared foods was not provided upon request. Further observations revealed that the sanitizing solution used for cleaning countertops and washing pots and pans was not at the required concentration levels. The sanitizing water in the 3-bay sink and red buckets tested between 0-100 ppm, significantly below the required 400-600 ppm. The Director of Dietary identified an issue with the sanitizing chemical line, which was not flowing properly, and contacted the vendor for repair. The service report confirmed that the metering tip was clogged and replaced, restoring the sanitizer to 200 ppm, which is still below the required level since COVID-19 adjustments.
Failure to Conduct Interdisciplinary Care Conferences
Penalty
Summary
The facility failed to conduct an interdisciplinary care conference at least quarterly with the resident representative for Resident #16, who was admitted with Alzheimer's disease and dementia. The significant change of condition MDS assessment indicated that Resident #16 had severely impaired cognition, frequent incontinence, and required extensive assistance with various activities of daily living. Despite these needs, the resident representative reported that they only received phone calls from the social worker every three months and had not attended a meeting with the entire interdisciplinary team in at least the last year. The social worker confirmed that while she tried to meet with the IDT, it was usually just her providing updates via phone calls since COVID-19, and no progress notes from these meetings were entered into the electronic medical record. The MDS coordinator indicated that she was responsible for scheduling care conferences and mailing out invites to families, but acknowledged that the attendance sheets often did not have signatures from the resident representative or other departments. The facility's Care Planning Policy requires a comprehensive and individualized plan of care developed by the IDT in collaboration with the resident and/or their representative, with care conferences held at least quarterly. However, the review of the sign-in sheets and interviews revealed that the interdisciplinary team meetings were not being conducted as required, and the resident representative was not adequately involved in the care planning process as stipulated by the facility's policies and the Resident Rights Policy.
Failure to Document and Review Advance Directives
Penalty
Summary
The facility failed to accurately document the life support choices for Resident #43 and did not ensure that advance directives were reviewed with Resident #315 upon admission. Resident #43 was admitted with severe cognitive impairment and had a conservator who initially chose CPR. However, during a hospital stay, the conservator and family decided to change the code status to DNR, which was not properly documented upon readmission to the facility. The Director of Nursing Services (DNS) confirmed that the code status should not have been changed without proper consent from the conservator, and there was a gap between the physician's order and the signed advance directive consent form. For Resident #315, the facility did not review or obtain signatures for advance directives and other consents upon admission. The resident, who had intact cognition, confirmed that no information related to advance directives had been reviewed or signed since admission. The admission checklist indicated that the review of code status and consents was incomplete. Interviews with the nursing staff revealed that it was the responsibility of the admitting nurse to ensure all admission documentation, including advance directives, was completed. However, this was not done for Resident #315. The facility's policy on advance directives requires that the resident be provided with the policy and education on advance directives upon admission, and that the advance directives form be signed and dated by the resident and the person who reviewed the directives. This policy was not followed for both Resident #43 and Resident #315, leading to deficiencies in documenting and reviewing advance directives for these residents.
Failure to Notify Physician and Family of New Skin Blister
Penalty
Summary
The facility failed to ensure timely notification of the APRN/physician and resident representative regarding a newly identified skin blister for Resident #66. Resident #66, who had severe cognitive impairment, was at risk for pressure ulcers, and was dependent on staff for transfers and rolling, developed a superficial dime-sized blister on the left hip. The nurse's note documented the blister and notified the nursing supervisor, but the APRN was only informed through a note in the communication book, which may not have been seen until the following Monday. The facility's policy required immediate notification of the attending physician and responsible party for significant changes in a resident's condition, which was not followed in this case. The nurse's notes from the date the blister was identified until the end of the month did not indicate that Resident #66's responsible party was notified of the change in skin condition. The wound specialist later noted that the blister had developed into a full-thickness wound, requiring specific treatment orders. Interviews with the DNS and APRN confirmed that the facility's communication process was not followed correctly, as the on-call provider should have been notified immediately. The facility's policies on Change in Resident Condition and Pressure Ulcer Prevention were not adhered to, leading to a delay in appropriate medical response and family notification.
Misappropriation of Controlled Substance Medication
Penalty
Summary
The facility failed to ensure that Resident #20 was free from misappropriation of a Schedule II Controlled Drug medication. Resident #20, who was admitted with Alzheimer's disease and vascular dementia, had Morphine Sulfate 100 mg/5 ml Solution prescribed for pain and shortness of breath. On 12/3/23, it was documented that 0.25 ml, 0.50 ml, and another 0.5 ml of the medication were borrowed for another resident, with two licensed staff signatures on the Controlled Substance Disposition Record (CSDR) for each instance. The facility's policy prohibits borrowing controlled substances from one resident to administer to another, and the licensed nurses are required to notify the supervisor and pharmacy if the medication is unavailable. However, this protocol was not followed in this case. Interviews with the facility staff revealed a lack of awareness and adherence to the policy. The Administrator was unaware of the borrowing incidents, and RN #1, who had been employed since October 2023, admitted to not knowing that borrowing controlled substances was prohibited until early 2024. The Director of Nursing Services (DNS) and the Medical Director also confirmed that borrowing controlled substances is against policy and that alternative measures should have been taken, such as checking the Omnicell or contacting the pharmacy and physician for further orders. The facility's abuse/resident policy and the Verification: Access to and administration of controlled substances form both clearly state that borrowing controlled substances is not allowed, yet these guidelines were not followed, leading to the misappropriation of Resident #20's medication.
Failure to Report Staff-to-Resident Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that local law enforcement was notified of a staff-to-resident abuse incident as per facility policy. Resident #31, who had diagnoses including dementia, traumatic brain injury, and dysphasia, was allegedly abused by LPN #8. The incident involved LPN #8 forcefully administering medication to Resident #31, resulting in a cut on the resident's lip. Multiple staff members witnessed the incident and reported it to RN #4, who did not take immediate action to address the situation or notify the police. LPN #8 continued to work for 2.5 hours after the incident, placing other residents at risk. The care plan for Resident #31 included interventions to report incidents to family and physician, watch for signs of distress, and investigate per facility policy. However, the facility's response was inadequate. Despite the severity of the allegations, including the use of profanity and physical aggression by LPN #8, the police were not notified, and the LPN was allowed to continue working. Statements from multiple staff members corroborated the incident, describing how LPN #8 held down Resident #31's arm and forcefully administered medication while the resident resisted and cried. The facility's abuse policy mandates immediate reporting of any alleged abuse to a supervisor and notification of the resident's representative, physician, DPH, and local police. However, this protocol was not followed. The incident was reported to the APRN and documented, but the failure to notify law enforcement and the delayed removal of LPN #8 from duty constituted a significant deficiency in the facility's handling of the abuse allegation.
Failure to Protect Resident from Potential Mistreatment
Penalty
Summary
The facility failed to protect Resident #31 from potential mistreatment following an allegation of abuse. Resident #31, who has diagnoses including dementia, traumatic brain injury, and dysphasia, was allegedly mistreated by LPN #8. The incident involved LPN #8 forcefully administering medication to Resident #31, holding the resident's wrist down, and using profanity in Spanish. Multiple staff members witnessed the incident and reported it to RN #4, who did not take immediate action to address the situation. LPN #8 continued to work for 2.5 hours after the incident, placing residents at further risk. The care plan for Resident #31 included interventions to report incidents to family and physician, watch for signs of distress, and investigate per facility policy. However, the facility did not notify the police, and the initial response from RN #4 was inadequate. Despite multiple staff members reporting the incident, RN #4 did not take the allegations seriously, and LPN #8 was not immediately suspended. The facility's abuse policy mandates immediate reporting and suspension of the accused individual, which was not followed in this case. Interviews with staff members revealed that Resident #31 was visibly distressed, crying, and had a cut on the lip following the incident. The facility's failure to act promptly and appropriately in response to the abuse allegation resulted in a deficiency. The facility's documentation and interviews indicate that the abuse policy was not adhered to, and the resident was not adequately protected from potential mistreatment.
Failure to Complete Timely Social Worker Assessments
Penalty
Summary
The facility failed to complete comprehensive social worker assessments in a timely manner for three residents. Resident #10, who was admitted with diagnoses including atrial fibrillation, anxiety, major depression, and paranoid schizophrenia, had only one social services assessment completed nearly two years after admission. The social worker admitted to being behind on assessments due to workload and staff shortages, resulting in missed quarterly and annual assessments for Resident #10 from the time of admission until over a year later. Resident #16, admitted with Alzheimer's disease and dementia, also did not receive timely social worker assessments. The clinical record showed no quarterly or annual assessments from the time of admission until the survey date, with only progress notes being completed. The social worker responsible for Resident #16 acknowledged the missed assessments and cited staff shortages and personal leave as reasons for the delays. Resident #31, admitted with a stroke and dementia, had only one social worker assessment completed at the time of admission. Subsequent quarterly and annual assessments were not completed, with the social worker attributing the delays to extended personal leave and an overwhelming workload. The facility's administrator was aware of the issue and was in the process of hiring additional staff to address the backlog of assessments.
Failure to Update PASARR for Resident with New Dementia Diagnosis
Penalty
Summary
The facility failed to ensure the PASARR was updated for Resident #5 when there was a significant change in condition. Resident #5, who was admitted with diagnoses including dementia, major depression, and schizoaffective disorder, had a PASARR dated 3/23/17 that did not include a diagnosis of dementia. Despite the hospital discharge summary and physician's orders indicating a diagnosis of dementia, the PASARR was not updated upon admission or during subsequent evaluations. The Social Worker responsible for updating the PASARR missed the dementia diagnosis on multiple occasions, including during the psychiatric provider's follow-up on 10/26/22. Interviews with the Social Worker and the Administrator revealed that the Social Worker was responsible for updating the PASARR but failed to do so due to oversight. The Administrator confirmed that the diagnosis of dementia was not communicated effectively to the Social Worker. Additionally, the facility did not have a policy regarding the updating of PASARRs, contributing to the oversight. As a result, Resident #5's PASARR was not updated to reflect the new diagnosis of dementia, leading to a deficiency in the facility's compliance with PASARR requirements.
Multiple Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure neurological assessments were completed after multiple falls for two residents. Resident #10 experienced several unwitnessed falls, and despite the facility's policy requiring neurological checks for such incidents, these assessments were not documented. The Director of Nursing Services (DNS) confirmed that the neurological assessments were not completed as per the facility's policy, which mandates checks every 15 minutes for the first hour, then hourly for four hours, every four hours for 24 hours, and every shift for 48 hours. Similarly, Resident #48 had multiple unwitnessed falls, and the clinical record lacked documentation of neurological checks following these incidents. The DNS acknowledged issues with the responsible nurse's documentation and confirmed that the required assessments were not performed consistently as per the facility's policy. The facility also failed to ensure a physician's order for hospice services for Resident #16. Despite the social worker's notes indicating that the resident was evaluated and admitted to hospice services, the clinical record did not reflect a physician's order for hospice evaluation and treatment. The DNS confirmed that nursing was responsible for obtaining the order, which was missing from the clinical record until the surveyor's inquiry prompted a late entry. Additionally, the facility did not complete an RN assessment for a newly identified skin blister on Resident #66. The nurse's notes indicated the presence of a superficial area on the resident's left hip, but there was no documentation of an RN assessment until the wound specialist's evaluation days later. The DNS confirmed that an RN assessment should have been conducted and documented immediately upon recognizing the new wound. Furthermore, the facility failed to follow physician's orders for obtaining repeated labs for Resident #104 and did not obtain weights according to policy for Residents #2 and #315. The DNS and other staff acknowledged these lapses in following the facility's protocols and physician's orders.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure that weights were monitored per physician's order for a resident with a significant weight loss. Resident #94, who had a history of stroke, hypertension, and diabetes, was admitted with an order for weekly weights and vital signs. Despite this order, the facility did not consistently document the resident's weight on a weekly basis. The resident experienced a significant weight loss over several months, with weights recorded sporadically and not in accordance with the physician's order. The resident's weight dropped from 149.6 lbs in early March to 124.1 lbs by mid-March of the following year, indicating an 11.1% weight loss over six months. The facility's policy required weights to be obtained upon admission, weekly for four weeks, and then monthly unless otherwise directed by a physician's order. However, this policy was not followed for Resident #94, leading to a failure in monitoring the resident's nutritional status adequately. Interviews with the Medical Director and the Director of Nursing Services (DNS) revealed that the facility was aware of the resident's weight loss but did not ensure that weights were obtained as ordered. The DNS was unaware of the weekly weight orders and could not explain why the weights were not documented as required. The facility's failure to adhere to its own policy and the physician's orders resulted in inadequate monitoring of the resident's nutritional status, contributing to the resident's significant weight loss over time.
Failure to Properly Label, Date, and Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of respiratory equipment for two residents. Resident #49, who had diagnoses including dementia, hypertension, and Covid-19, was observed with oxygen tubing and nebulizer equipment that were not labeled, dated, or bagged as per facility policy. Interviews with LPN #1 and RN #1 confirmed that there were no physician orders for changing the oxygen and nebulizer tubing and mask, and that the equipment should have been labeled and dated. The DNS also confirmed that the equipment should be bagged when not in use to maintain cleanliness. Resident #268, diagnosed with metabolic encephalopathy, COPD, and dementia, was observed with BiPaP tubing that was not dated or bagged. LPN #6 acknowledged that the night shift should have updated the tubing and provided a bag. The DNS confirmed that the tubing should be changed weekly, labeled with the date, and bagged when not in use. The facility's policy on BiPaP/CPAP care and oxygen and nebulizer tubing changes was not followed, leading to the deficiencies observed during the survey.
Failure to Complete Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete annual employee performance reviews for certified nurse aides. Specifically, the personnel file of a certified nurse aide hired on 9/1/21 showed no performance review for the year 2023. The Director of Nursing Services (DNS), who began employment in July 2023, acknowledged that there were outstanding performance reviews and had developed a plan to address the backlog. The facility's policy mandates formal and documented performance reviews at the end of an employee's introductory period and annually thereafter.
Failure to Document and Monitor Behaviors with Antipsychotic Medication
Penalty
Summary
The facility failed to document and monitor specific behaviors with the use of antipsychotic medication for two residents. Resident #10, who was admitted with diagnoses including paranoid schizophrenia, major depressive disorder, anxiety disorder, and sleep disorder, was prescribed Zyprexa for anxiety. However, the Medication Administration Record (MAR) from 2/1/24 to 3/14/24 did not reflect documentation for specific behavior monitoring for the use of this antipsychotic medication. The Director of Nursing Services (DNS) was unaware that Resident #10's behavior was not being monitored daily, contrary to the facility's policy which requires behavior monitoring every shift for residents receiving antipsychotic medications. Resident #74, admitted with diagnoses including vascular dementia with behavioral and mood disturbances, psychotic disturbance, and anxiety, was prescribed Seroquel for dementia, delusions, and combativeness. The MAR from 1/1/24 to 3/8/24 failed to reflect consistent documentation of Resident #74's behaviors every shift. Despite a physician's order to monitor behaviors every hour for 48 hours starting on 1/14/24, the MAR and nurse's notes did not document Resident #74's behaviors during several shifts. The DNS was also unaware that Resident #74's behavior was not being monitored daily, as required by the facility's policy. Interviews with the DNS and MD #1 revealed that they were not aware of the lack of behavior monitoring for both residents. The facility's policy on behavior monitoring and antipsychotic medications mandates that specific target behaviors be identified and monitored every shift, with documentation on behavior flow sheets. The failure to adhere to this policy resulted in the deficiency noted in the report.
Failure to Document Neurological Checks and RN Assessments
Penalty
Summary
The facility failed to ensure complete and accurate documentation related to neurological checks and RN assessments following unwitnessed falls for Resident #48. The resident, who had diagnoses including dementia, repeated falls, and psychophysical visual disturbances, experienced multiple unwitnessed falls. The clinical records did not reflect the initiation of neurological checks or vital sign monitoring after these falls, as required by the facility's policy. Specifically, there were discrepancies in the documentation of falls on 9/2/23, with conflicting notes about whether the resident hit their head, and no additional documentation of neurological checks or vital sign monitoring was found for falls on 9/8/23, 9/11/23, and 9/22/23. The care plan for Resident #48, dated 9/4/23, identified a history of falls and included interventions such as offering toileting and incontinent care during the 3 PM-11 PM shift. Despite this, the clinical record showed that the resident had multiple unwitnessed falls, with no documentation of neurological checks or vital sign monitoring following these incidents. The admission MDS assessment indicated that the resident had severely impaired cognition, was frequently incontinent, and required assistance with transfers, toileting, and dressing. The resident had two or more falls with injury since admission. Interviews with the DNS revealed concerns about RN #10's clinical documentation and acknowledged that the documentation related to the falls on 9/2/23 appeared to be duplicate entries. The DNS confirmed that comprehensive RN assessments and updated vital signs should have been completed following each fall, and neurological checks should have been conducted per facility policy. The facility policy directed that neurological checks should be initiated for unwitnessed falls or head injuries and that these checks should be documented in the resident's medical record. However, the clinical records for Resident #48 did not reflect adherence to these policies, leading to incomplete and inaccurate documentation of the resident's condition following falls.
Incomplete Hospice Documentation for Resident
Penalty
Summary
The facility failed to maintain a complete medical record for a resident receiving hospice care. Specifically, the medical record for a resident with Alzheimer's disease and dementia did not include the hospice election form and the physician certification of terminal illness. The care plan indicated that the resident was receiving hospice care, but the necessary documentation was missing. Interviews with the Director of Nursing Services (DNS), Business Office staff, and Social Worker revealed that there was confusion and lack of communication regarding who was responsible for obtaining and maintaining these documents. The Business Office staff had requested the necessary forms from the hospice agency but had not received them in a timely manner. The hospice contract with the facility required that all services provided to hospice residents be documented accurately and promptly. However, the facility did not have a policy in place for required documentation from hospice services. The Business Office staff eventually received the consent and election of hospice benefit form, but it was not available at the time of the survey. This deficiency highlights a gap in the facility's process for managing hospice documentation, leading to incomplete medical records for residents receiving hospice care.
Delayed MDS Assessments and Transmissions
Penalty
Summary
The facility failed to ensure the timely completion and transmission of quarterly MDS assessments for three residents. Resident #10, who had diagnoses including atrial fibrillation, anxiety, major depression, and paranoid schizophrenia, had significant delays in the completion and transmission of MDS assessments. The significant change in condition MDS assessment was completed 22 days late and transmitted 14 days late, while the quarterly MDS assessment was completed 25 days late and transmitted 14 days late. RN #6, the Director of MDS coordinators, acknowledged these delays and attributed them to an increased workload due to the state optional MDS assessment for increased payment. Resident #16, diagnosed with Alzheimer's disease and dementia, also experienced delays in MDS assessments. The quarterly MDS assessment was completed 26 days late and transmitted 12 days late, while another quarterly MDS assessment was completed 18 days late and had not been transmitted as of the interview date. Resident #31, with diagnoses including stroke and dementia, had multiple instances of late MDS assessments, with delays ranging from 8 to 33 days for completion and up to 26 days for transmission. RN #6 indicated that the increased workload and lack of sufficient MDS coordinators were the primary reasons for these delays. The Administrator was aware of the issue and was in the process of hiring additional MDS coordinators to address the problem. The facility did not provide a policy for MDS assessments and transmission, but they followed state and federal requirements.
Inconsistent Shift-to-Shift Controlled Drug Counts
Penalty
Summary
The facility failed to consistently complete shift-to-shift controlled drug counts as required. Observations on March 11, 2024, revealed missing signatures on narcotic count sheets for multiple shifts across various units. Interviews with staff members indicated a lack of awareness and adherence to the protocol of counting and signing off on controlled substances at the beginning and end of each shift. The Director of Nursing Services acknowledged being aware of the issue and had implemented an educational form to reinforce the importance of accurate narcotic counts and documentation by licensed nurses.
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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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