Apple Rehab Middletown
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Connecticut.
- Location
- 600 Highland Ave, Middletown, Connecticut 06457
- CMS Provider Number
- 075089
- Inspections on file
- 26
- Latest survey
- December 11, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Apple Rehab Middletown during CMS and state inspections, most recent first.
A resident who was alert, oriented, and dependent on staff for care was subjected to inappropriate language by a nurse aide, who called the resident a "pain in the butt" during a disagreement about wheelchair equipment. This comment, witnessed by other staff and reported to social services, made the resident feel uncomfortable and disrespected, violating the requirement to treat residents with dignity and respect.
A resident with behavioral health diagnoses had a verbal altercation with a nurse aide, which was documented by an RN but not immediately reported to the DON or state agency as required. The incident was only reported the next day after administrative review, resulting in a delay in investigation and notification.
The facility failed to complete medication self-administration assessments as per policy for two residents receiving medication-assisted therapy. One resident, with opioid use and psychoactive substance abuse, did not have an updated assessment, while another, on methadone, required assistance to open medication despite being assessed as independent. Assessments were only updated after surveyor inquiry.
The facility failed to ensure medication availability and administration for a resident with liver cirrhosis, resulting in missed doses. Additionally, there were significant documentation gaps in shower provision for three residents requiring assistance, and a lack of admission body audit for a resident with existing wounds. Another resident did not receive a prescribed anti-fungal medication due to authorization issues, despite staff documenting it as administered. Lastly, the facility did not consistently monitor a resident's output as per the care plan.
The facility failed to maintain its dry food storage area free from insects, as uncovered ripe bananas in the storage room attracted fruit flies. The pest control logs had recommended covering bananas, but this was not communicated to the kitchen staff. The Dietary Director and Maintenance Director were unaware of the recommendation, leading to the infestation.
The facility failed to ensure call bells were within reach for three residents, leading to a deficiency. A resident with Parkinson's and dementia was unable to find the call bell, which was wrapped around a siderail. Another resident with polyarthritis and urge incontinence, and a third resident with severe cognitive impairment and fractures, also had call bells out of reach. The facility's policy requires call bells to be easily accessible, which was not followed.
The facility did not provide timely written responses to residents' concerns about call bells being within reach and staff response times, as noted in Resident Council meetings. From January to August 2024, these issues were not addressed until September. The Recreation Director acknowledged the existence of a form for documenting concerns but admitted it was not consistently used, with only two completed forms available and no written responses for the concerns raised during this period.
A facility failed to obtain and review advanced directives for a resident with severe dementia, resulting in a blank advanced directive form and no code status in the electronic record. Staff interviews revealed that frequent absences of MDS staff led to the oversight, and the resident was considered a Full Code by default.
A resident was prescribed Kerasal Nail Renewal for toenail fungus, but the medication was never dispensed or administered due to a lack of communication between the facility and the pharmacy. Nursing staff incorrectly signed off on the MAR, and the APRN was not informed of the issue until it was identified by a surveyor.
A resident with mild dementia was physically abused by their roommate, who has a history of aggression. The incident involved the roommate punching the resident's hands, witnessed by a Nurse Aide who intervened. Despite the facility's policy against abuse, the event occurred, highlighting a failure to protect the resident.
A facility failed to implement a comprehensive care plan for a resident with severe end-stage renal disease receiving specialized treatment. The resident's care plans did not include necessary details about the specialized treatment, fistula location, or required monitoring, as outlined in the facility's Hemodialysis Policy. Interviews revealed lapses in ensuring the care plan reflected the resident's needs.
A facility failed to revise a care plan for a resident with dementia, Covid-19, and weakness, regarding their shower preferences. Despite a physician's order for weekly body audits on shower days, progress notes did not reflect whether the resident refused or received showers. The resident's care card and plans lacked details on shower preferences and schedules, contrary to facility policies emphasizing resident rights and hygiene. The DNS confirmed the absence of documentation and adherence to the shower schedule.
A facility failed to supervise and educate staff on interventions for a resident with opioid dependence, leading to unauthorized visitor access and heroin use in the resident's room. The DNS did not ensure staff were aware of the 1:1 monitoring requirement, and a sign directing visitors to report to the nursing station was removed. The visitor log was missing, and staff were unaware of visitor restrictions.
A facility failed to document monthly weights for a resident with Type 2 diabetes and hypertension, missing weights for several months despite a care plan indicating potential nutritional decline. Interviews with staff revealed that weights were expected to be documented monthly after the initial admission period, but this was not done, potentially affecting the assessment of the resident's weight changes.
Two residents in the facility were not administered oxygen per physician's order, and their oxygen tubing was not labeled as required. One resident was using oxygen at 4 lpm without an active order, while another was observed with oxygen set at 3 lpm instead of the ordered 4 lpm, and the tubing was unlabeled. Staff interviews revealed a lack of clarity regarding the orders and labeling practices.
A resident with an egg allergy was served food containing eggs on two occasions. Despite the allergy being documented in the resident's diet slip, the dietary staff failed to adhere to the allergy information. The Dietary Manager acknowledged that the staff member responsible for plating the food had not completed the necessary in-service training on the new diet slip program.
The facility failed to submit assessment data for four residents to the state agency within the required 7-day timeframe, with delays exceeding 120 days. This occurred due to the absence of the LPN responsible for MDS coordination, during which corporate staff were supposed to assist but did not ensure timely submissions.
A resident with incontinence issues was left soaked in urine for hours due to incomplete documentation and staff shortages. The resident's care was not consistently documented across multiple shifts, violating facility policy. Staff interviews confirmed the lack of documentation, and the DNS was unaware of the incident.
Resident Not Treated with Dignity and Respect Due to Inappropriate Staff Language
Penalty
Summary
A resident with diagnoses including atrial fibrillation, weakness, and arthritis, who was alert, oriented, and dependent on staff for personal hygiene and mobility, was not treated with dignity and respect by a nurse aide. The resident, who had a care plan addressing behaviors characterized by ineffective coping, reported that a nurse aide used inappropriate language, specifically calling the resident a "pain in the butt" during an interaction involving the placement of a wheelchair arm. This incident was witnessed by two other staff members and was later reported by the resident to the social worker, who documented that the resident felt uncomfortable due to the aide's remark. Interviews with the social worker, the nurse aide involved, and the administrator confirmed that the inappropriate comment was made and that it caused the resident to feel disrespected. The facility's Residents Rights Policy requires that residents be treated with consideration, respect, and full recognition of their dignity and individuality. The failure to uphold this policy resulted in the resident experiencing a lack of dignity and respect during the incident.
Failure to Timely Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident with anxiety, schizoaffective disorder, and asthma in a timely manner. The resident, who was alert, oriented, and exhibited behavioral symptoms, had a verbal altercation with a nurse aide, during which the resident yelled obscenities and racial slurs and expressed dissatisfaction with the aide's communication. The incident was documented in the nurse's note and shift report, but the Nursing Supervisor did not notify the Director of Nursing or initiate an investigation, as she was unaware that the verbal interaction could be indicative of abuse. The facility's policy required immediate reporting to the Administrator or designee and to the state agency within two hours of an abuse allegation. However, the incident was not reported to the state agency until the following day, after the Administrator and Director of Nursing reviewed the documentation. The delay in reporting and failure to initiate an immediate investigation constituted a deficiency in the facility's response to the abuse allegation.
Failure to Complete Medication Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that a medication self-administration assessment was completed according to policy for two residents receiving medication-assisted therapy. Resident #17, diagnosed with opioid use and psychoactive substance abuse, was identified as wishing to self-administer medications and was assessed as cognitively intact and independent with activities of daily living. However, the Self Administration of Medications assessment was not updated quarterly as required by the facility's policy, and it was only updated after surveyor inquiry. Resident #52, diagnosed with opioid dependence, depression, and generalized anxiety disorder, was receiving methadone and was supposed to self-administer the medication. Although the resident was assessed as independent in opening medications, an observation revealed that a nurse had to open the methadone bottle for the resident due to a functional limitation. The Self-Administration of Medications Assessment was not completed quarterly as required, and it was only completed after surveyor inquiry. The facility's policy directed that such assessments be completed on admission, quarterly, and annually.
Medication and Care Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the availability and administration of prescribed medication for Resident #6, who was diagnosed with hypertension, heart failure, and liver cirrhosis. Despite a physician's order for Rifaximin 550 MG to be administered twice daily, the medication was not available or administered on multiple occasions from 8/18/2024 to 8/29/2024. The Director of Nursing Services (DNS) could not explain the unavailability of the medication, and the pharmacy indicated that the medication was not sent due to insurance issues and a lack of authorization from the facility. Resident #6 was eventually transferred to the hospital on 8/30/2024. The facility also failed to consistently document the provision of showers for Residents #26, #27, and #52, who required assistance with activities of daily living. Despite being scheduled for weekly showers, there were significant gaps in the documentation, with no evidence of showers being provided for extended periods. The DNS was unable to explain the discrepancies between the master shower schedule and the nurse aide care cards, nor the lack of documentation for missed showers or resident refusals. Additionally, the facility did not complete a body audit for Resident #215 upon admission, despite the presence of existing wounds that required assessment and treatment orders. The nursing staff failed to document an admission nursing assessment, and subsequent weekly skin assessments did not identify or address the existing wounds. Furthermore, Resident #415 did not receive a prescribed anti-fungal medication due to a lack of authorization for dispensing, yet staff inaccurately documented the medication as administered. Lastly, the facility did not consistently monitor Resident #64's output according to the care plan, with missing records for intake and output over a specified period.
Failure to Follow Pest Control Recommendations Leads to Fruit Fly Infestation
Penalty
Summary
The facility failed to maintain its dry food storage area free from insects and did not adhere to the recommendations of their pest control program. Observations during a tour of the facility's kitchen revealed a large cardboard box in the dry storage room containing many ripe bananas, some of which were completely black in color. The box was uncovered, and numerous fruit flies were observed flying above it. The Dietary Director was unaware of how long the bananas had been there and indicated that they were not part of the menu plan and would be discarded with the next delivery. The pest control logs showed that a service report from an outside pest control company had recommended covering bananas to prevent fruit flies. However, the Dietary Director was not aware of this recommendation, as the pest control reports were reviewed by the maintenance department. The Director of Maintenance, who was responsible for reviewing these logs, was also unaware of the recommendation to cover bananas. This lack of communication and failure to follow pest control recommendations led to the presence of fruit flies in the dry storage area.
Failure to Ensure Call Bells Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for three residents, leading to a deficiency in accommodating the needs and preferences of each resident. Resident #20, diagnosed with Parkinson's disease, dementia, and a cognitive communication deficit, was observed sitting in a wheelchair unable to find the call bell, which was wrapped around a lowered siderail out of reach. The care plan for Resident #20 indicated a risk for falls and required staff to encourage the resident to call for assistance, highlighting the importance of having the call bell accessible. Similarly, Resident #41, with diagnoses including polyarthritis and urge incontinence, was found unable to reach the call bell, which was moved by a nursing supervisor after being informed. Resident #59, with severe cognitive impairment and fractures, also had the call bell out of reach, which was repositioned by the same nursing supervisor. The facility's policy on call bells mandates that they should be positioned for easy access by residents, which was not adhered to in these cases, resulting in the deficiency.
Failure to Address Resident Council Concerns on Call Bells
Penalty
Summary
The facility failed to ensure timely written responses to residents' concerns regarding call bells being within reach and staff response times, as expressed during Resident Council meetings. A review of the Resident Council Minutes from January 2024 through August 2024 revealed that these concerns were not addressed until the September 2024 minutes. An interview with the Recreation Director on October 7, 2024, indicated that while a form exists for documenting Resident Council concerns, it was not consistently used. The Recreation Director could only provide two completed forms and no written responses for the concerns raised from February 2024 through August 2024. The Recreation Director mentioned discussing the issues with the relevant department head, but no written documentation was available to confirm these actions.
Failure to Obtain and Review Advanced Directives for a Resident
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were obtained and reviewed in a timely manner. Resident #10, who was diagnosed with severe dementia, hypertension, and hyperlipidemia, was admitted with a moderate cognitive impairment. Despite the resident's condition, the care plan did not include any information regarding advanced directives. An observation of the clinical record revealed that the advanced directive forms were blank, and there was no indication of the resident's code status in the electronic record. Interviews with staff, including an LPN and the MDS Coordinator Nurse, revealed that the advanced directives were overlooked due to frequent absences of MDS staff, leading to a lack of routine review at care plan meetings. The facility's policy requires that advanced directives be reviewed with the resident or responsible party upon admission, but this was not adhered to, resulting in the resident being considered a Full Code by default. The oversight was acknowledged by the staff, who could not understand how the advanced directives were missed.
Failure to Administer Prescribed Medication Due to Lack of Communication
Penalty
Summary
The facility failed to notify the physician when a prescribed medication was not available for administration to a resident. The resident, who was admitted with diagnoses including sepsis, dysphagia, and generalized anxiety disorder, was prescribed Kerasal Nail Renewal External Liquid for toenail fungus. The medication was to be applied twice daily and kept in the resident's room. However, the medication was never dispensed by the pharmacy, and the nursing staff incorrectly signed off on the Medication Administration Record (MAR) as if it had been administered. Interviews revealed that the resident had requested the medication upon admission, but it was never provided. A nurse admitted to running out of the medication and planning to reorder it, while the Director of Nursing Services (DNS) confirmed that the pharmacy had not dispensed the medication due to a lack of authorization from the facility. The Advanced Practice Registered Nurse (APRN) was not informed of the issue until it was brought up by the surveyor, despite the medication being prescribed for the resident's comfort. This oversight led to a failure in communication and medication administration for the resident.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #64, who has mild dementia, anxiety, and other health conditions, was moderately cognitively impaired and required total care with bathing. On a specific date, Resident #64 was physically abused by their roommate, Resident #36, who has a history of aggression and various medical conditions, including borderline personality disorder. Resident #36 was observed punching Resident #64's hands while holding their wrist, an incident witnessed by a Nurse Aide who intervened. The facility's documentation and interviews revealed that Resident #36 believed Resident #64 was trying to trip them, leading to the aggressive behavior. Despite Resident #36's history of aggression towards staff, there was no prior history of hitting other residents. The facility's abuse policy prohibits any form of abuse or mistreatment, requiring immediate reporting and thorough investigation of any allegations. However, the incident occurred, indicating a failure to ensure Resident #64's safety from abuse.
Failure to Implement Comprehensive Care Plan for Specialized Treatment
Penalty
Summary
The facility failed to ensure a comprehensive care plan was in place for a resident with severe end-stage renal disease, diabetes mellitus, and polyneuropathy, who was receiving specialized treatment. The resident was admitted with a physician's order for a renal diet and fluid restriction, and was scheduled for specialized treatment three times a week. However, the physician's orders did not specify the location of the resident's fistula or the necessary monitoring for a bruit and thrill every shift. Additionally, the admission MDS assessment did not reflect that the resident was receiving specialized treatment, and the care plans did not identify the specialized treatment, the fistula, or the required monitoring. Interviews with the Director of Nursing Services (DNS) revealed that the nurse responsible for the admission failed to ensure the baseline care plan included the resident's specialized treatment needs. The MDS nurse also did not ensure the comprehensive care plan included the specialized treatment and monitoring requirements. The facility's Hemodialysis Policy outlined the need for physician orders to include details about the specialized treatment center, frequency, and fistula care, but these were not followed. The facility was unable to provide a policy for comprehensive care plans when requested.
Failure to Revise Care Plan for Resident's Shower Preferences
Penalty
Summary
The facility failed to revise the care plan and care card for a resident with dementia, Covid-19, and weakness, regarding their shower preferences. The resident was admitted with a physician's order to perform a body audit on admission and weekly on shower day. However, progress notes from the specified period did not reflect whether the resident refused a shower or was provided a shower versus a bed bath weekly. The admission MDS assessment indicated the resident had severely impaired cognition, was occasionally incontinent, and required extensive assistance with personal hygiene, toileting, and transfers. The resident expressed that choosing between a shower, tub bath, bed bath, or sponge bath was very important, yet the care card and care plans did not specify the resident's preference or the day and shift for the shower. The facility's DNS acknowledged that the nursing assistants were expected to know the shower schedule based on the care card and a weekly shower schedule sheet at the nurse's station. If a resident did not receive their shower, the nursing assistant was to inform the charge nurse, who would then document it in the progress notes. However, there were no progress notes indicating that the resident refused showers or was given a bed bath. The DNS confirmed that the shower day and shift were not documented in the baseline care plan, comprehensive care plan, or resident care card. The facility's policies emphasized the importance of offering a full bath or shower weekly and respecting resident rights to make choices about their care, but these were not adhered to in this case.
Failure to Supervise and Educate Staff on Resident Monitoring
Penalty
Summary
The facility failed to provide necessary supervision and education regarding interventions for a resident with a history of opioid dependence, depression, and generalized anxiety disorder. The resident was on a Methadone Maintenance Program and required maximum assistance with daily activities. Despite being cognitively intact, the resident admitted to snorting heroin in their room on two occasions, facilitated by a visitor. The facility did not ensure that staff were aware of the intervention requiring all visits to be 1:1 in a common area, as indicated in the resident's care plan. The Director of Nursing Services (DNS) acknowledged that the staff were not educated about the intervention, relying instead on staff to review care plans and care cards each shift. A sign directing visitors to report to the nursing station was removed for confidentiality reasons, and there was no shift report or weekend receptionist to monitor visitor access. Additionally, the visitor log for the relevant period was missing, and staff were unaware of the visitor restrictions, leading to a failure in preventing unauthorized access to the resident's room.
Failure to Document Monthly Weights for a Resident
Penalty
Summary
The facility failed to ensure that monthly weights were completed and documented in the clinical record for a resident diagnosed with Type 2 diabetes mellitus and hypertension. The resident's care plan indicated a potential for nutritional decline following a recent hospitalization, with an intervention to weigh the resident as ordered. A physician's order directed weekly weights for four weeks, but there were no follow-up orders noted. The review identified missing weights for January, February, May, June, and August 2024. Interviews with facility staff, including an RN and a dietician, revealed that the facility's expectation was for weights to be performed and documented monthly after the initial admission period. The RN confirmed that weights were missing for several months and that nursing assistants were responsible for obtaining weights, while nursing staff were responsible for documentation. The dietician noted that missing weights could affect the assessment of weight loss or gain, and confirmed that the resident was not deemed at nutritional risk, thus requiring monthly weights. The facility's weight monitoring policy also indicated that weights should be taken monthly unless otherwise specified by a physician or dietician.
Failure to Administer Oxygen Per Physician's Order and Label Tubing
Penalty
Summary
The facility failed to administer oxygen per physician's order and label the oxygen tubing for two residents. Resident #40, who has diagnoses including diabetes mellitus, hypertension, and muscle weakness, was observed using oxygen at 4.0 liters per minute (lpm) via a nasal cannula without an active physician's order. Despite being dependent on staff for personal hygiene and requiring maximum assistance for bed mobility, there was no documentation of an active oxygen order, only a discontinued order to titrate oxygen below 92% from March 2024. Interviews with the LPN and DNS revealed that Resident #40 had been using oxygen at 4.0 lpm for several weeks without a current physician's order, and the DNS confirmed that any charge nurse could initiate an order with physician approval. Resident #366, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), dysphagia, and hypothyroidism, was observed with oxygen set at 3 liters per minute instead of the ordered 4 liters per minute. Additionally, the oxygen tubing was not labeled as per facility practice. The physician's order dated 9/10/24 directed continuous oxygen at 4 lpm, but observations on 9/30/24 and 10/01/24 showed discrepancies in the oxygen administration. An LPN was unsure why the oxygen was set at 3 liters and why the tubing was not labeled, although the facility's policy requires a physician's order for oxygen administration.
Failure to Prevent Serving Allergenic Food to Resident
Penalty
Summary
The facility failed to ensure that a resident with a known egg allergy was not served food containing eggs. Resident #215, who was admitted with diagnoses including cellulitis, dysphagia, and anxiety, had an allergy to eggs documented in their admission nursing assessment and diet slip. Despite this, the resident was served French toast, which contains eggs, at breakfast. After the resident informed the server of their allergy, plain toast was provided instead. The Dietary Manager acknowledged that the diet slip indicating the egg allergy was not updated until after breakfast, and there was no diet slip available for the resident at that time. On a subsequent occasion, scrambled eggs were plated for the same resident, despite the diet slip prominently displaying the egg allergy in red ink. The server, Dietary Aide #1, noticed the allergy on the slip and removed the plate before it was served. The Dietary Manager admitted that [NAME] #1, who plated the eggs, had not completed the required in-service training on the new diet slip program. The Dietary Manager had no explanation for allowing [NAME] #1 to serve residents without completing the training.
Delayed Submission of Resident Assessments
Penalty
Summary
The facility failed to submit the assessment data of four residents to the state agency within the required timeframe of 7 days. The assessments for these residents were delayed for over 120 days. This deficiency was identified during a review of the residents' assessments and staff interviews. The delay occurred because the LPN responsible for coordinating the Minimum Data Set (MDS) assessments was on leave during several months, including July, September, October through December, and again in February. During her absence, corporate staff were supposed to assist with completing and submitting the MDS assessments, but the submissions were not made timely.
Incomplete Documentation of Bladder and Bowel Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with bladder and bowel incontinence. The resident, who was admitted with diagnoses including muscle weakness, hemiplegia, and anxiety disorder, reported being left soaked in urine for several hours without assistance. The resident also mentioned that the call bell was out of reach, and when a staff member entered the room, they were advised to use the call bell, which was not possible. The clinical record review revealed missing documentation of bladder and bowel care on multiple shifts, including the day the resident reported the incident. Interviews with staff, including a nurse aide and registered nurses, confirmed that documentation of care was not consistently completed by the end of each shift, as required by facility policy. The nurse aide assigned to the resident on the day of the incident admitted to providing care but did not document it due to staff shortages. The charge nurse and the Director of Nursing Services were unaware of the incident and could not explain the lack of documentation. The facility's policy mandates that documentation should be completed as soon as possible after care is provided, ideally within the same shift, and any late entries should be clearly identified.
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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