Apple Rehab Mystic
Inspection history, citations, penalties and survey trends for this long-term care facility in Mystic, Connecticut.
- Location
- 28 Broadway Ave, Mystic, Connecticut 06355
- CMS Provider Number
- 075327
- Inspections on file
- 25
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Apple Rehab Mystic during CMS and state inspections, most recent first.
A resident with a history of bipolar disorder and moderate cognitive impairment engaged in a verbal altercation with another resident, including threats of physical violence. Multiple staff members documented the incident, but the DON was not informed, resulting in a 51-day delay in reporting the abuse allegation to the State Agency as required by facility policy.
Nine residents on precautions for MDROs did not have trash receptacles positioned inside their rooms for proper PPE disposal, as required by CDC guidance. Staff reported a shortage of trash cans and admitted to discarding PPE in bathrooms or hallway trash bins. The infection control nurse had not performed required spot checks, and the facility's EBP policy lacked guidance on trash can placement and monitoring adherence.
The facility did not update care plans with new interventions after the discovery of new or worsening skin impairments in three residents with complex medical histories, including wounds and pressure ulcers. Despite documentation of ongoing skin issues and nursing notes indicating care plan updates, reviews showed that care plans were not revised for extended periods, contrary to facility policy and staff expectations.
Three residents with significant risk factors for skin breakdown did not receive weekly skin assessments as ordered by physicians, resulting in missed documentation and delayed identification of wounds, including pressure ulcers and diabetic wounds. Nursing staff failed to consistently perform and document required weekly body audits, despite facility policy and physician directives.
A resident with chronic pain and a terminal illness died, but their prescribed narcotic medication (Dilaudid) was not removed from the medication cart for 20 days. Staff interviews revealed that narcotics were not consistently removed in a timely manner after residents were discharged or expired, and that required co-signatures and removal procedures were not followed according to facility policy.
A resident with memory deficits and depression left the facility without staff knowledge and was later found by police at a nearby location. The facility failed to perform quarterly elopement risk assessments as required by its policy, both for this resident and for additional residents, resulting in missed identification of elopement risk.
The facility failed to review and obtain advance directives and code status for three residents upon admission. One resident with alcoholic cirrhosis and another with osteomyelitis experienced delays in completing Medical Interventions Consent forms and physician's orders for code status, which were not documented until several days after admission. A third resident with syncope and brain neoplasm also faced similar delays. The facility's policy requires these directives to be reviewed and documented upon admission, but this was not followed.
A facility failed to ensure proper medication administration and storage. A resident was found with expired nasal spray at the bedside without evaluation for self-administration. Additionally, two residents received medications without proper identification checks by LPNs, contrary to facility policy requiring the use of identifiers.
The facility failed to conduct proper neurological assessments for two residents after unwitnessed falls, did not administer an anxiolytic medication as ordered for a resident with mental health issues, and lacked a physician's order for a resident's indwelling catheter. These deficiencies highlight lapses in following facility policies and protocols.
A resident with chronic health issues and a history of falls experienced multiple unwitnessed falls due to inadequate supervision and delayed updates to their care plan. Despite being at high risk, the facility failed to implement timely interventions after each fall, leaving the resident unsupervised in areas not visible from the nurse's station. The facility's policy required care plan updates after each fall, but this was not consistently done.
A resident with CHF and other medical conditions was not weighed daily as ordered by the physician, resulting in an unmonitored weight loss of 8.5 pounds. Facility staff were unaware or did not communicate the missed weights, leading to a deficiency in care.
The facility failed to maintain accurate records for controlled drugs brought in by two residents from an outside pharmacy. The DNS's office, where discontinued drugs were stored, was found unsecured, and the key to the cabinet was easily accessible. Tramadol and Clonazepam lacked proper reconciliation forms, and the documentation provided was incomplete and incorrect, violating the facility's policy for controlled substance management.
A resident with Parkinson's Disease, falls, and dementia was prescribed Doxycycline without a documented indication for its use. The facility's records, including nurse's notes and physician's progress notes, failed to identify a reason for the antibiotic use or any chronic skin condition. The resident's quarterly MDS also noted the use of an antibiotic without indication. Interviews revealed a lack of awareness regarding the resident's antibiotic use, and the Dermatology Consultant's Office Manager confirmed the resident had been taking Doxycycline intermittently for Rosacea flare-ups but had not been seen by the provider since 2022.
The facility failed to properly store controlled drugs, label over-the-counter medications with open dates, and monitor medication refrigerator temperatures. Controlled drugs were not stored in a separately locked, permanently affixed compartment, and the key was easily accessible. Over-the-counter medications lacked open dates, and the facility did not maintain temperature logs for the medication refrigerator, which is essential for storing certain medications and vaccines.
The facility failed to ensure proper hand hygiene during medication administration and resident care. An LPN did not perform hand hygiene while administering medications to two residents, and a nurse aide failed to change gloves or wash hands between handling dirty dishes and assisting residents. The DON confirmed these actions were against the facility's handwashing policy.
Failure to Timely Report Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to ensure timely notification to the State Agency regarding an allegation of verbal abuse between two residents. On the date of the incident, one resident with a history of bipolar disorder and moderate cognitive impairment engaged in a verbal confrontation with another resident who was alert and oriented. The confrontation included threats of physical violence, with one resident referencing a prior incident where physical aggression had occurred. Staff, including a social worker, observed and documented the altercation, and the involved residents were separated. The resident who initiated the threats was later calmed and escorted back to their room by the ADNS. Despite multiple staff members documenting the incident in the medical record, there was a breakdown in communication regarding the reporting of the event. The social worker, psychiatric APRN, and nursing staff all made notes about the incident, but the DON was not informed about the resident-to-resident verbal aggression and threats. The DON stated that if she had been notified, she would have recognized the event as an allegation of verbal abuse and reported it to the State Agency as required by facility policy. The facility's abuse policy mandates that allegations of abuse be reported promptly, with supervisors immediately notifying the DON and Administrator, who are responsible for reporting to the State Agency within two hours. However, the State Agency was not notified until 51 days after the incident, following inquiry by surveyors. This delay constituted a failure to follow established procedures for timely reporting of suspected abuse.
Failure to Provide Proper PPE Disposal and Monitoring for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper implementation of Enhanced Barrier Precautions (EBP) for nine residents who required personal protective equipment (PPE) due to being on precautions for multidrug-resistant organisms (MDROs). Observations and interviews revealed that trash receptacles for discarding PPE were not positioned inside the doorways of the affected residents' rooms, as required by CDC guidance. Instead, the only available trash cans were located inside the bathrooms with closed doors, making it difficult for staff to properly dispose of contaminated PPE upon exiting the rooms. Staff interviews confirmed that, due to a shortage of trash receptacles, PPE was sometimes discarded in bathroom trash cans or in community hallway trash cans rather than at the point of exit from the resident rooms. Additionally, the infection control nurse, who was responsible for ensuring the availability of precaution supplies and monitoring staff adherence to EBP, had not conducted the required spot checks of the rooms. The facility's EBP policy did not address the required placement of trash receptacles or the need for periodic monitoring of staff compliance. These lapses were identified through review of facility records, direct observation, and staff interviews, and were not corrected until after the deficiency was observed.
Failure to Timely Revise Care Plans After New Skin Impairments Identified
Penalty
Summary
The facility failed to review and revise Resident Care Plans (RCPs) to include additional interventions after the identification of new skin impairments for three residents. For one resident with a history of cellulitis, rheumatoid arthritis, and chronic pain syndrome, a new open area on the right foot was identified and treated, but the RCP was not updated to reflect the presence of rheumatoid arthritis nodules or the new skin impairment until more than a month later, after the resident had passed away. Documentation showed that the resident had multiple wounds, including a large full-thickness wound, but the care plan did not include these findings or new interventions in a timely manner. Another resident with subarachnoid hemorrhage and epilepsy developed pressure ulcers on the right lateral foot and ankle, which remained unhealed for several months. Although nursing notes indicated that the RCP was updated with new interventions, a review of the clinical record did not show any revisions or additional interventions added to the RCP for over a year. The care plan continued to list only general interventions, such as skin inspection and offloading heels, without addressing the new or ongoing wounds. A third resident with dementia, diabetes, peripheral vascular disease, and neuropathy developed a diabetic wound on the right second toe. Nursing documentation noted the wound and indicated that the RCP was updated, but no revisions or new interventions were found in the care plan for nearly a year. Interviews with nursing staff confirmed that RCPs should be revised immediately upon discovery of new skin impairments, but they were unable to explain why this was not done for these residents. Facility policies required timely and interdisciplinary updates to care plans to address changes in resident status, but these were not followed in the cases reviewed.
Failure to Complete Weekly Skin Assessments per Physician Orders
Penalty
Summary
The facility failed to complete weekly skin assessments as ordered by physicians for three residents with significant risk factors for skin breakdown and wounds. For one resident with diagnoses including cellulitis, rheumatoid arthritis, and chronic pain syndrome, a physician's order required weekly body audits on shower days. While one audit was documented, subsequent weekly audits were missing for several weeks. During this period, the resident developed multiple skin impairments, including an open foot ulcer and cellulitis, which were only identified after a significant lapse in weekly assessments. The care plan addressing skin breakdown risk factors was not updated until well after the impairments were identified and after the resident's passing. Another resident with a history of subarachnoid hemorrhage and epilepsy was also subject to a physician's order for weekly body audits. Documentation showed that after an initial audit, no further weekly audits were recorded for several months, despite the resident developing pressure ulcers on the right lateral foot and ankle. Nursing notes and the wound tracker confirmed that these wounds remained unhealed and required ongoing wound care, yet there was a lack of consistent weekly documentation as required by the physician's order and facility policy. A third resident, diagnosed with dementia, diabetes, peripheral vascular disease, and neuropathy, also had a physician's order for weekly body audits. The clinical record revealed no completed weekly audits for an extended period, during which the resident developed a diabetic wound on the right second toe. Nursing documentation of skin assessments was absent until weeks after the wound was identified. Interviews with facility staff confirmed that weekly skin audits were expected per physician orders and facility policy, but these were not consistently performed or documented for the residents in question.
Delayed Removal of Narcotic Medication After Resident Death
Penalty
Summary
The facility failed to ensure the timely removal of a narcotic medication, Dilaudid, from the medication cart following the death of a resident with diagnoses including cellulitis, rheumatoid arthritis, and chronic pain syndrome. The resident had a physician's order for Dilaudid to be administered as needed for severe pain, and the medication was last given prior to the resident's death. Despite the resident being pronounced dead, the Dilaudid remained in the medication cart for 20 days before being removed and returned to the office, as documented in the pharmacy Controlled Substance Disposition Record. Interviews with nursing staff and administrative personnel revealed that the process for removing narcotics after a resident's discharge or death was not consistently followed. Staff reported delays in removing narcotics due to lack of prioritization and refusal by the previous Director of Nursing Services (DNS) to co-sign for removal. The facility's policy directed that discontinued medications should be removed from the resident's supply once an order is received, but this was not adhered to in this case, resulting in the narcotic remaining accessible in the medication cart well beyond the resident's death.
Failure to Conduct Required Elopement Risk Assessments
Penalty
Summary
The facility failed to conduct quarterly elopement risk assessments in accordance with its own policy for one of three sampled residents who left the facility without staff knowledge. The resident, who had diagnoses including hemiparesis following a stroke, depression, and anxiety, was identified as having some memory recall deficits and self-propelled in a wheelchair. The care plan noted depression related to restricted physical activity, but interventions did not address elopement risk. On the day of the incident, the resident was discovered missing during a medication pass, was not signed out, and was later found by police at a nearby gas station. The resident stated this was the first time leaving the facility without a family member. Review of the clinical record showed the last elopement risk assessment was conducted over eight months prior, with the next assessment only completed after the elopement event, at which point the resident was identified as at risk and a wanderguard was initiated. Further review revealed the facility did not consistently conduct elopement assessments quarterly as required by policy, affecting an additional eighteen of fifty-one residents. The facility policy required elopement risk assessments on admission, readmission, quarterly, with a change in condition, and after an elopement attempt, but this was not followed.
Failure to Obtain Advance Directives and Code Status on Admission
Penalty
Summary
The facility failed to review and obtain advance directives and code status for three residents upon their admission. Resident #257 was admitted with diagnoses including alcoholic cirrhosis of the liver, muscle weakness, and difficulty walking. The Medical Interventions Consent form was not completed at the time of admission, and the physician's orders did not specify the resident's code status until five days later. The resident was responsible for themselves, and the delay in completing the necessary documentation was acknowledged by the nursing staff. Resident #258, admitted with osteomyelitis, chronic obstructive pulmonary disease, and a non-ST elevation myocardial infarction, also experienced a delay in the completion of the Medical Interventions Consent form and the physician's order for code status. The form remained blank upon admission, and the resident's choices were not documented until five days later. The nursing staff recognized that the documentation should have been completed on admission. Similarly, Resident #260, with diagnoses including syncope, neoplasm of the brain, and atrioventricular blocks, did not have their Medical Interventions Consent form completed until four days after admission. The resident's code status was not documented in the physician's orders until this time. The facility's policy requires that advance directives be reviewed and documented upon admission, but this was not adhered to for these residents.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that a physician-ordered medication was administered by a licensed nurse and was not left at the bedside for Resident #26. The resident, who had chronic respiratory failure, heart attack, and stroke, was found with a bottle of saline nasal spray at the bedside, which was expired. The nurse assigned to the resident discarded the expired nasal spray and replaced it with a new one, which was then locked in the medication cart. The facility's policy required that medications be kept in a locked location unless the resident was evaluated and deemed capable of self-administration, which had not been done for Resident #26 until after the surveyor's inquiry. The facility also failed to utilize resident identifiers during medication administration for two residents. For Resident #308, the LPN administered medications without verifying the identification band, relying on memory from the previous day. Similarly, for Resident #31, another LPN administered medications without checking an identification band, as the resident was not wearing one. The facility's policy required the use of at least two identifiers before administering medication, which was not followed in these instances. The facility's policies on self-administration of medication and medication administration were not adhered to, leading to these deficiencies. The policies required that medications be stored securely and that residents be evaluated for self-administration capabilities. Additionally, the policies mandated the use of resident identifiers to ensure correct medication administration, which was not consistently practiced by the nursing staff.
Deficiencies in Fall Assessments, Medication Administration, and Catheter Orders
Penalty
Summary
The facility failed to ensure proper neurological assessments and post-fall assessments were completed for two residents who experienced multiple unwitnessed falls. One resident, with a history of Alzheimer's Disease and a recent femur fracture, was found on the floor on two separate occasions without documented neurological checks for 72 hours post-fall, as required by the facility's policy. Another resident, with chronic health conditions and a history of falls, experienced several unwitnessed falls over a period of months. The clinical records for these incidents lacked complete neurological assessments and post-accident and incident monitoring, which should have been conducted every shift for 72 hours following each fall. The facility also failed to administer an anxiolytic medication according to the physician's order for a resident with a history of mental health issues, including anxiety and depression. The resident missed four doses of Alprazolam due to the medication being unavailable, which led to the resident experiencing nausea and vomiting. The pharmacy did not receive the order or a signed prescription until several days after the resident's admission, resulting in the medication being delivered late. This oversight was acknowledged by the facility's DNS, who noted that the physician was unavailable to sign prescriptions during this period. Additionally, the facility did not obtain a physician's order for an indwelling catheter for a resident admitted with a catheter in place. The resident's records indicated the presence of a Foley catheter, but there was no evidence of a physician's order for its use. An RN confirmed that there should have been a diagnosis and an order for the catheter, highlighting a lapse in following proper protocol for medical device management.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide necessary supervision and implement timely interventions to prevent falls for a resident identified as being at high risk for falls. The resident, who had chronic myeloproliferative disease, COPD, and difficulty walking, was admitted with a care plan that included keeping the call bell within reach and ensuring a clutter-free environment. Despite these measures, the resident experienced multiple unwitnessed falls, starting with a fall from bed on February 26, 2024, and continuing with several other incidents, including falls in the bathroom and while seated in a wheelchair. The care plan was not consistently updated with new interventions following each fall, indicating a lack of adequate response to the resident's changing needs. For instance, after a fall on March 8, 2024, the care plan was updated 13 days later to include keeping the resident's shoes within reach. However, subsequent falls on April 8, April 9, May 1, and May 15, 2024, did not result in new interventions being implemented. It was only after a fall on July 5, 2024, that an intervention was added to ensure the resident was not left unattended in the Serenity room. Observations during the survey period revealed that the resident was often left without supervision, particularly in the Serenity room, which was not directly visible from the nurse's station. The facility's policy on falls required that each fall be evaluated and the care plan updated with strategies to prevent future incidents, but this was not consistently followed. The Director of Nursing, who had been employed for eight weeks, acknowledged the frequent falls and was working to improve fall interventions, but the lack of timely and effective measures contributed to the ongoing risk of falls for the resident.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to ensure daily weights were completed for a resident with a physician's order for daily monitoring due to congestive heart failure (CHF). The resident, who had diagnoses including acute chronic systolic heart failure, Alzheimer's Disease, and anorexia, was admitted with a care plan that required daily weight monitoring. Despite the physician's order dated 7/25/24 to weigh the resident daily and report significant weight changes, the facility did not obtain weights on 14 out of 19 days between 7/25/24 and 8/12/24. This resulted in an unmonitored weight loss of 8.5 pounds, representing a 7.07% loss. Interviews with facility staff revealed a lack of awareness and communication regarding the daily weight order. An LPN was unaware of the order and did not receive reports of the resident's weight loss. Another LPN acknowledged the order but did not weigh the resident on nights when the resident was sleeping and failed to notify anyone of the missed weights. The RN Supervisor and DNS both expected weights to be completed as ordered, but the facility's weight monitoring policy was not followed, leading to the deficiency.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain an accurate record of receipt and disposition of controlled drugs brought into the facility from an outside pharmacy. During an observation, it was noted that the Director of Nursing Services (DNS) stored discontinued controlled drugs in a locked file cabinet in her office, which was supposed to be secured by the office door acting as a second lock. However, the office door was found wide open with no staff present, and the key to the file cabinet was easily accessible, hanging visibly from a lanyard in the office. Upon inspection, it was discovered that two controlled drugs, Tramadol and Clonazepam, brought in by residents from an outside pharmacy, lacked proper reconciliation forms. The facility's documentation was insufficient to enable accurate reconciliation of these medications. The Resident Medication Sheet provided for Clonazepam was incomplete and contained incorrect information, such as the wrong strength of the medication. Additionally, a Post-it note attached to the form did not provide adequate details for reconciliation, missing critical information like the medication's name, strength, quantity, and the resident's name. The facility's policy required controlled substances to be counted and documented at each shift change or at least once daily, but no reconciliation forms had been maintained for these medications since April 2024. The facility contacted a former nursing supervisor who admitted the residents with these medications, but the lack of proper documentation persisted.
Inadequate Indication for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure an adequate indication for the prophylactic use of an antibiotic for a resident with a history of Parkinson's Disease, falls, and dementia. The resident was prescribed 50mg of Doxycycline daily without a documented indication for its use. Both the nurse's notes and physician's progress notes from early March to late March did not identify any reason for the prophylactic antibiotic use or any chronic skin condition. The resident's quarterly MDS also noted the use of an antibiotic without indication and did not identify a skin problem. An APRN note later identified the resident had chronic impetigo, but no episodes occurred while at the facility, and the Doxycycline was prescribed by dermatology. The care plan failed to address the prophylactic antibiotic use or any chronic skin condition. Interviews with the Infection Control Nurse revealed a lack of awareness regarding the resident's antibiotic use and the absence of consultation reports from the dermatologist. The Dermatology Consultant's Office Manager confirmed the resident had been taking Doxycycline intermittently for Rosacea flare-ups but had not been seen by the provider since 2022. The facility's Antibiotic/Antimicrobial Stewardship policy emphasizes treating residents with symptomatic infections only and reviewing antibiotic usage, which was not adhered to in this case.
Deficiencies in Drug Storage and Temperature Monitoring
Penalty
Summary
The facility failed to store controlled drugs in a separately locked, permanently affixed compartment, and did not limit access to these drugs. During an observation, it was found that discontinued controlled drugs were stored in a file cabinet in the Director of Nursing Services' (DNS) office, which was not permanently affixed and had only one lock. The office door, intended to act as a second lock, was left open with no staff present, and the key to the file cabinet was easily accessible. The DNS admitted to not keeping the office door closed and locked and acknowledged that the key should have been carried on her person. Additionally, the facility did not ensure that over-the-counter drugs were labeled with an open date as per facility policy. During a medication administration observation, several pill bottles in the medication cart were found to be opened and lacked open dates. The DNS confirmed that all over-the-counter medications should be dated with an open date and discarded after 30 days, and the date should include a day, month, and year. The facility also failed to monitor and record the temperatures of the medication refrigerator, which is crucial for storing certain medications and vaccines at the correct temperatures. During an observation, it was found that the medication refrigerator temperature log was blank, and the facility was unable to provide temperature logs from March 2024 through July 2024. Interviews with nursing staff revealed that third shift nurses were responsible for monitoring the refrigerator temperatures, but the DNS was unaware of a process for this monitoring.
Failure in Hand Hygiene Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices during medication administration and resident care, as observed in two separate instances involving licensed staff and nurse aides. During a medication administration observation, an LPN did not perform hand hygiene at any point while preparing and administering medications to two residents. The LPN admitted to forgetting to wash her hands during the process. This oversight was noted during a surveyor's observation and was acknowledged by the Director of Nursing, who confirmed that hand hygiene should be performed before and after administering medications. In another instance, a nurse aide was observed failing to perform hand hygiene while collecting dirty dishes from multiple resident rooms and after removing gloves. The nurse aide entered several resident rooms without changing gloves or performing hand hygiene, even after handling dirty dishes and assisting a resident with positioning. The nurse aide admitted to not knowing the proper hand hygiene protocol after glove removal and continued to handle items with dirty gloves. The Director of Nursing confirmed that hand hygiene should be performed before and after entering resident rooms and after removing gloves, as per the facility's handwashing policy.
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 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 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 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 significant cardiac and respiratory diagnoses experienced respiratory symptoms and wheezing that prompted multiple APRN evaluations and orders, including a chest x-ray and IV Lasix. Staff notes later documented hypoxia, oxygen administration, and stat orders for labs and a chest x-ray on the day the resident died from heart failure related to sick sinus syndrome and COPD. However, the clinical record lacked documentation of an earlier chest x-ray order, any reason it was not performed, and respiratory assessments prior to the acute decline, despite staff recalling prior wheezing. Leadership acknowledged that nursing staff should have documented the change in condition and related assessments in accordance with the facility’s documentation policy.
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.
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 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 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 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 Document Respiratory Change in Condition and Ordered Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with multiple cardiac and respiratory diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease. The resident’s care plan directed staff to administer medications as ordered and monitor for abnormal breath sounds, difficulty breathing, and signs of heart failure. An APRN evaluated the resident due to respiratory symptoms and increased wheezing and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from that period did not contain an order for the chest x-ray, nor any documentation explaining why the x-ray was not performed. Subsequently, the APRN again evaluated the resident at nursing’s request for a change in respiratory condition and documented that there were no signs of dyspnea, CHF, or glycemic issues, and that the resident was not in apparent distress. Later, the APRN documented another visit for increased respiratory distress, during which Lasix 40 mg IV was administered and a stat chest x-ray was ordered. Nursing notes documented that 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 ordered stat labs, a stat chest x-ray, and continuation of oxygen. The resident’s death was later pronounced the same day, with the death certificate listing heart failure due to sick sinus syndrome and COPD as the primary cause of death. Record review showed no documentation of the chest x-ray order on the earlier date, no documentation for the reason the chest x-ray was not performed, and no documentation of respiratory-related assessments prior to the later date, despite staff recalling episodes of wheezing and respiratory concerns in the week prior. The APRN confirmed she had ordered a chest x-ray and discussed the plan with a nurse but could not recall which staff member or why the order was not entered or carried out, and could not locate documentation explaining the omission. The ADON and the President of Clinical Services stated that nursing staff should have documented the change in condition and related assessments when the APRN was asked to see the resident for respiratory changes, and that the facility failed to follow its Documentation Policy requiring complete, accurate, and timely documentation by the end of the shift in which assessments or care occurred.
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.
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