Apple Rehab Rocky Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Rocky Hill, Connecticut.
- Location
- 45 Elm Street, Rocky Hill, Connecticut 06067
- CMS Provider Number
- 075211
- Inspections on file
- 29
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Apple Rehab Rocky Hill during CMS and state inspections, most recent first.
A resident with dementia and moderate cognitive impairment, who was not identified as an elopement risk, left the facility unnoticed and was found by police over two hours later in a snowbank, confused and with signs of cold exposure. Staff did not monitor the resident's whereabouts or meal intake, and there was a lack of communication between staff regarding the resident's location. The facility could not provide a policy on routine safety monitoring, and documentation of ADL tasks was lacking for the shift.
A resident with multiple serious diagnoses was denied admission after arrival due to lack of notification and documentation, and the Medical Director was not informed of the situation. In a separate case, another resident missed 24 doses of prescribed pregabalin for chronic pain, with no provider notification or documentation of the omissions, despite facility policy requiring such communication.
A resident with chronic and neuropathic pain missed 24 doses of pregabalin over six weeks due to a prescription error and subsequent supply issues. The provider's order for pregabalin three times daily was not followed after a prescription was sent to the pharmacy with incorrect instructions, leading to limited supply and denied refills. The pharmacy did not question the unusual order, and no alternative medication was provided when pregabalin was unavailable. Facility policy requiring immediate provider notification and documentation was not followed.
A resident with multiple acute medical conditions was transferred from a hospital for skilled nursing care, but due to a breakdown in the admissions process—including lack of notification, missing documentation, and failure to communicate with the hospital or admissions staff—the resident was not admitted and left the facility without receiving intended care. Key staff were unaware of the pending admission, and the medical director was not informed of the issue until after the resident's departure.
A resident with dementia and a history of falls, who required one-person assistance and a rolling walker for ambulation, was left unsupervised while walking without an assistive device. Staff failed to maintain visual supervision as one nurse aide left to retrieve the resident's wheelchair and another staff member returned to her office. During this lapse in supervision, the resident fell, resulting in a right humerus fracture and a laceration to the eyebrow.
A resident with multiple medical conditions experienced a fall resulting in a fracture and was discharged from the ED with instructions for orthopedic follow-up within one week. The facility failed to arrange this follow-up in a timely manner, resulting in a delay of over two months before the resident was seen by orthopedics. Documentation and staff interviews confirmed that the process for arranging the appointment was overlooked, and no evidence of timely contact with the orthopedic office was found.
A resident with significant mobility needs developed a stage 2 pressure ulcer after staff failed to inspect the skin under a soft cast for over two months, despite facility policy requiring regular skin checks. Documentation and interviews confirmed that no orders or assessments for skin integrity beneath the splint were completed, resulting in the ulcer being discovered only when the splint was removed.
The facility failed to maintain a clean, safe, and homelike environment, with observations of dirt, debris, and damage in resident rooms and common areas. Infection control documentation lacked specificity, and staff interviews confirmed awareness of these issues. On the Ambrosia Unit, cable TV wiring obstructed views, with plans to resolve this with a new provider. Policies and job descriptions were not provided.
A facility failed to keep an emergency exit clear, with equipment blocking access, and did not complete timely fall risk assessments for a resident with multiple falls. Despite initial corrective actions, the exit was repeatedly obstructed by carts, wheelchairs, and lifts. Additionally, a resident with a history of falls and injuries did not receive consistent fall risk assessments as required by the facility's policy.
The facility failed to ensure staff understood the protocol for Enhanced Barrier Precautions (EBP), as five rooms with residents on EBP lacked visible signage. Instead, orange stickers were used, but staff interviews revealed a lack of understanding of their significance. The Infection Preventionist could not provide documentation of training, and some nurse aides were not included in the education records. The DNS and Regional Nurse confirmed that staff should verbalize the meaning of the stickers, as per policy.
The facility failed to offer the 2023-24 COVID-19 vaccine to residents, as documented in the clinical records of five residents. Interviews revealed a lack of communication and documentation regarding vaccine education and consent. The prior Administrator cited an unverified FDA disapproval as the reason for not offering the vaccine, which was contradicted by the Pharmacy Representative. The Medical Director was unaware of the issue, and the facility's policies on vaccination were not adhered to.
The facility failed to notify resident representatives and physicians of significant changes in condition for multiple residents. One resident's representative was not informed of new medical orders following a change in condition, while another resident's physician was not notified when a medication was held without parameters. Additionally, a resident's aggressive behavior was not reported to the physician or psychiatric provider, despite the potential impact on care.
A resident with schizophrenia and impaired cognition was stabbed in the neck with a fork by their roommate, who had major depressive disorder and PTSD, in a LTC facility. The attacking resident was disoriented and making nonsensical statements prior to the incident, which was reported to a nurse. The facility failed to prevent the abuse, despite warning signs of the attacking resident's altered mental state.
A resident with schizophrenia was attacked by another resident with PTSD using a fork, resulting in a neck abrasion. The incident was witnessed and reported internally, but the facility failed to notify the State Survey Agency within the required timeframe, violating state law and facility policy.
A facility failed to conduct a Level II PASARR rescreen for a resident after a new diagnosis of schizophrenia, despite federal requirements. The resident, admitted with previous mental health diagnoses, was not evaluated following the change, and the clinical record lacked evidence of psychiatric consultation in the months following the diagnosis. Interviews revealed that staff were unaware of the need for a rescreen, highlighting a deficiency in compliance with PASARR requirements.
The facility failed to conduct proper assessments for two residents after unwitnessed falls, neglecting required neurological and post-accident assessments. Additionally, a resident did not receive medication as per physician's orders, with the LPN holding the medication without proper parameters or physician notification.
The facility failed to maintain and store respiratory equipment properly for three residents with COPD and other conditions. Oxygen tubing for a resident was not changed as per physician orders, and nebulizer and BiPAP masks for two residents were not stored in a sanitary manner. Interviews confirmed these deficiencies, and no policy for equipment care was provided.
A facility failed to maintain accurate fluid intake records for a resident on a fluid restriction due to end-stage renal disease and congestive heart failure. Despite physician orders for a 1000ml daily fluid limit, the Intake and Output log showed missing documentation for several shifts. Interviews revealed inconsistencies in staff responsibilities for recording intake, with nurse aides and charge nurses both involved but lacking clear accountability. The facility's policies required accurate documentation, yet the records were incomplete, indicating a breakdown in compliance with medical orders.
The facility did not complete annual performance reviews for nurse aides in 2023, as required by policy. The HR Director and DNS, both new to the facility, were unaware of the previous year's reviews, and the staff development nurse responsible for them was no longer employed. The Administrator, also new, acknowledged the issue, which was contrary to the facility's policy of conducting formal reviews annually.
Failure to Supervise Resident with Dementia Resulting in Elopement and Exposure
Penalty
Summary
A resident with dementia, moderate cognitive impairment (BIMS score of 10), and a court-appointed conservator was admitted with multiple diagnoses including cardiomyopathy, nicotine dependence, and chronic kidney disease. The resident was care planned for dementia, poor judgment, and required assistance with activities of daily living (ADLs), but was noted to ambulate independently. There were no physician orders for a leave of absence, and the resident was not identified as an elopement risk by staff. On the day of the incident, the resident was last seen by staff in the dining room and lobby around 5:40 PM, wearing two coats and shoes, but left the facility at 5:36 PM as confirmed by video footage. Staff did not notice the resident's absence until notified by local police at 8:15 PM, over two hours later. The resident was found by police approximately half a mile from the facility, lying face down in a snowbank, confused, wet, and missing a shoe. Emergency services responded, removed wet clothing, and transported the resident to the hospital, where the resident was diagnosed with a fall and frostnip. The resident reported leaving the facility to buy cigarettes but could not recall the timing or duration of the absence. The outside temperature at the time was 13°F with light snow, and the resident was found in a residential area along a main road with a 45 mph speed limit. Documentation and interviews revealed that staff did not monitor the resident's whereabouts or meal consumption after the resident left the facility. Nursing assistants and nurses assumed the resident was either in their room or visiting another unit, as the resident often ate meals later and ambulated independently. There was a lack of communication between dining room and unit staff regarding the resident's location and meal intake. The facility was unable to provide a policy regarding routine monitoring of residents for safety, and there was no documentation of ADL tasks for the resident during the relevant shift. Staff were unaware of the resident's absence for 2 hours and 39 minutes until police notification.
Failure to Notify Medical Provider of Admission Denial and Medication Omissions
Penalty
Summary
The facility failed to notify the Medical Director when a resident, who had been accepted for admission, was denied entry after arrival. The resident, with diagnoses including acute respiratory failure, acute decompensated heart failure, and moderate malnutrition, was transferred from an acute care hospital to the facility by ambulance. Upon arrival, the nursing supervisor was not aware of the pending admission, and the resident was not in the facility's electronic medical record system. Despite having the necessary paperwork from the ambulance personnel, the staff could not process the admission and believed the resident was sent to the wrong facility. The resident was ultimately not admitted, left the facility, and the Medical Director was not notified of the situation until after the resident had departed. Additionally, the facility failed to ensure provider notification when a resident's medication, pregabalin, was omitted on twenty-four occasions. The resident, who had chronic pain and neuropathic pain, had a physician's order for pregabalin three times daily. Review of the Medication Administration Record and nurse's notes revealed multiple missed doses over February and March, with no documentation that a provider was notified of the omissions. Interviews with the medical provider and APRN confirmed they were not informed of the missed doses, and both indicated they would have considered alternative pain management if notified. Facility policy required notification of the attending physician or Medical Director in the event of significant changes in a resident's condition, including medication omissions. However, in both cases, the required notifications were not made, and there was no documentation of provider contact regarding the issues. The failures were confirmed through clinical record reviews, facility documentation, and staff interviews.
Failure to Administer Pain Medication as Ordered Due to Prescription and Supply Errors
Penalty
Summary
A deficiency occurred when a resident with chronic and neuropathic pain was not administered pregabalin as ordered by the provider, resulting in 24 missed doses over a six-week period. The provider's order specified pregabalin 200 mg to be given orally three times daily, but medication administration records and controlled substance logs revealed multiple omissions. The resident was cognitively intact, independent with activities of daily living, and experienced frequent pain, for which scheduled and as-needed pain medications were prescribed. The missed doses were traced to a series of events involving a prescription error and subsequent supply issues. On one occasion, a prescription was sent to the pharmacy with incorrect directions, stating pregabalin should be administered once daily at bedtime for constipation, rather than three times daily for pain. This error led to the pharmacy dispensing a limited supply and subsequent refill attempts being denied as 'too soon.' The pharmacy did not question the unusual prescription instructions, and the facility did not obtain an alternative medication when pregabalin was unavailable. Interviews with facility staff, the provider, and the pharmacy confirmed awareness of the missed doses and the prescription error. The facility's medication administration policy required immediate physician notification and documentation if a medication was unavailable, but there was no evidence these steps were taken. Documentation of the written or electronic prescriptions sent to the pharmacy was not provided for review.
Failure to Admit Resident Due to Breakdown in Admission Communication and Procedures
Penalty
Summary
A resident with diagnoses including acute respiratory failure, acute decompensated heart failure, and moderate malnutrition was transferred from an acute care hospital to the facility for skilled nursing services. The resident arrived by ambulance, was placed in a room, and the transfer of care was completed by EMS to facility staff. However, the facility staff were not aware of the pending admission prior to the resident's arrival, as the required notification and documentation were not received through the facility's centralized admissions process. The resident's information did not appear in the electronic medical record system, preventing staff from completing the admission process. The nursing supervisor on duty did not obtain a report from the hospital prior to the resident's arrival and did not contact the hospital after the resident arrived. Believing the resident may have been transported to the wrong facility due to the lack of paperwork and system notification, the supervisor contacted the DON and Administrator. The resident, who was alert and oriented, was asked to leave the facility after refusing to return to the hospital, and ultimately left to return home. The DON was later informed of the situation and attempted to contact the resident after learning of the misunderstanding regarding the admission. Interviews revealed that the admissions coordinator had not sent the required notification to the facility due to employee error, and there was no established process for contacting the on-call admissions contact after business hours. The medical director was not notified of the admission issue until after the resident had left the facility, contrary to expectations for provider notification in such situations. The lack of communication and failure to follow established admission procedures resulted in the resident not being admitted as intended.
Resident Left Unattended During Ambulation Resulting in Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with dementia, difficulty walking, weakness, osteoporosis, and chronic pain, who was assessed as a fall risk and required assistance of one staff member with a rolling walker for ambulation, was left unattended while ambulating without an assistive device. The resident's care plan and physician's orders specified the need for staff assistance and use of a rolling walker, and interventions included encouraging the resident to wait for staff assistance and to use proper footwear and mobility aids. Despite these directives, the resident was observed pushing a wheelchair for stability, then left the wheelchair and began walking unaided in the hallway. A nurse aide, aware of the resident's need for assistance, left the resident's side to retrieve the wheelchair, during which time the resident was not within the staff's line of sight. Another staff member, who had observed the resident ambulating alone, instructed the nurse aide to get the wheelchair but did not remain to supervise. As a result, the resident fell, sustaining a right humerus fracture and a laceration to the right eyebrow, requiring hospital treatment. Facility policy required ambulation according to the care plan and supervision as needed, but these were not followed at the time of the incident.
Failure to Ensure Timely Orthopedic Follow-Up After Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with anoxic brain damage, muscle weakness, and anxiety disorder sustained a fall resulting in a right tibial/ankle fracture. Following the fall, the resident was evaluated in the Emergency Department (ED), where a splint was placed and clear instructions were given for orthopedic follow-up within one week. Despite these directives, a review of the clinical record and facility documentation revealed that no order for orthopedic follow-up was entered, and there was no evidence that the orthopedic office was contacted or that the resident attended a follow-up appointment within the recommended timeframe. The resident did not receive an orthopedic evaluation until over two months after the injury, at which point the orthopedic provider noted that the splint had been left in place for an extended period and expressed concern about the lack of timely follow-up. Interviews with facility staff confirmed that nursing was responsible for arranging the appointment, but the process was overlooked, and the delay was not identified until much later. The facility was unable to provide policies regarding following physician's orders and arranging outside appointments when requested.
Failure to Inspect Skin Under Splint Leads to Pressure Ulcer
Penalty
Summary
A deficiency occurred when staff failed to inspect a resident's skin following the application of a splint, contrary to facility policy, which resulted in the development of a stage 2 pressure ulcer. The resident, who had diagnoses including anoxic brain damage, muscle weakness, and anxiety disorder, required extensive assistance with mobility and was dependent on staff for transfers. After sustaining a right tibial fracture and receiving a soft cast, there was no documented order to assess the skin under the splint, and nursing notes did not indicate that skin checks were performed beneath the device during the period it was in place. Facility documentation and interviews revealed that weekly body audits and shift assessments were either not completed or did not mention the presence of the soft cast or the condition of the skin underneath. The splint remained in place for approximately two and a half months without documented skin assessments, and the first outpatient evaluation since the injury occurred only after this period. Upon removal of the splint, a stage 2 pressure ulcer was discovered on the resident's right lateral ankle, which required wound care intervention. Interviews with facility staff, including the prior DNS, APRN, and wound care physician, confirmed that it was expected practice to check the skin under removable splints or casts every shift and document these assessments. However, there was no order in place to do so, and staff did not document that such checks were performed. The lack of skin inspection and documentation directly contributed to the development of the pressure ulcer under the splint.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations and documentation reviews. During an initial tour, surveyors noted stains, dirt, debris, and food debris on the floors in the hallways leading to the lobby and across all four unit hallways. Further inspections revealed damaged, chipped, and stained walls in numerous resident rooms and common areas, as well as damaged and peeling doors, rusty radiators, and stained or torn curtains. Additionally, there were issues with sticky floors, wax buildup, and spider webs, indicating a lack of thorough cleaning and maintenance. The infection control surveillance and safety rounds worksheet, completed by RN #1 and the Housekeeping Manager, documented that the resident rooms and common areas did not meet cleanliness standards. However, the forms did not specify which units were inspected. Interviews with facility staff, including the Infection Preventionist, Administrator, and Housekeeping Manager, confirmed awareness of these environmental issues. The Administrator, who had been with the facility for a short time, acknowledged the need for a plan to address these concerns, while the Housekeeping Manager, employed for approximately two months, indicated plans for meetings to discuss cleanliness and repairs. On the Ambrosia Unit, surveyors observed cable TV wiring hanging below television screens, obstructing views and posing potential hazards. The Administrator and Housekeeping Manager explained that the wiring was necessary for the current cable provider's equipment but anticipated the issue would be resolved with a new provider. Despite requests, the facility did not provide a policy for maintaining a safe, clean, and homelike environment, nor did they provide job descriptions for the housekeeping manager. The facility's infection control policy required quarterly surveillance rounds, but the lack of specific documentation and follow-through contributed to the ongoing deficiencies.
Emergency Exit Obstruction and Incomplete Fall Risk Assessments
Penalty
Summary
The facility failed to ensure that one of the two emergency exit points on a resident unit was free of equipment and clutter, which obstructed access to the exit doors. During an initial tour, it was observed that the emergency exit doors located at the end of the west side corridor were blocked by soiled linen/trash carts, a stand assist device, wheelchairs, and Hoyer lifts, leaving only 18-24 inches of space between the equipment. This obstruction was confirmed during interviews with the Director of Nursing Services (DNS) and the Administrator, who acknowledged that the corridor should have been clear to allow full access to the emergency exit and fire extinguisher. Despite initial corrective actions to clear the corridor, subsequent observations revealed that the emergency exit doors were again partially blocked on multiple occasions. Equipment such as soiled linen/trash carts, wheelchairs, and a Hoyer lift continued to obstruct the corridor, compromising access to the emergency exit doors and fire extinguisher. The DNS admitted that additional staff education was necessary to ensure compliance with the facility's fire safety policy, which mandates that all passageways, corridors, and fire door exits remain unobstructed. Additionally, the facility failed to complete timely fall risk assessments for a resident with a history of multiple falls and injuries. The resident, who had diagnoses including a history of falling and muscle weakness, experienced several unwitnessed falls, some resulting in injuries such as a nasal fracture and a clavicle fracture. The clinical record showed that fall risk assessments were not consistently completed following each fall, contrary to the facility's policy, which requires assessments upon admission, quarterly, annually, and after significant changes in condition or following a fall. The DNS acknowledged the oversight in completing the necessary assessments for the resident.
Failure to Ensure Staff Understanding of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff understood the protocol for informing personnel and visitors about residents on Enhanced Barrier Precautions (EBP). During the survey, it was observed that five rooms with residents on EBP did not have visible signage at the entrance. Instead, the facility used orange circular stickers on the resident name plates to maintain resident dignity. However, RN #1, the assigned Infection Preventionist, could not provide documentation of training for staff and visitors on the use of these stickers. Interviews with several licensed staff and nurse aides revealed a lack of understanding of the significance of the orange stickers. Additionally, a review of the education records showed that some nurse aides were not included in the documented training. The Director of Nursing Services (DNS) and Regional Nurse confirmed that staff should be able to verbalize the meaning of the stickers, as per facility policy, which requires visible signage and education on EBP. The deficiency was identified due to the lack of staff knowledge and documentation regarding the EBP protocol.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that residents were given the opportunity to accept or refuse the 2023-24 COVID-19 vaccine during the fall/winter virus season. This deficiency was identified for five residents whose clinical records did not document that they were provided education on the benefits of the COVID-19 booster, nor was there any signed consent or refusal documentation. The residents' immunization records showed that the last COVID-19 booster was either refused or administered in previous years, with no updates for the 2023-24 season. Interviews with facility staff, including the Infection Control Nurse (RN #1), the prior Facility Administrator, and the Director of Nursing Services (DNS), revealed a lack of documentation and communication regarding the offering of the COVID-19 vaccine. The prior Administrator mentioned a canceled vaccine clinic due to an alleged FDA disapproval, which was not corroborated by the Pharmacy Representative, who stated that vaccines were available and no recall or disapproval had occurred. The DNS confirmed that the vaccine was not offered to residents or staff during the entire season, and there was no investigation into approved alternatives. The Medical Director was unaware of the situation and emphasized the importance of vaccine education and recommendation. The facility's COVID-19 policy encourages staying up to date with vaccinations, and the vaccination policy directs that vaccines be offered in accordance with CDC guidance. However, these policies were not followed, leading to the deficiency in ensuring residents had the opportunity to receive the COVID-19 vaccine.
Failure to Notify Resident Representatives and Physicians of Changes in Condition
Penalty
Summary
The facility failed to notify the resident representative of Resident #8 when there was a change in the resident's condition that required new medical orders. Resident #8, who had a history of heart failure, atrial fibrillation, and pulmonary embolism, experienced increased coughing and a loss of voice. The APRN ordered a chest x-ray, nebulizer treatments, and new medications, but there was no documentation that the resident representative was informed of these changes. This lack of communication persisted despite multiple new orders and changes in the resident's condition over several days. For Resident #65, the facility did not ensure that the physician was notified when a medication for low blood pressure, Midodrine, was held without parameters. The resident had a history of anemia and cardiovascular issues, and the medication was not administered on several occasions due to the nurse's decision based on blood pressure readings. However, there were no documented parameters for holding the medication, and the physician was not informed of these omissions, which occurred multiple times over a period of weeks. Additionally, the facility failed to notify the attending physician and psychiatric provider when Resident #31, who had a history of major depressive disorder and PTSD, exhibited aggressive behavior. After returning from the hospital with a diagnosis of acute encephalopathy, Resident #31 attacked another resident with a fork and made a threatening gesture towards a nurse aide. Despite the severity of the incident, there was no documentation that the physician or psychiatric provider was informed of the behavior, which could have been critical for the resident's ongoing care and management.
Resident Stabbed by Roommate Due to Facility's Failure to Prevent Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in an incident where one resident was stabbed in the neck with a fork by their roommate. The resident who was attacked had diagnoses including schizophrenia and anxiety disorder, and was noted to have severely impaired cognition and required assistance for mobility. The attacking resident had diagnoses of major depressive disorder, PTSD, and mild cognitive impairment, but was noted to have intact cognition and independence in activities of daily living. Prior to the incident, the attacking resident had been disoriented and was making nonsensical statements, which was reported to a nurse by a speech-language pathologist. The incident occurred when the attacking resident approached the other resident and stabbed them with a fork, causing an abrasion to the neck. The attack was witnessed by a nurse aide who intervened and secured the fork. The attacking resident was disoriented and made threatening gestures following the incident. The facility's abuse policy mandates immediate notification of the Director of Nursing Services or Administrator upon witnessing abuse, completion of an incident report, and an investigation. However, the report highlights a failure in preventing the abuse from occurring, despite the presence of warning signs of the attacking resident's disorientation and altered mental state.
Failure to Report Resident Abuse Incident Timely
Penalty
Summary
The facility failed to immediately report a witnessed incident of abuse to the State Survey Agency, as required by state law. The incident involved Resident #31, who attacked Resident #11 with a fork, causing an abrasion to the neck. Despite the attack being witnessed and documented, the facility did not notify the State Survey Agency within the mandated 2-hour timeframe. The Director of Nursing Services (DNS) acknowledged the oversight in notification, which was a violation of the facility's abuse policy that mandates immediate reporting of any abuse or mistreatment. Resident #11, who has diagnoses including schizophrenia and anxiety disorder, was attacked by Resident #31, who has major depressive disorder and PTSD. At the time of the incident, Resident #31 was disoriented and had recently returned from the hospital with a diagnosis of acute encephalopathy. The attack was witnessed by a nurse aide, who intervened and reported the incident to the charge nurse. Despite the immediate separation of the residents and notification to the police and resident representatives, the facility failed to report the results of the investigation to the State Survey Agency within 5 working days, as required.
Failure to Conduct PASARR Rescreen After New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to complete a rescreen PASARR for a resident following a new diagnosis of schizophrenia on January 13, 2022. The resident, who was admitted in August 2019, had previous diagnoses including delusional disorder, paranoid personality, and anxiety disorder. Initially, a PASARR Level I screening conducted in August 2019 did not require a Level II evaluation. However, after the new diagnosis of schizophrenia, the facility did not conduct a Level II PASARR screening as required. Additionally, the clinical record did not show that the resident was seen by psychiatry in January or February 2022 following the new diagnosis. Interviews with the Director of Nursing Services (DNS) and the social worker revealed a lack of awareness regarding the need for a PASARR rescreen following the resident's change in mental health diagnosis. The social worker acknowledged that a PASARR rescreen referral should have been completed at the time of the diagnosis change. The facility's PASARR policy, which aligns with federal requirements, mandates evaluations for mental illness to ensure appropriate placement and services. The oversight in conducting a Level II PASARR evaluation represents a deficiency in adhering to these requirements.
Deficiencies in Fall Assessment and Medication Administration
Penalty
Summary
The facility failed to ensure proper assessments and follow-up care for residents who experienced unwitnessed falls. Resident #19, who had severe cognitive impairment and was at risk for falls, experienced an unwitnessed fall. However, the clinical record did not reflect that a registered nurse conducted an assessment following the fall, nor were any neurological assessments or additional post-accident and incident (A&I) assessments completed as per facility policy. Resident #26, with a history of falls and moderate cognitive impairment, experienced multiple unwitnessed falls. The facility's documentation was incomplete, lacking necessary neurological assessments and post A&I monitoring for several incidents. Despite the facility's policy requiring such assessments, they were not conducted, and the documentation was inconsistent and incomplete, failing to provide a clear record of the resident's condition following the falls. Additionally, the facility failed to administer medication as per physician's orders for Resident #65, who had moderately impaired cognition and was at risk for cardiac issues. The medication Midodrine was not administered on several occasions without proper parameters or physician notification. The LPN held the medication based on personal judgment rather than documented medical guidelines, and there was no facility policy to support this decision. The DNS was unaware of these omissions, indicating a lack of communication and oversight in medication administration procedures.
Deficiencies in Respiratory Equipment Maintenance and Storage
Penalty
Summary
The facility failed to maintain and store respiratory equipment in a clean and sanitary manner and did not change respiratory equipment according to physician orders for three residents. Resident #11, who had chronic obstructive pulmonary disease (COPD) and heart failure, was observed with oxygen tubing that had not been changed for 20 days, despite physician orders to change it weekly. Interviews with LPNs and the Director of Nursing Services (DNS) confirmed that the tubing should have been changed weekly, but no policy detailing the care and management of oxygen equipment was provided. Resident #18, who had COPD and a history of stroke, was found with a nebulizer mask placed on a bedside table without a label or cover, contrary to the expectation that it should be stored in a plastic bag when not in use. Similarly, Resident #39, who had COPD and a recent history of pneumonia, had a BiPAP mask on the floor and a nebulizer mask uncovered on the bedside table. Interviews confirmed that these items should have been stored in a bag when not in use, and a physician's order for the use of the BiPAP machine was not located. The facility did not provide a policy for the care and management of oxygen equipment despite requests.
Failure to Maintain Accurate Fluid Intake Records for Dialysis Resident
Penalty
Summary
The facility failed to maintain an accurate daily fluid intake record for a resident on a fluid restriction. Resident #14, who was admitted with diagnoses including end-stage renal disease and congestive heart failure, was on a physician-ordered fluid restriction of 1000ml in 24 hours. Despite this, the facility's Intake and Output log showed missing documentation for several shifts throughout September 2024, indicating a failure to accurately monitor and record the resident's fluid intake. Interviews with facility staff revealed inconsistencies in the responsibility for documenting fluid intake. Nurse aides were expected to record intake totals, but the charge nurse was ultimately responsible for ensuring documentation was complete. However, several shifts lacked recorded intake totals, and staff interviews indicated a lack of clarity and accountability in maintaining these records. The facility's policy required that all nursing personnel record intake and output, with the nurse responsible for completing subtotals at the end of each shift. The facility's Hemodialysis policy also required maintaining fluid restrictions and monitoring intake and output, yet the documentation was incomplete. The DNS and RN Supervisor both expressed expectations that intake totals be documented and monitored, but the failure to do so was evident in the missing records. This deficiency highlights a breakdown in the facility's processes for ensuring compliance with physician orders and maintaining accurate health records for residents requiring specialized medical treatment.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete performance reviews for nurse aides once every 12 months, as required by their policy. A review of facility documentation, including nurse aide personnel files, indicated that performance reviews were not conducted for the year 2023. Interviews with the HR Director and the Director of Nursing Services (DNS) revealed that the HR Director was new to the facility and was unsure about the previous year's performance reviews. The DNS mentioned that the staff development nurse, who conducted the reviews last year, was no longer working at the facility. The Administrator, also part of the new management team, acknowledged the oversight and indicated that performance reviews would be addressed in the future. The facility's policy mandates a formal and documented performance review at the end of an employee's introductory period and annually thereafter, emphasizing the importance of these reviews for discussing work expectations, results, and goals with supervisors.
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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