Apple Rehab Saybrook
Inspection history, citations, penalties and survey trends for this long-term care facility in Old Saybrook, Connecticut.
- Location
- 1775 Boston Post Rd, Old Saybrook, Connecticut 06475
- CMS Provider Number
- 075070
- Inspections on file
- 30
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Apple Rehab Saybrook during CMS and state inspections, most recent first.
A resident with catatonic disorder, major depressive disorder, anxiety, delusional disorder, and unspecified psychosis had physician orders for lorazepam 0.5 mg multiple times daily for restlessness and catatonia. Over several days, multiple scheduled lorazepam doses were not administered because the medication was unavailable, and eMAR notes only indicated that the drug was on order, with no documentation that a provider was notified. The psychiatric APRN and a regional RN both reported they were unaware of the missed doses and stated that the provider should have been notified and the pharmacy contacted, while facility policy required immediate physician notification, informing the resident or responsible party, contacting the pharmacy to expedite delivery, documenting all actions, and notifying a supervisor when medications are unavailable.
A resident with multiple psychiatric diagnoses and cognitive deficits was started on Abilify, later increased in dose, to address delusional disorder and psychosis. Despite physician orders and psychiatric APRN notes documenting the initiation and adjustment of this antipsychotic, the Resident Care Plan over the following weeks did not include any care plan addressing the antipsychotic use, such as monitoring for side effects or ongoing behaviors. The DON, Regional Nurse, and MDS Coordinator acknowledged that residents on antipsychotics are required to have a corresponding care plan and that both nursing staff and the MDS Coordinator are responsible for initiating it, but the resident was missed, and the care plan was not revised in accordance with facility policy.
A resident with multiple psychiatric diagnoses and a high fall risk experienced several falls, but the facility failed to ensure RN post-fall assessments were consistently completed and documented, and that the resident remained in place until assessed. In multiple incidents, LPNs completed SBAR forms without full assessments, including missing range-of-motion evaluations, and in one case an LPN, with a NA, moved the resident from the floor to a wheelchair before an RN could assess the resident. Although supervisors and providers were notified and the resident was sometimes sent to the ED, the clinical record lacked required RN assessment notes after several falls, contrary to facility policy and the DON’s stated expectations.
A resident with psychiatric conditions, cognitive deficits, impaired balance, and dependence for transfers experienced two falls after being placed in a tilt‑in‑space wheelchair that staff reclined to an almost lying position to prevent the resident from climbing out. On one occasion, the resident was found on the floor in the dining area with a laceration after the wheelchair had been reclined flat; on another, the wheelchair tipped backwards at the nurse’s station and the resident slid out over the headrest. Staff reported routinely reclining the chair for safety and rest because the resident leaned and lunged forward and could not always be closely observed. Therapy later found the wheelchair’s tilt stop was broken, allowing it to recline beyond forty‑five degrees, and the OT stated it was unsafe to use the reclining function in this way, while the DON reported being unaware that staff had been reclining the resident in the wheelchair before the falls.
A resident with multiple psychiatric diagnoses, including catatonic disorder, depression, anxiety, delusional disorder, and unspecified psychosis, was started on Abilify and later had the dose increased due to ongoing restlessness and yelling out. Facility policy required that specific target behaviors be identified and monitored every shift and that a behavior flow sheet be initiated whenever an antipsychotic is started. However, review of the eMAR for two consecutive months showed no documentation of targeted behavior monitoring related to the Abilify use. In interviews, the psychiatric APRN, DON, and a regional RN acknowledged that behavior monitoring, including restlessness, impulsiveness, delusions, hallucinations, and paranoia, should have been initiated when the antipsychotic was ordered and confirmed.
A resident with a history of aggressive behavior and cognitive impairment was placed in a shared room with another resident who had severe cognitive and physical limitations. Staff witnessed the aggressive resident forcibly removing the roommate from the room, resulting in physical injuries. The incident occurred despite prior knowledge of the resident's behavioral risks and facility policy prohibiting abuse.
A resident with cognitive impairment and a history of behavioral issues made a verbal threat in the dining room, which was reported by a nursing assistant to a supervisor who failed to act or investigate. The incident was not reported to the State Agency or documented as required by facility policy, and an investigation was not initiated until days later after further reporting.
A resident with cognitive impairment and a history of behavioral issues made a verbal threat to choke someone, which was reported by a nursing assistant to a supervising nurse on two occasions without action. The incident was later reported to another nurse and administration, but no investigation or incident report was initiated, contrary to the facility's abuse policy.
Several residents did not receive prescribed medications due to unavailability, and nursing staff failed to notify the provider as required. Documentation was incomplete or missing regarding the reasons for missed doses and provider notification, with staff interviews confirming that notifications were not made or were assumed to be handled by others. The facility's policy required provider notification and documentation for medication errors, but this was not followed.
The facility did not ensure that nurse aide documentation for showers and body audits was complete for three residents with cognitive and physical impairments, as required by physician orders and policy. Additionally, the facility failed to retain the medical record for a resident for the required period, with both the Administrator and DNS unable to locate it. These deficiencies were identified through record review and staff interviews.
The facility failed to review its infection control policies annually, conduct quarterly environmental rounds, and complete monthly infection surveillance reports. Additionally, quarterly water management meetings were not documented due to high staff turnover and lack of proper documentation maintenance.
The facility failed to ensure proper medication administration for two residents who had medications left at their bedside without a self-administration order, and for another resident who received medications late. The responsible nurse admitted to leaving medications unattended, contrary to facility policy. Additionally, a new LPN administered medications outside the prescribed time frame without notifying the provider.
A facility failed to provide necessary podiatry services to a resident with type 2 diabetes mellitus. Despite physician orders and requests for podiatry services due to long toenails, the resident was not seen by a podiatrist from September to December. The resident was marked as Do Not Treat because the facility did not provide required documentation for podiatry payment. Interviews revealed that nursing staff were not allowed to trim toenails for diabetic residents, and the DNS acknowledged the oversight in not supplying the missing information to the podiatric service provider.
The facility failed to complete and review its antibiotic surveillance tracking report at quarterly medical staff meetings, as required by its antibiotic stewardship program. Documentation from August 2022 to September 2023 was missing, and the Infection Preventionist did not present necessary reports on antibiotic usage and infection rates. Interviews confirmed the lack of adherence to policies requiring monitoring and reporting of antibiotic use patterns and resistance trends.
The facility failed to offer and administer pneumococcal vaccinations to two residents upon admission. One resident, with conditions including anemia and heart failure, did not receive the vaccine despite giving consent. Another resident, with conditions such as hypertension and diabetes, was not offered the vaccine, and consent was not documented. The facility's policy required offering the vaccine according to CDC guidelines, but the process was not followed, and documentation was incomplete.
Two residents had incomplete MDS assessments, missing critical sections on cognitive function, mood, behaviors, and participation in goal setting. One resident, with diabetes and liver cirrhosis, had no documented reason for the incomplete assessment. Another resident, with hemiplegia and depressive episodes, could communicate but lacked documentation for the incomplete assessment. The Corporate Director of Social Services noted the oversight due to a vacant social worker position.
A resident with severe cognitive impairment and multiple diagnoses had an outdated care plan that was not reviewed or revised quarterly as required. The care plan included resolved issues such as anti-coagulant therapy and skin conditions, which were not reflected in current physician's orders. The RN responsible for updates was unfamiliar with the electronic system and failed to document reviews, leading to non-compliance with facility policy.
The facility did not complete annual performance reviews for two nurse aides, hired in 1983 and 2002, for the years 2023 and 2024. The DNS admitted to not prioritizing these reviews, despite receiving monthly reminders from HR. The facility's policy requires annual performance evaluations.
The facility failed to maintain completed and signed vaccination consent forms for two residents who received COVID-19 booster vaccines. Despite documentation confirming vaccine administration, the facility could not provide the required consent forms during a survey. Interviews with staff revealed that the facility's policy required written consent to be obtained and retained in the resident's clinical records, but these were not found.
Failure to Notify Provider and Obtain Antianxiety Medication Resulting in Multiple Omitted Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the provider when an antianxiety medication was unavailable, resulting in multiple omitted doses for a resident with significant psychiatric diagnoses. The resident’s conditions included catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and the admission MDS showed a BIMS score of 10/15, indicating some memory recall deficits. The resident’s care plan documented that the resident was receiving antianxiety medication, with interventions to administer medications as ordered and update the provider of any concerns, complications, or changes in condition. A physician’s order directed lorazepam 0.5 mg by mouth three times daily for restlessness and catatonia, and later an order changed the lorazepam to 0.5 mg four times daily. Review of the MAR showed that lorazepam doses were not administered on multiple occasions because the medication was unavailable. On one date, two scheduled doses were omitted due to unavailability, with no documentation in the eMAR notes that the provider was notified. On subsequent dates, six additional lorazepam doses were omitted for the same reason, and the eMAR notes only indicated that the medication was not available and was on order, without any indication that the provider was notified. The psychiatric APRN stated she was not aware of any missed lorazepam doses and that a provider should have been notified, and the Regional Nurse similarly stated that a provider should have been notified for all missed doses and that the pharmacy should have been contacted for STAT delivery. The facility’s Medication Administration policy required that when medications are unavailable, the physician be notified immediately, the resident or responsible party be informed, the pharmacy or alternative suppliers be checked to expedite delivery, all actions be documented in the medical record, and the supervisor be notified, but the documentation reviewed did not show that these steps occurred.
Failure to Update Care Plan for New Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s care plan to address the initiation and subsequent dose increase of an antipsychotic medication. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and an admission MDS showing a BIMS score of 10/15 with some memory deficits and need for assistance with ADLs. On one date, a psychiatric APRN documented concerns about possible undiagnosed bipolar disorder, depression, or significant trauma history and ordered a trial of Abilify 2 mg daily for delusional disorder, which was entered as a physician’s order. A later psychiatric APRN note documented ongoing restlessness and yelling out and directed an increase of Abilify to 5 mg daily for psychosis, which was also entered as a physician’s order. From the time Abilify was first ordered through a later review date, the Resident Care Plan did not include any care plan addressing the use of this antipsychotic medication. The RCP from the initial Abilify order date through the survey review date lacked documentation of a care plan to address the antipsychotic, including monitoring for side effects and continued behaviors. During interviews, the DON and Regional Nurse (RN #7) stated that any resident on antipsychotic medications should have a care plan to guide care, and that both nursing staff and the MDS Coordinator are responsible for initiating such care plans; they were unable to explain why a care plan had not been developed despite the medication having been ordered 15 days earlier and noted the resident was missed in weekly psychotropic risk meetings. The MDS Coordinator confirmed that a care plan should have been developed to target the antipsychotic use. The facility’s Care Planning policy required a comprehensive, individualized care plan developed by the IDT, based on identified needs, and reviewed and updated as necessary to reflect changes in resident status, but this was not done for the addition of Abilify for this resident.
Failure to Complete RN Post-Fall Assessments and Keep Resident in Place After Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality for a resident with a history of falls and identified as a high fall risk. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and required one-person assistance for transfers, ambulation, and positioning. The care plan identified numerous fall-prevention interventions, including environmental modifications, toileting schedules, therapy involvement, and close observation. Despite these identified needs and risks, the facility did not consistently complete required RN post-fall assessments or adhere to its own policy that an RN assess the resident immediately after each fall and before the resident was moved. On one fall dated 11/21/25, documentation showed the resident got out of bed without assistance, fell, and struck the face and head, sustaining two lacerations above the left eyebrow. The charge nurse, an LPN, completed the SBAR and arranged transfer to the ED, but the nurse’s notes did not document that the nursing supervisor (an RN) assessed the resident following the fall, and the SBAR lacked range-of-motion assessment. On 12/3/25, the resident was found lying on the floor on the left side with minimal swelling to the left temporal region; the nursing supervisor, APRN, and family were notified and neuro checks were initiated, but again the nurse’s notes did not document that an RN assessment was completed, and the SBAR completed by the LPN did not include range of motion. On 11/23/25, the resident was found on the floor after attempting to transfer from a wheelchair. The charge nurse, an LPN, later reported that she panicked, did not immediately call the RN supervisor, and instead enlisted a nurse aide to help move the resident from the floor to the wheelchair before an RN assessment. She then cleansed the laceration to the right side of the resident’s head and only afterward notified the RN supervisor. The RN supervisor’s subsequent note documented that the resident was already in the wheelchair, had a laceration near the right eye, and could move all extremities, and the resident was sent to the ED. On 12/22/25, the resident was observed sliding backward out of the wheelchair to the floor and possibly hitting the back of the head; the RN supervisor was notified and reportedly assessed the resident immediately, but there was no RN assessment note in the record, the SBAR was incomplete, and range of motion was not assessed. The DON stated that a full RN assessment was required after each fall and prior to moving a resident, and was unaware that full RN assessments had not been completed after several of the resident’s falls.
Improper Wheelchair Reclining and Positioning Leading to Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was safely positioned in a tilt‑in‑space wheelchair and not reclined beyond forty‑five degrees, which contributed to two falls. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and had a BIMS score of 10/15 indicating some memory deficits. The admission assessment and care plan identified impaired balance, substantial assistance needs for bed mobility, and dependence on staff for transfers, with fall‑risk interventions such as encouraging time at the nurse’s station, scheduled toileting, and removal of the walker. On one occasion, nursing staff responded to a report of a fall and found the resident lying on the right side in the dining room with a 2 cm laceration to the right eyebrow. At that time, the resident’s wheelchair was found reclined so that the resident had been lying flat, and staff reported the chair had been reclined to prevent the resident from climbing out, although they could not identify who reclined it. The resident had been assisted back into the wheelchair by two staff, and the incident was documented, including notification of family, the DON, and the provider. On a subsequent occasion, the resident was again in a reclined position in a tall‑back custom wheelchair near the nurse’s station when the wheelchair tipped backwards and the resident slid out over the headrest. Staff reported that the resident had a history of leaning and lunging forward in the wheelchair and that they often reclined the wheelchair to an almost lying position to prevent the resident from getting out, to help the resident rest, and because staff could not always watch the resident. Therapy later identified that the tilt stop on the wheelchair was broken, allowing the chair to be fully reclined beyond forty‑five degrees, and the OT stated staff should never have used the reclining function to keep the resident in the chair and that reclining beyond forty‑five degrees was not safe. The DON reported being unaware that staff had been reclining the resident in this manner prior to the falls, and there was no facility policy on wheelchair positioning available for review.
Failure to Implement Targeted Behavior Monitoring for Antipsychotic Use
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement targeted behavior monitoring for a resident who was started on an antipsychotic medication. The resident had diagnoses including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and an admission MDS BIMS score of 10/15 indicating some memory recall deficits. On 12/23/25, a psychiatric APRN documented concerns about possible undiagnosed bipolar disorder, depression, or significant trauma history and ordered a trial of Abilify 2 mg daily for delusional disorder. Facility policy dated 06/2019 required that residents receiving antipsychotic medications have specific target behaviors identified and monitored every shift, and that a behavior flow sheet be initiated any time a resident is started on an antipsychotic. Despite these requirements, review of the December 2025 eMAR showed no documentation that targeted behaviors were monitored every shift after Abilify was initiated. On 1/2/26, the psychiatric APRN documented that the resident continued to exhibit restlessness and yelling out and increased the Abilify dose to 5 mg daily for psychosis, with additional behaviors of concern including avolition and impulsiveness. Review of the January 2026 eMAR again failed to show targeted behavior monitoring every shift related to the Abilify use. In interviews, the psychiatric APRN stated that behavior monitoring should have been implemented upon initiation of Abilify, including monitoring restlessness, impulsiveness, delusions, hallucinations, and paranoia. The DON and a Regional Nurse (RN #7) also confirmed that targeted behavior monitoring should have been initiated when the Abilify order was started and that Nursing Supervisors or Nursing Administration who confirmed the order should have ensured an order for targeted behavior monitoring was put into place.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical Harm
Penalty
Summary
A resident with a history of Wernicke's encephalopathy, alcohol dependence, and atrial fibrillation, and who had demonstrated moderately impaired cognition, was involved in multiple incidents of aggressive behavior toward roommates. The resident's care plan identified previous altercations, including grabbing a roommate's shirt and making verbal threats. Despite these documented behaviors and recommendations for staff intervention and psychiatric support, the resident was returned to a shared room after a period in a private room, following the discharge of a previous roommate. A new roommate, who had severe cognitive impairment and was dependent on staff for mobility and transfers, was admitted to the same room. Shortly after, staff witnessed the first resident dragging the new roommate by the arm and throwing them into the hallway. The new roommate sustained superficial abrasions and a skin tear, and was transferred to the hospital for evaluation. Interviews with staff confirmed that the aggressive resident had a known history of altercations related to noise and that staff were aware of the risks associated with placing another resident in the same room. The facility's abuse policy prohibits mistreatment of any kind, including resident-to-resident abuse. Despite this, the decision to place a vulnerable resident in a shared room with a resident known for aggressive behavior resulted in physical harm. Staff interviews and documentation indicated that the aggressive resident should not have had a roommate due to prior incidents and impaired judgment, yet this precaution was not maintained.
Failure to Timely Report and Investigate Resident Threat
Penalty
Summary
The facility failed to act promptly on a report of a verbal threat made by a resident with a history of behavioral issues, including a prior altercation with a roommate. The resident, who had moderately impaired cognition and diagnoses including Wernicke's encephalopathy and a history of alcohol dependence, made a threatening statement in the dining room that was overheard by a nursing assistant. The nursing assistant reported the incident immediately to a nursing supervisor, who did not respond or investigate the situation. The assistant reported the incident again the following day to the same supervisor, who again did not act. The incident was finally reported to another supervisor two days later, who then initiated a psychiatric consult and placed the resident under observation. Despite the eventual response, the facility did not complete an incident report or initiate an investigation at the time the threat was first reported. The State Agency was not notified of the verbal threat, contrary to facility policy, which requires immediate reporting and investigation of suspected abuse or threats. Interviews with staff and the administrator confirmed that the incident was not acted upon in a timely manner, and documentation failed to show that required notifications and investigations were completed as per policy.
Failure to Investigate Resident's Verbal Threat in Accordance with Abuse Policy
Penalty
Summary
A resident with a history of Wernicke's encephalopathy, alcohol dependence, and atrial fibrillation, and who had previously exhibited behavioral issues including a prior altercation with a roommate, made a verbal threat in the dining room stating an intention to choke someone. This threat was overheard by a nursing assistant, who immediately reported the incident to the supervising nurse on two consecutive days. The supervising nurse did not respond to the report or assess the resident at that time. The nursing assistant subsequently reported the incident to another nurse, who then notified administration. Despite being notified, the administrator did not initiate an investigation, citing that the threat was not directed at a specific individual. No incident report was completed, and the facility failed to follow its abuse policy, which required immediate reporting, notification of administration, and initiation of an investigation for any suspected abuse or mistreatment. Interviews confirmed that the required steps, including documentation and investigation, were not taken in response to the verbal threat.
Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
The facility failed to notify the appropriate medical provider in a timely manner regarding multiple missed or omitted medication doses for three residents recently admitted with complex medical conditions. For one resident with a left femur fracture and hypothyroidism, several prescribed medications, including antihypertensives, cholesterol-lowering agents, antidepressants, and thyroid replacement therapy, were not administered on multiple occasions due to unavailability from the pharmacy or other reasons. Documentation did not show that the provider was notified of these missed doses, and nursing notes lacked explanations or follow-up for several omissions. Another resident with Parkinson's disease and constipation did not receive prescribed doses of Carbidopa-Levodopa and Linzess because the medications were not available. Nursing staff documented the omissions but did not notify the provider as required, instead passing the information to the next shift or assuming another nurse would handle the notification. There was no documentation in the clinical record that the provider was informed of these missed doses. A third resident with hypertension, atrial fibrillation, and congestive heart failure missed doses of Apixaban, Carvedilol, and Allopurinol due to the medications not being available from the pharmacy. Nursing notes indicated the medications were not administered, but there was no evidence that the provider was notified. Interviews with nursing staff revealed a lack of clarity regarding responsibility for provider notification and documentation, and the facility's policy required such notifications and documentation for medication errors, but this was not followed in these cases.
Incomplete Documentation of Showers and Missing Medical Record
Penalty
Summary
The facility failed to ensure complete and accurate documentation of showering and body audits for three residents with varying degrees of cognitive and physical impairment. For one resident with severe dementia and dependence on staff for bathing, nurse aide documentation did not show that showers were provided on scheduled days as required by physician orders and facility policy. Similarly, another resident with intact cognition and a history of falls did not have documentation of showers or body audits on the required dates, despite being scheduled for weekly showers and having a physician order for body audits. A third resident with moderate cognitive impairment and left-sided hemiplegia also lacked documentation of showers and body audits on the specified days, even though both the care plan and physician orders required these interventions. Interviews with the Director of Nursing Services (DNS) revealed inconsistencies between the unit shower schedules and the physician orders for body audits, with the DNS unable to explain the discrepancies. The DNS stated that nurse aides are expected to follow the shower schedules and document care provided or refused, and that any missed or refused showers should be reported to the nurse for reassignment. However, the documentation review showed that tasks were left blank or marked as not applicable, indicating a lack of compliance with documentation requirements. Additionally, the facility failed to retain the complete medical record for another resident as required by its own policy, which mandates retention of medical records for at least seven years after discharge or last encounter. Both the Administrator and DNS confirmed that they were unable to locate the clinical record for this resident. Facility policies reviewed directed that all care provided, including showers and ADLs, must be documented and that medical records must be retained for the specified period.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure that its infection prevention and control program policies and procedures were reviewed annually. The Infection Control Program Policies and Procedure manual was reviewed in March 2022 and August 2024, but there was no documentation of a review in 2023. Interviews with the Regional Director of Nursing Services (RN) and the Infection Preventionist (IP) Nurse revealed that the review was the responsibility of the Director of Nursing Services (DNS) and the Administrator, but they were not employed at the facility during the time the review was due. Additionally, there was no policy available related to the annual review of the infection control policy and procedures manual. The facility also failed to conduct quarterly environmental rounds for infection control. Documentation was missing for the last quarter of 2022 and the first three quarters of 2023. The responsibility for completing these rounds lay with the previous IP nurse, who was no longer employed at the facility. Furthermore, the facility did not complete monthly surveillance infection reports and analysis of infection trends from August 2022 to April 2024, nor were these presented at the quarterly Medical Staff Meetings. The IP nurse was responsible for tracking and analyzing infection rates, but the reports were not located, and the previous IP nurse could not be contacted for them. Lastly, the facility did not document quarterly water management plan meetings for several quarters, including October 2022, January 2023, July 2023, and October 2023. The Director of Maintenance and the Administrator, who had only recently started working at the facility, were unable to locate the meeting minutes. The responsibility for maintaining the water management plan binder, which included meeting minutes, was with the Administrator, but due to high turnover, these documents were not available.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered as ordered for two residents, Resident #24 and Resident #55, who were observed with medications left at their bedside without a self-administration order. Resident #24, who was cognitively intact and dependent on care for various activities, was found with a medicine cup containing six pills on the bedside table. The nurse responsible, RN #7, admitted to leaving the medications at the bedside and acknowledged that it was her responsibility to ensure the resident took the medications. The facility's policy requires that nurses stay with residents until medications are taken, which was not followed in this instance. Similarly, Resident #55, who had moderate cognitive impairment and required assistance with personal hygiene, was found asleep with a medicine cup containing five pills left at the bedside. The resident was unaware of the medications being there until woken up by RN #7, who then administered the medications. Again, there was no self-administration order for this resident, and the facility's policy was not adhered to, as the nurse left the medications unattended. Additionally, the facility failed to administer medications according to prescribed times for Resident #50, who had diagnoses including chronic systolic congestive heart failure and hypokalemia. The resident reported receiving medications late, and the electronic medication administration audit confirmed that several medications were administered outside the expected time frame. LPN #2, who was new to the facility, admitted to being late in passing medications and was not familiar with the residents and their medications. The facility's policy requires medications to be administered within a two-hour window, and any deviations should be documented and reported to the provider, which was not done in this case.
Failure to Provide Podiatry Services for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident with type 2 diabetes mellitus, identified as Resident #53, received necessary podiatry services. The resident's care plan, dated August 14, 2023, included interventions for foot care due to the risk of hypoglycemia associated with diabetes. Despite physician orders for podiatry services as needed, the resident was not seen by a podiatrist from September 2024 through December 2024. Nurse's notes from September 10, 2024, and December 2, 2024, indicated that the resident had long toenails and requests for podiatry services were sent, but the resident was not treated due to missing information required for processing podiatry payment. The podiatrist visited the facility on October 28, 2024, and December 31, 2024, but Resident #53 was marked as Do Not Treat (DNT) because the facility did not provide the necessary medical necessity documentation. Interviews with facility staff revealed that the nursing staff was not permitted to trim the toenails of residents with diabetes, and the Director of Nursing Services acknowledged the oversight in not following up with the podiatric service provider to supply the missing information. The facility's Ancillary Services policy stated that podiatry services would be provided as required by the resident's conditions, but this was not adhered to in the case of Resident #53.
Failure in Antibiotic Stewardship Program Monitoring
Penalty
Summary
The facility failed to ensure that its antibiotic surveillance tracking report, which monitors antibiotic use, patterns, and resistance trends, was completed and reviewed at the quarterly medical staff meetings for multidisciplinary collaboration. During a review of the antibiotic stewardship program from August 2022 to December 2024, it was found that there was no documentation of monthly reviews of the program from August 2022 to September 2023. Additionally, the quarterly Medical Staff Meeting agendas and documentation for 2023 and the first quarter of 2024 did not include any information related to infection control and antibiotic usage presented by the Infection Preventionist. Interviews with the Regional Director of Nursing Services and the Infection Preventionist revealed that the monthly Antibiotic Tracking tool and at-risk meeting minutes were only available from September 2023 to April 2024. The Infection Preventionist was responsible for providing a report on antibiotic usage and monthly infection rates at the quarterly medical staff meetings, but this was not done. The Director of Nursing Services and the Administrator confirmed that it was the responsibility of the Infection Preventionist to submit a written infection control report prior to the meetings, but no such report was found from the previous Infection Preventionist. The facility's policies required monitoring and reporting of antibiotic use patterns and resistance trends, but these were not adhered to, leading to the deficiency.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and administer pneumococcal vaccinations to two residents, Resident #20 and Resident #55, upon their admission. Resident #20, admitted in March 2023 with conditions including anemia, acute respiratory failure with hypoxia, and heart failure, was cognitively intact according to a quarterly MDS assessment. Despite giving consent for the pneumococcal vaccine in October 2024, the facility did not administer the vaccine, and there was no documentation of a change in the resident's decision. Interviews with the Regional Director of Nursing Services and the Infection Preventionist Nurse revealed that the vaccine could have been offered upon admission, but it was not administered despite consent being obtained. Resident #55, admitted in March 2024 with diagnoses including anemia, hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia, had moderate cognitive impairment. The facility's records did not show that the pneumococcal vaccine was offered or assessed for past immunization. Although consent was obtained in September 2024, the vaccine was not administered, and there was no documentation of a change in decision. The facility's policy required offering the vaccine according to CDC guidelines upon admission, but the process was not followed, and the necessary documentation was incomplete. The responsibility for assessing and offering the vaccine was attributed to a previous Infection Preventionist Nurse.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the completion of annual Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident #5, diagnosed with type 2 diabetes mellitus, cirrhosis of the liver, and dependence on renal dialysis, had an incomplete MDS assessment. The assessment lacked information in sections C, D, and E, which cover cognitive function, mood, and behaviors, respectively. There was no documentation explaining why these sections were incomplete. The Corporate Director of Social Services, who had been assisting due to a vacant social worker position, confirmed that the social workers are responsible for these sections and should document any refusal by the resident to participate in the assessment. Similarly, Resident #17, admitted with hemiplegia, hemiparesis, lymphedema, and depressive episodes, also had an incomplete MDS assessment. The assessment was missing information in sections C, D, E, and Q, which include cognitive function, mood, behaviors, and participation in assessment and goal setting. Despite the resident's ability to communicate using gestures and a tablet, there was no documented reason for the incomplete assessment. The Corporate Director of Social Work acknowledged the oversight, noting that the facility had not identified the missing work until after the previous social worker left. Attempts to contact the former social worker responsible for these assessments were unsuccessful.
Failure to Maintain Comprehensive and Updated Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident with diagnoses including type 2 diabetes mellitus, cerebrovascular disease, and hemiplegia and hemiparesis was comprehensive and up-to-date. The care plan, dated 8/13/23, lacked documentation of reviews or revisions, despite multiple MDS assessments being completed. The care plan contained outdated concerns such as the risk of bruising and abnormal bleeding related to anti-coagulant therapy, a resolved rash to the groin, and a resolved skin impairment to the right ankle. These issues were no longer relevant, as confirmed by the absence of corresponding physician's orders and the acknowledgment by RN #1 that these problems had been resolved. RN #1, responsible for updating the care plan, admitted to not being familiar with the facility's electronic health record system and had been documenting care plan reviews on paper, but failed to provide any documentation of such reviews. The DNS confirmed that RN #1 was responsible for reviewing the care plan quarterly and was aware that updates were behind schedule. The facility's policy mandates that care plans be reviewed and updated at least quarterly and as necessary to reflect changes in the resident's status, which was not adhered to in this case.
Failure to Conduct Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for two of the three nurse aides reviewed. Specifically, the employee files for NA #4 and NA #9 did not contain performance evaluations for the years 2023 and 2024. NA #4 was hired on September 12, 1983, and NA #9 was hired on April 20, 2002. During an interview, the Regional Nurse (RN #5) confirmed that the performance reviews for these years had not been conducted but did not provide a reason for this oversight. The Director of Nursing Services (DNS) acknowledged responsibility for completing the performance reviews and admitted to not prioritizing them, despite receiving monthly emails from human resources indicating which employees were due for evaluations. The facility's Performance and Review policy mandates a formal and documented performance review at the end of an employee's introductory period and at least annually thereafter.
Failure to Maintain Vaccination Consent Forms
Penalty
Summary
The facility failed to ensure that completed and signed vaccination consent forms were included in the medical records for two residents. Resident #20, who had diagnoses including anemia, acute respiratory failure with hypoxia, and heart failure, was cognitively intact and dependent on care for personal hygiene. The facility's records did not contain a copy of the COVID-19 booster vaccine consent form for Resident #20, which was administered in June 2023. Despite a physician's order and documentation in the Medication Administration Record (MAR) confirming the administration of the vaccine, the facility could not provide a signed consent form upon request during the survey. Similarly, Resident #53, who had diagnoses including type 2 diabetes mellitus, hypertension, and cerebrovascular disease, was severely cognitively impaired and dependent on care. The facility's records also lacked a completed COVID-19 booster vaccine consent form for Resident #53, administered in December 2023. Although the MAR confirmed the administration of the vaccine and the immunization record indicated consent was confirmed, the facility was unable to provide a signed consent form. Interviews with the Regional Director of Nursing Services and the Infection Preventionist revealed that the facility's policy required written consent to be obtained and retained in the resident's clinical records, but these were not found for the residents in question.
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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