Apple Rehab Uncasville
Inspection history, citations, penalties and survey trends for this long-term care facility in Uncasville, Connecticut.
- Location
- 5 Richard Brown Drive, Uncasville, Connecticut 06382
- CMS Provider Number
- 075438
- Inspections on file
- 39
- Latest survey
- December 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Apple Rehab Uncasville during CMS and state inspections, most recent first.
A resident who was cognitively intact and required assistance with toileting was told by a nurse aide to urinate in a diaper if unable to wait, rather than being provided timely help. The resident was left sitting in feces overnight before care was given, and inappropriate language was used by staff, failing to honor the resident's dignity and rights.
Licensed nursing staff left prescribed medications at the bedside for two residents who had not been assessed or authorized to self-administer, failing to observe medication consumption as required by facility policy. In both cases, LPNs exited the room before confirming that the medications were taken, despite having received education on proper medication administration procedures.
A resident with dementia and seizure precautions did not have ordered two-half siderails and padded siderails in place after a bed change, despite nursing staff documenting compliance on the TAR for all shifts. Interviews revealed that staff did not verify the presence of these safety interventions before signing off, and the DNS was unaware that the required equipment was missing until the survey.
A resident with dementia and seizure precautions did not have physician-ordered side rails or side rail padding in place after a bed change, yet nursing staff repeatedly documented on the TAR that these interventions were present. Staff interviews confirmed that documentation was completed without verifying the interventions, and the DON acknowledged a lack of communication and oversight regarding the bed change and required equipment.
A resident with multiple chronic conditions, including stroke and heart failure, did not receive prescribed doses of Losartan and Lexapro via G-tube as ordered. An LPN was identified as having administered incorrect doses, and the DON was notified after another nurse raised concerns. The LPN denied the error and resigned following the incident.
Multiple residents were observed without identification bracelets or visible forms of identification, despite facility policy requiring such identification for all residents. Interviews confirmed that some residents had not received name bands, and the DON was aware of the issue but it remained unresolved at the time of the survey.
The facility experienced delays in administering prescribed Oxycodone for a resident with severe pain due to cellulitis and diabetic chronic kidney disease. Despite a care plan and interventions in place, the resident faced delays in receiving medication, leading to severe pain episodes. Nursing staff encountered challenges in accessing the medication from the pharmacy and automated dispensing system. Communication gaps and documentation discrepancies further complicated timely pain management.
The facility failed to review the infection prevention control program policies and procedures annually, did not conduct quarterly infection control surveillance and safety rounds for several months in 2022 and 2023, and did not complete monthly infection reports or analyze infection trends for 2022 and the first half of 2023. The DNS confirmed these lapses and attributed them to the absence of the previous IP nurse.
The facility failed to ensure that the antibiotic stewardship program, including antibiotic usage and audit tool results, was reviewed and presented at the quarterly medical staff meetings for the periods of 2022 and 2023. The DNS was unable to locate any relevant documentation for these periods, except for the last quarters of 2023, which she completed herself.
The facility failed to maintain a consistent designated Infection Preventionist (IP) with the required specialized training in infection control for 2022 and 2023. The DNS served as the IP from July to December 2023, and there were gaps in having a designated IP during these years. Human Resources did not provide certification or specialized training documentation for the individuals hired as IPs.
A facility failed to develop a comprehensive care plan for a resident with an indwelling urethral catheter. The care plan lacked specific details such as the type of catheter, frequency of changes, and general care instructions. Despite the resident's complex medical needs, the care plan was insufficiently detailed, and monthly physician's orders did not address catheter care.
A facility failed to administer a nicotine patch to a newly admitted resident with a history of smoking due to a lack of stock. Despite a physician's order, the resident did not receive the patch until their significant other brought it to the facility. The facility's policy for interim/stat/emergency deliveries was not followed.
A resident with multiple medical conditions was injured during a transfer via mechanical lift due to the facility's failure to follow manufacturer's recommendations and facility policy. The lift tipped over because the wheelbase was not expanded, causing the resident to fall and sustain a back injury. The incident was not properly documented, and the care card lacked specific instructions for the lift's use.
The facility failed to properly discard a controlled medication by its expiration date. An LPN was unsure why the expired Lorazepam oral liquid was still in the refrigerator, and the DNS mentioned that there is no set schedule for medication destruction. The facility's policy was not followed in this instance.
The facility failed to notify the LTC Ombudsman's office of resident discharges and transfers within a timely manner. Reviews revealed consistent delays in sending notifications for several months, with delays ranging from one to fifty-two days. An interview with the responsible social worker confirmed the delays were due to an oversight.
The facility failed to complete annual performance reviews for three nurse aides and did not complete the background check for an LPN. The HR Director acknowledged the missing reviews and background check, citing recent changes in HR and DNS positions as contributing factors.
The facility failed to protect two conserved residents with severely impaired cognition from sexual abuse. One resident was found in another's room, both naked from the waist down, despite care plans and policies in place to manage behaviors and ensure safety. Immediate intervention and subsequent evaluations found no injuries, but the incident revealed significant lapses in resident protection.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
A deficiency occurred when a nurse aide instructed a cognitively intact resident, who required assistance with toileting and transfers, to urinate in a diaper if unable to wait for help. The resident, who had diagnoses including bradycardia, pacemaker placement, and high blood pressure, had a physician's order for transfer with assist of one and a rolling walker. Facility documentation and interviews confirmed that the aide used the term 'diaper' and told the resident to relieve themselves in it rather than providing timely assistance or appropriately communicating the need to wait. The resident was left to sit in feces overnight before staff returned to provide care. Facility policy and the resident's care plan required staff to encourage and assist with toileting and to use dignified language such as 'brief' or 'incontinent care products.' The incident report and interviews indicated that the aide's actions and language did not honor the resident's right to dignity and failed to provide care in a respectful manner.
Failure to Observe Medication Administration and Unauthorized Bedside Medication Placement
Penalty
Summary
Licensed nursing staff failed to ensure that residents consumed prescribed medications prepared for them before leaving their rooms. In two cases, medications were left at the bedside of residents who had not been assessed or authorized to self-administer their medications. One resident, with diagnoses including adult failure to thrive, anemia, and atrial fibrillation, was observed receiving medications prepared by an LPN, who then left the medication cup on the bedside table and exited the room without confirming ingestion. The clinical record did not indicate that this resident was assessed for self-administration of oral medications. Another resident, with a history of anxiety disorder, chronic pain, and a parathyroid gland neoplasm, also had medications left at the bedside on multiple occasions. In one instance, the LPN left the medications at the bedside while the resident's family was visiting, assuming the family would ensure the medications were taken. The family later reported the incident, and the LPN acknowledged the error. In a separate incident, another LPN left medications at the bedside because the resident previously refused to take them in her presence, intending to return later to check if they had been taken. The clinical record did not show that this resident was authorized for self-administration. Facility policy and inservice education clearly stated that medications should not be left at the bedside unless a resident is assessed and authorized to self-administer. Both LPNs involved acknowledged awareness of this policy and had received relevant education. Despite this, medications were left unattended at the bedside, and the required observation of medication consumption was not performed.
Failure to Follow Physician's Orders for Bed Safety Interventions
Penalty
Summary
A deficiency occurred when the facility failed to follow physician's orders for a resident with Alzheimer's disease, dementia, impaired vision, hearing loss, and difficulty walking. The physician had ordered two-half siderails and padded siderails for the resident's bed to support mobility, safe transfers, and seizure precautions. Despite these orders, after the resident's bed was switched to a low bed, no side rails or side rail padding were attached or present in the room. Nursing staff continued to document on the Treatment Administration Record (TAR) that the required side rails and padding were in place for every shift, even though they were not. Interviews with nursing staff revealed that they signed off on the TAR without actually verifying the presence of the side rails or padding. Staff admitted to not checking the bed before signing off and were unaware that the interventions were missing until it was brought to their attention during the survey. The Director of Nursing Services (DNS) acknowledged that the change to a low bed required communication with maintenance to install the side rails and padding, but was unsure if this had occurred. The DNS also stated that nursing staff are expected to follow physician's orders and verify interventions, but could not explain why staff had documented compliance when the interventions were not in place. The facility was unable to provide a policy for following physician's orders when requested.
Failure to Accurately Document and Implement Physician-Ordered Bed Safety Interventions
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident when nursing staff documented that side rail and side rail padding interventions were in place, despite these interventions not being present as ordered by the physician. The resident in question had diagnoses including Alzheimer's disease with late onset, dementia with behavioral disturbances, age-related cataract, bilateral sensorineural hearing loss, and difficulty walking. Physician's orders required two-half side rails for mobility and safe transfers, as well as seizure precautions including a low bed with fall mats and padded side rails. The resident's care plan also reflected these interventions. Upon observation, the resident's bed was found to be a low bed without any side rails or side rail padding, and only one fall mat was in place, with the other mat propped against the wall. Interviews with nursing staff revealed that they had signed off on the Treatment Administration Record (TAR) for multiple shifts, indicating that the side rails and padding were in place, even though they were not. Staff admitted to not verifying the presence of these interventions before documenting them as completed, citing being busy or unaware of the missing equipment. The Director of Nursing Services (DNS) acknowledged that the change to a low bed was not properly communicated to maintenance for side rail installation and was unsure why nursing staff continued to document the interventions as present. The facility's policy required all documentation to be factual, complete, and reflective of the resident's current condition and care provided, which was not followed in this instance.
Failure to Administer Medications as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral vascular infarction, congestive heart failure, hypertension, and depression did not receive medications as ordered by the physician. The resident, who was dependent on staff for activities of daily living and received nutrition via a gastrostomy tube, had physician orders for Losartan Potassium to treat high blood pressure and Escitalopram (Lexapro) for depression, both to be administered daily through the G-tube. On a specified date, both medications were omitted during the morning medication pass, as documented in the Medication Error Report, and the responsible party and physician were notified of the omission. An investigation by the Director of Nursing (DON) revealed that the wrong dose of both Losartan and Lexapro had been administered by a charge nurse, identified as an LPN. The DON was alerted to the issue by another nurse and, upon contacting the LPN involved, the LPN denied the allegation and subsequently resigned. The facility was unable to interview the LPN further regarding the incident.
Failure to Provide Required Resident Identification
Penalty
Summary
The facility failed to ensure that residents wore identification bracelets or other visible forms of identification as required by policy and professional standards. During observations of the memory care unit, three out of five residents in the dining room were found without any visible identification. Additional observations in the upper and lower resident units, recreation area, common areas, and rehab area revealed multiple residents without identification bracelets or other visible identification. Two residents interviewed confirmed they had not been provided with identification name bands. The Director of Nursing (DON) acknowledged awareness of the issue a week prior and stated that the expectation was for all residents to have identification name bands, which are used by nurses for medication administration. The DON had instructed charge nurses to audit and ensure residents had visible identification, but an audit subsequently found several residents still without name bands. The facility's policy requires that all residents be provided with an identification bracelet at admission, but this was not consistently implemented.
Delayed Administration of Pain Medication for Resident with Severe Pain
Penalty
Summary
The facility failed to administer pain medication as ordered for Resident #236, who was assessed to be in severe pain. Despite having a care plan in place that identified the resident's risk for pain and interventions for pain management, including the administration of Oxycodone for severe pain every three hours, the resident experienced delays in receiving the prescribed medication. Resident #236, who had diagnoses of cellulitis of both legs and Type 2 diabetes mellitus with diabetic chronic kidney disease, was observed crying in bed and expressing severe pain on multiple occasions. Interviews with nursing staff revealed that there were delays in obtaining and administering the Oxycodone, with discrepancies in documentation of medication administration on the MAR. The nursing staff, including LPN #1 and RN #5, were aware of Resident #236's pain but faced challenges in accessing the prescribed medication promptly. LPN #1 mentioned difficulties in obtaining the Oxycodone from the pharmacy and the automated medication dispensing system, leading to delays in medication administration. Despite being notified by the MDS Coordinator about the resident's pain, LPN #1 did not escalate the issue to the Nursing Supervisor when the medication was unavailable, and the resident's pain level remained at a severe level. The facility's policy on receiving interim/stat/emergency medications was not followed, as there were delays in obtaining the necessary medication for Resident #236 in a timely manner. The resident's pain management was further complicated by the lack of documentation of medication administration and communication gaps between staff members. Despite Resident #236's repeated complaints of severe pain and the availability of the prescribed pain medication, there were instances where the medication was not administered as ordered. The facility's failure to ensure timely and appropriate pain management for a resident in severe pain highlights deficiencies in medication administration processes and communication among the nursing staff involved in the resident's care.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to review the infection prevention control program policies and procedures at least annually, as required. Specifically, the Infection Control Program Policies and Procedure manual was not reviewed in 2022. The DNS, who was the former IP and currently oversees the IP program, confirmed that the manual was reviewed on 7/18/23 and 1/1/24 but could not provide documentation for 2022. The DNS acknowledged that the review should be conducted annually and attributed the lapse to the absence of the previous IP nurse during the required review period. The facility's policy mandates an annual review and updates to the program as necessary to align with national standards changes. Additionally, the facility did not conduct quarterly infection control surveillance and safety rounds for several months in 2022 and 2023, including April, July, and October of 2022, and January and April of 2023. The DNS was unable to locate the documentation for these rounds and indicated that it was the responsibility of the previous IP nurse. Furthermore, the facility failed to complete monthly infection reports or analyze infection trends for the year 2022 and the first half of 2023. The DNS could not find the monthly reports or quarterly infection control reports for the specified periods. The facility's policies require monthly infection reports to compute infection rates and quarterly reports to be presented to the infection control committee for review and recommendations.
Failure to Review Antibiotic Stewardship Program at Quarterly Medical Staff Meetings
Penalty
Summary
The facility failed to ensure that a review of the antibiotic stewardship program, including antibiotic usage and audit tool results, was presented at the quarterly medical staff meetings. Documentation for the period of January 2023 to June 2023 did not include any records of monthly reviews of the antibiotic stewardship program. Additionally, there was no documentation that a quarterly review of antibiotic usage for 2022 and 2023 was presented at the medical staff meetings. The DNS, who was not working at the facility during the time frame in question, was unable to locate any reports related to the antibiotic stewardship program for the specified periods, except for the last quarters of 2023, which she completed herself. The facility's Antibiotic Stewardship policy mandates that all infections be tracked by the IP or designee and reviewed for trends, with findings to be presented quarterly at the medical staff meetings. However, the review of the Medical Staff Meeting agendas for all quarters in 2022 and 2023 showed no topics related to infection control and antibiotic usage/antibiotic stewardship program presented by the Infection Preventionist. The DNS confirmed that it was the responsibility of the previous IP to complete and present these reports, but no such documentation was found in the Medical Staff Meeting binder for the specified periods.
Inconsistent Designation and Training of Infection Preventionist
Penalty
Summary
The facility failed to maintain a consistent designated Infection Preventionist (IP) with the required specialized training in infection control for the years 2022 and 2023. The Director of Nursing Services (DNS) served as the IP from July 2023 until December 2023, after which her role changed to DNS, and she continued to oversee the program until a newly hired nurse completed the required specialized training. Interviews with Human Resources and the Corporate Nurse revealed that three different nurses held the IP position in 2022 and 2023, but none had consistent tenure, and there were gaps in having a designated IP during these years. Additionally, Human Resources failed to provide certification or specialized training documentation for the individuals hired as IPs during this period, despite requests for such information. The facility's Infection Prevention and Control Program policy stated that the facility would designate one or more individuals as the infection control preventionist who had completed specialized training in infection prevention and control. However, the facility did not adhere to this policy, as evidenced by the inconsistent assignment of the IP role and the lack of documentation for specialized training. This deficiency was identified through interviews, review of facility documentation, and examination of employee punch history, which confirmed the absence of a consistently designated and properly trained IP for the specified years.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with an indwelling urethral catheter. The care plan did not include specific details such as the type of catheter, frequency of catheter changes, the size of the balloon to be used, and general care instructions for the catheter. This deficiency was identified through observations, review of facility documentation, and interviews with staff. The resident in question had multiple diagnoses, including Type II diabetes mellitus with diabetic polyneuropathy, above the knee right side amputation, neuromuscular dysfunction of the bladder, and renal dialysis. Despite these complex medical needs, the care plan was insufficiently detailed to guide staff in providing appropriate care for the indwelling catheter. The quarterly Minimum Data Set (MDS) assessment confirmed that the resident had an indwelling Foley catheter and was dependent on staff for mobility, transfers, and personal care. However, the care plan dated 3/6/2024 only mentioned the presence of the catheter without providing specific instructions for its management. Additionally, the monthly physician's orders for March 2024 did not address the use or care of the catheter. Interviews with the Director of Nursing Services (DNS) and the MDS coordinator revealed that the initial care plan is typically completed by the admission nurse or MDS coordinator, but in this case, it lacked the necessary details. The facility's Care Planning Policy mandates the development of a comprehensive and individualized plan of care, which was not met in this instance.
Failure to Administer Nicotine Patch to Newly Admitted Resident
Penalty
Summary
The facility failed to administer a nicotine patch to a newly admitted resident with a recent history of smoking. Resident #236, who had diagnoses including cellulitis of both legs, Type 2 diabetes mellitus with diabetic chronic kidney disease, and tobacco use, was admitted with a physician's order for a NicoDerm CQ 24hr 21mg patch. Despite this order, the resident did not receive the nicotine patch due to the facility's lack of stock. Interviews with the resident and staff confirmed that the patches were unavailable over the weekend, and the resident's significant other had to bring the patches to the facility on Monday, which was the first time one was applied. The facility's medication administration record did not document the application of the patch until the evening of March 12th, 2024. The Director of Nursing (DON) confirmed that the facility should have kept at least one box of each dosage of nicotine patches on hand and that orders are typically placed on Fridays and received on Mondays. The DON also noted that if a medication is not available, it should be ordered stat from the pharmacy, although the pharmacy does not usually deliver NicoDerm patches as a stat medication. There was no documentation that the medication was ordered stat on March 9th, 2024. The facility's policy directed immediate notification to the pharmacy for interim/stat/emergency deliveries, which was not followed in this case.
Failure to Ensure Safe Transfer via Mechanical Lift
Penalty
Summary
The facility failed to ensure that Resident #286 was transferred safely via a mechanical lift, leading to an accident. Resident #286, who had multiple diagnoses including type II diabetes mellitus with diabetic polyneuropathy, above the knee right side amputation, and morbid obesity, required a total mechanical lift transfer with the assistance of two staff members. During a transfer from a wheelchair to a bed, the mechanical lift tipped to the right because the wheelbase was not in the expanded position, causing the resident to fall and hit his back on the side rail of the bed. This incident resulted in severe back pain and a subsequent hospital visit where a CT scan showed a small disc protrusion and probable disc bulges/herniations, although detailed assessment was limited due to the resident's obesity. The report indicates that the mechanical lift was not operated according to the manufacturer's recommendations and facility policy, which require the base legs to be locked in the open position for maximum stability. Interviews with staff revealed that the wheelbase was not expanded during the transfer, leading to the lift tipping over. Additionally, the care card for Resident #286 did not specify which mechanical lift or pad to use, contributing to the improper use of the equipment. The facility's policies and the manufacturer's guidelines were not followed, resulting in the resident's fall and subsequent injury. Further interviews and documentation reviews revealed that the incident was not properly documented in the clinical record, and there was a lack of information on how the incident occurred and the injuries sustained. The nursing supervisor on duty at the time of the incident failed to document the resident's refusal for assessment and pain medication. The facility's failure to adhere to proper mechanical lift procedures and inadequate documentation contributed to the deficiency in ensuring a safe environment for Resident #286.
Failure to Discard Expired Controlled Medication
Penalty
Summary
The facility failed to properly discard a controlled medication by its expiration date. During an observation of the medication storage room refrigerator, Lorazepam oral liquid for a resident was found with an opened date and a discard date that had passed. An LPN was unsure why the medication was still in the refrigerator and noted the medication's storage guidelines. The DNS mentioned that staff call her if a medication is expired, and she conducts weekly rounds to check for expired medications, but there is no set schedule for destruction. The facility's policy directed that all expired medications should be destroyed or returned according to guidelines, but this was not followed in this instance.
Failure to Timely Notify Ombudsman of Discharges and Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman's office of resident discharges and transfers within a timely manner. The review of the facility's documentation for several months revealed consistent delays in sending notifications. For September 2023, notifications for eleven residents were sent one day late. In October 2023, notifications for twelve residents were sent six days late. In November 2023, notifications for twenty-six residents were sent fifty-two days late. In January 2024, notifications for sixteen residents were sent thirty-five days late. In February 2024, notifications for twenty-six residents were sent six days late. An interview with the responsible social worker confirmed that the delays were due to an oversight on her part. The facility's policy requires that notifications be made by the 5th of the following month for the previous month. The policy also mandates that for any other types of facility-initiated discharges, the facility must provide notice of discharge to the resident and resident representative along with a copy of the notice to the State Long-term care ombudsman 30 days prior to the discharge. The director of social services is responsible for running the monthly report at the beginning of each month.
Failure to Complete Annual Performance Reviews and Background Check
Penalty
Summary
The facility failed to complete annual performance reviews for three nurse aides (NA #1, NA #2, and NA #3) and did not complete the background check for LPN #5. The employees' files for the nurse aides, hired on various dates between 2012 and 2019, lacked the required performance reviews for 2023. During interviews, the Human Resources Director (HRD) acknowledged the missing performance reviews and the absent background check for LPN #5. The HRD noted that performance reviews are typically conducted annually around the employee's hire date but cited a change in HR and the Director of Nursing Service (DNS) positions as a contributing factor to the oversight. The facility's Performance and Review policy mandates formal and documented performance reviews at the end of the introductory period and annually thereafter.
Failure to Protect Conserved Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that two conserved residents, who were unable to provide consent, were free from sexual abuse. Resident #1, diagnosed with dementia and major depressive disorder, was found in Resident #2's room, naked from the waist down, with Resident #2 leaning towards Resident #1's private area. Both residents had severely impaired cognition and were under conservatorship, meaning they could not consent to sexual activities. The incident was discovered by RN #1, who immediately intervened and separated the residents, calling for additional staff assistance. Resident #1 was placed under 1:1 monitoring at the nursing station, and the incident was reported to the MD and Resident #1's family. A subsequent physical examination and hospital evaluation found no injuries or trauma to Resident #1's private areas. Resident #2, diagnosed with epilepsy and adjustment disorder, had a history of inappropriate sexual behavior. The care plan for Resident #2 included interventions to manage this behavior, such as distraction and avoiding conversations that could lead to inappropriate actions. Despite these measures, Resident #2 was found in a compromising situation with Resident #1. Interviews with staff revealed that both residents were last seen in common areas shortly before the incident. The facility's Director of Nursing Services (DNS) confirmed that both residents were placed on 1:1 observation following the event and that Resident #2's room was relocated to a different floor. The facility's Resident Abuse policy and the resident bill of rights were reviewed, both of which emphasize the importance of treating residents with dignity and protecting them from abuse. The facility failed to adhere to these policies, resulting in a situation where two residents were exposed to potential sexual abuse. The report highlights the facility's inability to prevent such incidents, despite having policies and care plans in place to manage residents' behaviors and protect their well-being.
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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