Apple Rehab Watertown
Inspection history, citations, penalties and survey trends for this long-term care facility in Watertown, Connecticut.
- Location
- 35 Bunker Hill Rd, Watertown, Connecticut 06795
- CMS Provider Number
- 075181
- Inspections on file
- 29
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Apple Rehab Watertown during CMS and state inspections, most recent first.
A resident with cardiovascular disease, prior stroke, and moderate cognitive impairment experienced escalating agitation and combative behavior, including attempts to climb out a window and physical aggression toward staff, leading an APRN to order hospital transfer after an unsuccessful attempt to administer antianxiety medication. EMS transported the resident, and the hospital later adjusted psychiatric medications and recommended follow-up. Documentation showed that LPNs recorded the behavioral changes, the transfer, and the resident’s eventual return from the hospital, but no RN assessments were documented at the time of the significant change in condition or upon readmission, despite facility policies and expectations from the RN supervisor and DON that an RN assessment be completed and documented in both situations.
A resident with cardiovascular disease, a history of stroke, and moderate cognitive impairment became unresponsive during morning care and was found with a carotid pulse of 30 bpm before regaining responsiveness, at which time low blood pressure and bradycardia were documented and the APRN was notified. A physician then ordered vital signs every shift for three days, and the MAR was initialed each shift to indicate that vital signs were obtained; however, no actual vital sign values were documented in the MAR, nursing notes, or vital sign records for multiple consecutive shifts. The DON reported that staff were expected to follow physician orders and document temperature, BP, pulse, and respirations promptly per the facility’s Nursing Documentation Policy, but could not explain why the ordered vital signs were not recorded.
A resident with multiple chronic conditions experienced significant changes to their diabetes management, including discontinuation of sliding scale insulin and frequent blood glucose checks, as well as an increase in long-acting insulin dosage. Despite facility policy requiring family notification of such changes, there was no documentation that the resident's family was informed.
A resident with diabetes and multiple comorbidities did not have a Hemoglobin A1C test obtained as ordered, despite clear recommendations and agreement from medical staff. The order for the bloodwork was not implemented, and no documentation was provided to explain the omission, resulting in a failure to follow physician orders and facility policy.
Two residents at risk for falls in an LTC facility experienced multiple falls due to inadequate supervision and failure to implement care plan interventions. One resident, with a history of falls and severe cognitive impairment, was not monitored hourly as required, leading to a fall and hip fracture. Another resident with dementia had 13 falls over several months, with documentation missing for required 15-minute checks. Staff interviews revealed a lack of adherence to monitoring protocols, contributing to the residents' injuries.
The facility failed to manage and account for resident council funds after the closure of a bank account in 2021, with $1808.64 unaccounted for. Residents were unaware of the funds, and there was no designated treasurer. The Director of Recreation and Business Office Manager could not locate the funds, and the VP of Operations confirmed no record of the funds in the corporate account. Facility policies on fund management and resident rights were not followed.
An LPN failed to maintain resident confidentiality by leaving a computer screen open with personal information visible during medication administration. The LPN was unaware of the requirement to close the screen, and the DNS confirmed the breach of protocol, emphasizing the need for privacy as per facility policies.
The facility was found to have numerous deficiencies in maintaining a clean and homelike environment across all units. Inspections revealed issues such as damaged floors, stained walls, and rusty radiator covers. Staff interviews indicated a lack of awareness or partial awareness of these problems, and the infection control surveillance form failed to document room conditions. The deficiencies suggest a failure to execute responsibilities outlined in staff job descriptions.
The facility failed to maintain proper temperature logs for refrigeration units, address maintenance issues with the walk-in freezer, and adhere to food labeling and storage practices. Observations revealed incomplete temperature logs, significant frost buildup in the freezer, unlabeled and expired food items, and improper storage of personal items in the kitchen. Additionally, dietary staff did not consistently wear beard guards, and food temperatures were not recorded before serving.
An LPN failed to perform hand hygiene during medication administration, as observed in multiple instances. The LPN prepared and administered medications to residents without sanitizing hands before or after the process, despite being educated on the importance of hand hygiene. Interviews with the DNS and Infection Control Nurse confirmed that the facility's policy required hand sanitization before and after medication preparation and direct resident contact.
The facility failed to manage roam alert bracelets effectively, resulting in expired devices and undocumented orders. Additionally, neurological and post-fall assessments were incomplete for residents who experienced falls, and weight monitoring was not conducted as per physician's orders for residents with specific health conditions.
A resident with acute respiratory failure and other conditions did not have their oxygen saturation monitored as ordered by the physician. Despite a care plan that included oxygen therapy and regular monitoring, the facility only measured oxygen saturation 16 times out of 51 opportunities. The DNS confirmed that physician's orders were not followed, as oxygen levels should have been checked every shift.
The facility failed to date and discard Insulin medications properly in two medication carts. An LPN found a Humalog Insulin vial expired and a Lispro Insulin pen undated on the upper level. On the lower level, a Lispro Insulin pen and a Levemir Insulin pen were opened without dates. The DNS confirmed that Insulin should be dated when opened and discarded per pharmacy guidelines.
A resident with multiple sclerosis and dementia was burned after staff reheated soup without checking its temperature, contrary to facility policy. The resident, who required assistance with daily activities, spilled the soup and sustained a second-degree burn. Interviews revealed that staff were not trained or equipped to check food temperatures, despite a policy against reheating outside food.
The facility failed to maintain accurate documentation for several residents, leading to deficiencies in care. One resident's burn incident was not properly documented, another resident's pressure ulcer was not recorded before a physician's evaluation, and a third resident's fall was inaccurately documented with entries made before the fall and after hospital transfer. The DNS and ADNS were unable to provide complete and accurate records.
A resident with multiple sclerosis and dementia sustained a burn from hot soup after facility staff reheated it, contrary to policy. The resident, dependent on staff for daily living activities, requested a smaller portion of their favorite soup, which was brought in by a visitor. The soup was reheated for the usual time, likely making it hotter, and the resident was left alone, resulting in a burn. The facility's policy prohibited reheating outside food, but this was not enforced, contributing to the incident.
The facility failed to ensure staff documented care as performed by licensed personnel per the physician's order for a resident with multiple diagnoses, including dementia and an unstageable pressure ulcer. The Treatment Administration Record showed multiple instances where there were no nurses' signatures indicating that the wound care and offloading of heels were performed as ordered. The DON confirmed the absence of documentation and acknowledged it should have been done per policy.
Failure to Complete Timely RN Assessments After Change in Condition and Hospital Return
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely RN assessments in response to a significant change in condition and upon readmission from the hospital for one resident. The resident had a history of stroke, thyroid disorder, hypertension, and cardiovascular disease related to bradycardia and hyponatremia, and required assistance with ADLs and transfers. On 12/30/2024, LPN staff documented that the resident became increasingly agitated and combative, attempting to climb out of a window, hitting, scratching, and yelling at staff, and being considered a danger to self. An APRN was notified, a one-time antianxiety medication was ordered and attempted but spit out by the resident, and the APRN then ordered a transfer to the hospital. EMS records showed the resident was transported that evening. Despite this documented significant change in mental and behavioral status and transfer to the hospital, record review did not identify that an RN assessment was completed at the time of the change in condition. After evaluation and treatment at the hospital, including psychiatric assessment and medication changes, the resident returned to the facility on 1/1/2025. A nursing note by an LPN documented the resident’s return, and the hospital discharge summary included recommendations for medication adjustments and geriatric psychiatric follow-up. However, review of the 24-hour report sheets and the resident’s medical record revealed no RN assessment documented upon the resident’s return from the hospital. Interviews with the RN supervisor who worked on the date of the initial change in condition confirmed she could not recall assessing the resident and stated that if she had done so, it would have been documented. She also acknowledged that an RN assessment should be completed for a significant change in condition and upon admission/readmission. The DON similarly stated she would expect an RN assessment in these circumstances. Facility policies on Change in Resident Condition and Nursing Documentation required an RN assessment when there is a significant change in physical, mental, or emotional status and that documentation occur as soon as possible after the assessment, but no such RN assessments were found for either the change in condition or the readmission.
Failure to Document Ordered Vital Signs After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record and to ensure vital signs were recorded timely after a change in condition was identified for one resident. The resident had a history of stroke, convulsions, thyroid disorder, and hypertension, and a quarterly MDS showed moderate cognitive impairment, no behaviors, assistance needed with ADLs and transfers, and no antianxiety or antidepressant medications. The resident’s care plan noted cardiovascular disease due to bradycardia and hyponatremia, with interventions to obtain vital signs and provide medications as ordered. During morning care, the resident became unresponsive while moving bowels; an RN assessed the resident and found them unresponsive to tactile and verbal stimuli with a carotid pulse of 30 beats per minute. After a few minutes, the resident became responsive, and vital signs were documented at that time as blood pressure 90/60, pulse 50, and respirations 14, and the APRN was updated. Following this event, a physician order directed that vital signs be obtained every shift for three days. Although vital sign monitoring was initiated as ordered on the afternoon of the same day, the clinical record did not contain documentation of the vital signs for multiple subsequent shifts. The MAR for the relevant days showed that staff had initialed all shifts to indicate vital signs were obtained, but the actual vital sign values were not recorded on the MAR, in nursing notes, or in any vital sign records for the night shift of the first day, all three shifts of the next two days, and the day shift of the final day. The DON stated that nursing staff were expected to follow physician orders and document temperature, blood pressure, pulse, and respirations in the medical record, and that she did not know why staff failed to document the ordered vital signs. The facility’s Nursing Documentation Policy directed that documentation should occur as soon as possible after care was completed, but this was not followed in these instances.
Failure to Notify Family of Significant Change in Medication and Care Plan
Penalty
Summary
The facility failed to notify the family of a resident when there were significant changes in the resident's medication regimen and plan of care. The resident, who had diagnoses including type 2 diabetes mellitus, liver cirrhosis, dementia, and Alzheimer's disease, was receiving insulin therapy and regular blood glucose monitoring. Following a pharmacist's recommendation and subsequent physician orders, the resident's sliding scale insulin and frequent blood sugar checks were discontinued, and the dosage of long-acting insulin was increased. Despite these changes, there was no documentation that the resident's family was informed of the modifications to the medication and care plan. Interviews with facility staff, including the APRN and DNS, confirmed that it was the nurses' responsibility to notify the resident's next of kin about such changes. However, the DNS was unable to provide evidence that the family had been notified as required by facility policy, which mandates reporting all significant changes in a resident's condition to both the physician and family. This lack of documentation and communication constituted a failure to follow established procedures for family notification during changes in the resident's care.
Failure to Obtain Ordered Diabetes Bloodwork
Penalty
Summary
A deficiency occurred when the facility failed to ensure that diabetes bloodwork, specifically a Hemoglobin A1C test, was obtained for a resident with type 2 diabetes mellitus, liver cirrhosis, dementia, and Alzheimer's disease. The resident's care plan included interventions for diabetes management, such as administering medications as ordered, monitoring for symptoms of hypo- or hyperglycemia, and obtaining labs as ordered. Despite a physician's note and a pharmacist's medication review recommending regular A1C monitoring, and an APRN agreeing to the order, the A1C was not obtained as required. The last documented A1C was several months prior, and no new result was available in the medical record within the expected timeframe. Interviews with the APRN and MD confirmed that the expectation was for the resident's A1C to be monitored every six months, and the order to obtain the test had been agreed upon and should have been implemented. The DNS acknowledged that the nurses and/or ADNS are responsible for reviewing pharmacy recommendations and implementing physician orders, but could not provide documentation or an explanation for why the order to obtain the A1C was not carried out. Facility policy requires all physician orders to be complete and accurate, but this was not followed in this instance.
Failure to Implement Fall Prevention Measures for At-Risk Residents
Penalty
Summary
The facility failed to implement adequate interventions and supervision to prevent falls for two residents at risk, resulting in injuries. Resident #27, who had a history of frequent falls, was admitted with conditions including diabetes, atrial fibrillation, and dementia. Despite a care plan requiring hourly monitoring after a fall on 11/20/23, documentation showed that this monitoring was not conducted between 11/21/23 and 11/23/23. This lapse in supervision led to another fall on 11/23/23, resulting in a femoral neck fracture that required surgical intervention. Resident #41, diagnosed with dementia, experienced 13 falls between 1/24/24 and 5/30/24. The care plan included interventions such as 15-minute checks and analysis of fall patterns, but documentation failed to show that these checks were consistently performed. The resident's care card indicated the need for frequent monitoring, yet the facility did not adhere to these guidelines, leading to multiple unwitnessed falls, one of which resulted in a head injury requiring sutures. Interviews with facility staff, including the DNS, revealed a lack of awareness and adherence to the monitoring protocols outlined in the care plans. The facility's policies on close monitoring and fall prevention were not followed, as evidenced by the absence of documentation for required checks and the failure to update care plans with necessary interventions. This oversight contributed to the repeated falls and injuries sustained by the residents.
Mismanagement of Resident Council Funds
Penalty
Summary
The facility failed to properly manage and account for the resident council funds, as evidenced by the closure of the Resident Council Funds bank account in April 2021, with a withdrawal of $1808.64, and the subsequent lack of documentation or discussion regarding these funds in resident council meetings. Interviews with several residents revealed that they were unaware of any funds or accounts associated with the resident council, and there was no designated treasurer to manage these funds. The Director of Recreation, who was previously the Assistant Director, indicated that the prior Director of Recreation had managed the funds, but upon their departure, the account was closed, and the funds were reportedly held in the business office, although this could not be confirmed. Further interviews with the Business Office Manager and the VP of Operations revealed that there was no ledger or accounting documentation for the $1806, and the funds could not be located in the business office or the corporate account. The Business Office Manager, who started in January 2024, was unaware of the corporate account containing resident council funds and confirmed that there was no record of the $1806 being transferred or deposited. The facility's policies on Resident Council Funds and Resident Rights emphasize the residents' right to manage their personal financial affairs and the facility's responsibility to maintain and account for these funds, which was not adhered to in this case.
Failure to Maintain Resident Confidentiality During Medication Administration
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information during medication administration. On the morning of June 17, 2024, an LPN was observed administering medications to residents without closing the computer screen on the medication cart, which displayed personal demographics of 16 residents, including names, photos, and room numbers. This occurred multiple times as the LPN moved between residents' rooms and the nurse's station, leaving the computer screen open and unattended. Interviews revealed that the LPN was unaware of the requirement to close the computer screen when not in use, believing it was only necessary when medication lists were visible. The Director of Nursing Services (DNS) confirmed that the LPN should not have left the computer screen open with resident information visible and explained the procedure to either close the screen or activate a screen saver to protect resident confidentiality. The facility's policies on medication administration and resident rights emphasize the importance of maintaining privacy and confidentiality of resident information.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment across all four units, as observed during multiple inspections. The inspections revealed numerous issues, including damaged, missing, or broken floor tiles in bedrooms and bathrooms, stained and chipped walls, and rusty or broken radiator covers. Additionally, there were problems with stained and dirty floors, peeling ceilings, and damaged furniture such as nightstands and dressers with missing knobs. These deficiencies were noted in various rooms across the [NAME], Crestbrook, Cortland, and Taft units. Interviews with facility staff, including the Housekeeper/Laundry Supervisor, Maintenance Supervisor, RN #1, and the Administrator, indicated a lack of awareness or partial awareness of these issues. The Housekeeper/Laundry Supervisor, who had been employed for approximately eight months, was unaware of the stained and dirty floors and curtains. The Maintenance Supervisor, employed since October 2023, acknowledged some awareness of the issues and mentioned ongoing repair efforts. RN #1, with three years of employment, was also aware of some issues, and the Administrator, employed for four months, recognized the need for improvement in maintaining a homelike environment. The facility's infection control surveillance and safety rounds form, dated 4/24/24, did not document the conditions of resident rooms, indicating a gap in monitoring and reporting. The job descriptions for the Maintenance Supervisor, Maintenance Technician, Housekeeping Supervisor, and Housekeeping Assistant outlined responsibilities for maintaining a safe and clean environment, yet the observed deficiencies suggest these duties were not fully executed. The report highlights a systemic issue in ensuring the facility's environment meets the required standards for resident safety and comfort.
Deficiencies in Food Safety and Maintenance Practices
Penalty
Summary
The facility failed to maintain proper temperature logs for their refrigeration units, as observed during a kitchen tour. The temperature logs for the walk-in refrigerator and freezer were incomplete, with several days missing records. The Director of Dietary (DOD) indicated that the cook was responsible for recording these temperatures but had not done so due to being absent. Additionally, the milk refrigerator and ice cream freezer logs were also incomplete, with numerous instances of missing temperature recordings. This lack of documentation was attributed to dietary aides not fulfilling their responsibilities. The facility also failed to address maintenance issues with the walk-in freezer, which had a significant frost buildup. The DOD and the Director of Maintenance were aware of the problem, which persisted even after a new door was installed. The Director of Maintenance had not successfully contacted the company responsible for the door installation to address the issue, leading to continued frost accumulation. This issue was known for several months, but no effective action was taken until prompted by the surveyor's inquiry. Furthermore, the facility did not adhere to proper food labeling and storage practices. Observations revealed that prepared food items in the walk-in refrigerator were not labeled or dated, and some items were not discarded after the recommended three-day period. Personal items were improperly stored in the kitchen area, and dietary staff did not consistently wear beard guards while preparing food. Additionally, expired food items were found in the resident nourishment refrigerator, and the facility failed to record food temperatures before serving, as required by their policy.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene was practiced by a nurse during medication administration, as observed on multiple occasions. An LPN was seen moving a medication cart to a resident's room, preparing and administering medications without performing hand hygiene before or after the process. The LPN also touched a resident's roommate and another resident without sanitizing hands afterward. Despite being educated on hand hygiene, the LPN admitted to not knowing why she failed to perform it during these instances. Interviews with the Director of Nursing Services (DNS) and the Infection Control Nurse confirmed that the facility's policy required nurses to sanitize their hands before and after preparing medications, after direct contact with residents, and between residents during medication passes. The facility's Medication Administration Policy also emphasized the importance of appropriate hand hygiene before and after direct resident contact. Despite this, the LPN did not adhere to these protocols, leading to the identified deficiency.
Deficiencies in Roam Alert Management, Fall Assessments, and Weight Monitoring
Penalty
Summary
The facility failed to effectively manage roam alert bracelets for residents at risk of elopement. Several residents were found wearing expired roam alert bracelets, and there were discrepancies in the documentation of bracelet serial numbers in the physician orders. Additionally, some residents were wearing elopement bracelets without a physician's order. The facility's policy required the night supervisor to check the roam alerts nightly, but the Assistant Director of Nursing Services (ADNS) was responsible for overseeing the process. The discrepancies were identified during testing, revealing expired devices and mismatched serial numbers. The facility also failed to ensure that neurological assessments and post-fall assessments were completed following falls for two residents. One resident experienced multiple unwitnessed falls, and the facility's documentation was incomplete or missing for neurological checks and post-fall assessments. The facility's policy required neurological checks for 72 hours following an unwitnessed fall, but the documentation did not reflect this practice. The Director of Nursing Services (DNS) acknowledged the lack of completed assessments and indicated a need for staff education. Furthermore, the facility did not follow physician's orders related to weight monitoring for two residents. One resident had orders to check weight three times weekly, but the clinical record did not document weights as frequently as required. Another resident, who had a history of congestive heart failure, was supposed to have weekly weight monitoring, but the documentation was inconsistent. The DNS recognized the failure to follow physician's orders and planned to reeducate staff on the importance of adhering to weight monitoring protocols.
Failure to Monitor Oxygen Saturation as Ordered
Penalty
Summary
The facility failed to monitor oxygen saturation as ordered by the physician for a resident who was admitted with acute respiratory failure with hypoxia, malignant neoplasm of breast, and supraventricular tachycardia. The resident's care plan included interventions for cardiovascular disease, such as oxygen therapy and monitoring oxygen saturations as ordered. A physician's order required monitoring oxygen saturation with a pulse oximeter every 8 hours and adjusting oxygen levels to maintain saturation above 90% on room air. However, from June 1 to June 17, out of 51 opportunities, oxygen saturations were only measured 16 times. The Director of Nursing Services (DNS) confirmed that it was expected for physician's orders to be followed, and oxygen saturations should have been measured and documented every shift for titration.
Failure to Date and Discard Insulin Medications
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of Insulin medications in two of four medication carts. During a review of the medication cart on the upper level, a Humalog Insulin vial was found to be opened and expired without being discarded, and a Lispro Insulin pen was opened but not dated. Similarly, on the lower level, a Lispro Insulin pen and a Levemir Insulin pen were both opened without being dated, despite stickers indicating they should be discarded after a specific number of days once opened. An interview with the Director of Nursing Services (DNS) confirmed that all Insulin vials and pens should be dated when first opened and discarded based on the date written on them, as per pharmacy recommendations. The DNS acknowledged that each type of Insulin has a different shelf life once opened, which the nursing staff is expected to adhere to.
Resident Burned Due to Improper Food Reheating
Penalty
Summary
The facility failed to ensure that food reheated for a resident was at a safe temperature, resulting in a second-degree burn. Resident #8, who has multiple sclerosis, spasmodic torticollis, and dementia, required assistance with activities of daily living and had severely impaired cognition. On a specific date, the resident requested that a portion of soup brought in by a visitor be reheated. The staff reheated the soup without checking its temperature, as there was no system in place to do so. This led to the resident spilling the soup and sustaining a burn on the chest area. Interviews revealed that the facility's policy prohibited staff from reheating outside food, and staff were not trained or provided with thermometers to check food temperatures. Despite this policy, staff had been reheating food for residents without proper temperature checks. The Director of Nursing Services confirmed that the policy had been in place for several years, but staff were not in-serviced on reheating temperatures, leading to the incident where Resident #8 was burned.
Deficiencies in Documentation and Incident Reporting
Penalty
Summary
The facility failed to maintain accurate and complete documentation for several residents, leading to deficiencies in care. For one resident, the clinical record did not accurately reflect the circumstances surrounding a burn incident. The resident, who had multiple sclerosis and spasmodic torticollis, spilled hot soup on themselves after it was reheated by facility staff, contrary to the facility's policy that prohibited staff from reheating outside food. The Director of Nursing Services (DNS) was aware of the incident but did not document the details in the clinical record or reportable event form. Another resident's clinical record lacked documentation of a newly identified pressure ulcer. The wound care physician noted the ulcer during an evaluation, but there was no prior nursing assessment or provider notification documented. The wound care nurse and the LPN involved in the resident's care acknowledged the oversight in documentation, as the ulcer was identified before the physician's visit. Additionally, the facility failed to provide accurate documentation following a resident's unwitnessed fall. The neurological checks and post-accident assessments were incorrectly documented, with entries made before the fall occurred and after the resident had been transferred to the hospital. The Assistant Director of Nursing Services (ADNS) could not explain the discrepancies and was unable to produce the original documents, indicating a failure to maintain accurate medical records.
Failure to Honor Resident Meal Choice Leads to Burn Incident
Penalty
Summary
The facility failed to honor a resident's meal choices, leading to an incident where a resident sustained a burn from hot soup. The resident, who had multiple sclerosis, spasmodic torticollis, and dementia, was dependent on staff for assistance with activities of daily living and required setup only with meals. On the day of the incident, the resident spilled soup on themselves, resulting in a second-degree burn with blistering on the chest area. The soup was brought in by a visitor and reheated by facility staff, contrary to the facility's policy. Interviews revealed that the resident had a favorite soup brought in by a visitor, which was reheated by staff upon request. On the day of the incident, the resident requested only half a cup of soup to be reheated for the usual time, which likely resulted in the soup being hotter than expected. The facility's policy stated that outside food should not be reheated by staff, yet this practice was not followed, leading to the resident being left alone with the hot soup and subsequently getting burned. The facility's policy on reheating outside food was not consistently enforced, as staff had been reheating food for residents prior to the incident. The DNS confirmed that the policy prohibited staff from reheating outside food, and no thermometers were available to check food temperatures. This lack of adherence to policy and absence of proper equipment contributed to the incident, highlighting a failure to ensure resident safety and choice in meal preferences.
Failure to Document Care as Ordered
Penalty
Summary
The facility failed to ensure staff documented care as being performed by licensed personnel per the physician's order for one of three sampled residents. Resident #1, who had diagnoses including dementia, muscle wasting and atrophy, an unstageable pressure ulcer to the sacrum, urinary tract infection, and acute kidney failure, required extensive assistance with daily living tasks and was frequently incontinent. A physician's order directed that Resident #1's heels be offloaded when in bed each shift, and another order required specific wound care for a stage 2 sacrum pressure ulcer. However, the Treatment Administration Record (TAR) for September and October 2023 showed multiple instances where there were no nurses' signatures indicating that the wound care and offloading of heels were performed as ordered. The Director of Nursing (DON) confirmed during an interview and chart review that the facility policy requires staff to document care when it is provided. The DON acknowledged the absence of documentation for the wound care and offloading of heels on the specified dates and was unsure why the care was not documented. The facility policy on nursing documentation directs that it should provide an account of the resident's health care status, changes in condition, current assessments, and any concerns that alter the resident's plan of care. The lack of documentation indicates a failure to adhere to this policy, leading to the identified deficiency.
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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