Apple Rehab West Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in West Haven, Connecticut.
- Location
- 308 Savin Avenue, West Haven, Connecticut 06516
- CMS Provider Number
- 075403
- Inspections on file
- 39
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 35 (1 serious)
Citation history
Health deficiencies cited at Apple Rehab West Haven during CMS and state inspections, most recent first.
A resident with a history of needing a Kennedy cup for all liquids was readmitted without the adaptive device being re-ordered or provided, resulting in the resident being served hot coffee in a regular cup. The resident spilled the coffee and sustained a significant burn. Staff interviews revealed that the need for the Kennedy cup was not communicated or documented on the drink cart list, and there was no process to reconcile previous adaptive equipment orders upon readmission.
A resident with Alzheimer's disease and diabetes was prescribed an antibiotic for a UTI, but five doses were missed due to unavailability, refusal, and leave of absence. Nursing staff did not notify the provider or supervisor of the missed doses, and documentation was incomplete, contrary to facility policy. Interviews revealed staff were unaware of the requirement to notify the provider for each missed dose, and the APRN was not informed, missing the opportunity to adjust the treatment plan.
A resident with diabetes and myotonic muscular dystrophy was admitted with a physician's order for an endocrinology follow-up within 1-2 weeks. The facility failed to schedule the appointment over a period of more than three months, despite daily documentation of the outstanding order. Interviews confirmed that nursing staff were responsible for scheduling such appointments, but the process was not completed and no relevant policies were provided.
A resident with multiple complex diagnoses experienced a significant change in condition, including unresponsiveness and abnormal vital signs. Nursing staff failed to document a body temperature and blood glucose level prior to transferring the resident to the hospital, despite facility policy and the resident's diabetic status. The omission resulted in an incomplete clinical record of care provided before the transfer.
Staff responsible for water temperature maintenance lacked knowledge of safe temperature ranges, leading to multiple instances where hot water in resident bathrooms exceeded safe limits. Water temperatures were not routinely monitored or documented in resident care areas, and no policy existed for temperature checks. Staff and management were unaware of the correct limits, and no corrective actions were taken for several months despite elevated readings, resulting in Immediate Jeopardy due to the risk of scalding.
The facility did not have a written policy or procedure for monitoring and maintaining safe water temperatures, as evidenced by water at resident sinks reaching up to 130°F and only verbal instructions available for staff response. This deficiency was identified through observations and staff interviews.
A nurse aide was hired without documentation of a completed state or federal background check, including the required fingerprint-based screening. The facility's abuse policy did not specify procedures for background checks, and no pre-employment screening policy was available, resulting in the staff member being employed without proper verification.
Multiple residents did not receive medications and treatments as ordered by physicians, including missed weekly weights, unavailable medications, and late or undocumented medication administration. Staff failed to follow facility policies for timely administration, documentation, and physician notification, resulting in missed doses and incomplete records.
The facility did not maintain adequate nursing staff coverage on weekends, as PBJ data and staff interviews revealed lower staffing levels compared to weekdays. Multiple callouts among nursing aides led to shifts being understaffed, and the facility was unable to consistently replace absent staff. The staffing plan required more aides than were present, and there was no documentation provided to show that resident care needs were met during these periods.
A nurse aide did not receive a required annual performance evaluation or the minimum 12 hours of in-service education, including training based on identified weaknesses. Staff interviews and record reviews confirmed the absence of documentation and completion of these requirements, with no explanation provided for the oversight.
Several residents with medical conditions did not receive meals within the required 14-hour window, as dinner and breakfast were served 15 hours apart. Residents reported that substantial snacks were not consistently provided between these meals, with snack carts offering only limited options like crackers and apple sauce, and requests for more substantial food were often denied or met with resistance from staff.
Surveyors found that staff used uncovered ice cube trays handled with bare hands to provide ice due to a broken ice machine, with food stored above the trays. Multiple food items in kitchen storage were unlabeled and undated, a dented can was not removed from dry storage, food temperature logs were incomplete, and cleaning schedules lacked signatures or clear responsibility. Staff interviews confirmed these practices did not follow facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents receiving psychotropic medications did not have documented consent from their representatives, as required by facility policy. Staff were unable to provide signed consent forms or evidence that representatives were informed of the risks and benefits, despite the residents' cognitive impairments and need for representative involvement.
A resident with osteoarthritis, an artificial knee, and lower back pain did not receive a timely comprehensive assessment as required. Although pain management interventions were in place, the MDS assessment was not completed within the mandated timeframe, and the responsible staff member could not explain the delay. Facility policy required individualized care planning but did not specify the MDS process.
The facility did not update care plans for two residents after significant changes in their conditions. One resident experienced multiple falls and had ongoing oral care needs that were not reflected in the care plan, despite dental findings and staff observations. Another resident receiving continuous oxygen therapy did not have this intervention included in the care plan, even though it was ordered by a physician and observed in use. The DON acknowledged that care plans should have been revised to address these changes.
A resident with schizophrenia, dementia, and anxiety did not receive a prescribed medication or a urine culture because a nurse failed to transcribe the physician's orders into the electronic health record, despite marking them as noted. Only laboratory blood work was processed, and the facility could not provide its policy on physician's orders when requested.
A resident with dementia and incontinence was left unattended for an extended period after requesting bathroom assistance, despite repeated requests and staff awareness. Interviews and observations confirmed that the resident did not receive timely help with toileting, contrary to facility policy and staff expectations.
A resident with hearing loss and cognitive impairment was left without hearing aids after they went missing, despite care plan requirements for daily use and prompt audiology follow-up. Staff interviews revealed uncertainty and lack of documentation regarding the process for replacing the hearing aids, and the audiology vendor confirmed no appointments were scheduled. Facility policy did not clarify expectations for resolving missing sensory devices.
Two residents with respiratory conditions did not receive safe and appropriate respiratory care. One resident was administered supplemental oxygen without a current physician's order, despite facility policy requiring such orders. Another resident experiencing acute shortness of breath was not properly evaluated by an LPN, who failed to assess the resident's oxygen therapy and did not recognize that the oxygen supply was disconnected. The facility's oxygen administration policy lacked criteria for evaluating residents in respiratory distress.
Surveyors found that open ophthalmic solutions and an insulin pen on two medication carts were not labeled with open or expiration dates as required by facility policy. Nursing staff acknowledged the responsibility to label medications upon opening but could not explain the omissions. The DON confirmed that these medications should be labeled and discarded after 28 days, as outlined in facility policy.
A resident with multiple chronic conditions was prescribed several medications, including metformin, which requires periodic lab monitoring due to potential risks. The pharmacy consultant recommended A1c and BMP labs, but the recommendation was not communicated to the physician or acted upon, and no lab orders were placed. This lapse was due to a backlog in the process for handling pharmacy recommendations after a change in DON.
Two residents experienced significant medication errors when one did not receive a prescribed topical medication due to unavailability, and another was nearly given an expired multivitamin. Nursing staff failed to ensure timely reordering and proper checking of medication expiration dates, and did not consistently notify the physician when doses were missed, resulting in a 7% medication error rate during the observed period.
Surveyors found that required shift-to-shift controlled substance reconciliation logs were missing numerous signatures across multiple medication carts. Nursing staff and the DON confirmed that both off-going and oncoming nurses are responsible for counting and signing for controlled substances at each shift change, but logs showed consistent non-compliance with this policy. Staff could not explain the missing signatures, and the deficiency was identified through observation and interviews.
The QAA Committee did not consistently include all required members during its meetings, as shown by missing signatures from the Infection Preventionist, DON, and Medical Director on sign-in sheets. Staff interviews confirmed that the committee met quarterly, but some required members were absent, and at one point, there was no Infection Preventionist employed.
Staff failed to follow infection control practices during a wound dressing change for a resident with a pressure ulcer, including not performing hand hygiene and using unclean surfaces. Dirty linens and personal care items were left in a shower area for consecutive days, and laundry areas were unsanitary and lacked adequate emergency linen supplies. Additionally, tube feeding for a resident was not labeled or discarded according to policy, with inconsistent dates on feeding equipment and staff unaware of proper procedures.
Surveyors found that staff failed to administer influenza, pneumococcal, and COVID-19 vaccines in a timely manner after consent was obtained for several residents, and did not consistently follow up with responsible parties to secure or document consent. Incomplete consent forms, lack of documentation for family communications, and unexplained delays in vaccine administration were observed, resulting in noncompliance with facility immunization policies.
Two residents were not properly offered or timely administered the COVID-19 vaccine. In one case, an LPN failed to follow up with a family for consent, leaving the consent form incomplete and undocumented. In another case, a resident's family gave verbal consent, but the vaccine was not administered for over two months, with no documented reason for the delay.
A resident with respiratory conditions was found unable to access the call bell, which was on the floor and out of reach while the resident was in bed. The resident, dependent for mobility and transfers, was unaware of the call bell's location and later had to yell for help due to breathing difficulties. An LPN responded after being alerted by a surveyor, and the call bell was then returned to the bed. The assigned nursing assistant was unaware of how the call bell became inaccessible, despite facility policy requiring call bells to be within easy reach.
A review of staff training records showed that nurse aides did not receive the required 12 hours of annual in-service education, with documented hours ranging from none to four. Training included a skills day and some dementia care modules, but the total hours were insufficient. The RN responsible for training confirmed the records were complete and that not all staff completed the available training.
A resident with severe cognitive impairment who sustained a second-degree burn did not receive several scheduled medications, treatments, and assessments as ordered, and the provider was not notified of these omissions. Nursing staff confirmed the missed doses and lack of documentation, and facility leadership was unaware of the lapses until the survey. Facility policy requiring prompt provider notification and documentation of medication errors or omissions was not followed.
A resident with severe cognitive impairment and a recent burn injury did not receive multiple physician-ordered medications, treatments, pain assessments, and vital sign checks as required. Nursing staff did not administer or document these interventions, nor did they notify the provider of the omissions, contrary to facility policy.
A resident with dementia and severe cognitive impairment did not have complete documentation for several ordered medications and treatments, including pain assessments, Miralax, Risperdal, and Silvadene cream. An LPN admitted to administering the medications and treatments but failed to document them after leaving early, and records did not show evidence of administration as required by facility policy.
A resident with dementia, dysphagia, and GERD experienced a change in condition involving respiratory distress and vomiting. Facility staff failed to perform and document a complete and current assessment, did not provide up-to-date vital signs to EMS, and did not carry out all care plan interventions before the resident was transferred to the hospital. Interviews confirmed that required assessments and documentation were not completed during the emergency.
A resident with dementia, dysphagia, and GERD experienced a change in condition and was found by EMS in respiratory distress with vomit in the mouth and no staff present. Staff failed to monitor, implement care plan interventions, or provide a thorough handoff report, resulting in the resident being transferred to the hospital with aspiration pneumonia.
Failure to Provide Required Adaptive Drinking Device Upon Readmission
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, diabetes, peripheral vascular disease, congestive heart failure, and chronic obstructive pulmonary disease was readmitted to the facility following a hospital transfer. The resident had a documented need for a Kennedy cup, an adaptive drinking device, for all hot and cold liquids due to a risk of aspiration and a history of spilling drinks. Upon readmission, the nursing assessment did not identify any changes in functional status, but the order for the Kennedy cup was not reactivated, as it had been discontinued during the hospital transfer and was not included in the hospital's transfer documentation. On the day of readmission, the resident was served hot coffee in a regular cup with a lid, rather than the required Kennedy cup. The resident removed the lid and spilled the coffee on their right thigh, resulting in a second-degree burn measuring 17 cm by 9.5 cm. The temperature of the coffee was measured at 171 degrees Fahrenheit. Nursing staff responded to the incident, and subsequent assessments documented the extent of the burn and the resident's pain level. The Kennedy cup was not provided until after the incident occurred. Interviews with staff revealed that the nurse aide assigned to the drink cart was unaware of the resident's need for a Kennedy cup, as the resident was not listed as requiring special equipment on the drink cart list. The occupational therapist confirmed the resident's long-standing need for the Kennedy cup and noted that the order had not been reactivated upon readmission. The Director of Nursing acknowledged that there was no process in place to reconcile previous orders or interventions upon readmission, which led to the omission of the Kennedy cup and contributed to the resident's injury.
Failure to Notify Provider of Missed Antibiotic Doses
Penalty
Summary
The facility failed to notify a provider when an antibiotic prescribed to treat a urinary tract infection was omitted five times for a resident with Alzheimer's disease and type 2 diabetes mellitus. The resident, who had memory recall deficits and was dependent on staff for personal hygiene and toileting, was prescribed cefuroxime axetil to be administered twice daily for ten days. The medication was not administered on five occasions due to reasons such as unavailability, resident refusal, and the resident being on a leave of absence. Documentation in the Medication Administration Record and nurse's notes indicated missed doses, but there was no evidence that the provider or nursing supervisor was notified of these omissions as required by facility policy. Interviews with nursing staff revealed a lack of awareness regarding the requirement to notify the provider for each missed medication dose. The Advanced Practice Registered Nurse confirmed she was not informed of the missed doses and stated that notification could have led to changes in the treatment plan. The Director of Nursing also acknowledged that each missed dose should have been documented with the reason and notification details, and that staff should have reapproached the resident after refusals and documented these actions. The facility's medication administration policy required documentation of refusals, provider notification, and actions taken when medications were unavailable, but these procedures were not followed in this case.
Failure to Schedule Required Endocrinology Appointment for Resident
Penalty
Summary
A deficiency occurred when the facility failed to schedule a required endocrinology appointment for a newly admitted resident with diagnoses including Alzheimer's disease, type 2 diabetes mellitus, and myotonic muscular dystrophy. Upon admission, the resident was assessed as alert with good memory recall and required staff assistance for positioning and transfers. The care plan identified the resident as being at risk for hypo/hyperglycemia, and a physician's order directed that a follow-up appointment with endocrinology be scheduled within one to two weeks. However, review of the clinical record and medication administration records over a period of more than three months showed that the appointment was never scheduled, nor was the resident seen by endocrinology, despite daily documentation indicating the order remained active. Interviews with facility staff revealed that the process for scheduling outside appointments involved the charge nurse, who was responsible for making the appointment within 72 hours or notifying the nursing supervisor if unable to do so. The DON confirmed that nursing staff were responsible for scheduling such appointments and acknowledged that the order should have been followed. Despite this, the order remained unsigned for its intended purpose and was simply carried over daily for several months. No facility policies regarding following physician's orders or scheduling offsite appointments were provided upon request.
Failure to Document Critical Assessment Data Prior to Hospital Transfer
Penalty
Summary
A deficiency occurred when nursing staff failed to ensure a complete and accurate clinical record for a resident with Alzheimer's disease, type 2 diabetes mellitus, and myotonic muscular dystrophy who experienced a significant change in condition. The resident was found barely responsive, with labored breathing, tachycardia, pale and cold skin, and appeared very weak. Despite these symptoms and the resident's known diabetes diagnosis, neither a body temperature nor a blood glucose level was documented or communicated to the provider prior to the resident's transfer to the emergency department. The facility's own policy required prompt and complete documentation of assessments and significant events, but this was not followed. Upon review, it was found that the hospital documented the resident as febrile and with a critically high blood glucose level upon arrival. Interviews with nursing staff revealed that although a nurse performed an assessment and believed she had obtained vital signs and a blood sugar, she did not document these findings before the end of her shift, citing the resident's condition as a distraction. The Director of Nursing confirmed that documentation should have been completed as close to the event as possible, and was unaware that it had not been done. The lack of documentation resulted in an incomplete clinical record regarding the care provided prior to the resident's transfer.
Failure to Monitor and Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that staff responsible for maintaining water temperatures were knowledgeable about acceptable hot water temperature ranges, resulting in water temperatures in resident bathrooms that exceeded safe limits. Observations revealed that water temperatures at multiple resident bathroom sinks were measured between 127 and 133 degrees Fahrenheit, which is above the normal range of 110 to 120 degrees Fahrenheit. The Administrator and Maintenance Director were unaware of the correct temperature limits, and there was no documentation of water temperature checks in resident bathrooms prior to surveyor inquiry. Review of facility documents showed that monthly water temperature logs from May through July indicated consistently elevated temperatures, with no evidence of corrective action or documentation of subsequent temperature checks to confirm adjustments. The logs only included temperatures from shower and tub rooms on the 2nd and 3rd floors, omitting resident bathrooms. Additionally, the Maintenance Director believed the acceptable limit was 130 degrees Fahrenheit and only sought clarification after several months of elevated readings. No interventions were implemented during this period to address the high temperatures. Interviews with staff revealed a lack of awareness regarding the risks associated with hot water temperatures, and there was no facility policy or procedure for monitoring water temperatures. Staff reported that water from the hot tap was often too hot to touch, and adjustments were made informally without documentation. The lack of knowledge, monitoring, and policy resulted in Immediate Jeopardy due to the potential for resident scalding.
Failure to Maintain and Monitor Safe Water Temperatures
Penalty
Summary
The facility failed to ensure the existence and implementation of a policy and procedure for monitoring water temperatures to maintain them within acceptable ranges. During an observation, water temperatures at bathroom sinks shared by residents were found to be as high as 130 degrees Fahrenheit, which was confirmed by the administrator and felt hot to the touch. When requested, the facility was unable to provide a written policy or procedure for monitoring hot water temperatures, only offering verbal instructions on how staff would respond to elevated temperatures. The deficiency was identified through direct observation and interviews, revealing a lack of documented processes to prevent residents from exposure to excessively hot water.
Failure to Complete Required Background Checks Prior to Staff Hire
Penalty
Summary
The facility failed to conduct a thorough investigation into the background of a prospective staff member, specifically a nurse aide, prior to her hire date. Review of the employee file revealed that, although the nurse aide had signed consents for background checks, there was no documentation of a completed state or federal background check, including the required fingerprint-based screening through the Applicant Background Check Management System (ABCMS). The Human Resources Director was unable to provide evidence of an ABCMS screening and could not explain why it was missing from the file. The Administrator also could not account for the absence of the background check or ABCMS screening prior to employment. Additionally, the facility was unable to produce a policy for pre-employment screening when requested. The abuse policy provided during the survey only referenced ensuring an active license or certification and reviewing regulatory action reports, but did not outline a process for completing background checks or ABCMS screenings. This lack of documentation and policy resulted in the facility hiring a nurse aide without verifying her background as required.
Failure to Administer Medications and Treatments per Physician Orders
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for multiple residents. For one resident with diagnoses including dysphagia and rhabdomyolysis, there was a physician's order for weekly weights, but only one weight was obtained over several weeks, and there was no documentation of refusal or explanation for the missed weights. Nursing assistants were responsible for obtaining weights, but the resident was only listed for monthly weights, contrary to the physician's order. The facility's policy required weights to be obtained as ordered, but this was not followed. Another resident with spina bifida and a stage 4 pressure ulcer did not receive a prescribed topical medication because it was not available in the facility. The LPN responsible for reordering the medication delayed faxing the request to the pharmacy, resulting in missed doses. There was no documentation that the physician was notified about the missed medication, as required by facility policy. Additionally, the medication was not available for administration for more than a day, and the resident missed several scheduled applications. For three residents, medications were not administered at the scheduled times according to physician orders. An LPN administered morning medications several hours late without notifying the physician, and the medication administration record was inaccurately documented to reflect the scheduled rather than actual administration times. Another resident missed multiple scheduled medications, including antipsychotics, blood thinners, and diabetic agents, with no documentation of refusal or explanation in the nursing notes or MAR. The facility's policies required timely administration and documentation, but these were not followed.
Insufficient Weekend Nursing Staff Coverage
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available on weekends, as evidenced by a review of Payroll-Based Journal (PBJ) staffing data and staff interviews. PBJ data showed that weekend staffing levels were consistently lower than weekday staffing during two fiscal quarters. On specific weekends, scheduled staffing was not met due to multiple callouts, particularly among nursing aides. For example, on one Sunday, six nursing aides called out for the 7-3 PM shift, and only one could be called in, resulting in six aides working instead of the scheduled ten. Similarly, for the 3-11 PM shift, five aides called out, and only three could be called in, leaving the shift short-staffed for several hours. The facility did not provide documentation to demonstrate that resident care needs were met during these periods of reduced staffing. Interviews with the scheduler and administrator confirmed that callouts, including those due to inclement weather, contributed to the staffing shortages. The facility's staffing plan, as outlined in the Facility Assessment, called for 11 nursing aides for the 7-3 PM shift with an average daily census of 83 residents. The assessment also identified staffing as a weakness, citing a unionized workforce and limited availability of per-diem or temporary staff. The administrator was unaware that the facility had been flagged for low weekend staffing in PBJ reports and acknowledged that the facility was not utilizing agency staff during the periods in question. Additionally, the DNS and ADNS occasionally filled in as RN supervisors but did not clock in as direct-care staff.
Failure to Complete Annual Performance Evaluation and Required In-Service Education for Nurse Aide
Penalty
Summary
The facility failed to complete an annual performance evaluation for one nurse aide, despite the aide having been employed for over a year. Review of the personnel file showed no documentation of a required annual or earlier performance evaluation. Additionally, the nurse aide did not receive at least 12 hours of in-service education per year, nor was there evidence of education addressing any areas of weakness identified through performance review. Interviews with staff confirmed that the required evaluation and in-service education were not completed, and the responsible staff could not provide an explanation for the omission.
Failure to Provide Timely Meals and Substantial Snacks Between Dinner and Breakfast
Penalty
Summary
The facility failed to ensure that meals were served within the required 14-hour window for four residents with various medical conditions, including anxiety, adjustment disorder, epilepsy, Type 2 diabetes mellitus, hypertension, dysphagia, gastro-esophageal reflux disease, anemia, localized edema, and orthostatic hypotension. According to the facility's meal schedule, dinner was served at 4:45 PM and breakfast at 7:45 AM, resulting in a 15-hour gap between meals. Clinical record reviews and resident interviews confirmed that these residents did not receive a substantial snack between dinner and breakfast, with some reporting that the snack cart was not consistently available or only offered limited options such as crackers. Further observations and staff interviews revealed that the snack carts, which were supposed to be provided three times daily, typically contained only crackers, apple sauce, and oatmeal cookies. Residents reported that requests for more substantial snacks, such as sandwiches or peanut butter and jelly, were often met with resistance from staff or not fulfilled. The nourishment room observation supported these claims, showing a limited variety of snacks available. These findings indicate that the facility did not meet the nutritional needs and preferences of residents who required or requested food outside of scheduled meal times.
Deficient Food Handling, Storage, and Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary food handling and storage practices in several areas. Observations revealed that the kitchen ice machine was non-operational and padlocked, with no scoop available, leading an LPN to use uncovered ice cube trays in the nourishment room freezer to provide ice. The LPN handled the trays with bare hands, and food items in a cloth bag were stored directly above the open trays. The ice machine had reportedly been broken for 1-2 months, and there was no documented policy for the use of ice cube trays in this manner. Additionally, the freezer had also been out of order for several months, with no alternative process for ice delivery in place. Further deficiencies were identified in the kitchen and storage areas. Multiple food items in the refrigerators and freezers were found without labels or dates, including containers of various substances and sandwiches. A dented can was found in dry storage, contrary to facility policy requiring such items to be removed and returned to the vendor. Review of food temperature logs showed missing entries for three consecutive days, and cleaning schedules lacked signatures or clear assignment of responsibility. Interviews with dietary staff and the director confirmed that these practices did not align with facility policies, and staff were unsure why proper procedures were not followed.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the required reporting process for such incidents. The report indicates that when an event involving suspected abuse, neglect, or theft occurred, the facility did not fulfill its obligation to promptly notify the appropriate authorities or provide the outcomes of its internal investigation as required.
Failure to Obtain and Document Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document consent from residents' representatives for the use of psychotropic medications for two residents reviewed for unnecessary medications. For one resident with diagnoses including anxiety disorder, dementia, and borderline personality disorder, the clinical record and care plan indicated regular use of antipsychotic medication. Despite multiple requests, staff were unable to provide a signed consent form for the psychotropic medication, and the required documentation was not available in the resident's record or psychiatric consultant notes. The facility's policy required involvement and documentation of the resident or representative in discussions about medication risks and benefits, which was not followed in this case. For another resident with dementia, diabetes, and chronic kidney disease, the clinical record also failed to show evidence that the resident's representative was informed of the risks and benefits of psychotropic medication use or that consent was obtained. Staff interviews confirmed that the consent form could not be located, and although a psychiatric note indicated the resident consented, the resident was cognitively impaired and conserved, making representative consent necessary. No documentation was provided to show that the conservator had given consent for the medication.
Failure to Complete Timely Comprehensive Assessment for Pain Management
Penalty
Summary
A deficiency occurred when the facility failed to complete a comprehensive assessment for a resident in a timely manner. The resident, who was cognitively intact and had diagnoses including unilateral primary osteoarthritis, an artificial right knee, and lower back pain, was admitted and had a care plan identifying pain management interventions, including medication and ice packs for the right knee. Despite these interventions, the Minimum Data Set (MDS) assessment, which should have been completed within 14 days of admission, was not completed on time. The MDS coordinator confirmed the assessment was late and could not provide a reason for the delay. Facility policy required a comprehensive and individualized plan of care but did not address the MDS completion process.
Failure to Update Care Plans After Falls, Oral Care Changes, and Oxygen Therapy
Penalty
Summary
The facility failed to update and revise care plans for two residents following significant changes in their conditions and care needs. For one resident with schizophrenia and dementia, the care plan was not updated after multiple falls, including a recent incident where the resident was found unconscious with a hematoma and required hospital evaluation. The fall investigation documentation was incomplete, lacking supervisor review and signatures, and there was no evidence that the care plan was revised to address new interventions or needs following the fall or after the resident's return from the hospital. Additionally, the same resident's care plan did not reflect current oral care needs and preferences, despite a dental exam noting moderate plaque, gingivitis, and buildup on the teeth. Observations over several days confirmed visible buildup on the resident's gumline, and staff interviews revealed that the resident preferred to perform oral care independently but required assistance. The care plan was not updated to reflect these preferences or the findings from the dental evaluation. For another resident with acute respiratory failure and hypoxia, the care plan did not include specific interventions for oxygen use, despite physician orders for continuous oxygen therapy and observations confirming ongoing oxygen use. The care plan only referenced checking oxygen saturation but did not address the need for or management of oxygen therapy. The DON confirmed that the care plan should have been updated to reflect these interventions, but no explanation was provided for the omission.
Failure to Transcribe and Implement Physician's Orders for Medication and Lab Work
Penalty
Summary
A deficiency occurred when a physician's order for a resident with schizophrenia, dementia, and anxiety was not properly transcribed and implemented. The resident, who had moderate cognitive impairment and required assistance with daily activities, was evaluated by a psychiatry APRN due to behavioral disturbances, including increased confusion, agitation, and combativeness. The APRN ordered Seroquel 25 mg by mouth every 12 hours as needed for agitation and combative behaviors, as well as laboratory tests including a Depakote level, CBC with diff, CMP, and a urine culture with sensitivity. The written physician's order sheet was marked as 'noted' and initialed by a Registered Nurse Supervisor, indicating that the orders were to be transcribed and followed up on according to facility policy. However, upon review, it was found that only the laboratory work was transcribed into the electronic health record, while the medication order for Seroquel and the urine culture with sensitivity were not entered or acted upon. The laboratory book also showed that a urine sample pick-up was never arranged. Interviews and record reviews confirmed that the required medication and urine specimen orders were not transcribed, despite documentation indicating otherwise. The facility was unable to provide a copy of its Physician's Orders Policy when requested.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
Resident #29, who has diagnoses including unspecified dementia, Type 2 diabetes mellitus, and chronic kidney disease, was identified as requiring maximal assistance with activities of daily living, including toileting, due to moderate cognitive impairment and frequent urinary incontinence. Observations on 8/7/2025 documented that the resident requested to use the bathroom at 9:32 AM, but was not assisted by staff for an extended period, remaining unattended in the hallway and by the nursing station until at least 11:38 AM. Despite repeated requests and visible presence near staff, the resident did not receive timely toileting assistance. Interviews with nurse aides and an LPN confirmed that residents are expected to be assisted with toileting as soon as possible, and that waiting beyond two hours is considered excessive. One staff member reported this was the first time she was informed of the resident's need that day, while another visitor noted the resident had been left wet from urination the previous day. Facility policy requires prompt assistance with ambulating to the bathroom, and the Director of Nursing stated that 15 minutes is a reasonable timeframe for such assistance. The failure to provide timely care and assistance with toileting for Resident #29 constitutes a deficiency in meeting the resident's needs.
Failure to Ensure Timely Audiology Follow-Up for Missing Hearing Aids
Penalty
Summary
Resident #35, who has diagnoses including unspecified hearing loss, adjustment disorder, and age-related physical debility, was identified as moderately cognitively impaired and dependent on staff for activities of daily living. The resident's care plan required that hearing aids be in place daily and functioning, with audiology appointments made as needed. On 7/25/25, a missing property form documented that the resident's hearing aids were missing, and the interdisciplinary team was to add the resident to the audiology list for replacement. However, on 8/12/25, the resident was observed without hearing aids and was unable to hear the surveyor during an introduction. Interviews with staff revealed confusion and lack of follow-through regarding the process for replacing the missing hearing aids. The LPN was unsure if the resident had been added to the audiology list, and the social worker indicated that after the missing property form was completed, the DNS was responsible for contacting the audiology vendor. The DNS could not locate any documentation or email confirming that the resident had been added to the audiology list, attributing the lapse to her transition into the role. The audiology vendor confirmed that no residents were scheduled for services at the facility. The facility policy did not specify expectations for resolving missing items, contributing to the failure to ensure the resident received necessary audiology follow-up.
Failure to Ensure Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for two residents. For one resident with diagnoses including acute respiratory failure with hypoxia and hypercapnia, the facility failed to ensure there was a current physician's order for oxygen therapy. Despite the resident being observed on supplemental oxygen via nasal cannula at a specified flow rate, a review of both electronic and paper health records did not reveal an active physician's order for oxygen therapy. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that orders should be documented in the electronic health record, but no such order was present at the time of review. Facility policy requires a physician order for the admission of oxygen, which was not followed in this case. For another resident with chronic obstructive pulmonary disease, asthma, and respiratory failure, the facility failed to ensure that licensed staff appropriately evaluated the resident's oxygen therapy during a potentially urgent medical situation. The resident, who was dependent for bed mobility and transferring and was receiving oxygen therapy and non-invasive mechanical ventilation, was observed experiencing significant shortness of breath and calling for help. The LPN who responded did not initially assess the resident's oxygen therapy, instead attempting to adjust the room's air conditioner and fan. The resident's oxygen was later found to be disconnected from the concentrator, and only after intervention by another staff member was it reconnected. The LPN returned with a pulse oximeter and found the resident's oxygen saturation to be below the target level. Additionally, the facility's policy and procedure manual for oxygen administration did not include evaluation criteria for residents experiencing shortness of breath while receiving oxygen therapy. This lack of clear guidance contributed to the failure to provide appropriate and timely evaluation and intervention for the resident in respiratory distress.
Failure to Label and Discard Open Medications per Policy
Penalty
Summary
Surveyors observed that medication storage practices on two medication carts failed to comply with facility policy regarding the labeling and disposal of medications. Specifically, multiple open bottles of ophthalmic solutions and an insulin pen were found without open dates or expiration dates recorded. In some cases, open dates were present but indicated the medication had surpassed the 28-day expiration period as outlined in facility policy. Interviews with nursing staff confirmed that it is the responsibility of the nurse who opens a medication to label it with the open and expiration dates, but staff were unable to explain why this was not done for the medications observed. The Director of Nursing confirmed that both ophthalmic solutions and insulin pens are to be labeled with open and expiration dates and discarded after 28 days, in accordance with facility policy and manufacturer instructions. Policy reviews further supported these requirements, directing staff to record the date opened and the date to expire on containers of medications with shortened beyond-use dates. Despite these clear policies, the observed failure to label and discard medications as required constituted a deficiency in pharmaceutical services and medication management.
Failure to Communicate Pharmacy Lab Recommendations to Physician
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician was made aware of a pharmacy consultant's recommendation for laboratory monitoring for a resident with multiple diagnoses, including atrial fibrillation, dementia, hypertension, heart failure, and diabetes. The resident was receiving several medications, including metformin, which carries a boxed warning for lactic acidosis risk, especially in those with kidney disease. The pharmacy consultant recommended checking A1c and BMP labs every six months, but this recommendation was not communicated to or acknowledged by the physician, and no corresponding order was found in the resident's electronic health record. The facility's process required pharmacy recommendations to be placed in a book for physician review, with the expectation that the physician would accept or deny the recommendation and sign the form. However, due to a backlog following a change in the Director of Nursing, this process was not completed, resulting in the physician not being informed of the pharmacy's recommendation and the necessary lab orders not being placed. The facility's policy directed that medication review recommendations be provided to relevant staff, but this was not followed in this instance.
Medication Errors Due to Unavailable and Expired Medications
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication availability and administration practices. One resident with spina bifida, paraplegia, and a stage 4 pressure ulcer did not receive prescribed clotrimazole-betamethasone cream as scheduled because the medication was not available in the facility. Nursing staff were unable to locate the cream in the medication cart or room, and although a paper pharmacy re-order form was completed in the morning, it was not faxed to the pharmacy until late at night. The resident missed multiple scheduled applications of the cream, and there was no clear documentation that the physician was notified of the missed doses, contrary to facility policy. Another resident with dementia and chronic kidney disease was nearly administered an expired multivitamin with minerals. During medication preparation, an LPN placed a tablet from a bottle with an expiration date that had already passed into the resident's medication cup. Upon surveyor inquiry, the LPN removed the expired medication and sought a replacement. The nursing supervisor confirmed that nurses are expected to check expiration dates daily and during monthly cart cleaning, but was unsure which shift was responsible for the monthly checks. The expired medication was found in the medication cart trash and was subsequently removed for proper disposal. Facility policy requires that medications be administered as prescribed, with doses checked against the Medication Administration Record and medication labels, and that physicians be notified when a dose is missed. In both cases, these procedures were not followed, resulting in a medication error rate of 7% during the observed period.
Failure to Complete Controlled Substance Shift-to-Shift Reconciliation Logs
Penalty
Summary
Surveyors observed that the facility failed to ensure proper completion of controlled substance shift-to-shift reconciliation sign off sheets for all four medication carts reviewed. Specifically, numerous required signatures were missing from the controlled substance logs for both July and August 2025 across multiple units. For example, on the 2-east medication cart, 31 out of 186 possible signatures were missing for July, and 20 out of 74 were missing for August. Similar deficiencies were found on the 2-west, 3-east, and 3-west medication carts, with missing signatures ranging from 9 to 61 per log. Interviews with nursing staff and the Director of Nursing confirmed that it is facility policy for both the off-going and oncoming nurses to count controlled substances together and sign the log at each shift change, but staff were unable to explain the missing signatures. Review of facility policy dated August 1, 2024, confirmed the requirement for incoming and outgoing nurses to count all schedule two controlled substances and other medications with a risk of abuse or diversion at each shift change or at least once daily, and to document the results on a verification sheet. Despite this policy, the observed logs showed consistent non-compliance, with staff acknowledging the process but not adhering to the documentation requirements. No explanation was provided for the missing signatures, and the deficiency was identified solely through observation and staff interviews. No specific residents or patient conditions were mentioned in relation to the deficiency.
QAA Committee Lacked Required Members During Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) Committee included all required members during scheduled meetings, as evidenced by missing signatures from key committee members on multiple occasions. Record review of QAA Committee sign-in sheets revealed that on one date, the Infection Preventionist, Director of Nursing, and Medical Director did not sign in, and on another date, the Infection Preventionist's signature was missing. Staff interviews confirmed that the QAA committee met at least quarterly, but the Administrator could not explain the absence of required members at certain meetings, noting that there was no Infection Preventionist employed at the time of one meeting. Facility policy specifies that the QAA committee must include the Administrator, DNS, Medical Director, Infection Control Nurse, and at least three other members.
Infection Control and Linen Management Deficiencies
Penalty
Summary
Staff failed to follow infection prevention and control practices during a wound dressing change for a resident with a pressure ulcer. The LPN did not perform hand hygiene before donning gloves, between glove changes, or after removing gloves, despite handling soiled dressings and clean supplies. The LPN also placed clean dressing supplies on an unclean tray table surface and used tape from her pants pocket, further breaching infection control protocols. The facility's policy required cleaning the work surface and performing hand hygiene before applying clean gloves, which was not followed. Observations over two consecutive days revealed that dirty linens were left on the floor and on surfaces in a shower area, and personal care items were improperly stored in the same area. The same linens and personal items remained in place from one day to the next, indicating a lack of timely removal and cleaning. In the laundry area, dirty linen bags were stored on the floor due to limited space and equipment breakdowns, and clean linens were stored in unsanitary conditions. Wall fans and ceiling exhaust fans blowing toward clean linen areas were found to be dirty, and the emergency linen supply was inadequate, lacking essential items such as washcloths, top sheets, pillowcases, blankets, bed pads, and bedspreads. Sinks in both the dirty and clean sides of the laundry were unclean and obstructed, with one sink cracked and used for storage of dry supplies, and the other surrounded by dust and debris. For a resident receiving tube feeding, the facility failed to ensure that the tube feeding was labeled correctly and discarded in a timely manner. The tube feeding bottle was found hanging without a date, time, or feeding rate, and the water bag and tubing had inconsistent labeling dates. Staff interviewed were unaware of the labeling discrepancies or how long the feeding had been hanging, despite facility policy requiring clear labeling of tube feeding systems with resident name, date, time, contents, rate of flow, and nurse's initials.
Delayed and Incomplete Vaccine Administration and Consent Documentation
Penalty
Summary
Surveyors identified deficiencies in the facility's administration of influenza, pneumococcal, and COVID-19 vaccinations for residents. In four out of five clinical records reviewed, staff failed to provide vaccines in a timely manner after consent was obtained and did not consistently follow up with responsible parties to secure consent or declination. For one resident, the consent form was incomplete, lacking a signature or date, and although the family was noted as deciding, there was no documentation of follow-up attempts after the initial entry. Another resident's family provided verbal consent for vaccinations, but the vaccines were not administered until over two months later, with no documented reason for the delay. In a third case, the consent form indicated the resident was conserved and awaiting family decision, but there was no date or documentation of follow-up efforts. For a fourth resident, vaccines were administered 17 days after consent was given, again with no explanation for the delay. Facility policies for influenza, pneumococcal, and COVID-19 vaccines require timely offering and administration of vaccines, documentation of refusals, and re-offering as appropriate, in accordance with CDC guidelines. However, staff interviews and record reviews revealed lapses in following these policies, including lack of documentation for family communications, delays in vaccine administration after consent, and incomplete consent forms. These actions and omissions resulted in noncompliance with the facility's own infection control and immunization protocols.
Failure to Offer and Timely Administer COVID-19 Vaccinations
Penalty
Summary
The facility failed to properly offer and document COVID-19 vaccinations for two out of five residents reviewed for immunizations. For one resident, the clinical record showed a consent form with a refusal box checked and handwritten notes indicating the family was deciding, but there was no signature or date from the resident or responsible party. The LPN responsible acknowledged that after an initial note stating 'awaiting family consent,' no further attempts were made to follow up with the family, and there was no documentation of any conversation or outreach to obtain consent or declination. This resulted in the resident or responsible party not being given a clear opportunity to accept or refuse the COVID-19 vaccine. For another resident, the family member had provided verbal consent for the COVID-19 vaccine, but the vaccine was not administered until approximately two and a half months later. The LPN could not provide a reason for this delay or any documentation explaining why the vaccine was not given in a timely manner. The facility's policy required that residents or responsible parties be offered the vaccine according to CDC guidance and that refusals and re-offers be documented, but these procedures were not followed for the two residents in question.
Inaccessible Call Bell in Resident Room
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease, asthma, and respiratory failure was found in bed with the call bell lying on the floor, out of reach. The resident, who was cognitively intact but dependent for bed mobility and transfers, was unaware of the call bell's location and could not access it when needed. During the surveyor's observation, the resident was seen facing away from the call bell, which was on the opposite side of the bed and not accessible. Shortly after the initial observation, the resident began yelling for help due to difficulty breathing and was visibly short of breath. The surveyor responded by alerting an LPN, who attended to the resident. The call bell remained on the floor until the LPN placed it back on the bed after being notified by the surveyor. When interviewed, the nursing assistant assigned to the resident was unaware of why the call bell was out of reach and stated that call bells are typically clipped or wrapped onto the bed. Facility policy requires that call bells be positioned so residents can easily access them.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required minimum of 12 hours of annual in-service training. A review of training records for five nurse aides revealed that none had documentation of completing the mandated training hours, with recorded in-service hours ranging from zero to four. The training records included participation in a yearly skills day and some dementia care modules, but the total documented hours fell short of regulatory requirements. During an interview, the RN responsible for training confirmed that the records were complete and acknowledged the deficiency, noting that while training was made available, not all staff completed it.
Failure to Notify Provider of Medication and Treatment Omissions After Resident Burn
Penalty
Summary
A deficiency occurred when the facility failed to notify a provider of medication and treatment omissions following an incident in which a resident with dementia and severely impaired cognition sustained a second-degree abdominal burn from spilled coffee. The resident required significant assistance with daily activities and had multiple physician orders in place, including pain assessments, administration of medications for agitation and constipation, wound care, and vital sign monitoring. After the burn, new orders were obtained for wound care and increased monitoring. On a specific day, several scheduled medications and treatments, including pain assessments, Miralax, Risperdal (both oral solution and tablet), Tylenol, vital sign checks, and Silvadene cream application, were not documented as administered. There was no evidence in the clinical record that these omissions were communicated to the provider, as required by facility policy. Interviews with nursing staff confirmed that the medications and treatments were not given or documented, and that the provider was not notified of these omissions. The Director of Nursing Services (DNS) and the Advanced Practice Registered Nurse (APRN) both stated that all medication omissions should be reported to the provider and documented, but were unaware of the lapses until the survey. Facility policy requires accurate administration and documentation of medications and treatments, as well as prompt provider notification of any errors or omissions, which did not occur in this case.
Failure to Administer and Document Physician-Ordered Medications and Treatments
Penalty
Summary
A deficiency occurred when a resident with dementia and severe cognitive impairment, who had recently sustained a second-degree burn from spilled coffee, did not receive medications and treatments as ordered by the physician. The resident's care plan included specific interventions for the burn, such as the application of Silvadene cream, regular pain assessments, administration of Tylenol for pain, and monitoring of vital signs. However, documentation and review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed that on a specific day, several medications and treatments—including Miralax, Risperdal (both oral solution and tablet forms), Tylenol, Silvadene cream, and required pain assessments and vital sign checks—were not administered or documented as given. There was also no evidence that the provider was notified of these omissions, as required by facility policy and physician orders. Interviews with nursing staff confirmed that the medications and treatments were not administered or documented, and that the provider was not notified of the missed doses. The nurse involved acknowledged the difficulty in administering medications to the resident but admitted that if medications were not signed off, they were not given. The nurse also recognized the failure to document the omissions and notify the provider, as well as the lack of completed pain assessments. The APRN and Director of Nursing both stated that all medication omissions should be reported to the provider and that physician orders must be followed and documented, but were unaware of the lapses until the survey. Facility policy required that all medications and treatments be administered according to physician orders, with immediate documentation in the MAR or TAR, and that any medication errors or omissions be reported and documented. Despite these requirements, the facility failed to ensure compliance, resulting in the resident not receiving prescribed care and treatments, and the provider not being notified of these deficiencies.
Failure to Document Medication and Treatment Administration
Penalty
Summary
A deficiency was identified when a resident with dementia and severely impaired cognition did not have complete and accurate documentation in their medical record regarding medication and treatment administration. Multiple physician orders, including those for pain assessments, Miralax for constipation, Risperdal for agitation and anxiety, and Silvadene cream for a burn, were not signed off as completed or administered on specific dates and times. Review of the Medication Administration Record (MAR), Treatment Administration Record (TAR), and clinical notes failed to show evidence that these medications and treatments were provided as ordered. An LPN interviewed acknowledged that although she administered the medications and treatments, she failed to document them due to leaving her shift early. The Director of Nursing Services (DNS) confirmed that all medication and treatment administration should be documented and that omissions should be reported to the provider. Facility policies reviewed required timely and accurate documentation of care provided, but these were not followed in the instances cited.
Failure to Complete Timely Assessment and Documentation After Resident Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to conduct a complete and accurate assessment for a resident who experienced a change in condition requiring emergency services and hospital transfer. The resident, who had diagnoses including dementia, dysphagia, and GERD, was dependent on staff for all activities of daily living and had care plan interventions to prevent aspiration. On the morning of the incident, the resident was found unresponsive and in respiratory distress, with documentation showing outdated vital signs and no evidence that current or repeated assessments were performed. EMS arrived to find the resident with rapid, gurgling respirations, low oxygen saturation, and evidence of recent vomiting, with staff unable to provide current vital signs or details about the timing of the vomiting episode. Interviews revealed that staff did not remain with the resident during the emergency, did not document or communicate up-to-date assessments, and failed to perform or record appropriate interventions such as airway clearance and positioning as outlined in the care plan. The DON confirmed that the expectation was for staff to check vital signs, complete an assessment, perform interventions, and document all actions when a resident has a change in condition, which was not done in this case. The lack of timely and thorough assessment and documentation contributed to the deficiency identified during the survey.
Failure to Monitor and Intervene During Resident Change in Condition
Penalty
Summary
A deficiency occurred when staff failed to monitor and implement appropriate interventions for a resident with dementia, dysphagia, and GERD who experienced a change in condition and required transfer to the hospital. The resident, who was dependent on staff for all activities of daily living and had a care plan indicating a risk for aspiration, was found by EMS in respiratory distress, unresponsive, and with vomit and sputum in the mouth. Facility staff were not present in the room when EMS arrived, and the resident was only on two liters of oxygen with no other interventions being performed. EMS had to clear the airway, increase oxygen, and reposition the resident to improve breathing. Staff were unable to provide details about when the resident had vomited and did not provide vital signs or a thorough handoff report to EMS, only written transfer paperwork. Facility documentation and interviews confirmed that staff did not follow care plan interventions such as elevating the head of the bed, turning the resident on the side, or cleaning the mouth after vomiting. The DON stated that the expectation was for staff to remain with the resident, monitor vital signs, perform appropriate interventions, and provide a verbal report to EMS, none of which were done in this case. The resident was later diagnosed with aspiration pneumonia, influenza A, and a urinary tract infection at the hospital.
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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