Ark Healthcare & Rehabilitation At Governor's Ho
Inspection history, citations, penalties and survey trends for this long-term care facility in Simsbury, Connecticut.
- Location
- 36 Firetown Rd, Simsbury, Connecticut 06070
- CMS Provider Number
- 075338
- Inspections on file
- 28
- Latest survey
- December 30, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Ark Healthcare & Rehabilitation At Governor's Ho during CMS and state inspections, most recent first.
Two residents with risk factors for pressure injuries did not have Braden scale assessments and weekly skin checks completed and documented as required by facility policy. Documentation was missing for several required assessments and skin checks, and wound evaluations did not consistently include full body skin checks.
Two residents with cognitive impairments experienced disrespectful and undignified treatment by staff, including an incident where a staff member allegedly shouted and threw juice at a resident during lunch, and another where a staff member made derogatory remarks about a resident's hygiene and room odor. Staff interviews and facility documentation confirmed that these actions did not align with the facility's policy requiring residents to be treated with respect and dignity.
A resident with intellectual disability and behavioral needs was involved in an incident where a staff member allegedly shouted and threw juice at them during a meal. Another staff member witnessed the event but did not report it immediately, waiting several days and only notifying the DON after encouragement from a colleague. Facility policy required immediate reporting of abuse allegations, but this was not followed, resulting in a delayed response to the incident.
A resident with cerebral vascular infarction, pleural effusion, and hemiplegia, identified as moderately cognitively impaired and at risk for pressure ulcers, did not have a care plan including interventions for skin breakdown or heel off-loading. A DTI wound on the left heel was observed, leading to physician orders for heel offloading cushion and skin prep application. Nursing staff interviews revealed a lack of heel off-loading prior to the DTI development and highlighted the necessity of a care plan for pressure ulcer prevention upon admission. The facility's policies for Care Plan and Skin Assessment and Pressure Ulcer Prevention were not fully implemented in this case.
The facility did not ensure annual review of its Infection Prevention Control Program (IPCP) policies and procedures by the Administrator, Medical Director, and Director of Nursing, as evidenced by missing signatures on the policy manual. Additionally, the facility failed to maintain an updated list of residents with Multidrug Resistant Organisms (MDRO). Discrepancies were found in the MDRO list, and the Director of Admissions was unaware of the current list, despite claims to the contrary.
The facility failed to respond to pharmacy recommendations for PRN psychotropic medications for two residents, leading to deficiencies in medication management. Despite multiple recommendations, the facility did not include stop dates or reassess the need for these medications, resulting in non-compliance with guidelines.
The facility failed to comply with regulations regarding PRN psychotropic medications for two residents, leading to prolonged administration without proper reassessment or documentation. Despite pharmacy recommendations and facility policy requiring a 14-day limit, the medications were administered over several months without appropriate oversight.
A resident's upper dentures were missing for about a week, but the issue was not reported by staff, preventing the initiation of a grievance. The resident had multiple medical conditions and required assistance for daily activities. Interviews revealed that staff were unaware of the missing dentures, and a nurse aide assumed someone else had reported it.
The facility failed to initiate Resident Care Plans for two residents with specific medical conditions and corresponding medication use. One resident with A-fib did not have an RCP for their anticoagulant medication, and another resident with diabetes did not have an RCP for their diabetic medications. These oversights were confirmed by an RN and were not identified during a Resident Care Conference.
The facility failed to update the RCP for a resident regarding the discontinuation of anti-embolism stockings and the initiation of interventions following multiple falls. The RCP was not revised to reflect new interventions required for the resident's care, including reminders to lock the wheelchair and the use of rubber sole shoes, until after the surveyor's inquiry.
The facility failed to document a treatment refusal for a resident with dementia and did not verify gastrostomy tube placement before administering medication to another resident with severe malnutrition and a malignant neoplasm. The DNS did not document the refusal in the nursing notes, and an LPN administered medication without checking tube placement, contrary to facility policy.
The facility failed to complete an RN assessment after an allegation of mistreatment, obtain physician orders for multiple hospital transfers, and transcribe RN pronouncement orders before pronouncing a resident dead. These deficiencies were confirmed by the DNS and involved staff.
The facility failed to apply a hip abduction splint daily for a resident with cerebral vascular infarction, as directed by the physician. The error was due to an incorrect entry by a former travel PT, resulting in the splint not being included in the treatment admission record. Observations and staff interviews confirmed the deficiency.
A resident with respiratory conditions was using oxygen therapy without a physician's order, contrary to facility policy. Nursing staff were unable to locate any active or discontinued orders for the oxygen administration, despite the resident having been on oxygen for several weeks.
The facility failed to administer the Influenza vaccine to a resident after receiving consent and did not document offering the Pneumonia vaccine to another resident. One resident was hospitalized for Influenza, and another had no record of being offered the Pneumonia vaccine, with the facility directing short-term rehab residents to their primary care physicians for the vaccine.
The facility failed to ensure that two residents were educated and given the opportunity to consent or decline the COVID-19 vaccine upon admission. Both residents, who were moderately cognitively impaired and dependent on assistance, were not offered the vaccine or provided with education about it, and there was no documentation of their vaccination status.
The facility failed to ensure that required training and inservices were completed for two LPNs and one RN. The review revealed that new employee orientation and mandatory training on Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health were not documented. The Administrator confirmed the oversight and mentioned that the responsible person had resigned.
The facility failed to ensure that a newly hired nurse aide completed the required training and inservices, including Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health. The Administrator confirmed the lapse and noted that the person responsible for the training had resigned.
The facility failed to notify the state Ombudsman of hospital transfers for four residents, despite being aware of the requirement. The Social Worker could not explain why these residents were not included in the notification list, and the facility lacked a policy for such notifications.
The facility failed to document bed hold notifications for residents hospitalized, with staff interviews revealing confusion about responsibilities and incomplete or missing documentation for multiple residents.
The facility failed to ensure the accuracy of its direct care staffing information submitted to CMS for Quarter 3 of 2023, with PBJ submissions identifying excessively low weekend staffing. The Administrator noted that actual staffing levels were not low and indicated a need to review the contracted company's reporting procedures.
The facility failed to review infection control policies annually and did not calculate or analyze monthly antibiotic use percentages as required. Both the current and previous Infection Preventionists were unaware of these requirements.
Failure to Complete and Document Braden Scale Assessments and Weekly Skin Checks
Penalty
Summary
The facility failed to ensure that Braden scale assessments and weekly skin checks were documented and completed according to facility policy for two residents reviewed for pressure injuries. For one resident with peripheral vascular disease and dementia, the clinical record did not show that Braden scale assessments were completed weekly during the first month of admission, missing two out of four required assessments. Additionally, the care plan required weekly skin checks, but documentation was incomplete. For another resident with a history of stroke, diabetes, and gastrostomy, the care plan required Braden scale assessments on admission and per protocol, as well as weekly skin checks. The medical record lacked documentation of a skin check for one week and missed a Braden scale assessment for another week during the first month. Further, several weeks lacked documentation of weekly skin checks, and wound evaluations did not consistently indicate that a full body skin check was performed. Facility policy and interviews confirmed that these assessments and documentation were required but not completed as specified.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that two residents were treated with respect and dignity, as required by resident rights regulations. One resident with intellectual disability, autism, and anxiety, who required assistance with activities of daily living and had a history of impulsive behaviors, was involved in an incident during lunch where a nursing assistant allegedly shouted at the resident and threw a cup of juice at their face. The incident was reported by another nursing assistant, who stated that the staff member yelled at the resident and made a derogatory comment before leaving the dining room. The accused staff member denied the allegations, stating that the juice was spilled accidentally when the resident squeezed the cup, and that her exclamation was a reaction to being soaked. The facility did not substantiate the abuse allegation due to lack of additional witnesses, but staff interviews confirmed that the resident's clothing was not wet and the incident was reported eight days after it occurred. Another resident, who had pressure injuries and required maximal assistance for personal hygiene, reported that a nursing assistant made a disrespectful comment about the resident's personal hygiene and the odor in their room. The resident stated that the nursing assistant screamed at them and accused them of making false accusations, while also making derogatory remarks about the resident and the room. The nursing assistant admitted to making a comment about the room's smell in the hallway, believing the resident could not hear, but acknowledged that the comment was inappropriate. Interviews with other staff confirmed that the comment was made as the nursing assistant left the room with the resident's dinner tray. Facility policy directs that residents have the right to be treated with respect, kindness, and dignity. In both cases, staff actions and comments failed to uphold these standards, resulting in residents being subjected to disrespectful and undignified treatment. The incidents were documented through facility reportable event forms, staff interviews, and resident statements, demonstrating a failure to consistently honor residents' rights to a dignified existence and respectful communication.
Failure to Timely Report Alleged Staff-to-Resident Abuse
Penalty
Summary
Staff failed to report an allegation of staff-to-resident abuse in a timely manner for a resident with intellectual disability, autism, and anxiety who required assistance with activities of daily living. During a lunch period, a nursing assistant was observed by another staff member to have shouted at the resident and thrown a cup of juice at the resident's face, accompanied by a verbal outburst. The observing staff member did not immediately report the incident, citing discomfort and being new to the unit. Instead, he continued his shift and only reported the incident several days later after being encouraged by another staff member. The delay in reporting was further compounded when the staff member who was informed of the incident also failed to immediately notify supervisory staff, assuming the original observer would do so. The incident was ultimately reported to the Director of Nursing eight days after it occurred. Facility policy required immediate reporting of any witnessed or known abuse to supervisory staff, the DON, and the Administrator, which was not followed in this case. Interviews confirmed that both staff members involved in the delayed reporting acknowledged their failure to report the incident as required.
Deficiency in Heel Off-Loading for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure off-loading of the heels was implemented to prevent a pressure ulcer for Resident #39, who was admitted with a diagnosis of cerebral vascular infarction, pleural effusion, and hemiplegia. Despite being identified as moderately cognitively impaired and at risk for developing a pressure ulcer, the Resident Care Plan did not include interventions for skin breakdown or off-loading of heels. A DTI wound on the left heel was observed on 11/3/23, leading to subsequent physician orders for heel offloading cushion and skin prep application. Interviews with nursing staff revealed a lack of off-loading heels prior to the DTI development and highlighted the necessity of a care plan for pressure ulcer prevention upon admission. The facility's policies for Care Plan and Skin Assessment and Pressure Ulcer Prevention were not fully implemented in Resident #39's case, as evidenced by the delayed initiation of interventions to prevent pressure ulcers. The observations and interviews indicated a gap in care planning and implementation, with staff acknowledging the importance of off-loading heels, repositioning, and regular skin checks for residents at risk of skin breakdown.
Infection Control Policy Review and MDRO List Management Deficiencies
Penalty
Summary
The facility failed to ensure that its Infection Prevention Control Program (IPCP) policies and procedures were reviewed annually by the Administrator, Medical Director, and Director of Nursing, as evidenced by the absence of signatures on the policy manual reviewed on 3/1/24. Additionally, the facility did not maintain an updated list of residents with Multidrug Resistant Organisms (MDRO), with discrepancies noted in the MDRO list last updated on 4/14/23. Despite RN #7 indicating that the Director of Admissions had a current list of MDRO residents, an interview with the Director of Admissions on 3/1/24 revealed she had no knowledge of such a list. Subsequently, the facility completed an updated MDRO log on 3/4/24.
Failure to Respond to Pharmacy Recommendations for PRN Psychotropic Medications
Penalty
Summary
The facility failed to respond to pharmacy recommendations related to PRN psychotropic medications for two residents. Resident #7, diagnosed with Alzheimer's disease, anxiety disorder, and Type 2 diabetes, was prescribed Ativan 0.5 mg PRN for anxiety prior to showers without a stop date. Despite pharmacy recommendations on multiple occasions indicating that PRN psychotropic drugs are limited to 14 days, the facility did not act on these recommendations. The Director of Nursing Services (DNS) was unable to locate the signed pharmacy recommendations and could not explain why the approved order was not placed in the medical records. Resident #43, diagnosed with dementia and depressive episodes, was prescribed Trazodone 25 mg PRN for agitation and Ativan 0.5 mg PRN for anxiety, both without a stop date. The resident received these medications on several occasions, but the orders were renewed monthly without reassessment. Pharmacy recommendations to include a stop date or reassess the need for these medications were repeatedly ignored. The DNS and the prescribing physician could not provide a reason for the lack of response to these recommendations. Interviews with the pharmacy consultant and the DNS confirmed that the facility did not follow the guidelines for PRN psychotropic medications, which require a reassessment or a stop date after 14 days. The facility's failure to act on pharmacy recommendations and properly document and reassess the use of PRN psychotropic medications led to the identified deficiencies for both residents.
Failure to Adhere to PRN Psychotropic Medication Guidelines
Penalty
Summary
The facility failed to comply with regulations regarding the administration of PRN psychotropic medications for two residents. Resident #7, diagnosed with Alzheimer's disease, anxiety disorder, and Type 2 diabetes, was prescribed Ativan 0.5 mg PRN for anxiety/agitation prior to showers without a stop date. Despite pharmacy recommendations to limit PRN usage to 14 days, the medication was administered multiple times over several months without proper reassessment or documentation. The Director of Nursing Services (DNS) was unable to provide a reason for the oversight, and the psychiatrist's note directing a 14-day limit was not seen by the DNS. Resident #43, diagnosed with dementia, depressive episodes, and a history of fractures, was prescribed Trazodone 25 mg PRN for agitation and Ativan 0.5 mg PRN for anxiety, both without a 14-day stop date. The resident received these medications on multiple occasions, and although the PRN orders were renewed monthly, there was no documentation of reassessment or rationale for continued use. Interviews with the medical director and pharmacy consultant confirmed awareness of the 14-day limit, but the orders were not appropriately managed. The facility's policy on psychotropic medication PRN usage requires renewal every 14 days, with a new order and documented rationale for continued use. The failure to adhere to this policy resulted in prolonged administration of psychotropic medications without proper oversight, contributing to the identified deficiencies in the care of Residents #7 and #43.
Failure to Report Missing Dentures
Penalty
Summary
The facility failed to report missing dentures for Resident #19, who had diagnoses including unspecified sequelae of cerebral infarction, paroxysmal atrial fibrillation, and Type 2 diabetes mellitus. The Annual Minimum Data Set (MDS) assessment indicated that Resident #19 required varying levels of assistance for daily activities. On 3/4/24, Resident #19 reported that his/her upper dentures had been missing for about a week but could not recall if this was communicated to anyone. Interviews with facility staff, including an LPN, a social worker, and a nurse aide, revealed that none were aware of the missing dentures. The nurse aide noticed the dentures were missing but did not report it, assuming someone else had already done so. This failure to report prevented the initiation of a grievance to resolve the issue.
Failure to Initiate Resident Care Plans for Specific Diagnoses and Medications
Penalty
Summary
The facility failed to initiate a Resident Care Plan (RCP) for two residents with specific medical conditions and corresponding medication use. Resident #2, diagnosed with Atrial Fibrillation (A-fib), dementia, and hypothyroidism, had a physician's order to administer Apixaban for A-fib. However, the RCP did not reflect the A-fib diagnosis or the use of the anticoagulant medication. This oversight was confirmed during an interview with RN #1, who acknowledged the missing RCP for the anticoagulant medication. Similarly, Resident #58, admitted with diagnoses including type 2 diabetes mellitus, morbid obesity, and Raynaud's syndrome, had physician's orders for Toujeo and Mounjaro to manage diabetes. The RCP for this resident also failed to include a care plan for diabetes or the use of diabetic medications. RN #1 confirmed that the RCP for diabetes was not initiated upon admission and was not identified during a Resident Care Conference. The facility's Care Planning policy mandates a comprehensive care plan within 7 days of the resident assessment, which was not adhered to in these cases.
Failure to Update Resident Care Plan After Falls and Discontinuation of Anti-Embolism Stockings
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for Resident #15 regarding the discontinuation of anti-embolism stockings and the initiation of interventions following multiple falls. Resident #15, who had diagnoses including dementia, a history of falling, and difficulty walking, had a physician's order for Thrombo-Embolus Deterrent (Ted) stockings that was not updated in the RCP even after the resident stopped using them. Additionally, after a fall resulting in a hip fracture and subsequent hospitalization, the RCP was not updated to reflect the new interventions required for the resident's care upon readmission to the facility. This included the failure to remove the intervention for Ted stockings from the RCP despite the absence of a current physician's order and the resident no longer utilizing them. The intervention was only removed after the surveyor's inquiry. Furthermore, the RCP was not updated to include the intervention to remind the resident to lock the wheelchair when stationary, which was identified as a corrective action following another fall that resulted in thoracic fractures. This intervention was also added to the RCP only after the surveyor's inquiry. Lastly, the RCP did not include the intervention for the resident to wear rubber sole shoes, which was identified as a corrective action following another fall with reported spine pain. This intervention was added to the RCP only after the surveyor's inquiry.
Failure to Document Treatment Refusal and Verify Gastrostomy Tube Placement
Penalty
Summary
The facility failed to complete a nurse's note for the refusal of treatment for Resident #15, who had diagnoses including dementia, depression, and anxiety disorder. The resident's care plan included interventions for urinary incontinence and decreased communication skills. A reportable event form indicated that the resident reported inappropriate touching overnight, leading to an investigation. Despite the family member's refusal to send the resident to the ER for evaluation, the Director of Nursing Services (DNS) did not document this refusal in the nursing notes, only on the reportable event form. A late entry nursing note was added later after surveyor inquiry to document the refusal chronologically. The facility also failed to check the placement of a gastrostomy tube before administering medication and feeding for Resident #33, who had diagnoses including Parkinson's disease, severe protein-calorie malnutrition, and a malignant neoplasm of the head and neck. The resident's care plan required checking tube placement before each use. During an observation, an LPN administered medication through the gastrostomy tube without verifying its placement, contrary to facility policy. The LPN was unaware of the requirement to check tube placement each time it was accessed, indicating a lack of adherence to the facility's enteral tube policy.
Failure to Complete RN Assessment, Obtain Physician Orders, and Transcribe RN Pronouncement Orders
Penalty
Summary
The facility failed to complete an assessment by a Registered Nurse (RN) after an allegation of mistreatment for a resident diagnosed with dementia, depression, and anxiety disorder. The resident reported inappropriate touching to a family member, which led to an investigation. Despite the facility's policy requiring an immediate examination by a licensed nurse or physician, no RN assessment was completed. The Director of Nursing Services (DNS) acknowledged the oversight but could not provide a reason for the failure to conduct the assessment. For another resident with chronic obstructive pulmonary disease, heart failure, and respiratory failure, the facility failed to obtain physician orders for multiple hospital transfers. The resident was transferred to the hospital on three separate occasions without corresponding physician orders in the clinical record. The DNS confirmed that the clinical record should have included physician orders for each transfer, as per facility policy, but these were not recorded. Additionally, the facility did not transcribe RN pronouncement orders before an RN pronounced a resident dead. The resident, who had diagnoses including Hodgkin's lymphoma and chronic obstructive pulmonary disease, was found not breathing and was pronounced dead by an RN. However, the RN pronouncement order was only placed in the electronic health record after the pronouncement. The DNS and the RN involved confirmed that the order was not in place at the time of death, contrary to the facility's expectations and policies.
Failure to Apply Hip Abduction Splint as Directed
Penalty
Summary
The facility failed to ensure that a hip abduction splint was applied daily as directed by the physician for Resident #39, who was admitted with diagnoses including cerebral vascular infarction, pleural effusion, and lung cancer. The resident was moderately cognitively impaired and required assistance with various activities of daily living. A physician order dated 11/7/23 directed the application of a hip abduction splint when the resident was in a wheelchair, but this was not documented in the treatment admission record (TAR) from 11/7/23 through 2/28/24. Observations on 2/28/24 confirmed that the resident was in a wheelchair without the splint, and staff interviews revealed that the splint was not included in the TAR due to an error by a former travel Physical Therapist. The Rehab Director confirmed that the order for the hip abduction splint was incorrectly entered into the computer system, resulting in the splint not being applied as required. The resident needed the splint for proper positioning due to a condition called wind swept, where the resident sat to one side. The facility's policy on splints indicated that therapists should coordinate with the interdisciplinary team to determine splinting needs and monitor appropriate use. However, this coordination and training for staff did not occur, leading to the deficiency in care for Resident #39.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration for Resident #55, who had diagnoses including respiratory failure with hypoxia, pneumonia, and Chronic Obstructive Pulmonary Disease (COPD). The resident's care plan indicated the need for supplemental oxygen, and observations confirmed the resident was using oxygen at 2.0 liters per minute (lpm) via a nasal cannula on multiple occasions. However, both LPN #6 and RN #2 were unable to locate any active or discontinued physician orders for the oxygen therapy, despite the resident having been on oxygen for several weeks. Interviews with the nursing staff revealed that the resident had recently visited a pulmonary physician, and it was suggested that the order might not have been transcribed. The facility's policy on the use of oxygen required a verified physician's order before administration, which was not adhered to in this case. The deficiency was identified during a surveyor interview, and it was confirmed that no physician's order was present in the clinical record at the time of the observations.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to ensure that a resident was provided with the Influenza vaccine after receiving consent. Resident #26, who was admitted with heart disease, dementia, and diabetes, had consented to receive the Influenza vaccine for the 2023/2024 season. However, after recovering from Covid-19, the resident was not administered the vaccine, leading to hospitalization for Influenza. This oversight was identified during an interview and review of the facility's immunization tracking with the Infection Control Nurses on 3/1/24. Additionally, the facility did not ensure that another resident or their representative was educated and given the opportunity to consent or decline the Pneumonia vaccination upon admission and subsequent to admission. Resident #39, admitted with cerebral infarction, pleural effusion, and lung cancer, had no documentation indicating they were offered the Pneumonia vaccine. The facility's practice of not offering pneumonia vaccines to residents in the short-term rehab unit and directing them to their primary care physician was confirmed during an interview with the Infection Control Nurse on 3/1/24.
Failure to Offer COVID-19 Vaccine and Education to Residents
Penalty
Summary
The facility failed to ensure that residents or their representatives were educated and given the opportunity to consent or decline the COVID-19 vaccine upon admission. Specifically, two residents, one with an autoimmune disease, sepsis, and kidney issues, and another with chronic obstructive pulmonary disease, sepsis, and congestive heart failure, were not offered the COVID-19 vaccine or provided with education about it. Both residents were identified as moderately cognitively impaired and dependent on assistance for various activities of daily living. Interviews with the facility's Infection Preventionists and a review of the facility's immunization tracking revealed that neither resident was offered the COVID-19 vaccine upon admission or at any time since. Additionally, there was no documentation indicating that the residents or their representatives were educated about or given the opportunity to receive or decline the vaccine. The facility's policy states that all residents should be offered vaccines unless medically contraindicated, and any refusals should be documented, which was not done in these cases.
Failure to Complete Required Employee Training
Penalty
Summary
The facility failed to ensure that the required employee training and inservices were completed for three staff members: two Licensed Practical Nurses (LPNs) and one Registered Nurse (RN). The review of the facility's documentation and employee files revealed that the new employee orientation training, as well as mandatory training on Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health, were not completed and documented for these employees. The employees had been working in the facility for several months without the required training being verified in their files. During an interview and record review with the facility Administrator, it was confirmed that the required training should have been completed upon hire. However, the Administrator was unable to provide documentation that the training had been completed for the three employees. The Administrator also mentioned that the person responsible for conducting the training had resigned, which may have contributed to the oversight. The facility's policy mandates that all newly hired personnel must attend a 10-hour orientation program within their first five days of employment, which was not adhered to in these cases.
Failure to Complete Required Training for Newly Hired Nurse Aide
Penalty
Summary
The facility failed to ensure that the required employee training and inservices were completed for one of the two nurse aides reviewed. The nurse aide in question was hired on 9/28/23 and had worked in the facility from that date to the present. However, a review of her employee file revealed that no documentation of the required inservices, including Abuse/Neglect/Exploitation, Dementia, Infection Control, Communication, and Behavioral Health, had been provided. During an interview and record review with the facility Administrator on 3/6/24, it was confirmed that the required training should have been completed upon hire, but no documentation was available. The Administrator was unaware of the reason for this lapse and noted that the person responsible for conducting the training had resigned. Facility policy mandates that all newly hired personnel must attend a 10-hour orientation program within their first five days of employment.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide the required notification of transfer/discharge to the state Ombudsman's office for four residents who were hospitalized. Resident #18, diagnosed with Parkinson's disease and other conditions, was hospitalized after pulling out a PEG tube but there was no documentation of notification to the Ombudsman. Resident #19, with a history of cerebral infarction and diabetes, was transferred to the hospital due to chest pain, but again, no notification was documented. Resident #43, suffering from dementia and other ailments, was also transferred to the hospital without the required notification. Lastly, Resident #59, with diagnoses including metabolic encephalopathy and dementia, was sent to the hospital for abdominal pain, but the Ombudsman was not notified. Interviews and record reviews with the facility's Social Worker revealed that although he was aware of the requirement to notify the Ombudsman, he had not done so for these residents. The Social Worker mentioned that he generated a report for the Ombudsman from the electronic health record system but could not explain why these residents did not appear on the list. Additionally, the facility could not provide a policy for notification of the Ombudsman when a resident is admitted to the hospital.
Failure to Document Bed Hold Notifications
Penalty
Summary
The facility failed to provide documentation that the bed hold notice was given to residents or their representatives upon hospitalization. For Resident #18, who had diagnoses including Parkinson's disease and cognitive communication deficit, there was no documentation of bed hold notification when the resident was hospitalized after pulling out a PEG tube. Similarly, Resident #19, who had intact cognition and required assistance with various activities, was transferred to the hospital due to chest pain, but there was no record of bed hold notification during the hospitalization period. Interviews with staff revealed confusion about responsibilities for notifying residents or their representatives about the bed hold policy, with the Social Worker, Business Office Manager, and Admissions Director each indicating it was not their responsibility or that they did not document the notification in the medical record. Resident #55, who had chronic obstructive pulmonary disease and heart failure, was hospitalized multiple times, but the facility failed to document bed hold notifications for these hospitalizations. The Resident Bed Hold Documentation Forms were either incomplete or missing for some hospitalizations. For Resident #59, who had acute cholecystitis and dementia, the facility did not provide a written bed hold notice or document the bed hold status in the clinical record when the resident was sent to the hospital. Interviews with the Social Worker and Business Office Manager confirmed that they did not handle bed hold notifications, and the facility's Administrator and Admissions Assistant acknowledged that the bed hold policy was not followed. The facility's Bed Hold Notice and Readmission Process policy requires that a copy of the bed hold policy be provided to the resident at the time of transfer and that the Business Office Manager or designee follow up with a phone call to verify the bed hold. This conversation should be documented in the resident's medical record. However, the facility failed to adhere to this policy for the residents reviewed, resulting in a lack of documentation and communication regarding bed hold notifications during hospitalizations.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility failed to ensure the accuracy of its direct care staffing information submitted to CMS for Quarter 3 of 2023. The Payroll Based Journal (PBJ) submissions for this period identified excessively low weekend staffing. During an interview, the Administrator stated that the facility provides payroll hours for both their employees and agency employees to a contracted company, which then submits the data to CMS. The Administrator also noted that the staffing levels were not actually low during this period, and the long-term care facility company identified the low staffing pattern submissions, indicating a need to review the contracted company's reporting procedures.
Failure to Review Infection Control Policies and Analyze Antibiotic Use
Penalty
Summary
The facility failed to ensure that the policies related to infection control and antibiotic stewardship were reviewed on an annual basis and that data was kept and analyzed according to federal regulations. During a review of the facility's infection control policy and procedure manual with the current and previous Infection Preventionists, it was found that the manual had not been reviewed annually. Additionally, the antibiotic stewardship program did not include the calculation of monthly antibiotic use percentages, nor were these percentages reviewed with the Quality Assurance program on a quarterly basis. Both Infection Preventionists were unaware of the requirement to keep and analyze these percentages, as well as the need for annual review and signatures from the Medical Director, Director of Nursing, and the Administrator on the infection control and intravenous policies and procedures.
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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