Ark Healthcare & Rehabilitation At St. Camillus
Inspection history, citations, penalties and survey trends for this long-term care facility in Stamford, Connecticut.
- Location
- 494 Elm St, Stamford, Connecticut 06902
- CMS Provider Number
- 075320
- Inspections on file
- 17
- Latest survey
- October 18, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ark Healthcare & Rehabilitation At St. Camillus during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments, requiring two-person assistance for bed mobility, was left unattended by a single nurse aide during incontinent care. The aide attempted to turn the resident alone, resulting in the resident falling from bed and sustaining a displaced spiral femur fracture that required surgical intervention. This occurred despite clear physician orders and care plan directives for two-person assistance and use of bed rails.
The facility failed to provide accessible contact information for the State Long-Term Ombudsman Program. Residents were unaware of the Ombudsman and where to find contact details. The information was posted high on elevator walls, inaccessible to wheelchair users and not visible to those facing forward. It was also absent from bulletin boards outside elevators and on units, violating facility policy.
The facility did not inform residents about the grievance process or ensure that grievance forms were accessible. Residents were unaware of how to complete a grievance or where to find the forms. A social worker could not locate the forms in the designated area and acknowledged they were not easily accessible. Despite a request, a copy of the grievance policy was not provided.
The facility failed to revise care plans for three residents, leading to deficiencies in managing physical limitations, skin integrity, and fall risk. A resident with hand deformities did not have a care plan update to manage the condition. Another resident with a stage 3 pressure ulcer lacked a care plan for offloading boots, despite recommendations. A third resident's care plan was not updated after a fall, missing necessary interventions.
A resident at risk for pressure ulcers developed a new DTI on the left heel due to the facility's failure to consistently document turning and repositioning. Despite recommendations from a wound physician, the facility did not obtain physician's orders for offloading boots, contributing to the ulcer's progression to stage 3. Interviews revealed a lack of communication and documentation regarding pressure-relieving interventions, indicating non-compliance with the facility's skin care management policies.
The facility failed to ensure timely evaluation and treatment for residents with limited mobility and contractures. A resident developed bilateral hand deformities without proper evaluation or treatment, while another experienced contractures post-stroke with delayed intervention. Additionally, a resident prescribed splints for contracture management did not receive them as ordered, with staff unaware of the requirements.
The facility's kitchen was found to be unsanitary, with issues such as dirty ceiling tiles, a broken dishwasher cover, and unlabeled food items. Temperature logs were incomplete, and a cook was not wearing a beard guard. The Dietary Manager acknowledged these deficiencies.
The facility failed to properly dispose of garbage and refuse, with numerous debris items found alongside the dumpsters, including mattresses, televisions, and broken furniture. The Dietary Director had informed the Maintenance Director about the need for cleanup two weeks prior, and the Maintenance Director confirmed the situation, stating that a company was scheduled to pick up the items.
The facility failed to investigate a missing item report for a resident, resulting in confusion about the item's recovery. Additionally, the facility environment was unsanitary, with a rusted medicine cabinet, dusty fan, and poorly maintained shower rooms. Maintenance staff were unaware of repair needs, and there was no documentation of maintenance rounds or cleaning policies.
A facility failed to ensure the accuracy of the MDS assessment for a resident with a serious mental illness. The resident, diagnosed with dementia and schizoaffective disorder, was incorrectly coded on the MDS as not having a PASRR related condition. An RN responsible for MDS coding admitted to the oversight, despite the RAI instrument directing that such conditions be coded under Section A 1500 PASRR related condition.
A resident with Type 2 diabetes and incontinence was given Lactulose syrup borrowed from another resident's supply due to a depletion of their own medication. The LPN admitted to routinely borrowing medications, contrary to facility policy, which states that medications should not be shared and the pharmacy should be contacted if a medication is unavailable.
A resident with heart failure, diabetes, and neuropathy was found with long, dirty fingernails despite being dependent on staff for personal hygiene. The resident had requested nail care but did not receive it, and there was no documentation of nail care being offered or refused. Staff interviews revealed no specific schedule for nail care, and the DNS stated that staff should proactively offer nail care. The facility's policy required daily cleaning and regular filing of nails.
A resident with Alzheimer's and wandering behavior was inadequately supervised, leading to unsupervised wandering and access to potentially hazardous items. Despite being on 15-minute checks, the resident was observed without supervision, entering another resident's room, and handling personal items, highlighting a failure in implementing the care plan and facility policy.
A facility failed to maintain a complete communication log for a resident receiving dialysis, missing critical information such as nurse names, access site conditions, vital signs, and meal times. Staff interviews revealed inconsistencies in understanding documentation requirements, leading to incomplete records despite the facility's policy for comprehensive communication with the treatment center.
A facility failed to ensure staff was knowledgeable about using electronic care cards, leading to a resident experiencing pressure on their feet and legs due to improper use of offloading booties. The RN supervisor could not find a physician order or care plan for the booties, and a nurse aide was unaware of their necessity due to a lack of available care cards and reliance on verbal reports. The process for reviewing assignments and documenting care on electronic tablets was not followed, and there was no documentation of the booties' implementation or effectiveness.
A resident's prescribed Lactulose medication was unavailable, leading an LPN to use another resident's medication, contrary to facility policy. The facility's policy prohibits borrowing medications and emphasizes timely reordering to ensure availability.
The facility's PBJ data for Quarter 3 of 2023 was found to be incomplete and inaccurate, with excessively low weekend staffing levels. Despite meeting state staffing requirements on certain dates, the HR Director could not explain the low weekend staffing trigger. Staffing data was compiled from payroll and agency invoices and submitted to CMS by an outside consultant.
Failure to Provide Required Assistance with Bed Mobility Resulting in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to provide the required assistance with bed mobility for a resident with significant cognitive and physical impairments. The resident had diagnoses including Parkinson's disease, dementia, abnormal gait, and generalized muscle weakness, and was assessed as severely cognitively impaired and fully dependent for bed mobility and ADLs. Physician orders and the care plan specified that two staff members were required to assist with bed mobility, and that 1/4 bed rails should be used as an enabler during repositioning. Despite these directives, a nurse aide provided incontinent care to the resident alone, without seeking assistance, because other aides were busy and she believed she could manage by herself. During the process of turning the resident, the aide turned the resident onto their right side, at which point the resident's foot slid off the mattress and the resident fell out of bed onto the floor. Initial assessment did not reveal injuries, but swelling and deformity of the left leg were noted the following morning, and subsequent hospital evaluation confirmed a displaced spiral fracture of the left femur requiring surgical intervention. The Director of Nursing confirmed that the nurse aide did not follow physician orders, which were in place to prevent such falls, and the facility's fall prevention policy required individualized interventions to prevent falls.
Inaccessible Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that residents were provided access to the contact information for the Office of the State Long-Term Ombudsman Program in a manner that was accessible and understandable. During a meeting with eight residents, it was identified that they were unaware of who the State Ombudsman was and where to locate the contact information. An interview with a social worker revealed that the contact information was posted on bulletin boards located on each elevator. However, observations showed that the information was posted high on the back wall of the elevator, making it inaccessible to individuals in wheelchairs and not visible to residents facing the front of the elevator. Additionally, the information was not posted on bulletin boards outside the elevator doors or on the units, contrary to the facility's policy requiring such postings to be accessible and understandable to residents and their representatives.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to inform residents about the grievance process and ensure that grievance forms were accessible and available to residents and visitors. During a meeting with eight residents, it was revealed that they were unaware of how to complete a grievance or where to find the forms. An interview with a social worker indicated that the grievance forms were supposed to be located in the nursing office behind the nursing station on both floors. However, during an observation, the social worker was unable to locate the forms in the designated area and could not provide any other location for them. The grievance policy, which was reviewed, stated that forms should be easily accessible, especially for those wishing to remain anonymous. The social worker acknowledged that the forms were not easily accessible and mentioned that the location would be changed to better meet the residents' needs. Despite a request, a copy of the facility's grievance policy was not provided.
Care Plan Deficiencies in Resident Management
Penalty
Summary
The facility failed to revise the comprehensive care plan for Resident #13, who was identified with physical limitations of the hands. Despite the resident's left-hand deformity being noted in an interdisciplinary rehabilitation screen and bilateral hand contractures being documented in progress notes, the care plan did not include any interventions for managing these deformities to prevent progression. The Director of Nursing acknowledged that the care plan should have been revised once the physical limitation was identified. For Resident #98, the facility did not develop a care plan to address the resident's skin integrity to prevent further skin breakdown. The resident, who had a stage 3 pressure ulcer on the left heel, was recommended to use offloading boots by a wound physician. However, there was no physician's order for the boots, and the care plan was not updated to reflect this recommendation. The wound care nurse confirmed that the recommendation for offloading boots was overlooked, and the care plan did not include this intervention until after surveyor inquiry. Resident #54 experienced a fall, but the facility failed to revise the resident's care plan timely post-fall. Although the care plan indicated the resident was at risk for falls, it did not show updated interventions after the fall occurred. The Director of Nursing stated that staff are expected to update the care plan with new interventions to prevent injuries after a fall, but the care plan reviewed was the most updated version available, lacking any new interventions post-fall.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to consistently provide evidence of turning and repositioning a resident, leading to the development of a pressure ulcer. The resident, who was at risk for pressure ulcers due to paraplegia, diabetes mellitus, and incontinence, developed a new Deep Tissue Injury (DTI) on the left heel. Despite having a care plan that included interventions to prevent pressure ulcers, there were multiple instances of missing documentation for turning and repositioning the resident, which is a fundamental practice to prevent pressure ulcers. Additionally, the facility did not obtain physician's orders for recommendations made by a consulting wound physician, which contributed to the further decline of the pressure ulcer. The wound physician recommended the use of offloading boots to prevent further injury, but there was no physician's order for their use, and the care plan did not reflect this intervention. The resident's pressure ulcer progressed from a DTI to a stage 3 pressure ulcer, indicating a lack of timely and appropriate intervention. Interviews with staff revealed that there was a lack of communication and documentation regarding the use of offloading boots and other pressure-relieving interventions. The facility's policies on skin care management and prevention of pressure injuries were not adequately followed, as evidenced by the missing documentation and lack of physician's orders for recommended treatments. This deficiency highlights the need for consistent documentation and adherence to care plans to prevent the development and worsening of pressure ulcers.
Failure to Address Mobility and Contracture Needs
Penalty
Summary
The facility failed to ensure timely evaluation and treatment for residents with newly identified limited mobility and contractures. Resident #13, who was admitted with mild cognitive impairment and other conditions, developed bilateral hand deformities over time. Despite multiple screenings and observations indicating the presence of contractures, a full evaluation to determine the extent of the limitations and appropriate treatment was not conducted until after surveyor inquiry. The lack of timely intervention and preventative measures potentially contributed to the progression of the contractures. Resident #97, diagnosed with cerebral infarction and hemiplegia, also experienced a lack of timely evaluation and intervention for contractures. Initial therapy sessions identified impairments and recommended services to increase functional activity tolerance. However, after discharge from therapy, no further recommendations were made to prevent further loss of mobility. Subsequent screenings noted increased tone and contractures, but no evaluations or interventions were conducted until prompted by surveyor inquiry. The absence of a documented physician's order for a recommended splint further delayed necessary treatment. Resident #86, with a history of hemiplegia and cerebral infarction, was prescribed splints for contracture management. However, the facility failed to ensure the application of these splints as per physician's orders. Observations revealed that the resident was not wearing the prescribed splints, and staff interviews indicated a lack of awareness and communication regarding the splint application. The facility's failure to adhere to its own policies and procedures for splint application and staff training contributed to the deficiency.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour of the Dietary Department. Several issues were identified, including ceiling tiles with a brown substance, a broken and discolored dishwasher cover, and black substances around the dishwasher edges and on the tiles in the kitchen and dishwasher room. The floor throughout the kitchen was dirty with debris and food, and the second-floor nourishment refrigerator had a red substance inside. Additionally, the baking oven and cooktop were covered with a brown substance, and the ceiling vent in the main kitchen had a brown substance around it. The facility also failed to ensure proper food labeling and storage, with numerous items in the dry goods storage area and freezer found unlabeled or undated. The temperature logs for the freezer and refrigerator were missing several evening readings, and the day cook was not wearing a beard guard as required by policy. Interviews with the Dietary Manager revealed that staff were responsible for labeling and dating items, and that hair coverings, including beard guards, were to be worn around food. The Dietary Manager acknowledged the issues and identified that the facility had hired a company to steam clean the kitchen, but it was not as clean as expected.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed by surveyors. During an inspection with the Dietary Director, numerous debris items were found alongside the dumpsters and facility, including discarded mattresses, old televisions, a nightstand, a tire, broken pieces of wood, and chairs. The Dietary Director acknowledged that the area was not well-kept or cleaned and mentioned that these items were from maintenance, not dietary-related. He had informed the Maintenance Director about the need for cleanup two weeks prior, and noted that the dumpsters are emptied twice a week. The Maintenance Director confirmed that the Dietary Director had spoken to him about the debris on June 29, 2024. He identified the items beside the dumpsters and stated that a company was scheduled to pick them up on the day of the inspection. He also acknowledged his responsibility for maintaining the cleanliness of the dumpsters and surrounding area, and stated that the area had only been in that condition since June 29, 2024.
Deficiencies in Resident Safety and Facility Maintenance
Penalty
Summary
The facility failed to thoroughly investigate a report of a missing item for a resident diagnosed with morbid obesity, heart failure, and an above-the-knee amputation. The resident, who was cognitively intact, reported a missing Apple watch, which was initially documented as recovered by a social worker. However, subsequent interviews revealed that the watch had not been located, and there was confusion about whether the resident actually possessed the watch. The facility's policy for missing items was not followed, as there was no detailed investigation or conclusion documented regarding the missing watch. The facility environment was found to be unsanitary and not homelike, with a rusted medicine cabinet without doors and disconnected light bulb sockets in a bathroom. Maintenance staff were unaware of how long the cabinet had been in disrepair, and there was no documentation of repair requests or maintenance rounds. Additionally, a resident with chronic obstructive pulmonary disease had a fan in their room that was covered in dust, which had not been cleaned for at least six months. The facility lacked a policy for cleaning fans, and the housekeeping/maintenance director was unsure of the cleaning procedures. The facility's shower rooms were observed to be in poor condition, with chipped and cracked paint, black substances on floors and walls, torn wallpaper, and rusty shower curtain rods. The director of housekeeping/maintenance acknowledged the need for repairs but failed to document any concerns in the environmental rounds logs. The facility did not provide a maintenance policy or documentation of maintenance rounds, indicating a lack of oversight and attention to maintaining a safe and sanitary environment for residents.
Inaccurate MDS Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident identified with a serious mental illness. This deficiency was identified during a review of clinical records, facility policy, and interviews. Specifically, for one of the sampled residents, the facility did not accurately code the Preadmission Screening and Resident Review (PASRR) related condition on the MDS. The resident in question was admitted with diagnoses including dementia and schizoaffective disorder, and a PASRR level II outcome had previously identified the resident as meeting criteria for a serious mental illness. However, the Annual MDS assessment incorrectly indicated that the resident did not have a PASRR related condition for serious mental illness or intellectual disability. An interview with a Registered Nurse (RN) revealed that she was responsible for MDS coding and acknowledged that the PASRR should be coded on the MDS upon admission, annually, and with significant changes. Despite this, the RN entered incorrect information on the MDS due to an oversight, even though social services were responsible for coding the MDS for residents with serious mental illness. The Resident Assessment Instrument (RAI) used for MDS coding directs that all conditions related to serious mental illness or intellectual disability be coded under Section A 1500 PASRR related condition.
Medication Borrowing Leads to Deficiency
Penalty
Summary
The facility failed to meet professional standards of quality during medication administration for a resident diagnosed with Type 2 diabetes mellitus and incontinence. The resident had a physician's order for Lactulose Oral Solution to be administered daily for constipation. However, during an observation, it was noted that the Lactulose syrup administered to the resident was borrowed from another resident's supply because the resident's own supply was depleted. The LPN involved admitted that it was their usual practice to use other residents' medications when a resident's supply was unavailable. The facility's policy clearly states that medications prescribed for one resident should never be administered to another resident, and if a medication cannot be located, the pharmacy should be contacted. Despite this policy, the LPN did not adhere to the guidelines, leading to the deficiency. The RN Unit Manager confirmed that the facility's practice is not to borrow medications and emphasized the importance of reordering medications to ensure availability for residents.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure that a resident's fingernails were clean and cut, as observed in the case of a resident with diagnoses including heart failure, diabetes mellitus, and neuropathy. The resident was cognitively intact and required substantial assistance for personal hygiene. Despite being dependent on staff for bathing and personal hygiene, the resident's fingernails were observed to be long with a black and brown substance underneath. The resident reported having requested nail care about a week prior but could not recall the staff member they spoke to. The medical records from the relevant period did not document any offer or refusal of nail care. Interviews with staff revealed that there was no specific schedule for cutting residents' fingernails, although nurse aides were expected to notice and address long or dirty nails during routine care. The Director of Nursing Services (DNS) indicated that staff should proactively ask residents if they would like their nails cut, rather than waiting for residents to request it. The facility's policy on fingernail care emphasized daily cleaning and regular filing to prevent infection, but this was not adhered to in the case of the resident in question.
Inadequate Supervision of Resident with Wandering Behavior
Penalty
Summary
The facility failed to provide adequate supervision for a resident diagnosed with Alzheimer's disease, disorientation, wandering, unspecified dementia, and unspecified psychosis. The resident was identified as cognitively impaired and at risk for elopement, with a care plan that included frequent safety checks and supervision when off the unit. Despite these interventions, the resident was observed wandering without supervision, entering another resident's room, and handling personal items, which posed a safety concern. On the morning of the incident, the resident was seen walking in the hallway without undergarments and later wandering in socks without shoes. The resident was redirected by staff but continued to wander unsupervised, eventually obtaining a bowl of applesauce from a medication cart and entering another resident's private room. The resident handled items such as shaving cream and a bottle of sterile water and attempted to drink from a used coffee mug before being assisted by a nurse aide. The facility's policy on wandering and elopements aimed to prevent harm while maintaining a least restrictive environment. However, the resident's frequent checks were not adequately documented or executed, as evidenced by the resident's unsupervised wandering and access to potentially hazardous items. The Director of Nursing Services acknowledged the safety concerns and indicated that the resident was on 15-minute checks, but the checks were not effectively implemented, leading to the observed deficiencies.
Incomplete Dialysis Communication Log for Resident
Penalty
Summary
The facility failed to consistently maintain a communication log for a resident receiving specialized dialysis treatment. The resident, diagnosed with end-stage kidney disease, dementia, and Parkinson's disease, required dialysis three times a week. The care plan highlighted the risk of dehydration and fluid deficit, necessitating close monitoring of intake, output, and vital signs. However, the communication log, which was supposed to document the resident's status and treatment details, was found to be incomplete on several occasions. Missing information included the nurse's name, the condition of the specialized access site, the resident's last vital signs, and the time of the last meal. Interviews with facility staff revealed discrepancies in understanding the documentation requirements. The nurse unit manager expected the log to include vital signs, weight, and access site status, while an LPN believed only vital signs were necessary. The facility's policy required comprehensive communication between the long-term care facility and the specialized treatment center, but this was not consistently followed. The specialized treatment center did not have access to the resident's electronic medical record, relying instead on the communication log and telephone updates, which were not adequately maintained.
Failure to Ensure Staff Knowledge on Electronic Care Card Use
Penalty
Summary
The facility failed to ensure that staff was knowledgeable about using the electronic care card to provide resident care according to the plan of care. During an observation and interview, it was found that a resident was experiencing pressure on various parts of their feet and legs while seated in a wheelchair. Although there was an indication that offloading booties were ordered for the resident, the RN supervisor could not find a physician order or care plan for their use. The RN supervisor also could not explain how licensed nurses were supposed to monitor for pressure on the resident's feet and heels while out of bed. Additionally, a nurse aide who had not worked on the resident's unit for some time was unaware of the need for pressure-relieving booties, as there were no care cards available in the resident's room or at the nurse's station. The nurse aide relied on verbal reports from the outgoing aide and the resident's own instructions for care. The RN supervisor identified that the process for reviewing assignments and documenting care on electronic tablets was not followed, as the nurse aide did not review the assignment at the beginning of the shift. Furthermore, there was no documentation of the implementation, consistent use, or evaluation of the effectiveness of the booties, and the nurse aide had not received prior education on using the electronic documentation system.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that a resident's supply of Lactulose medication was available for administration as per the physician's orders. Resident #45, who has a diagnosis of Type 2 diabetes mellitus and incontinence, was prescribed Lactulose Oral Solution to be administered daily for constipation. During a medication administration observation, it was found that the Lactulose syrup intended for Resident #45 was depleted, and the Licensed Practical Nurse (LPN) used medication prescribed for another resident instead. This action was contrary to the facility's policy, which prohibits borrowing medications from other residents. The incident was observed during a medication administration session, where the LPN admitted to using another resident's medication due to the unavailability of Resident #45's supply. The LPN stated that an order had been sent to the pharmacy the previous day. The facility's policy on medication administration emphasizes the importance of administering medications as prescribed, using the Five Rights, and explicitly states that medication for one resident should never be administered to another. The RN Unit Manager confirmed that the facility's practice is to ensure medications are reordered in a timely manner to prevent such occurrences.
Inaccurate PBJ Data Submission
Penalty
Summary
The facility failed to ensure that its Payroll-Based Journal (PBJ) data for Quarter 3 of 2023 was complete and accurate. A review of the facility's PBJ submissions for this period revealed excessively low weekend staffing levels. Despite meeting minimum state staffing requirements on specific dates, such as May 21 and June 10, 2023, the overall data indicated inconsistencies. The Human Resource (HR) Director explained that staffing data was compiled from the facility's payroll provider and agency staffing invoices, which were then sent to an outside consultant for submission to the Centers for Medicare and Medicaid Services (CMS). However, the HR Director could not account for the low weekend staffing trigger in the PBJ data, suggesting fluctuations in staffing levels that were not accurately reflected in the submissions.
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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