Avery Nursing Home/noble Building
Inspection history, citations, penalties and survey trends for this long-term care facility in Hartford, Connecticut.
- Location
- 705 New Britain Ave, Hartford, Connecticut 06106
- CMS Provider Number
- 075063
- Inspections on file
- 28
- Latest survey
- October 6, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avery Nursing Home/noble Building during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering was able to exit a secured unit unsupervised due to a nonfunctioning exit door alarm, resulting in a fall and injuries outside the building. Staff last observed the resident two hours before the incident, and the courtyard area contained multiple environmental hazards, including uneven pavement, unsecured stones, and an easily opened gate. The facility lacked a specific policy for wandering behaviors and could not explain the alarm failure or address the environmental risks, leading to an immediate jeopardy finding.
The facility did not assess, care plan, or document the need for placement of several residents on a secured unit, nor did it obtain required consents or demonstrate that this was the least restrictive setting. Residents with various cognitive and psychiatric conditions were placed on a locked unit without documented criteria, assessment, or consent, and facility leadership confirmed the absence of formal guidelines or documentation for such placements.
The facility did not provide documentation showing that required quarterly environmental rounds were completed for infection prevention and control during a specified period. The current Infection Preventionist reported that the previous nurse was responsible for these rounds and no records could be found for the timeframe in question, despite facility policy mandating regular completion and reporting of such rounds.
The facility did not ensure that residents were properly assessed for or offered pneumococcal and influenza vaccines, as required by policy. Several residents with cognitive impairment and chronic conditions had no documentation of vaccine assessment, administration, or refusal, and the Infection Preventionist acknowledged not fulfilling these responsibilities due to workload and being new to the role.
A resident with severe cognitive impairment and multiple medical conditions had clearly documented advance directive choices, including full code status and specific interventions, but the facility failed to ensure these choices were reflected in the physician's orders. Staff interviews and policy review confirmed that such orders should have been present and entered into the medical record, but this was not done.
The facility did not timely develop or update comprehensive care plans for multiple residents, resulting in care plans that failed to reflect current ADL, mobility, and skin integrity needs. In several cases, care plans were incomplete, not updated after significant changes, or did not address all areas identified in assessments, including after new wounds or falls occurred.
A resident with multiple chronic conditions was found self-administering medications that had been left at the bedside by an RN, despite not having a self-administration order. The RN routinely left medications for the resident to take later and documented administration in the MAR without observing ingestion, contrary to facility policy and professional standards.
A resident with multiple medical conditions did not receive prescribed artificial tears and wound care during a scheduled shift, despite documentation indicating otherwise. The resident reported the missed care, and subsequent review confirmed that the treatments were not administered as ordered, with the MAR inaccurately reflecting completion by an LPN.
Two residents experienced deficiencies in pressure ulcer care due to delayed documentation, lack of timely wound assessment, and failure to implement recommended nutritional interventions. One resident's pressure ulcer progressed from stage II to unstageable before being properly assessed by a wound physician, while another resident's dietary recommendation for protein supplementation was not implemented until a second request was made. Facility staff demonstrated inconsistent communication and documentation practices, and relevant policies were not followed.
A resident with significant mobility impairments and dependent on a Hoyer lift was transported alone in a reclining shower chair without a seatbelt, resulting in a fall when the chair was pushed over a raised threshold. Staff interviews revealed inconsistent understanding of transport requirements, and facility documentation lacked clear guidance or training on safe shower chair use.
Medication carts were found unlocked and unattended in the hallway, with one cart's drawer open and oxygen tubing on top. A resident was observed wandering near one of the unlocked carts while the charge nurse was not present to monitor them. Facility staff and policy confirmed that medication carts should be locked when not in use or out of direct view of nursing staff.
A resident with multiple dietary needs did not receive all menu choice items as listed on their meal ticket, with several items unavailable and no substitutions offered. Staff confirmed the unavailability and lack of communication regarding ordering, while the Dietician noted that substitutions should be provided. No documentation or policy was available to address the issue.
Two residents with moderately impaired cognition and multiple medical conditions were not administered or properly offered the COVID-19 booster vaccine despite having provided consent. Clinical records lacked documentation of vaccine administration or refusal, and the Infection Preventionist could not explain the omission, contrary to facility policy requiring vaccination opportunities for new admissions.
Several MDS assessments for multiple residents were not transmitted to CMS within the required 14-day period after completion. An LPN serving as the MDS Coordinator could not explain the delays, citing possible issues with a third-party company and potential system glitches. The facility's EMR system tracks due dates, but the required timelines were not met.
A resident with a history of muscle weakness, repeated falls, and impaired cognition, who was dependent on staff for bed mobility, slid off a low air-loss mattress during personal care and sustained multiple fractures, ultimately passing away at the hospital. Staff interviews revealed inconsistent understanding and application of the required assistance level, and the care plan was not updated in a timely manner to reflect the resident's changing needs.
A resident with multiple risk factors for falls and impaired cognition slid off a low air-loss mattress during care and sustained multiple fractures. After the fall, a nursing assistant and an LPN moved the resident prior to assessment by an RN, contrary to professional standards and facility policy. The resident was later transferred to the hospital and passed away. Staff interviews confirmed the resident was repositioned and changed on the floor before RN assessment, and the RN was not informed of these actions.
The facility did not update care plans for multiple residents following physical altercations, despite incidents involving residents with severe cognitive impairment and behavioral symptoms. In each case, care plans were not revised to include interventions to protect those involved or prevent future incidents, contrary to facility policy and regulatory requirements.
A resident with Alzheimer's disease experienced an incident where a nursing assistant was reported to be rough during a transfer. Although an assessment found no injuries, the nursing supervisor failed to document the assessment in the medical record, contrary to facility policy.
Failure to Supervise Wandering Resident and Maintain Safe Environment
Penalty
Summary
A deficiency occurred when a resident with a known history of dementia, severe cognitive impairment, muscle weakness, legal blindness, and bone density disorder was not adequately supervised despite being identified as at risk for wandering and/or elopement. The resident's care plan included interventions such as increased staff supervision, quarterly elopement assessments, and the use of exit alarms. However, on the night in question, the resident was last seen by staff at 2:00 AM and was found outside the building at 4:00 AM, having sustained abrasions, bruises, and a hematoma after a fall. The exit door alarm, which was supposed to alert staff if the door was opened, did not sound, and staff were unable to determine how long the resident had been outside. Interviews with staff revealed that the resident was known to ambulate independently and wander throughout the unit, especially during the day, and was generally redirectable. On the night of the incident, the nurse's aide had last assisted the resident to the bathroom at 2:00 AM and then returned to the nurse's station, where she could see down the hallway. The aide did not hear any alarm from the exit door and only discovered the resident outside after hearing yelling at 4:00 AM. The exit door, which should have been secured with an alarm, was found to be nonfunctional at the time of the incident, although it was reported to be working when tested later that day. The facility did not have a specific policy for residents with wandering behaviors, and the only relevant policy directed staff to report missing residents and ensure adequate safeguards for resident safety. Environmental observations identified additional hazards in the courtyard area accessible from the unit, including uneven pavement, unsecured stones with sharp edges, loose rocks creating tripping hazards, a steep drop-off, and an easily opened gate leading to a pathway toward a main road. The courtyard was intended to be accessible only under staff supervision, but the physical environment was not free from accident hazards, and the exit door alarm system failed to function as required. The facility was unable to explain why the alarm did not sound or why environmental hazards were not addressed, resulting in a finding of immediate jeopardy.
Failure to Assess, Care Plan, and Obtain Consent for Secured Unit Placement
Penalty
Summary
The facility failed to properly assess, care plan, and document the placement of residents on a secured unit, as well as to obtain necessary consents and demonstrate that this setting was the least restrictive option. Observations over multiple days confirmed that the secured unit, identified as Station 2, required a code for egress, effectively restricting residents' ability to leave. For three sampled residents with varying cognitive and psychiatric diagnoses, there was no evidence in their clinical records, care plans, or physician orders that their placement on the secured unit was assessed, justified, or consented to by the residents or their representatives. For one resident with schizophrenia, bipolar disorder, and dementia, care plans and physician orders did not mention secured unit placement, and psychiatric notes indicated the resident was not a danger to self or others. Another resident with Alzheimer's dementia and schizoaffective disorder was assessed as not at risk for elopement, yet was placed on the secured unit without documentation of criteria or consent. A third resident with Lewy Body dementia and severely impaired cognition was also not assessed as an elopement risk, but was placed on the secured unit, with no documentation supporting the need for this level of restriction. Interviews with facility leadership, including the DNS, ADNS, and Medical Director, revealed a lack of established criteria or documented process for determining placement on the secured unit. The facility assessment did not identify the existence of a secured unit or criteria for placement, and the facility was unable to provide requested documentation such as placement consents or assessments. Residents interviewed were aware of their inability to leave the unit, and staff interviews confirmed that decisions for placement were made without formal guidelines or documentation.
Failure to Document Quarterly Environmental Rounds for Infection Control
Penalty
Summary
The facility failed to provide documentation that environmental rounds were conducted on a quarterly basis as required by their policy. Review of records with the Infection Preventionist revealed no evidence that environmental rounds were completed for the first quarter of 2024, specifically for the months of January, February, and March. The current Infection Preventionist, who began her role in June 2024, stated that it was the responsibility of the previous infection control nurse to ensure completion of these rounds and was unable to locate any documentation for the period in question. Facility policy requires that environmental rounds be conducted regularly by charge nurses, supervisors, departmental heads, and the infection control practitioner, with a report generated to identify areas of noncompliance.
Failure to Assess and Offer Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly assessed for and offered pneumococcal and influenza vaccinations, as evidenced by the review of clinical records, facility policies, and staff interviews. For all five sampled residents, there was a lack of documentation indicating that the pneumococcal vaccine was assessed, offered, or administered, and in some cases, the influenza vaccine was not offered or documented as received. The Infection Preventionist acknowledged that it was her responsibility to ensure residents were up to date with vaccinations but admitted to not having done so due to being new to the role and busy with other tasks. Specific examples include residents with moderately to severely impaired cognition and multiple comorbidities such as anemia, hypertension, hyperlipidemia, schizoaffective disorder, vascular dementia, and diabetes mellitus. For these residents, records failed to show that vaccines were offered, administered, or refused, and in some cases, there was no assessment of prior vaccination history. The Infection Preventionist also noted difficulties in obtaining consent from responsible parties but did not document attempts or refusals related to the vaccines. Facility policy required that all residents be assessed for vaccination status upon admission and that vaccines be offered if not previously received. However, the review found that these procedures were not followed, as evidenced by missing documentation and lack of vaccine administration or offers. The Infection Preventionist had not completed planned audits to identify and address these gaps, resulting in the deficiency.
Failure to Document Advance Directive Choices in Physician Orders
Penalty
Summary
The facility failed to ensure that a physician's order was present to reflect a resident's wishes regarding cardiopulmonary code status, hospitalization, and intravenous fluids, as indicated in the resident's advance directive. The resident in question had diagnoses including dementia, hypertension, and muscle weakness, and was identified as having severely impaired cognition and requiring maximal assistance with daily activities. The care plan and an Advance Directive Consent Form, signed by the responsible party and physician/APRN, clearly documented the resident's election for full code status (CPR), hydration by IV fluids, nutrition by feeding tube, hospitalization to prolong life, and antibiotic therapy, with a refusal of comfort measures. Despite these documented choices, a review of the physician's orders over the relevant period did not reveal any orders addressing the resident's code status or the other elected interventions. Interviews with nursing staff and facility leadership confirmed that the code status should be reflected in the physician's orders and that it is the responsibility of nursing supervisors to ensure these orders are obtained and entered into the electronic medical record. The facility's own policy also requires that the physician write appropriate orders to indicate code status, to be verified by nursing upon admission. However, this process was not followed, resulting in the absence of required physician orders for the resident's advance directive choices.
Failure to Develop, Review, and Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans within the required timeframe and did not ensure that care plans were reviewed and revised to reflect residents' current conditions. For one new admission, the interdisciplinary care plan meeting was not held, and the comprehensive care plan was not completed within 21 days as required by facility policy. The baseline care plan did not address all areas triggered by the admission MDS assessment, such as activities of daily living, rehabilitation potential, urinary incontinence, falls, dehydration, and pressure ulcers. The responsible RN acknowledged the care plan was overdue and incomplete, and could not provide a reason for the delay. Another resident's care plan was not updated to reflect changes in their activities of daily living (ADL) status, specifically regarding transfer and mobility needs. Despite physician orders and therapy notes indicating the need for a Hoyer lift with two-person assist, the care plan inaccurately described the resident as transferring and ambulating independently. The care plan was only updated after a fall occurred, and staff interviews confirmed that the care plan did not accurately reflect the resident's status prior to the incident. For a resident with pressure injuries, the care plan was not reviewed or revised when new skin issues developed, including a sacral pressure ulcer and a left heel wound. Documentation showed that the care plan did not reflect the resident's current skin status until after surveyor inquiry, despite multiple nursing notes and wound care interventions. Staff interviews confirmed that care plans should be updated following significant changes, but this was not done in a timely manner for the resident who developed new wounds.
Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including muscle weakness, glaucoma, hypertensive heart and chronic kidney disease, was observed self-administering medications that had been left at the bedside by a registered nurse. The resident was cognitively intact and received several medications daily, as documented in the care plan and physician's orders. Despite this, the resident did not have an order permitting self-administration of medications. The nurse reported routinely leaving medications at the bedside because the resident preferred to take them later, and confirmed that she did not observe the resident taking the medications, even though she had signed off on the medication administration record (MAR) as if the medications had been administered. Further interviews with facility staff, including the nurse manager, confirmed that medications should not have been left at the bedside and that staff are required to observe residents taking their medications unless there is a specific self-administration order in place. The facility failed to provide a medication administration policy when requested. The facility's own policy on self-administration states that such practice is only permitted if the interdisciplinary team determines it is safe, which had not occurred in this case.
Failure to Administer Ordered Treatments and Medications
Penalty
Summary
A resident with a history of hereditary syndrome of bilateral lacrimal glands, dry eye disorder, and malignant melanoma of the right upper eyelid did not receive prescribed treatments during a specific shift. The resident was cognitively intact, required assistance with toileting, and was independent with eating. Physician orders included administration of artificial tears to both eyes twice daily and a specific wound care regimen for the right leg. On the evening in question, the resident reported not receiving either the artificial tears or the wound care treatment, despite using the call bell and being told someone would return, which did not occur. The resident subsequently reported the missed care to the next shift, at which point the wound care was completed, but the eye drops were not administered as the nurse was unaware they had been missed. Documentation on the Medication Administration Record (MAR) indicated that the treatments had been provided by the LPN assigned to the earlier shift, but interviews and physical evidence (the unchanged dressing) confirmed the care was not performed as ordered. The facility's policy required licensed nurses to perform dressing changes as ordered by the physician.
Failure to Document and Intervene Timely for Pressure Ulcers and Nutritional Needs
Penalty
Summary
The facility failed to ensure proper documentation and timely intervention for pressure ulcers in two residents, resulting in deficiencies in pressure ulcer care and prevention. For one resident with Parkinson's disease and significant mobility limitations, a pressure ulcer on the sacrum/coccyx was first identified as an excoriation and later documented as a stage II pressure ulcer. However, there was no evidence of weekly monitoring or assessment of the wound, and the wound was not referred to the wound care team or physician for nearly two months. During this period, the wound progressed to a stage III ulcer and later became unstageable due to necrosis, with the first wound physician assessment occurring only after significant deterioration. Facility documentation and communication practices were inconsistent, with staff interviews revealing confusion about notification procedures and a lack of clear documentation in the APRN communication book. Another resident, who was at risk for skin breakdown due to decreased mobility and other medical conditions, developed two new stage III pressure wounds. The dietician made a recommendation for increased protein supplementation to promote wound healing, but this recommendation was not implemented until nearly a month later, after a second recommendation was made. There was no documentation of the original dietary recommendation in the resident's chart or the APRN communication book, and staff interviews indicated uncertainty about the process for handling dietary recommendations. The facility was unable to provide a policy outlining how such recommendations should be processed, despite having a protocol that required the dietician to assess and recommend nutritional supplementation as appropriate. Facility policy required regular documentation of wound appearance, weekly progress notes, and prompt referral to the wound care team for wounds not improving within 2-3 weeks. The policy also outlined specific documentation requirements for wound site, stage, size, and appearance, as well as procedures for reporting and treating acquired wounds. Despite these policies, the facility failed to follow its own protocols, resulting in delayed assessment, inadequate documentation, and lack of timely intervention for pressure ulcers and related care needs.
Resident Fall Due to Inadequate Supervision During Shower Chair Transport
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including hemiplegia, muscle weakness, and a history of stroke, was transported in a reclining shower chair by a single nursing assistant. The resident required extensive assistance for mobility and transfers, as documented in clinical records and therapy notes, and was non-ambulatory, requiring a Hoyer lift with two staff for transfers. Despite these needs, the resident was moved alone in the shower chair, which did not have a seatbelt, and fell when the chair was pushed over a raised threshold, resulting in the resident hitting the back of their head. Interviews with staff revealed inconsistent knowledge and unclear policies regarding the number of staff required to transport residents in different types of shower chairs. Some staff believed two people were needed for certain chairs, especially for residents requiring a Hoyer lift, while others were unsure or could not specify requirements. The staff member involved in the incident acknowledged forgetting the two-person requirement and transported the resident alone, leading to the fall. Facility documentation and interviews indicated a lack of formal education or competency assessments regarding the use of shower chairs, except in response to incidents. The facility's bathing and grooming policy did not specify staff requirements for transporting residents in shower chairs, and the care card for the resident did not provide guidance for safe transport in the chair. This lack of clear procedures and staff training contributed to the unsafe transport and subsequent accident.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that medication carts on Station 2, including both the 2 South and 2 North carts, were left unlocked and unattended in the hallway, with one cart's drawer slightly open and oxygen tubing packets placed on top. At the time of observation, a resident was wandering in the hallway near one of the unlocked carts, while the charge nurse was in the nurses' office and unable to see the carts. Interviews with nursing staff and the Assistant Director of Nursing Services confirmed that facility policy requires medication carts to be locked when not in use or out of the nurse's direct view. Review of the facility's medication storage policy further indicated that only licensed nursing personnel should have access to locked medication carts, which are to remain locked at all times when not in use or in direct view.
Failure to Provide Menu Choice Items and Substitutions
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hyperlipidemia, dysphagia, and gastro-esophageal reflux disease was not provided with all menu choice items as listed on their meal ticket. The resident, who was cognitively intact and on a mechanically altered, therapeutic diet, received only a hot dog, apple juice, and water during a meal, while other listed items such as baked beans, chips, and pickles were unavailable. No substitutions were offered, and the resident reported that the kitchen was frequently out of stock of multiple items. Staff serving the meal confirmed the unavailability of the menu items and were unsure of the reason, noting they did not handle ordering. Further investigation revealed that the Food Service Director was unaware that the items had not been ordered or delivered, and there was no documentation indicating the items were out of stock. The Dietician acknowledged hearing resident concerns about not receiving chosen menu items and stated that appropriate substitutions should be offered when items are unavailable. Additionally, there were no notes from the monthly food committee meetings, and the facility was unable to provide a policy regarding food ordering and menu choices.
Failure to Administer or Document COVID-19 Booster Vaccination for Eligible Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 booster vaccine was administered or properly offered to two residents who were eligible and had provided consent. One resident, admitted with diagnoses including anxiety, hypertension, and depression, had moderately impaired cognition and was not up to date with COVID-19 vaccination. Although this resident gave consent for the COVID-19 Pfizer-BioNTech vaccine, there was no documentation of consent for the 2024-2025 booster, nor any record that the vaccine was administered or refused. Review of clinical records and immunization consent forms did not show evidence that the booster was offered or given, and the Infection Preventionist could not explain why the vaccine was not administered. Another resident with schizoaffective disorder, anemia, and nutritional deficiency, also with moderately impaired cognition, was similarly not up to date with COVID-19 vaccination. Consent for the 2024-2025 COVID-19 vaccine was obtained from the responsible party, but there was no documentation that the vaccine was administered or refused. The Infection Preventionist acknowledged responsibility for obtaining consents and administering vaccines but was unable to provide a reason for the failure to offer or administer the booster. Facility policy required that new admissions be offered vaccination after a clinic, but this was not followed for these residents.
Late Submission of MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for five sampled residents were transmitted to the Centers for Medicare & Medicaid Services (CMS) within the required 14-day timeframe following the completion of the assessments or care plans. Specifically, the quarterly and annual MDS assessments for these residents were submitted between seven and fourteen days late, as evidenced by a review of the facility's transmittal records. The electronic medical record (EMR) system in use at the facility compiles a list of due dates for MDS assessments, and the policy requires submission within 14 days of completion, but this protocol was not followed for the residents in question. During an interview, the MDS Coordinator, an LPN, was unable to provide a clear explanation for the late submissions. She indicated that a third-party company assists with MDS processing and sometimes reports that assessments have been submitted when, in fact, they have not. The LPN also mentioned the possibility of a system glitch contributing to the issue. The Resident Assessment Instrument Manual was referenced, confirming the requirement for timely submission of comprehensive and other MDS assessments.
Failure to Assess and Provide Appropriate Assistance During Bed Mobility Results in Resident Fall and Major Injuries
Penalty
Summary
A deficiency occurred when staff failed to ensure a timely and appropriate assessment of a resident's bed mobility needs during care, resulting in a fall with major injuries. The resident had a history of muscle weakness, repeated falls, anxiety disorder, and type 2 diabetes with neuropathy, and was identified as having moderately impaired cognition and being dependent on staff for bed mobility and transfers. The care plan indicated the resident was at risk for falls and required positioning in the middle of the bed before turning, with an update specifying a two-person assist during care after a previous fall. On the day of the incident, a nursing assistant was providing personal care and turned the resident onto their left side, at which point the resident slid off the side of a low air-loss mattress and landed on the floor. The assistant attempted to prevent the fall but was unsuccessful. Interviews revealed that the resident's ability to assist with bed mobility was inconsistent, and while some staff considered a two-person assist safer, the care plan had not been updated to consistently require this level of assistance prior to the incident. The last therapy evaluation for activities of daily living had been conducted several months prior, and no functional status changes had been reported to trigger a reassessment. Following the fall, the resident was found to have sustained multiple fractures, including bilateral femur and rib fractures, and subsequently passed away at the hospital. The facility's fall policy required assessment for fall risks and implementation of safeguards, but the lack of timely reassessment and inconsistent application of assistance levels during care contributed to the incident. Interviews with staff indicated uncertainty regarding the appropriate level of assistance needed for the resident, and the care plan interventions were not consistently aligned with the resident's fluctuating capabilities.
Failure to Follow Professional Standards in Post-Fall Care
Penalty
Summary
The facility failed to ensure that care and services provided to a resident were in accordance with accepted professional standards, specifically in the management of a fall with major injuries. The resident involved had multiple diagnoses, including muscle weakness, repeated falls, anxiety disorder, and type 2 diabetes with neuropathy, and was identified as having moderately impaired cognition and being dependent on staff for bed mobility and transfers. The resident was assessed as high risk for falls, with a care plan in place that included interventions such as ensuring the resident was positioned in the middle of the bed before turning and providing assistance of two during care. On the day of the incident, during morning care, the resident was turned onto their left side and slid off the side of a low air-loss mattress, landing on the floor with both legs extended and the right leg externally rotated. Staff interviews revealed that after the fall, the resident was initially in a sitting position with their back against the bed, but was subsequently moved by a nursing assistant and an LPN prior to assessment by a registered nurse (RN). The staff repositioned the resident to a lying position and straightened their legs, and later changed the resident's brief by turning them back and forth on the floor, despite the RN's directive not to move the resident until assessed. The RN was not informed that the resident had been moved prior to her assessment. The resident was later transferred to the emergency department, where multiple fractures were identified, including bilateral femur fractures and rib fractures. The resident became lethargic and was pronounced dead later that day. Facility policy directed that residents should be assessed for fall risks and that after any fall, an investigation and care plan review should occur. However, the staff did not follow professional standards by moving the resident prior to RN assessment after a fall with suspected fractures.
Failure to Update Care Plans After Resident Altercations
Penalty
Summary
The facility failed to update the care plans for several residents following physical altercations, as required by policy and regulation. In one incident, a resident with vascular dementia and severe cognitive impairment entered another resident's room, leading to a physical confrontation where both residents struck each other. Although one resident's care plan was updated after the incident, the other resident's care plan was not revised to include interventions to protect the resident or prevent recurrence. In another event, two residents with Alzheimer's disease and dementia, both with significant cognitive impairment, were involved in a physical altercation near the nurse's station. One resident kicked the other, who then pushed back, resulting in a scrape injury. Review of their care plans showed that neither was updated following the incident to address the altercation or implement measures to prevent future occurrences. Interviews with facility staff, including the Assistant Director of Nurses and the Director of Nurses, confirmed that care plans were not consistently updated after these incidents. Facility policy requires the interdisciplinary team to implement and revise care plans based on residents' needs and events, but this was not followed in the cases reviewed.
Incomplete Documentation Following Abuse Allegation
Penalty
Summary
The facility failed to ensure the clinical record for a resident was complete and accurate following an allegation of abuse. The resident, who was admitted with Alzheimer's disease and had severe cognitive impairment, was involved in an incident where a nursing assistant was reported to have been rude and rough during a transfer. The incident was reported by another nursing assistant, and a subsequent assessment by the nursing supervisor found no injuries or distress in the resident. However, the nursing supervisor did not document this assessment in the resident's medical record, which is a requirement according to the facility's policy. The facility's policy mandates that upon receiving reports of physical abuse, the nursing supervisor should direct the charge nurse to examine the resident and document the findings in the medical record. Despite this policy, the assessment conducted by the nursing supervisor was not recorded, leading to an incomplete clinical record. Interviews with the acting Director of Nursing and the Assistant Director of Nursing Services confirmed that the assessment should have been documented, but they were unaware of why it was not done.
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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