Bickford Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Windsor Locks, Connecticut.
- Location
- 14 Main Street, Windsor Locks, Connecticut 06096
- CMS Provider Number
- 075358
- Inspections on file
- 30
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 21 (2 serious)
Citation history
Health deficiencies cited at Bickford Health Care Center during CMS and state inspections, most recent first.
A resident with dementia, anxiety, rheumatoid arthritis, and moderate cognitive impairment required substantial/maximal assistance for transfers and was wheelchair dependent. The care plan contained conflicting directions, listing both one- and two-person assist for transfers, while the physician’s order and NA care card specified one-person assist with a gait belt. In practice, some RNs and an NA believed or used a mechanical (Hoyer) lift for transfers due to the resident’s leg weakness, but there was no corresponding physician order, care plan entry, or NA care card direction for lift use. The DON was unaware that a mechanical lift was being used and acknowledged that any change in transfer status should have been supported by an RN or therapy assessment and updates to orders and the care plan, which had not occurred.
Two residents did not receive care in accordance with physician orders and their care plans. One resident with severe cognitive impairment and multiple comorbidities was ordered to be transferred with a Hoyer lift using two staff into a custom wheelchair, but a NA performed the Hoyer transfer alone, after the resident had reported bilateral leg pain, and the resident was later found to have a hematoma on the leg. Another resident with dementia, osteoporosis, and a history of falls had physician‑ordered motion sensor alarms that were to remain on at the bedside and at the nurses’ station, but staff reported no alarm sounding when the resident was found on a bathroom floor with a non‑displaced clavicle fracture, and the alarm system was later determined to have been in the off position.
The facility failed to ensure clinical records were complete and accurately identified the individual documenting in the EMR. For two residents—one with dementia and severe cognitive impairment requiring ADL assistance, and another with bipolar and psychotic disorders, delusions, and a history of rejecting care—multiple nursing notes describing medication administration, tolerance, pain status, and refusal of care were signed using generic pool nurse identifiers (e.g., "2LPN pool2 LPN," "poolnurse supervisor RN") instead of specific staff names. The DON confirmed that all agency RNs, LPNs, and NAs share common EMR logins, acknowledged this as a long-standing practice, and stated that identifying the actual author of a note would require checking the staffing schedule, despite facility policy requiring documentation to include the name and title of the individual providing and documenting care.
Surveyors found that the facility failed to ensure an active, on-site Medical Director and appropriate physician coverage. The DON reported that the sole Medical Director was only available by phone and did not come into the building, and that a second physician had retired and was never replaced. Weekly Medical Director rounds did not occur as scheduled, with no physician present for recent rounds. The Administrator acknowledged there was no Medical Director available to conduct weekly rounds and that efforts to secure additional physician coverage were limited. The facility lacked a current executed contract defining the Medical Director’s responsibilities and availability, had no documented contingency or alternate coverage plan, and could not produce a policy outlining the Medical Director’s roles and oversight expectations.
The facility failed to ensure its QAA/QAPI group, including medical staff, met at least quarterly and maintained required documentation. The Medical Director had been unavailable to come into the facility for an extended period, and the only other physician had retired and was not replaced. The Administrator could not provide Medical Staff/QAPI meeting minutes or agendas for the previous year and could only recall an undocumented meeting several months earlier. A more recent planned Medical Staff/QAPI meeting did not occur due to lack of quorum, and no related facility policy was produced for surveyor review.
A resident with vascular dementia, severe cognitive impairment, and documented wandering/elopement risk was care planned and ordered to have a wander guard on the ankle with checks each shift, and was known by the DON to wander up and down the hallways. However, the annual MDS coded no pacing or wandering behaviors and indicated no wander/elopement alarm in use, despite existing assessments, care plans, and physician orders documenting wandering risk and wander guard use, resulting in an inaccurate assessment of the resident’s behaviors and alarm status.
Two residents with dementia and severe cognitive impairment experienced deficiencies in elopement risk management when elopement risk assessments were not completed as required, a wander guard was used without a corresponding physician order or clear initiation/discontinuation dates, and a malfunctioning wander guard device was not replaced promptly. One resident’s record lacked quarterly elopement risk evaluations despite documented roaming into other residents’ rooms and later identification of wandering into unsafe areas, while another resident’s care plan called for shift-by-shift wander guard checks, yet a nonfunctioning device remained in place for two days without documented 15‑minute safety checks, contrary to facility policy and the DON’s expectations.
Surveyors found that staff were unable to correctly identify, respond to, or silence multiple door alarms, and that egress doors were not reliably secured. Door alarms sounded for extended periods while staff walked by or incorrectly assumed a different door was alarming, and some staff reported they did not handle doors or did not respond because they believed it was not their door. One door could be opened and remain unarmed after a code was entered, with no way to re‑arm it from the stairwell side, and another door’s alarm continued without staff response despite personnel being nearby. No policy on securing egress doors was available for review.
The facility failed to maintain complete and accurate documentation of wander guard placement and function checks for five cognitively impaired residents assessed as at risk for elopement. Each resident had dementia or Alzheimer’s disease, severe cognitive impairment, and documented behaviors such as wandering, roaming into other rooms, or being near exit doors. Care plans, elopement risk evaluations, and physician orders required wander guard devices and shift-by-shift checks, yet the MAR/TAR contained multiple blank entries where these checks should have been recorded across various day, evening, and night shifts. The DON confirmed that nursing staff were expected to document all care, including wander guard checks, and acknowledged that the required documentation was missing despite a facility policy mandating accurate, timely, and complete nursing documentation.
A resident with dementia and identified elopement risk, including a care plan for a wander guard and redirection near exits, was last documented as sleeping during night rounds and later found missing from their room. Staff conducted internal and external searches and eventually found the resident lying outside on the ground in below-freezing temperatures, unresponsive except to painful stimuli. The facility did not notify police within 15 minutes of failing to locate the resident as required by its elopement policy, and the RN delayed calling 911 while assessing the resident and contacting leadership, despite a policy requiring immediate 911 activation for an unresponsive resident. EMS was eventually called, found the resident pulseless, apneic, extremely cold with lividity, and the resident was pronounced deceased, leading surveyors to cite Immediate Jeopardy for failure to prevent neglect and ensure timely notification of law enforcement and emergency services.
A resident with dementia, moderate cognitive impairment, and known elopement risk, ordered to use a wander guard and ambulate with supervised walker use, was able to leave the building unnoticed through inadequately secured exits. Staff charted the resident as in bed while external video showed the resident outside, walking unassisted and ultimately falling on a snow-lined sidewalk in subfreezing conditions. After a nurse aide discovered the resident missing, staff searched for approximately 30 minutes before notifying an RN, then conducted additional searches before finding the resident unresponsive and extremely cold on the front sidewalk. The resident was brought inside, undressed, and warmed while the RN assessed, reviewed DNR status, and called facility leadership; EMS was not contacted until over an hour after the resident was found. Surveyors also observed multiple exit doors that failed to latch or re-lock, had disabled or inaudible alarms, and in some cases had keypad codes posted, while other cognitively impaired, wandering residents in the facility were also identified as elopement risks with wander guards ordered or care planned.
Two residents experienced failures in timely physician notification. One resident with dementia and known wandering risk was found outside during the night with low temperature and low pulses; the supervising RN notified facility leadership and called 911, but documentation and interviews showed the on-call physician was not contacted at the time of the incident, despite facility policy requiring physician notification for accidents and significant changes in condition. Another resident with hypothyroidism had an elevated TSH level reported by the lab, but there was no evidence that nursing notified a physician or APRN, and the lab report lacked provider acknowledgment, even though the care plan and facility policy required reporting abnormal lab results to the physician.
Two residents with dementia and documented elopement risk did not receive care consistent with facility policy and physician direction. For one resident, elopement risk evaluations were not completed at required quarterly intervals despite documented independent ambulation, poor decision-making, and behaviors suggesting attempts to leave, and the wander guard use order was only reviewed during monthly order reviews. For another resident with severe cognitive impairment and a care plan directing frequent wander guard checks, the admission elopement risk assessment was not followed by a timely quarterly reassessment, and there was no physician order specifying daily function checks of the wander guard, even though the DON stated such orders and quarterly assessments were required by facility policy.
The facility did not maintain or provide a written agreement with a CLIA-certified laboratory to ensure timely access to required lab services when on-site services were not available. During surveyor review of facility documents and policies, no contract or agreement for laboratory services could be found. The Administrator reported being unable to locate the laboratory services contract, stating that important document binders had been moved during a recent facility-wide evacuation, and the facility was unable to produce any documentation showing how lab services were formally arranged.
The facility did not maintain or produce a written agreement for radiology and other diagnostic services that were not provided directly on-site. During surveyor review of facility documents and policies, no contract or agreement could be found to verify how these diagnostic services were arranged. In an interview, the Administrator reported being unable to locate the radiology services contract, noting that important document binders had been relocated after a recent facility-wide evacuation. Consequently, the facility could not demonstrate that it had a formal, documented arrangement to ensure timely access to required radiology and diagnostic services for residents.
Surveyors identified that the facility failed to maintain and provide documentation confirming 24-hour physician coverage for emergencies. During review, no written agreements, contracts, or other records were available to verify that physicians were on call at all times, and the Administrator was unable to produce such documentation, citing relocation of binders after a facility-wide evacuation. The facility also lacked a policy or procedure outlining how continuous physician availability is arranged, maintained, and verified for emergency medical oversight.
Surveyors found that the facility did not have a written transfer agreement policy or documentation of a current transfer agreement with a hospital to guide transfers when residents require acute care. During document review, no policy outlining the process for transferring residents to a hospital could be produced. In an interview, the Administrator stated she was unable to locate the requested policy, noting that important document binders had been moved after a recent facility-wide evacuation, but the transfer agreement materials were not found. The facility also could not provide any evidence of formalized arrangements with a hospital to ensure timely transfer of residents needing acute care services.
Surveyors identified that the facility did not have a written contract or agreement available to verify the designation and ongoing engagement of a physician as Medical Director responsible for resident care policies and coordination of medical care. During record review, no documentation of such an agreement could be produced, and the Administrator reported being unable to locate the contract after a recent evacuation in which key binders were moved. The facility also lacked a policy or procedure describing how the Medical Director contract is to be maintained, retained, or kept accessible.
The facility failed to maintain complete and accurate clinical records for three cognitively impaired residents at risk for wandering and elopement. One resident with dementia and an elopement risk had physician orders and a care plan for a wander guard, but the MDS did not reflect an alarm, and nursing staff left multiple blanks on the MAR/TAR for required function and placement checks. During the same period, a NA documented that this resident was asleep in bed at specific times, while police video showed the resident outside the building much earlier, demonstrating inaccurate rounding documentation. Two other residents with dementia and documented wandering or elopement risk had care plans calling for routine wander guard checks, yet nurses and LPNs failed to consistently document these checks, and one resident lacked corresponding physician orders for the monitoring that was being care-planned. The DON confirmed that the documentation for these residents was incomplete or missing despite a facility policy requiring accurate, timely, and complete nursing documentation.
The facility did not maintain or provide a written transfer agreement policy or documentation of formal arrangements with a Medicare- or Medicaid-certified hospital to ensure timely transfer of residents needing acute care. During surveyor review, no written policy outlining the process for hospital transfers could be produced. The Administrator reported that important document binders had been relocated during a recent facility-wide evacuation and the requested policy and transfer agreement documentation could not be located or verified.
The facility did not ensure safe water temperatures in resident-accessible areas, with multiple locations recording temperatures above policy limits and no documented interventions or notifications. The Maintenance Worker failed to recheck or report high temperatures, and several resident room sinks were not tested, creating a hazardous environment.
A resident with multiple health conditions experienced worsening of a pressure ulcer due to failures in timely physician notification, inconsistent wound care in accordance with orders, and delayed provision of an air mattress for pressure relief. Nursing staff did not consistently communicate changes in wound status, alternative treatments were applied without provider approval when prescribed medication was unavailable, and a recommended air mattress was not provided promptly, resulting in further wound deterioration.
A resident with multiple comorbidities experienced a worsening pressure ulcer, but staff failed to notify the practitioner in a timely manner about the decline. Nursing notes documented the wound's deterioration, but there was no evidence of provider notification, and staff interviews revealed confusion about responsibilities. Facility policy required prompt communication of changes, but this was not followed, resulting in a deficiency.
A resident with a worsening pressure ulcer did not receive wound care in accordance with physician's orders when Santyl ointment was unavailable. Instead, an LPN applied calcium alginate without notifying the provider or obtaining an alternative order, and the nursing supervisor was not informed of the medication's unavailability. Facility staff confirmed that substituting wound treatments without provider direction was not appropriate, and no documentation showed provider notification or an alternative order.
A resident with Parkinsonism and moderate cognitive impairment sustained a significant leg laceration requiring sutures after coming into contact with a sharp, exposed edge on a bedframe during a transfer. The facility did not perform monthly bedframe safety checks as recommended by the manufacturer, and annual checks by an outside vendor did not include inspection for structural hazards such as missing end caps.
The facility failed to ensure proper food safety and hygiene practices, as a dietary aide was observed without a beard net, and dishwasher temperatures were inconsistently logged, with some below the required range. Additionally, food temperatures were not consistently documented for all meals, with missing entries for various food items. The dietary manager and Director of Dietary could not explain these lapses.
The facility failed to inform residents about the grievance filing process and did not post necessary contact information for grievances. Residents were unaware of how to file grievances, and no information was displayed in the facility. Interviews revealed confusion between the Social Worker and Administrator regarding responsibility for grievances, and the facility did not maintain grievance records for the required three years.
A facility failed to protect residents from abuse and ensure immediate reporting of incidents. A resident with cognitive impairment was allegedly verbally abused by a staff member, but the incident was not reported until the next day, allowing the staff member to continue working. Another resident was involved in a physical altercation, but the facility did not document increased supervision or psychiatric evaluation. Staff interviews revealed a lack of recall about the incidents, indicating potential gaps in communication and training.
The facility failed to follow its abuse prevention policies in two incidents involving residents with cognitive impairments. In one case, a resident hit another with a newspaper, but the incident was not reported to the state agency or investigated. In another, a staff member allegedly yelled at a resident, but the incident was reported late, and the staff member continued working. The facility's policies require immediate reporting and investigation, which were not followed.
The facility failed to report abuse allegations and injuries in a timely manner for three residents. A resident with dementia reported mistreatment by an LPN, but the facility delayed notifying the state agency. Another resident's foot discoloration was not promptly reported or investigated, and a third resident's abuse allegation was reported late due to the DNS's lack of system access. The facility's policy requires immediate reporting, which was not followed in these cases.
The facility failed to protect residents after an altercation between two residents with cognitive impairments, as enhanced supervision was not documented. Additionally, a bruise on a resident's foot was not reported or investigated promptly, contrary to facility policy.
The facility failed to develop comprehensive care plans for residents at risk of pressure ulcers, leading to deficiencies in care. A resident with Alzheimer's and dementia was identified as at risk for pressure injuries, but no care plan was developed until after a stage 2 ulcer was found. Another resident with diabetes and vascular dementia had multiple pressure ulcers, but the care plan did not address the risk or include interventions. Similarly, two other residents at high risk for skin breakdown did not have preventive measures documented in their care plans.
The facility failed to timely update care plans for two residents at high risk for pressure ulcers. One resident, with a stage 2 ulcer on the coccyx, had a care plan lacking specific turning and repositioning frequencies. Another resident developed a stage 2 ulcer on the heel, but the care plan did not include necessary repositioning instructions. Both cases showed a lack of adherence to the facility's Pressure Ulcer Prevention Plan.
The facility failed to document the rationale for medication use in physician's orders for several residents, as required by professional standards. This deficiency was identified through record reviews and staff interviews, revealing that residents with various medical conditions received medications without documented reasons for their use. Interviews with staff, including the DNS and Medical Director, indicated a lack of awareness of this requirement, and no policy for writing medication orders was provided.
The facility failed to prevent pressure ulcers in residents, leading to the development and reopening of ulcers. A resident with cognitive impairment developed a stage 2 ulcer due to lack of repositioning interventions. Another resident with diabetes developed a stage 3 ulcer on the heel, with no preventive measures documented. A third resident experienced a reopening of a healed ulcer due to inconsistent monitoring. Lastly, a high-risk resident developed a stage 2 ulcer on the heel, with inadequate implementation of the prevention plan.
The facility failed to follow its weight monitoring policy for three residents, resulting in significant weight loss without timely intervention. A resident with malnutrition and dysphagia experienced weight fluctuations without proper documentation or follow-up. Another resident with dementia lost 13.6 pounds in 30 days, and the facility did not re-weigh as required. A third resident with diabetes lost 10.1 pounds, but the facility did not conduct a re-weigh within 48 hours, as policy dictates.
The facility did not meet the required RN hours for 2023, as PBJ submissions showed no RN hours reported. The facility was non-operational for part of the year and faced issues with a new payroll system. Despite having RN supervisors scheduled, the facility lacked CMS documentation confirming compliance.
The facility's PBJ data for 2023 was incomplete and inaccurate, showing a lack of 24-hour licensed nursing coverage, low weekend staffing, and no RN hours. The Administrator noted the facility's non-operational period and issues with a new payroll system as contributing factors.
Residents reported cold and drafty bedrooms during Resident Council Meetings, but the facility failed to address these concerns timely. The Recreation Director communicated the issues to relevant departments, but follow-ups were undocumented. The Maintenance Director acknowledged the problem but did not complete temporary fixes. The Administrator expected concern forms to be generated, but none were found, and no policy on handling such concerns was provided.
A facility failed to review a resident's Advanced Directive with the responsible party in a timely manner. The resident, diagnosed with cerebral infarction and Alzheimer's, had a physician's order for Full code status, but the code status was still to be determined. Facility staff, including an RN, SW, and LPN, could not locate the advanced directives documentation, and the COP was unresponsive. The facility policy for handling advanced directives was not followed.
A resident with severe cognitive impairment was transferred to a hospital twice and later expired there, but the facility failed to notify the Regional Ombudsman's Office of these transfers. Interviews revealed confusion among staff about notification responsibilities, and the facility lacked a policy for such notifications.
A facility failed to notify a resident and their responsible party of the bed hold policy during hospitalization. The resident, with severe cognitive impairment and multiple health issues, was transferred to an acute care facility twice without documentation of notification. Interviews indicated a lack of clarity on notification responsibilities, and the facility could not provide a bed hold policy.
Two residents' annual MDS assessments were not completed and transmitted within the required timeframe. One resident, with diabetes and hypertension, was cognitively intact but required supervision for mobility. Another resident, with dementia and dysphagia, was severely cognitively impaired and dependent for transfers. An LPN responsible for the assessments cited software errors and the need for an RN co-signer as reasons for the delay.
A facility failed to review or discontinue a PRN psychotropic medication for a resident with severe cognitive impairment and depression. The resident was prescribed Trazadone for agitation without a discontinuation date, and psychiatric notes lacked a review of its use. The DON acknowledged the oversight, and no policy for PRN psychotropic use was provided.
A facility failed to include a resident's death certificate in the clinical record, despite the resident being under palliative care with a DNR/DNI status. Staff interviews revealed a lack of awareness about the requirement to print and include death certificates in closed records after the process became electronic. The facility's Death Policy requires all records to be completed and forwarded to Medical Records, which was not followed in this instance.
Failure to Clearly Define and Update Resident Transfer Status and Method
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards by not clearly directing staff on a resident’s transfer method and not completing a timely assessment when the resident’s transfer ability changed. The resident had dementia, anxiety, and rheumatoid arthritis, with a BIMS score indicating moderate cognitive impairment, and required substantial/maximal assistance with toilet use and transfers, was dependent with wheelchair use, and was of small stature and low weight. The Resident Care Plan initially directed transfer with assistance of one staff to wheelchair, but was later updated to include two staff for transfers, resulting in conflicting directions that simultaneously called for one and two staff assistance. A physician’s order directed out-of-bed transfers with assistance of one staff using a gait belt, and the NA care card also directed transfer and mobility assistance of one staff. There was no documentation in the physician’s orders, care plan, or NA care card directing the use of a mechanical (Hoyer) lift. Despite the lack of documented orders or care plan direction for a mechanical lift, multiple staff interviews revealed that some nurses and NAs believed the resident required a Hoyer lift for transfers due to leg weakness. The regular NA reported providing one-person assist for transfers but felt it would be safer to use a mechanical lift, while two RNs stated the resident’s transfer status was via Hoyer lift and that NAs were expected to follow the care card for transfer status. The DON stated she was unaware staff were using a mechanical lift and indicated that a change in transfer status should have been supported by an RN assessment or therapy evaluation, with corresponding updates to physician/APRN orders, the care plan, and the NA care card. No facility policy specific to directing staff on transfer status or resident assessments was provided, although a general Hoyer lift procedure and a care plan policy existed, further underscoring that the resident’s actual transfer method in practice was not aligned with the documented plan of care and orders.
Failure to Follow Transfer and Alarm Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and the residents’ plans of care for two residents reviewed for accidents. For one resident with mild cognitive impairment, peripheral vascular disease, diabetes mellitus, and anxiety, the MDS showed severe cognitive impairment and a need for substantial/maximal assistance with transfers. Physician orders and the resident’s care plan required use of a Hoyer (mechanical) lift with two staff for all transfers out of bed to a tilt‑in‑space custom wheelchair. Despite these orders and the facility policy requiring two staff for Hoyer transfers, a nursing assistant performed a Hoyer lift transfer alone after being told by a nurse that assistance would be provided later, and transferred the resident into the custom wheelchair without a second staff member present. Following this solo transfer, the resident, who had reported bilateral lower extremity pain during morning care and was wearing geri‑sleeves for skin protection, again reported bilateral lower extremity pain. The facility’s reportable event documentation identified that during the transfer the resident’s left leg struck the left leg of the custom wheelchair, resulting in a 2 cm open hematoma that later was documented as a 9 cm coagulated hematoma. The resident was subsequently sent to the hospital for evaluation and followed by a wound physician. Interviews with the Director of Therapy and nursing leadership confirmed that the resident’s plan of care and facility policy required two staff for Hoyer lift transfers and that the transfer had been completed by one staff member, contrary to the physician order and care plan. For a second resident with dementia, osteoporosis, repeated falls, and major depressive disorder, the MDS showed severe cognitive impairment and a need for substantial/maximal to dependent assistance with transfers. Physician orders and the care plan required a motion sensor alarm to be in place and on at all times when the resident was in bed, with a bedside sensor and a corresponding alarm box at the nursing station to alert staff to attempts at independent ambulation. On the morning of the incident, the resident was later found sitting on a bathroom floor complaining of right arm pain and was diagnosed with a non‑displaced right clavicle fracture. Facility documentation and interviews indicated that multiple staff did not hear any alarm sound, one nursing assistant was unaware of a sensor alarm in the room, and subsequent investigation determined that the alarm box at the nursing station and the motion sensor alarms were in the off position at the time of the fall, contrary to the physician order and the resident’s care plan.
Shared EMR Logins Lead to Incomplete and Non-Identifiable Nursing Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records that identify the individual documenting in the electronic medical record (EMR), contrary to its own Charting and Documentation Policy. For a resident with dementia and severe cognitive impairment who required assistance with ADLs, multiple nursing notes over several days documented pain medication administration, medication tolerance, and absence of pain, but were electronically signed with generic identifiers such as "2LPN pool2 LPN" and "poolnurse supervisor RN" rather than the specific nurse’s name. For a second resident with bipolar disorder, psychotic disorder, anxiety, delusions, and a history of rejecting care, a nursing note describing the resident’s refusal of care and irritable, loud behavior was also signed with a generic “poolnurse supervisor RN” identifier. Additional notes for this resident were similarly signed with “2LPN pool2 LPN,” preventing identification of the specific staff member who provided and documented the care. During interview and record review, the DON confirmed that all agency (pool) RNs, LPNs, and NAs use shared, common logins for EMR access, resulting in documentation that does not display the individual staff member’s name. The DON stated that to determine who wrote a particular nursing note, she would need to cross-reference the facility schedule with the date and shift of the entry. The DON acknowledged that this shared-login practice was long-standing, that notes should include the name of the person writing the note, and that facility policy requires documentation to include the name and title of the individual who provided care and the signature and title of the individual documenting. Despite this, agency staff were not provided with individual EMR logins, leading to incomplete and non-individualized documentation for the residents reviewed for abuse.
Lack of On-Site Medical Director Oversight and Contractual Structure
Penalty
Summary
The deficiency involves the facility’s failure to ensure provision and oversight of a Medical Director in accordance with federal requirements. Interviews and document review with the Administrator and DON showed the facility had no current physicians coming to the facility. The DON reported that the facility had one physician designated as the Medical Director, but this physician was not available to come to the facility and was only available by phone. During the prior year there had been a second physician, but that physician retired on an unknown date and was not replaced. All residents were patients either of the Medical Director, who was not available to come to the facility, or of Optum, which provided APRN coverage. The DON stated that weekly Medical Director rounds were supposed to occur every Thursday, but no physician conducted rounds on the most recent scheduled date and none was scheduled for the following week; the last documented rounds occurred 12 days before the survey interview. The Administrator confirmed there was no Medical Director available to come into the facility for weekly rounds. After the second physician retired, the Administrator contacted two physicians about coverage and then waited for the Medical Director to locate a second physician, without advertising or using a staffing agency to secure coverage. The facility was unable to demonstrate that the designated Medical Director provided routine, ongoing oversight within the facility, including at least weekly on-site presence. Record review did not identify a current, executed contract defining the Medical Director’s responsibilities, availability, and coverage expectations. The facility also lacked documentation of a contingency agreement or alternate coverage plan for Medical Director services if the appointed Medical Director was unavailable or failed to provide required services, and could not provide a policy outlining the Medical Director’s roles, responsibilities, and expectations for facility involvement and oversight.
Failure to Hold and Document Required Quarterly Medical Staff/QAPI Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA)/QAPI group, including the medical staff, met at least quarterly as required. During interviews and document review with the Administrator, surveyors learned that the facility’s Medical Director had been unavailable to come into the facility since 2/19/2026, and the only other physician on staff had retired at an unknown time in 2025 and had not been replaced. The Administrator was unable to produce any Medical Staff/QAPI meeting minutes or agendas for the prior 12 months and reported that the last Medical Staff/QAPI meeting occurred in September or October 2025, but she could not provide documentation to verify that it took place. She also stated that a Medical Staff/QAPI meeting had been planned for 2/26/2026 but did not occur because they did not have a quorum. No facility policy related to these meetings was provided for surveyor review despite request. No specific residents or their medical conditions were mentioned in the report, and no additional clinical details were provided regarding individual patient involvement in this deficiency.
Inaccurate MDS Coding for Wandering Behavior and Wander Guard Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s behavioral status and use of a wander/elopement alarm. The resident had diagnoses of vascular dementia with behavior disturbances and depression, was cognitively impaired with poor decision-making skills, and had been identified on an elopement risk evaluation as ambulating independently and displaying behaviors that could indicate attempts to leave the facility. The resident’s care plan, initiated on the same date as the elopement risk evaluation, documented that the resident was at risk for wandering/elopement, had been observed near exterior doors, and required a wander guard device on the ankle with placement and function to be checked every shift. A physician’s order also directed that a wander guard device be applied to the resident’s ankle and checked every shift. Despite these documented behaviors and interventions, the annual MDS assessment coded the resident as having severe cognitive impairment (BIMS score 6/15) but no pacing or wandering behaviors, and indicated the resident ambulated independently with supervision using a walker. In Section E (Behavior), the MDS was coded to show delusions but no wandering behaviors, and in Section P (Restraints and Alarms), it was coded to show that no wander/elopement alarm was used. During interview, the DON stated that the resident’s baseline behavior was to always wander up and down the hallways and that the MDS nurse should use assessments, care plans, and progress notes to ensure accurate MDS coding. The DON acknowledged that the MDS did not accurately reflect the resident’s behaviors, and the facility did not provide a specific policy on MDS accuracy, only a general documentation policy stating that nursing documentation must be accurate, timely, complete, and reflective of the care provided.
Failure to Manage Elopement Risk Assessments and Wander Guard Devices
Penalty
Summary
The deficiency involves the facility’s failure to complete timely elopement risk assessments and obtain a physician order for a wander guard device for one resident, and failure to timely replace and document monitoring for a malfunctioning wander guard device for another resident. One resident had diagnoses including dementia with behavior disturbances and depression, with a significant change MDS showing a BIMS score of 99, indicating severe cognitive impairment and inability to complete the interview. The MDS coded no wandering behaviors and no use of a wander/elopement alarm, while the resident’s care plan dated 12/16/2025 identified that the resident roamed into other residents’ rooms and directed staff to ensure the resident did not roam into rooms. Nursing notes indicated the resident had a wander guard in use during 2024, but the clinical record did not show when the wander guard was initiated or discontinued, and there was no physician order directing its use. Further record review for this resident showed that no elopement risk assessments were completed from admission in 9/2024 through 2/18/2026. An elopement risk evaluation dated 2/19/2026 later identified that the resident ambulated independently, was cognitively impaired with poor decision-making skills, had a history of wandering into unsafe areas, and displayed behaviors that may indicate an attempt to leave the facility. The DON stated that elopement risk evaluations should be completed on admission, quarterly, and upon any readmission, and acknowledged that the assessments for this resident were not done as required. The DON also stated that if a wander guard is in use, there should be physician orders directing its use and documentation on the Medication Administration Record each shift and day it is functioning, which was not present in this case. For the second resident, who had diagnoses including dementia, transient ischemic attacks, and syncope, the quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and documented daily use of a wander/elopement alarm. An elopement risk evaluation identified that this resident ambulated independently, was cognitively impaired with poor decision-making skills, and displayed behaviors that may indicate an attempt to leave. The care plan dated 1/22/2026 identified the resident as at risk for elopement and directed staff to check wander guard function and placement every shift and daily. A nursing note documented that the resident’s wander guard was in place but not functioning and that every 15‑minute checks were initiated; however, the wander guard was not replaced until two days later. The DON confirmed that the device malfunctioned, that staff did not have access to a replacement device at the time, and that there was no documentation of the every 15‑minute checks on the dates the device was not functioning, despite the facility’s documentation policy requiring accurate, timely, and complete nursing documentation reflective of the care provided.
Failure to Secure Egress Doors and Respond Appropriately to Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to ensure egress doors were properly secured and that staff could effectively respond to and silence door alarms. During an observation with an RN, it was identified that staff were conducting 15‑minute rounds on thirteen egress doors in a rotating pattern that resulted in more than three hours between checks of the same door. While observing Door #8 near the hairdresser, the door alarm sounded and the RN did not know how to silence it. Multiple staff walked past the alarming door without intervening. The RN asked a NA and a housekeeper for assistance, but they reported they did not handle doors or had no information. The Housekeeping Director incorrectly stated the alarm was coming from Door #10, and another housekeeper attempted to silence the alarm at the keypad without success, also believing it was the back door. The alarm at Door #8 continued to sound for an extended period while staff attempted to identify and silence the source. Further observations showed similar issues at Door #10, the back door to the parking lot. After the DON and another staff member initially believed Door #10 was the source of the alarm and then determined it was not, they returned to Door #8 and silenced that alarm with a key. Subsequent observation of Door #10 showed it was secure and alarmed when opened, but entering a code into the keypad did not silence the alarm, and the alarm continued to sound without staff response, even though staff were present in the adjacent kitchen area. The Food Service Director and another staff member later stated they did not respond because they thought it was not the back door alarming, despite acknowledging staff should always respond to an alarming door. Additional observation of Door #12 near the nursing station revealed that entering a code on the keypad turned the indicator light green and allowed the door to open without an alarm, and once opened and closed, the door remained unarmed with no way to re‑arm it from the stairwell side. When the light was red, the door could still be opened without difficulty and no alarm sounded. No facility policy regarding securing egress doors was provided for review.
Incomplete Documentation of Wander Guard Checks for Multiple Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records regarding the placement and function checks of wander guard devices for five residents with dementia and elopement risk. For one resident with severe cognitive impairment and documented room-roaming behavior, the care plan and elopement risk evaluation identified a need for a wander guard and shift-by-shift checks. A physician order directed staff to check the wander guard every shift, yet the MAR/TAR for February showed missing documentation of wander guard placement checks on specified evening and night shifts. A second resident with severe cognitive impairment, elopement risk, and a documented daily wander/elopement alarm had a care plan and physician order requiring wander guard function and placement checks every shift. However, the MAR/TAR from mid to late February contained multiple blank entries where staff failed to document these checks across several day, evening, and night shifts. A third resident with dementia and behavioral disturbances, identified as an elopement risk and care planned to use an alarm device with checks for proper functioning, also had a physician order for wander guard placement checks every shift. The February MAR/TAR showed missing documentation of these checks on two separate day shifts. A fourth resident with vascular dementia, Alzheimer’s disease, and severe cognitive impairment was assessed as an elopement risk and care planned to have a wander guard on the ankle with placement and function checks every shift, supported by a physician order. The February MAR/TAR showed blank entries for required wander guard checks on multiple shifts. A fifth resident with Alzheimer’s disease, severe cognitive impairment, daily wandering behaviors, and a history of wandering into unsafe areas had a care plan and physician order requiring wander guard checks every shift. The MAR/TAR from mid to late February showed missing documentation of wander guard placement checks on identified day and evening shifts. In an interview, the DON confirmed that it was the expectation that nursing staff document all provided care, including wander guard checks, acknowledged the missing documentation for all five residents, and referenced the facility’s documentation policy requiring accurate, timely, and complete nursing documentation of treatments.
Failure to Follow Elopement and Emergency Response Policies for Missing, Unresponsive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively impaired resident at risk for elopement by not following its elopement and change in condition policies. The resident had dementia, an elopement evaluation identifying them as at risk for elopement, and a care plan including a wander guard on the right ankle with interventions to redirect the resident near doors and check the wander guard per protocol. A quarterly MDS showed moderate cognitive impairment, independent ambulation with supervision, and no wander/elopement alarm. Nurse aide documentation showed the resident was observed sleeping in bed at approximately 1:00 AM and 3:00 AM. According to staff statements, around 4:30 AM a nurse aide noted the resident was no longer in bed and began searching other rooms and another wing, informing a coworker who also searched while the aide went outside. The coworker then notified the nurse. The two aides searched outside and found the resident lying on the ground by the walkway. The nurse was notified, and the resident was brought back inside. RN documentation and interviews indicated the RN was informed at approximately 5:00 AM that the resident was missing, initiated another room search, then an outside search, and the resident was found on the sidewalk outside, only responding to painful stimuli and blinking. The facility’s elopement policy required that when a resident is discovered missing, the supervisor or DNS be informed, an overhead page be made, staff conduct repeated searches including outside, and the police be notified within 15 minutes if the resident was not located; staff interviews indicated the police should have been notified within 15 minutes of not locating the resident. After the resident was found outside in below-freezing temperatures and brought back inside, staff applied warm clothing and blankets. The RN reviewed the resident’s code status, assessed the resident, and contacted the DNS and Administrator before calling 911. The thermometer used to assess the resident read “LO,” consistent with a temperature below 89.6°F. EMS records showed 911 was called at 6:23 AM, EMS arrived to find the resident unresponsive, pulseless, apneic, extremely cold to the touch, with lividity noted on the left side and fixed, non-reactive pupils, and the resident was pronounced deceased at 6:46 AM. The facility’s change in condition policy directed that 911 should be called immediately if a resident is unresponsive. The facility failed to notify police within 15 minutes of the resident being identified as missing and failed to call 911 immediately when the resident was found unresponsive outside in severe cold, resulting in a finding of Immediate Jeopardy.
Elopement of Dementia Resident Due to Inadequate Supervision and Exit Door Security
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a cognitively impaired resident with known wandering and elopement risk, who was able to leave the building without staff knowledge in subfreezing temperatures. The resident had dementia, a BIMS score indicating moderate cognitive impairment, poor decision-making skills, and documented behaviors and statements about leaving. An elopement risk evaluation identified the resident as ambulatory and at risk for elopement, and the care plan and physician orders specified use of a wander guard bracelet and supervision with a four-wheeled walker. Despite this, the quarterly MDS noted no wander/elopement alarm, and the resident’s care plan interventions were limited to redirection near doors and checking wander guard function per protocol. On the night of the incident, nurse aide documentation recorded that the resident was observed sleeping in bed at approximately 1:00 AM and 3:00 AM. However, police-obtained video showed a person believed to be the resident outside at the back of the building at 1:50 AM, walking along the side of the building past the main entrance toward the road without a walker and with no apparent gait difficulty. A second video showed the same person at the driveway apron at 1:55 AM, then walking along the front sidewalk, slowing, bending down, and then falling face forward at approximately 1:58 AM, after which no further movement was observed. This timeline directly conflicted with the staff documentation that the resident was in bed at 3:00 AM. Staff statements indicated that around 4:30–4:45 AM, a nurse aide discovered the resident was not in bed and began searching the unit with another aide. They searched rooms and another wing before notifying the RN supervisor at about 5:00 AM, approximately 30 minutes after the resident was first identified as missing. After the RN was notified, staff conducted another internal search and then began searching outside. Around 5:11–5:12 AM, staff found the resident lying on the sidewalk in front of the building, unresponsive or minimally responsive, cold to the touch, with clothing described as cold and icy. The resident was brought inside in a wheelchair, undressed, given dry clothing and warm blankets and towels, and assessed. Vital signs were severely abnormal, including a pulse in the 20s–30s and a thermometer reading "LO," indicating a temperature below 89.6°F. The RN reviewed the DNR status, contacted the Administrator and DON by conference call at approximately 6:08 AM, and 911 was not called until 6:23 AM, about 1 hour and 11 minutes after the resident was found outside. The deficiency also includes multiple environmental and systems failures related to exit door security and elopement prevention. The facility had only one wander guard–equipped door (double fire doors near the nurse’s station leading to the lobby). Other exits near the resident’s unit and dietary area had no alarms to alert staff if residents passed through, and an outside door with a keypad had the access code posted above it. The alarm on that outside door was not audible in the adjacent hallway or at the nurse’s station. Observations showed that several exit doors (rear exit to back parking lot, kitchen exit near the hairdresser, and a T-wing exit to a courtyard) failed to latch or re-lock after being opened with the keypad code, and in some cases did not alarm or only briefly alarmed, allowing unrestricted entry and exit. A courtyard door from the dining room could be set with a code that left it unlocked for multiple entries/exits, and courtyard gates opened easily to the parking lot. The Director of Maintenance and Administrator acknowledged that keypad alarms had been turned off, that the code was improperly posted, and that doors were in "winter mode" with no functioning alarm notification to staff, and the facility lacked a policy to ensure proper functioning of emergency exit doors. Additional residents were also identified as elopement risks, with dementia, cognitive impairment, and wandering behaviors, and had orders or care plans for wander guards and checks of device function and placement. One resident’s MDS showed no wander/elopement alarm despite elopement risk, and another had a care plan for elopement risk with interventions to check wander guard function and placement every shift. These findings, combined with the malfunctioning and non-alarming exit doors, the posted keypad code, and the lack of audible alarms to the nurse’s station, demonstrate that residents at risk for elopement could exit the building or enclosed areas without staff awareness. The facility’s own leadership acknowledged that the resident should not have been able to exit without staff knowledge, that nurse aides should have notified the nurse immediately when the resident was found missing, and that 911 should have been called immediately after the resident was found outside.
Failure to Notify Physician of Significant Change in Condition and Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely physician notification following a significant change in condition for one resident and abnormal laboratory results for another resident, as required by facility policy. One resident with dementia, poor decision-making skills, and a history of wandering was assessed as an elopement risk and care planned to wear a wander guard on the right ankle, with interventions to redirect if near exit doors and to check the device per protocol. On the date of the incident, this resident was discovered missing from their room during overnight rounds, and a search revealed the resident lying outside on the sidewalk with the upper body in the snow, blinking and responding to painful stimuli but nonverbal. The supervising RN brought the resident back inside, performed an assessment that showed low temperature and low pulses, provided warm blankets and care, and called emergency services, but the facility’s reportable event documentation and investigation did not identify that the physician was notified at the time of the incident. Interviews and documentation further clarified the lack of timely physician notification for this event. The supervising RN reported notifying the Administrator, DON, and Infection Control Nurse before calling 911, but did not identify that he called the physician. The attending physician/Medical Director later stated he was not notified of the incident, and the facility’s on-call service confirmed that this physician was covering his own office during the relevant overnight hours with no other providers on call. The DON reported that the facility’s investigation could not determine whether the RN had notified the physician at the time of the incident. Facility policy on change in condition directed that the attending or on-call physician be notified when there is an accident or incident involving the resident, a significant change in condition, or a need to transfer the resident to a hospital or treatment center. A second deficiency involved failure to notify a provider of abnormal laboratory results for another resident. This resident had diagnoses including influenza A, UTI, and hypothyroidism, and was care planned as being at risk for nutritional issues related to vitamin deficiency and hypomagnesemia, with interventions to obtain lab work as ordered and report abnormal findings to the physician. Laboratory results showed an elevated TSH of 9.73 u/mL, above the normal range of 0.34–5.60 u/mL, but the lab report lacked a physician signature of acknowledgment, and record review did not show that the physician was notified of these results. A later progress note by an APRN referenced a TSH result of 9 from the same time period and documented a plan to increase levothyroxine and recheck TSH, but the DON was unable to verify that nursing had notified a physician or APRN about the elevated TSH, and the attending physician stated he was on-site on two subsequent dates and was not notified of the lab results, contrary to the facility’s policy requiring notification of abnormal laboratory reports.
Failure to Complete Timely Elopement Risk Assessments and Obtain Wander Guard Function Orders
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement appropriate physician orders for wander guard function checks and to complete elopement risk assessments according to policy for residents with dementia and identified elopement risk. For one resident with dementia and moderate cognitive impairment, an elopement risk evaluation documented independent ambulation, poor decision-making, statements about leaving, and behaviors suggesting attempts to leave. The care plan identified a wander guard on the right ankle with interventions to redirect near exits and check device functioning per protocol, and physician orders directed staff to check wander guard placement every shift and function daily. However, review of elopement risk evaluations showed they were not completed at quarterly intervals as required, with gaps of 124 and 174 days between assessments, and the physician order for wander guard use was only reviewed during monthly order reviews. For another resident with dementia and severe cognitive impairment, the MDS and elopement risk evaluation identified cognitive impairment, behaviors suggesting attempts to leave, and use of a wander/elopement alarm. The care plan documented elopement risk with interventions to check wander guard placement and function every shift and daily. Record review showed that the admission elopement risk evaluation was followed by the next evaluation 179 days later, exceeding the quarterly requirement. Additionally, although there was a physician order to check wander guard placement every shift, there was no physician order directing staff to perform daily function checks of the wander guard. The DON confirmed that elopement risk evaluations are required on admission, quarterly, and at readmission, and that physician orders should direct daily function checks of wander guards, but acknowledged that the assessments were not completed timely and that an order for function checks was not obtained for this resident, contrary to facility policies on wandering risk assessment and wander-guard security system use.
Failure to Maintain Written Agreement for Laboratory Services
Penalty
Summary
The facility failed to maintain and provide a written agreement with a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory to ensure timely availability of required laboratory services when such services are not provided on-site. During document and policy review, surveyors were unable to identify any written agreement or contract verifying arrangements for laboratory services. In an interview, the Administrator reported being unable to locate the requested laboratory services contract at the time of survey, explaining that binders containing important documents had been relocated following a recent facility-wide evacuation. The facility ultimately could not produce documentation verifying how laboratory services are formally arranged and maintained in compliance with regulatory requirements. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Failure to Maintain Written Agreement for Radiology and Diagnostic Services
Penalty
Summary
The facility failed to maintain and provide a written agreement for radiology and other diagnostic services when such services were not provided directly by the facility. During document and policy review, surveyors were unable to obtain any written agreement or contract verifying how radiology and other diagnostic services were arranged. An interview with the Administrator revealed that she could not locate the requested radiology services contract at the time of the survey. She explained that, following a recent facility-wide evacuation, binders containing important documents had been relocated, and the specific agreement for radiology and diagnostic services could not be produced. As a result, the facility was unable to provide documentation demonstrating that required diagnostic services were available in a timely manner to meet resident needs. No specific residents or their medical conditions were identified in the report.
Lack of Documentation and Policy for 24-Hour Physician Coverage
Penalty
Summary
The deficiency involves the facility’s failure to maintain and provide evidence of 24-hour physician coverage for emergency care. During document and policy review, surveyors were unable to obtain any written agreement, contract, or other documentation verifying that physician services were available around the clock to respond to resident medical emergencies. An interview with the Administrator revealed that she could not produce documentation demonstrating how 24-hour physician services are ensured, explaining that important binders had been relocated during a recent facility-wide evacuation and the requested documents could not be located at the time of survey. Additionally, the facility was unable to provide any policy or procedure describing how 24-hour physician availability is arranged, maintained, and verified to ensure timely medical oversight during emergencies. No resident-specific information, medical histories, or conditions at the time of the deficiency were documented in the report.
Failure to Maintain Written Hospital Transfer Agreement Policy and Documentation
Penalty
Summary
The facility failed to maintain and provide a written transfer agreement policy and documentation of a current transfer agreement with a hospital, as required for managing resident transfers when medically necessary. During document and policy review, surveyors were unable to obtain any written policy outlining the process for transferring residents to a hospital for acute care services. An interview with the Administrator revealed that she could not provide the requested transfer agreement policy at the time of survey, explaining that binders containing important documents had been relocated following a recent facility-wide evacuation, but the specific documentation could not be produced. Additionally, the facility was unable to provide any evidence of a current written transfer agreement or documentation verifying formalized arrangements with a hospital to ensure timely transfer of residents requiring acute care services. No specific residents or clinical situations were identified in the report; the deficiency centered on the absence of required written policies and formalized transfer arrangements at the facility level.
Lack of Written Medical Director Agreement and Contract Management Process
Penalty
Summary
The facility failed to maintain and provide evidence of a written agreement designating a physician as Medical Director responsible for implementation of resident care policies and coordination of medical care. During document and policy review, surveyors were unable to obtain any written contract or agreement verifying the appointment and ongoing contractual relationship between the facility and a Medical Director. An interview with the Administrator revealed that she could not locate the Medical Director contract at the time of survey, explaining that a recent facility-wide evacuation had led to relocation of important binders, but the requested contract still could not be produced. The facility also could not provide any policy or procedure describing how the Medical Director contract is to be maintained, retained, or made accessible. No specific residents, medical histories, or clinical conditions were described in the report in relation to this deficiency.
Incomplete and Inaccurate Documentation of Wander Guard Use and Resident Rounds
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records related to resident wandering risks, care checks, and wander guard devices. For one resident with dementia and identified elopement risk, the MDS documented no wander/elopement alarm despite physician orders and a care plan indicating use of a wander guard and the need to check its placement every shift and function daily. MAR/TAR review for this resident showed missing documentation by nursing staff on multiple dates for both wander guard function and placement checks. A reportable event documented that this resident, who had dementia and a history of wandering, was found outside the building early in the morning and was brought back inside, assessed, and later pronounced deceased by EMTs. Nurse aide care check rounds documentation and the aide’s written statement indicated that this resident was observed asleep in bed at approximately 1:00 AM and again around 3:00–3:30 AM, with the aide also documenting care to the roommate at 3:30 AM. However, video obtained by local police showed a person believed to be this resident outside at the back of the building at 1:50 AM, walking along the side of the building and appearing at the driveway apron at 1:55 AM, which conflicted with the aide’s documentation that the resident was in bed at 3:00 AM. The video also showed staff locating the resident on the sidewalk in front of the building at 5:11 AM. The discrepancy between the video evidence and the aide’s charted observations demonstrated that the resident location rounds documentation was not accurate. Two additional residents with dementia and significant cognitive impairment, both assessed as having wandering or elopement risk, also had incomplete documentation related to their wander guard devices. For one resident with daily wandering behaviors and a care plan directing wander guard checks every shift and as needed, MAR/TAR review showed missing nurse documentation on several dates for both function and placement checks. For another resident with severe cognitive impairment and a care plan directing wander guard function and placement checks every shift and daily, the MAR/TAR showed missed documentation of placement checks by two LPNs, and there was no physician order on file to monitor wander guard placement every shift and function daily. The DON stated it was her expectation that nursing staff document all care provided, acknowledged that the documentation for these residents was incomplete or missing, and that orders should be obtained for all residents to check wander guard placement every shift and function daily. A facility documentation policy stated that nursing documentation will be accurate, timely, complete, and reflective of the care provided.
Failure to Maintain Written Hospital Transfer Agreement Policy and Documentation
Penalty
Summary
The facility failed to maintain and provide a written transfer agreement policy and documentation of formalized arrangements with a Medicare- or Medicaid-certified hospital to ensure residents could be transferred when medically necessary. During document and policy review, surveyors were unable to obtain a written transfer agreement policy outlining the process for transferring residents to a hospital for acute care. In an interview, the Administrator stated she could not provide the requested transfer agreement policy at the time of survey, explaining that binders containing important documents had been relocated during a recent facility-wide evacuation and the documentation could not be produced. The facility also could not provide evidence of a current written transfer agreement or other documentation verifying formal transfer arrangements with a hospital for timely resident transfers. No specific residents, medical histories, or clinical conditions at the time of the deficiency were described in the report.
Failure to Maintain Safe Water Temperatures in Resident Areas
Penalty
Summary
The facility failed to maintain safe water temperatures in resident care areas, resulting in a hazardous environment that could have led to burn injuries. Observations by Building and Fire Inspection Safety identified water temperatures in multiple resident-accessible areas, including the East Shower Room, [NAME] Shower Room, and T Wing Hall bathroom, that exceeded the facility's policy limit of 120 degrees Fahrenheit, with some readings as high as 142 degrees Fahrenheit. Review of the Water Temperature Log over a three-month period showed that 40% of recorded temperatures in these areas were above the acceptable range, yet there was no evidence of intervention, notification to the Administrator, or re-evaluation of the temperatures to ensure resident safety. The facility's Domestic Hot Water Temperature Policy required immediate reporting of temperatures above 120 degrees Fahrenheit, but this was not followed. Interviews revealed that the Maintenance Worker, who was responsible for daily water temperature checks, did not consistently recheck or document corrective actions when high temperatures were found, nor did he inform the Administrator or educate staff about the hazard. The facility President acknowledged that he had not recently monitored the water temperatures, despite being aware of issues with one of the boilers. Additionally, only certain areas were being checked for water temperature, leaving several resident room bathroom sinks untested during the reviewed period. Staff interviews confirmed that water temperatures in some areas could become hot, but no systematic approach was in place to address or communicate these hazards.
Failure to Report Wound Deterioration and Implement Timely Pressure Ulcer Interventions
Penalty
Summary
A resident with multiple comorbidities, including Parkinson's disease, dementia, diabetes, and muscle weakness, was identified as being at moderate risk for developing pressure ulcers. The resident had a stage 2 pressure ulcer on the coccyx, which was present on admission, and required significant assistance with mobility and activities of daily living. The care plan included regular turning and repositioning, maintaining dry linens, therapy for wheelchair positioning, wound physician visits, and adherence to skin care protocols. Despite these interventions, the resident's wound deteriorated over time. Nursing documentation indicated that the wound worsened, with tunneling and increased drainage, but there was no evidence that the nursing supervisor or physician was notified of these changes as required. Interviews revealed conflicting accounts between nursing staff regarding whether the change in wound status was communicated. Additionally, when a new treatment (Santyl ointment) was ordered for the wound, it was not administered as prescribed due to unavailability, and an alternative treatment was applied without provider notification or a new order. The clinical record also failed to show timely notification to the physician when the wound appeared infected. Furthermore, a wound care physician recommended the use of an air mattress for pressure offloading, but this recommendation was not implemented in a timely manner. Staff interviews confirmed that the recommendation was missed, and an order for the air mattress was not entered, resulting in a delay in providing this essential intervention. The wound continued to deteriorate, with subsequent assessments documenting increased size and worsening tissue condition. Facility policies required timely assessment, reporting, and adherence to physician orders, but these were not followed in this case.
Failure to Timely Notify Practitioner of Pressure Ulcer Deterioration
Penalty
Summary
A deficiency occurred when facility staff failed to notify the practitioner in a timely manner regarding the deterioration of a resident's pressure ulcer. The resident, who had significant medical conditions including Parkinson's disease, dementia with behavioral disturbances, type 2 diabetes mellitus, and muscle weakness, was identified as having a stage 2 pressure ulcer on the coccyx. The care plan included regular turning, therapy, wound physician visits, and specific wound treatments. Despite these interventions, documentation showed that the wound worsened over several days, with increased tunneling and changes in wound measurements, but there was no evidence that the nursing supervisor or provider was notified of these changes during that period. Nursing notes indicated that the wound had worsened on multiple occasions, and staff interviews revealed confusion and lack of follow-up regarding provider notification. One LPN stated she informed the nursing supervisor about the wound's decline but did not confirm if the provider was notified, while the nursing supervisor denied receiving such notification. Additionally, when a prescribed wound treatment (Santyl) was unavailable, there was no clear documentation or confirmation that the provider was contacted for alternative orders, and staff instead used a previous treatment without provider approval. Further review of progress notes and interviews with medical staff confirmed that the wound physician was not contacted between scheduled visits despite the wound's deterioration. Facility policies required timely communication of changes in condition and collaboration with the healthcare team, but these procedures were not followed. The lack of timely notification and documentation of provider contact regarding the resident's declining wound condition constituted the deficiency.
Failure to Follow Physician's Orders for Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including Parkinson's disease, dementia, diabetes, and muscle weakness, developed a worsening unstageable pressure ulcer to the coccyx. The resident's care plan included specific interventions for pressure ulcer management, and a physician's order was in place to cleanse the wound and apply Santyl ointment daily. However, on one occasion, the Santyl ointment was unavailable, and the wound was instead treated with calcium alginate without a corresponding physician's order or provider notification. The LPN responsible for the resident's care documented that the Santyl was not available and applied alginate to the wound, referencing a previous treatment order. The LPN reported notifying the nursing supervisor but did not follow up to confirm whether the provider was contacted or if an alternative order was obtained. The nursing supervisor later stated she was not notified about the medication's unavailability and would have taken steps to secure an alternative treatment if she had been informed. Further interviews with facility staff, including the infection control nurse and an APRN, confirmed that it was not appropriate to substitute the wound treatment without provider direction. Review of facility policies indicated that staff are required to follow physician's orders and communicate changes or concerns regarding wound care to the healthcare team. No documentation was found to show that the provider was notified or that an alternative order was obtained for the use of alginate in place of Santyl.
Failure to Perform Monthly Bedframe Safety Checks Results in Resident Injury
Penalty
Summary
The facility failed to conduct monthly maintenance checks on resident bedframes to ensure they were free from sharp or jagged edges, as recommended by the manufacturer. This lapse resulted in a resident with Parkinsonism, major depressive disorder, and epilepsy sustaining a significant laceration to the leg during a transfer from a wheelchair to bed. The resident, who had moderate cognitive impairment and required moderate assistance for transfers, encountered a sharp, jagged edge on the bedframe that had become exposed due to a missing plastic end cap. The cap, originally intended to cover the hollowed metal support bar, had detached and was not replaced, as facility leadership considered it cosmetic and not a safety concern. Annual bed safety checks performed by an outside vendor focused only on functional and electrical safety, not on structural hazards such as missing end caps or sharp edges. Interviews with facility leadership confirmed that no regular bed safety checks were in place to identify or prevent such hazards. The manufacturer’s guidelines specified monthly visual inspections for broken welds, cracks, and loose hardware, including end caps, but these were not followed. As a result, the resident suffered an 8-centimeter laceration requiring eight sutures after coming into contact with the exposed sharp edge during a routine transfer.
Deficiencies in Food Safety and Documentation Practices
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a survey. A dietary aide was seen washing hands without wearing a beard net, despite having a mustache and short beard, and initially denied having a beard. The aide later applied a hairnet and face mask to cover exposed hair. Additionally, the facility did not consistently log dishwasher temperatures daily, with several instances of missing entries and recorded temperatures below the required range. The dietary manager was unable to explain the missing logs or the low temperatures, suggesting that the aide might not have taken the water temperature at the correct time. Furthermore, the facility failed to consistently document food temperatures for all meals daily. Missing entries were noted for various food items, including ground meat, dessert, soup, gravy, and alternate entrees on multiple dates. The Director of Dietary was unable to provide an explanation for the missing food temperature records. These deficiencies indicate lapses in adherence to professional standards for food safety and documentation within the facility's dietary department.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to inform residents about the grievance filing process and did not ensure that the necessary contact information for filing grievances with government officials was posted. During a Resident Council Meeting, several residents reported being unaware of how to file a grievance and were unable to locate any information within the facility to guide them. Observations confirmed that there was no contact information or instructions on how to file a grievance displayed in the main entrance area or on any units of the facility. Additionally, the facility did not maintain records of all grievances for at least three years, as required. Interviews with the Social Worker and the Administrator revealed a lack of clarity and communication regarding the grievance process. The Social Worker was not aware of a formal grievance policy and believed the Administrator was the point person for concerns. The Administrator, however, indicated that the Social Worker was responsible for handling grievances. Both parties were unaware of any postings within the facility that directed residents on how to file a grievance. The facility's policy outlined a process for handling grievances, but it was not effectively communicated or implemented, leading to confusion and non-compliance with regulatory requirements.
Failure to Protect Residents from Abuse and Ensure Immediate Reporting
Penalty
Summary
The facility failed to protect two residents from potential abuse and did not ensure immediate reporting of an abuse allegation. Resident #26, who was severely cognitively impaired and required extensive assistance, was allegedly verbally abused by a staff member. The incident was overheard by the Recreation Director but was not reported until the following day, allowing the staff member to continue working the remainder of their shift. The facility's investigation concluded there was no verbal abuse, but the delay in reporting the allegation compromised the resident's protection. Resident #44, also severely cognitively impaired, was involved in a physical altercation with another resident, #197. The altercation was witnessed by another resident and reported by a nurse aide. Although the residents were separated and assessed with no injuries found, the facility failed to document increased supervision or psychiatric evaluation for Resident #44 following the incident. The care plan interventions were not updated to reflect the necessary precautions to prevent further altercations. The facility's policies on abuse prevention and immediate reporting were not effectively implemented, as evidenced by the delayed reporting of the verbal abuse allegation and the lack of documentation for increased supervision and psychiatric evaluation after the physical altercation. The staff interviews revealed a lack of recall regarding the incidents, indicating potential gaps in communication and training on handling such situations.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its policies following an alleged incident of resident-to-resident physical and verbal mistreatment involving two residents. Resident #18, diagnosed with Parkinsonian and unspecified dementia, was observed hitting another resident with a newspaper. Despite the incident being reported to the nursing supervisor, there was no documented evidence that the incident was reported to the overseeing state agency or that an investigative report was completed. The facility's abuse prohibition policy requires immediate reporting and investigation of such incidents, which was not adhered to in this case. In another incident, Resident #26, who had dementia, seizures, and schizoaffective disorder, was allegedly verbally abused by a staff member. The Recreation Director overheard a nurse aide yelling at the resident but did not report the incident until the following day. The facility's investigation concluded there was no verbal abuse, but the delay in reporting and the continuation of the staff member's shift without immediate action violated the facility's policy. The policy mandates immediate removal of the alleged abuser and notification of the nursing supervisor, which did not occur promptly. Interviews with staff revealed inconsistencies in the handling of the incidents. The Director of Nursing Services and the Administrator were not informed of the alleged abuse until after the fact, and the Recreation Director was unclear about the reporting process. The facility's failure to follow its abuse prevention policy and ensure timely reporting and investigation of the incidents led to deficiencies in handling potential abuse cases.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical mistreatment involving Resident #18 in a timely manner. Resident #18, who has Parkinsonian and unspecified dementia, reported feeling mistreated by an LPN during medication administration. The incident was reported to a staff member, but the facility did not notify the overseeing state agency within the required time frame. The facility's policy mandates immediate reporting, but the administrator acknowledged the delay and stated that nursing staff are authorized to initiate notifications outside of routine business hours. In another incident, the facility did not properly address a bruise/discoloration on Resident #40's foot. Resident #40, diagnosed with dementia and other conditions, was observed with a discolored area on the foot during wound care. The discoloration was not reported or investigated promptly, and the DNS was unaware of the issue until the following day. The facility's policy requires immediate reporting and investigation of such incidents, but this was not followed, leading to a delay in assessment and documentation. Additionally, the facility delayed reporting an abuse allegation involving Resident #44, who has dementia and behavioral disturbances. The incident occurred but was not reported to the state agency until several days later. The DNS attributed the delay to a lack of access to the state system due to being a recent hire. The facility's policy requires immediate reporting of abuse allegations, but this was not adhered to, resulting in a significant reporting delay.
Failure to Protect Residents After Altercation and Unreported Injury
Penalty
Summary
The facility failed to ensure the protection of residents following an allegation of resident-to-resident physical mistreatment involving Resident #18 and Resident #98. Resident #18, who had diagnoses including Parkinsonian and unspecified dementia, was involved in an altercation with Resident #98 over a loud television. The incident occurred when Resident #18 was observed pushing a table towards Resident #98, who pushed it back. Although the altercation was not severe, the facility did not implement enhanced supervision for Resident #18 until six days later when a psychiatric evaluation was conducted. Resident #98, who had severe cognitive impairment, was involved in the same altercation. Despite the incident being reported, there was no documentation of new orders or enhanced supervision for Resident #98. The facility's policy required immediate actions such as separating residents and initiating one-to-one supervision, which were not documented as being followed. The Director of Nursing Services confirmed that residents should be placed on one-to-one supervision until evaluated by psychiatry, which was not done in this case. Additionally, the facility failed to report and investigate a bruise on Resident #40's foot, who had dementia and was at risk for skin breakdown. The discoloration was observed during wound care, but no incident report was completed, and the Director of Nursing Services was unaware of the issue until the following day. The facility's policy required immediate reporting and investigation of injuries of unknown source, which was not adhered to in this instance.
Failure to Develop Comprehensive Care Plans for Pressure Ulcer Risk
Penalty
Summary
The facility failed to develop comprehensive care plans for residents at risk of pressure ulcers, leading to deficiencies in care. Resident #5, admitted with a cervical spine fracture, Alzheimer's disease, and dementia, was identified as being at risk for pressure injuries. Despite a Braden scale score indicating moderate risk, no care plan was developed until after a stage 2 pressure ulcer was identified. The care plan was implemented 42 days after the risk was noted, and interventions such as frequent repositioning and incontinent care were delayed. Resident #26, with diabetes mellitus type II and vascular dementia, was admitted with multiple pressure ulcers. Although interventions like a low air loss mattress and repositioning were ordered, the care plan failed to address the resident's risk for pressure injuries or include interventions for existing ulcers. The DNS acknowledged the lack of a comprehensive care plan and the need for interventions such as cleanliness and repositioning to be documented. Resident #27, diagnosed with dementia and dysphagia, was identified as high risk for pressure ulcers, but no care plan was initiated for incontinence despite the MDS assessment indicating the need. Similarly, Resident #34, with diabetes mellitus Type 2 and peripheral vascular disease, was at high risk for skin breakdown, but the care plan did not include preventive measures. The facility's policy required care plans to be developed within seven days of the MDS completion, but this was not adhered to, resulting in deficiencies in care planning and risk management.
Failure to Revise Care Plans for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to timely revise the care plans for two residents at risk for pressure ulcer development. Resident #15, with diagnoses including diabetes mellitus and heart failure, was readmitted with a stage 2 pressure ulcer on the coccyx. Despite assessments indicating high risk for skin breakdown, the care plan did not reflect the necessary frequency for turning and repositioning every two hours as per the facility's Pressure Ulcer Prevention Plan. The care plan also failed to include specific interventions for incontinence care every two hours, which was noted in the Nurse Aide Care Card. Resident #40, diagnosed with dementia and dysphagia, was identified as high risk for skin breakdown. A progress note revealed a stage 2 pressure ulcer on the left heel, but the care plan did not specify how or when to reposition the resident in bed. The facility's Pressure Ulcer Prevention Plan required more frequent interventions, such as Q 1 hour turning for high-risk residents, which were not documented in the care plan. The care card also lacked instructions for turning and repositioning, contributing to the deficiency.
Failure to Document Medication Rationale in Physician's Orders
Penalty
Summary
The facility failed to ensure that the physician's orders for medications included the reason or rationale for their use, which is a requirement to meet professional standards of quality. This deficiency was identified through clinical record reviews and staff interviews for several residents. For instance, Resident #1, who had diagnoses including diabetes mellitus and cerebrovascular disease, had physician's medication orders from March 1, 2024, through April 25, 2024, that did not indicate the reason for use for all medications ordered during this period. Similar issues were found with other residents, such as Resident #3, who had vascular dementia and other conditions, and Resident #10, who was cognitively intact and received anticoagulant medication, yet their medication orders also lacked the necessary rationale. The deficiency was further highlighted during medication pass observations, where it was noted that the facility did not document the reasons for the use of routine and as-needed medications in the physician's orders. For example, Resident #15, who had moderate cognitive impairment and received multiple medications, had a physician's order for Seroquel without an indication for its use. An LPN confirmed that the order did not specify the reason for the medication, and there was a need to clarify this with the psychiatric APRN. This lack of documentation was consistent across other residents, such as Resident #18, who had parkinsonism and dementia, and Resident #23, who was cognitively intact but had multiple diagnoses including bacteremia and hypertension. Interviews with facility staff, including the DNS and the Medical Director, revealed a lack of awareness regarding the requirement to document the reasons for medication use in physician's orders. The DNS acknowledged the issue and mentioned discussions with psychiatric services to ensure compliance in the future. However, a policy for writing medication orders was requested but not provided, indicating a systemic issue in the facility's medication management practices.
Failure to Prevent Pressure Ulcers in Residents
Penalty
Summary
The facility failed to implement adequate interventions to prevent the development of pressure ulcers in several residents, leading to the development and reopening of pressure ulcers. Resident #5, who had a history of cognitive impairment and required substantial assistance, developed a stage 2 pressure ulcer on the coccyx after returning from the hospital. Despite being identified at risk for pressure ulcers, there was no evidence of turning and repositioning interventions being implemented for two months, as per facility practice. The care plan was only updated after the ulcer was identified, indicating a lack of proactive measures. Resident #34, with diagnoses including diabetes and peripheral vascular disease, developed a stage 3 pressure ulcer on the left heel. The clinical record did not reflect any offloading or repositioning interventions until after the ulcer was identified. The resident was at risk for skin breakdown, but the Braden Scale assessment was not completed due to an error, and the care plan lacked documentation of preventive measures. This oversight contributed to the development of the pressure ulcer. Resident #26, admitted with existing pressure ulcers, experienced a reopening of a previously healed stage 4 pressure ulcer. The facility failed to maintain a documented turning and repositioning schedule, and there was inconsistent documentation of weekly skin assessments. The Braden Risk assessment was not completed at the time of the ulcer reopening, indicating a lapse in monitoring and preventive care. Similarly, Resident #40, identified as high risk for skin breakdown, developed a stage 2 pressure ulcer on the left heel. The care plan did not include specific instructions for repositioning, and the facility's pressure ulcer prevention plan was not adequately implemented.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its weight monitoring policy for three residents, leading to significant weight loss without timely intervention. Resident #22, diagnosed with protein-calorie malnutrition and dysphagia, experienced a weight fluctuation from 116.2 pounds to 145.4 pounds and then down to 111.4 pounds within a short period. Despite a physician's order to monitor weight monthly and report significant changes, the facility did not document any weights or refusals from 8/5/23 to 8/16/23, missing the opportunity to address the resident's nutritional needs promptly. Resident #27, who has dementia and dysphagia, showed a significant weight loss of 13.6 pounds over 30 days. Although the care plan required monitoring and reporting significant weight changes, the facility did not re-weigh the resident after the initial weight loss was noted. The Registered Dietitian acknowledged the weight loss and noted the resident's refusal to eat, but the facility did not follow up with a re-weigh as per policy. Resident #34, with diagnoses including diabetes mellitus Type 2 and dysphagia, lost 10.1 pounds between 12/4/23 and 1/9/24. The facility's policy required a re-weigh within 48 hours of a significant weight change, but this was not done. Despite requests, the facility did not provide dietary/nutrition notes or weights since admission, indicating a lack of documentation and follow-through on weight monitoring protocols.
Failure to Ensure Required RN Hours
Penalty
Summary
The facility failed to ensure the required number of Registered Nurse (RN) hours as mandated. The Payroll Based Journal (PBJ) submissions for all four quarters of 2023 showed no RN hours reported. The facility was not operational from October 24, 2022, through March 15, 2023, which corresponds with the first two quarters of 2023. Additionally, the facility adopted a new payroll system in January 2023 and has been working with the software vendor to resolve issues with automatic data submission. Prior to this, PBJ data was entered manually. Despite providing staff schedules indicating RN supervisors were scheduled for various shifts from March 12, 2023, through September 30, 2023, the facility could not provide documentation from CMS confirming compliance with the required RN hours for the entire year.
Inaccurate PBJ Data and Staffing Deficiencies
Penalty
Summary
The facility failed to ensure that its Payroll Based Journal (PBJ) data was complete and accurate for the first four quarters of 2023. The PBJ submissions revealed that the facility did not maintain licensed nursing coverage 24 hours a day, had excessively low staffing on weekends, and reported no registered nurse (RN) hours. During an interview, the Administrator acknowledged the inaccuracies in the PBJ data and explained that the facility was not operational from late October 2022 through mid-March 2023, which affected the data for the first two quarters of 2023. Additionally, the facility had transitioned to a new payroll system in January 2023 and was experiencing issues with automatic data submission, which was previously done manually.
Failure to Address Resident Concerns on Room Conditions
Penalty
Summary
The facility failed to address resident concerns regarding cold and drafty bedrooms in a timely manner, as reported during Resident Council Meetings. Residents had repeatedly complained about the issue, but no resolution was achieved. The Recreation Director communicated these concerns to the relevant departments but did not document follow-ups or ensure that the issues were carried over to subsequent meetings. The Director of Maintenance acknowledged the drafty windows and the need for replacement, but temporary measures like caulking were not completed due to staff resignation. Additionally, there was no documentation of room temperature checks, and the facility lacked a formal process for handling Resident Council concerns. The Administrator stated that concern forms should be generated and addressed promptly, but the Concern Form Log did not contain any entries related to the residents' complaints about room temperatures. The Administrator was unable to locate any additional concern forms, and the facility did not provide a policy on handling Resident Council concerns. This lack of documentation and follow-up indicates a deficiency in the facility's process for addressing and resolving resident issues raised during council meetings.
Failure to Review Advanced Directive with Responsible Party
Penalty
Summary
The facility failed to ensure that a resident's Advanced Directive was reviewed with the responsible party in a timely manner. Resident #39, who has a diagnosis of cerebral infarction and Alzheimer's disease, had a physician's order dated 10/10/2023 for Full code status regarding Advanced Directives. However, a progress note from 10/11/2023 indicated that the code status was to be determined, and the resident had a Conservator of Person (COP) who was not responsive to communications. The quarterly Minimum Data Set (MDS) assessment noted that the resident had some difficulty in daily decision-making in new situations. Interviews and record reviews revealed that the facility staff, including a Registered Nurse (RN #1), a Social Worker (SW #1), and a Licensed Practical Nurse (LPN #2), were unable to locate the advanced directives documentation for Resident #39. SW #1 admitted to not documenting attempts to contact the COP since 10/11/2023, and LPN #2 noted that the COP had crossed out the Advanced Directives form upon admission but could not provide the form or any communication records with the COP. The facility's policy required that if a resident did not have an advanced directive on admission and was incapacitated, the form should be given to the family or responsible party and then to the social worker for completion, which was not followed in this case.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the Regional Ombudsman's Office regarding the transfer and discharge of a resident to an acute care facility. The resident, who was severely cognitively impaired and required substantial assistance for mobility and personal hygiene, was transferred to the hospital twice and eventually expired there. Despite these transfers, there was no documentation indicating that the Regional Ombudsman's Office was notified. Interviews with facility staff revealed a lack of clarity regarding the responsibility for such notifications, with the social worker indicating it was the business office's responsibility, and the Director of Nursing Services unaware of the notification process. The facility was unable to provide a policy outlining the procedure for notifying the Regional Ombudsman's Office of hospital admissions.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to provide evidence that a resident and their responsible party were notified of the bed hold policy during hospitalization. The resident, who had diagnoses including acute respiratory failure with hypoxia, hypertension, and heart disease, was identified as severely cognitively impaired and dependent on staff for mobility and personal hygiene. The clinical record showed that the resident was transferred to an acute care facility twice, with no documentation of bed hold policy notification on either occasion. Interviews revealed that the social worker did not contact the family about the bed hold policy, believing it was the responsibility of the business office, whose manager was unavailable. The Director of Nursing Services was also unaware of the bed hold process, and the facility could not provide a bed hold policy when requested.
Failure to Timely Complete and Transmit MDS Assessments
Penalty
Summary
The facility failed to complete and transmit the annual Minimum Data Set (MDS) assessments for two residents within the required timeframe. Resident #1, who has diagnoses including diabetes mellitus, hypertension, and anxiety, was identified as cognitively intact and requiring supervision for bed mobility, transfers, and ambulation. However, the MDS assessment for this resident was not signed or transmitted as required. Similarly, Resident #35, diagnosed with dementia without behavioral disturbances, hypertension, and dysphagia, was identified as severely cognitively impaired and dependent for transfers. The MDS assessment for this resident was also incomplete, with the signature page unsigned. The Licensed Practical Nurse (LPN) responsible for these assessments indicated that her assessments require a Registered Nurse (RN) co-signer. She reported that software errors had caused issues with the completion of the assessments, but she did not notify anyone of these problems. The LPN acknowledged that the assessments should have been signed and transmitted within 14 days of the Assessment Reference Date (ARD), as per the Resident Assessment Instrument (RAI) guidelines. The failure to complete and transmit the assessments in a timely manner constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Review PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to review or discontinue the use of a PRN psychotropic medication for a resident diagnosed with diabetes mellitus type II and vascular dementia. The resident was severely cognitively impaired and required total assistance for various activities. The care plan identified a diagnosis of depression and prescribed psychotropic medication, with interventions to provide psychiatric consultation and monitor for side effects. However, the physician's orders for Trazadone 25MG every six hours as needed for agitation and restlessness did not include a discontinuation date. Psychiatric progress notes did not document a review or decision regarding the continued use or discontinuation of Trazadone. An interview with the Director of Nursing Services confirmed that the medication should have been reviewed. The facility did not provide a policy for the PRN use of psychotropic medication when requested.
Failure to Include Death Certificate in Resident's Clinical Record
Penalty
Summary
The facility failed to ensure that the death certificate for a resident was included in the clinical record, which is a requirement according to accepted professional standards. The resident, who had diagnoses including dementia, hypertension, and hypothyroidism, was under palliative care with a Do Not Resuscitate and Do Not Intubate status. After the resident's death, the nurse's note documented the time of death and the notification of the family and funeral home. However, upon review, the clinical record did not contain a signed death certificate. Interviews with facility staff revealed that the process for handling death certificates had changed to an electronic system about a year prior, and the facility had not been printing out death certificates to include in the closed records. The Director of Nursing Services (DNS) and a Licensed Practical Nurse (LPN) were unaware of the requirement to print and include the death certificate in the medical record. The facility's Death Policy mandates that all records be completed and forwarded to Medical Records, but this was not adhered to in this case. A death certificate was eventually provided after surveyor inquiry, indicating a lapse in the facility's adherence to its own policies and procedures.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
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