Cambridge Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, Connecticut.
- Location
- 2428 Easton Tnpk, Fairfield, Connecticut 06825
- CMS Provider Number
- 075323
- Inspections on file
- 28
- Latest survey
- November 24, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Cambridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with schizophrenia did not receive a scheduled dose of Abilify because the medication could not be located. The LPN documented the omission and informed the supervising RN, but neither the APRN nor the next shift nurse was notified. The supervising RN assumed the medication was administered and did not follow up. The APRN was unaware of the missed dose and no alternate plan was established. The resident later attempted self-harm and was hospitalized. Facility policy required provider notification for changes in treatment, which did not occur.
Two residents experienced deficiencies: one did not receive a scheduled antipsychotic injection due to communication and follow-up failures among nursing staff, and another with COPD did not receive prescribed oxygen therapy when a portable tank was not monitored and became empty, compounded by the lack of a timely RN assessment after a change in condition.
A resident with a history of accusatory behaviors and multiple diagnoses was care planned to require two staff for all care. Despite this, a NA assisted the resident to the toilet alone, only seeking additional help after the resident complained of being hurt. Documentation and interviews confirmed the care plan was not followed, as the NA was aware of the two-person requirement but proceeded alone due to the resident's immediate need.
The facility failed to consistently document shift-to-shift narcotic counts, with missing signatures on audit sheets across multiple units and shifts. Interviews revealed that LPNs were aware of their responsibility to sign the sheets, but the Discharge Planner and DNS were unaware of the issue. The facility's policy requires a physical inventory of controlled drugs at each shift change, which was not adhered to, as evidenced by the missing signatures.
The facility failed to obtain and document advance directives for two residents upon admission, leading to deficiencies in honoring their code status. One resident with severe cognitive impairment was left as a full code due to an invalid DNR directive, while another resident with intact cognition had incomplete documentation of their CPR status. Staff interviews revealed inconsistencies in following the facility's policy for advance directives.
A facility failed to notify a resident's representative about changes to the resident's medication regimen, including the discontinuation of Lasix, Potassium Chloride, and Aspirin. Despite attempts by the APRN to reach the representative, no further documented efforts were made, contrary to the facility's policy. The representative was not informed until months later, leading to dissatisfaction.
A resident with a history of falls and severe cognitive impairment experienced multiple unwitnessed falls due to the facility's failure to consistently revise the care plan. Despite several incidents, the care plan was not updated with effective interventions, leading to a serious injury. The facility did not adhere to its policies on care plan revisions and fall prevention.
A resident with a history of surgery and depression was found with medications left at their bedside, contrary to the facility's policy. The resident wanted to wait until after breakfast to take the medications due to previous nausea. An LPN left the medications unattended, acknowledging the error. The facility's policy requires nurses to observe residents until medications are taken and prohibits leaving medications at the bedside.
The facility failed to monitor vital signs and conduct neurological checks for residents after unwitnessed falls, did not manage a diabetic resident's blood sugar levels, and inconsistently administered Humira for a resident with Hidradenitis Suppurativa. These deficiencies were contrary to facility policies and physician orders.
A resident at risk for pressure ulcers developed deep tissue injuries on both heels, but the facility failed to ensure proper assessment and documentation by a Registered Nurse. Additionally, the resident's air mattress was not set according to the manufacturer's recommendations, remaining at the maximum weight setting and in static mode instead of being adjusted to the resident's weight and set to alternating pressure.
A resident with a history of weight loss and malnutrition did not receive timely feeding assistance due to staff confusion over assignments. The resident's breakfast tray was left unattended for nearly an hour, contrary to the facility's nutrition and residents' rights policies.
The facility failed to administer oxygen as ordered for two residents. One resident with anemia and syncope had a disconnected nasal cannula, with the tubing on the floor and taped. Another resident with interstitial pulmonary disease also had a disconnected nasal cannula. The DNS confirmed the tubing should not have been taped and was unsure of the disconnection reason. Interviews revealed some tubing was not connecting properly, affecting the two residents identified.
A resident with nicotine dependence and other health issues was prescribed a Nicotine patch for agitation and anxiety. Despite a pharmacy recommendation to discontinue the patch after two weeks, it remained in use due to a breakdown in communication and responsibility among facility staff, including the APRN, ADNS, and DNS.
A resident with dementia and other health issues lost their dentures, leading to a downgraded diet. Despite a grievance filed and a dental follow-up scheduled, the facility delayed replacing the dentures due to a payment issue. The facility's policies on lost property, dental services, and grievance resolution were not effectively followed, resulting in the resident not receiving timely dental care.
A resident with a history of falls was repeatedly assessed as low risk for falls despite having severely impaired cognition and requiring assistance with daily activities. The facility's fall prevention policy was not followed, as the documentation did not accurately reflect the resident's fall history. The DNS confirmed the evaluations were documented incorrectly, and the facility could not provide a policy on maintaining clear and accurate records.
A resident with a history of subdural hemorrhage and incontinence did not receive incontinent care for five hours due to a staff assignment oversight. Despite reminders from an LPN, the assigned nurse aide failed to check on the resident, who was later found with a saturated brief. Facility policy mandates care every two hours, which was not followed.
A resident with cardiac conditions was readmitted to the facility with new medication orders for Digoxin and Diltiazem. Due to a failure in medication reconciliation, these medications were not transcribed into the MAR, resulting in missed doses. Interviews revealed a lack of communication and responsibility among nursing staff, contrary to facility policy.
A resident with multiple health conditions, including congestive heart failure and myelodysplastic syndrome, required IV therapy due to poor nutritional intake. The facility failed to document intake and output monitoring during IV fluid administration on two occasions, despite the care plan's directives and the DON's expectations. Additionally, the facility could not provide a policy for intake and output monitoring or nursing care for residents receiving IV fluids.
Failure to Notify Provider of Missed Antipsychotic Dose
Penalty
Summary
A deficiency occurred when staff failed to ensure timely notification of the physician or designee after an antipsychotic medication, Abilify, was unavailable for administration as ordered to a resident diagnosed with schizophrenia, morbid obesity, and pain. The resident was scheduled to receive a 400 mg intramuscular injection of Abilify on the first day of the month, but the medication could not be located by the LPN assigned. The LPN contacted the pharmacy, which confirmed delivery, and notified the supervising RN, who instructed the LPN to recheck the refrigerator and medication cart. The LPN documented the medication as unavailable in the MAR and wrote a nursing note but did not notify the APRN or follow up further with the supervisor. The supervising RN did not follow up with the LPN after the initial report and assumed the medication had been found and administered. The missed dose was not communicated to the APRN or the next shift nurse, resulting in a lack of awareness among key clinical staff. The APRN later confirmed she was unaware of the missed dose and stated she would have established an alternate plan if notified. The next shift LPN also reported not being informed about the missed dose and indicated she would have taken additional steps if she had known. The resident subsequently attempted self-harm and was placed on one-to-one observation before being transferred to the hospital. Facility policy required consultation with the healthcare provider when there was a need to alter treatment, but this did not occur. The failure to notify the appropriate medical staff of the missed medication dose constituted the deficiency identified in the report.
Failure to Administer Medications and Oxygen as Ordered, and Lack of Timely Assessment
Penalty
Summary
A deficiency occurred when a resident with schizophrenia, morbid obesity, and pain did not receive a scheduled dose of Abilify, an antipsychotic medication, as ordered by the physician. The medication was due to be administered intramuscularly on the first day of the month, but the assigned LPN was unable to locate the medication and, after checking with the pharmacy and supervisor, documented its unavailability in the Medication Administration Record. The LPN did not notify the APRN or follow up further, and the supervisor assumed the medication had been found and administered. There was no evidence of a new physician order to reschedule the medication, and the next shift nurse was not clearly informed of the missed dose. This lapse was discovered after the resident attempted self-harm and was transferred to the hospital, where it was confirmed the medication had not been given. Another deficiency involved a resident with chronic obstructive pulmonary disease (COPD), emphysema, and respiratory failure who required oxygen therapy. The resident complained of shortness of breath while on five liters of oxygen, and the APRN ordered an increase to ten liters via a non-rebreather mask. The LPN switched the resident to a portable oxygen tank but did not monitor the oxygen level in the tank after the switch. When emergency medical services arrived, they found the oxygen tank empty and the resident's blood oxygen level below normal. The LPN admitted to not checking the tank's oxygen level, relying instead on the appearance of the mask's bag, and did not reassess the tank after the initial switch. Additionally, there was a failure to complete a timely RN assessment for the resident experiencing a change in respiratory condition. Although the supervisor was initially notified and performed an assessment when the resident was on five liters of oxygen, she was not informed of the subsequent increase to ten liters or the switch to a portable tank, and did not reassess the resident before transfer to the hospital. Facility policies required monitoring of oxygen supply and timely RN assessment for changes in condition, but these were not followed in this instance.
Failure to Follow Care Plan for Resident Requiring Two-Person Assistance
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan for a resident with a history of accusatory behaviors and multiple diagnoses, including anxiety, persistent mood disorder, and muscle weakness. The resident was care planned to require the assistance of two staff members for all care due to these behaviors. Despite this, a nursing assistant (NA) assisted the resident to the toilet alone, without a second staff member present, and only sought additional help after the resident complained of being hurt during the transfer. The care plan, which was developed to address the resident's specific needs and behaviors, was not followed as required. Documentation and interviews confirmed that the NA was aware of the two-person assistance requirement but proceeded alone due to the resident's immediate need to use the bathroom. The incident was reported after the resident alleged being poked and hurt, although later clarified that the staff member was not abusive. The Director of Nursing Services (DNS) confirmed through investigation that the care plan intervention was not followed during this episode, as the resident was placed on the toilet without the required second staff member present.
Failure to Document Narcotic Counts
Penalty
Summary
The facility failed to consistently complete shift-to-shift narcotic/controlled drug counts, as observed during a review of medication carts and facility documentation. The narcotic drug change of shift audit sheets were missing signatures on multiple dates across various shifts and units, including Passport A, B, and C units, as well as [NAME] 1, [NAME] 2, and [NAME] units. The missing signatures indicate that the required narcotic counts were not properly documented by the on-coming and off-going nurses, as per the facility's policy. Interviews with several LPNs revealed that they were aware of the responsibility to sign the narcotic drug change of shift audit sheet at the beginning and end of each shift. However, the Discharge Planner and the Director of Nursing Services (DNS) were not aware of the missing signatures until the issue was brought to their attention. The facility's policy mandates that a physical inventory of all controlled drugs be conducted at each shift change by two licensed nurses, and this process should be documented on an audit record. The lack of adherence to this policy was evident in the missing signatures, indicating a lapse in the facility's controlled substance handling procedures.
Failure to Obtain and Document Advance Directives on Admission
Penalty
Summary
The facility failed to obtain and document the code status for two residents upon their admission, leading to deficiencies in honoring their advance directives. Resident #54 was admitted with severe cognitive impairment and other health issues, but the facility did not secure a valid advance directive or code status upon admission. Although the social worker noted the resident as a full code, the advance directive section was left blank, and a DNR status was later obtained over the phone without proper witnessing, rendering it invalid. The facility's policy required two nurses to witness such directives, but this was not followed, leaving the resident as a full code by default. Resident #87, who had intact cognition, was admitted with serious health conditions, but the facility also failed to document their advance directive choices or obtain a signed consent form. The care plan identified the resident's code status as CPR, but there was no physician's order to confirm this, and the advance directive form was incomplete. The charge nurse or nursing supervisor was responsible for ensuring these documents were completed, but this did not occur, resulting in a lack of clarity regarding the resident's wishes. Interviews with facility staff, including LPNs and the DNS, revealed inconsistencies in the process of obtaining and documenting advance directives. The facility's policy required that advance directives be reviewed and signed upon admission, with physician orders written accordingly. However, these procedures were not followed, leading to deficiencies in the facility's compliance with residents' rights to make decisions about their care.
Failure to Notify Resident Representative of Medication Changes
Penalty
Summary
The facility failed to notify the resident representative of changes to a resident's medication regimen. Resident #40, who had diagnoses including dementia and congestive heart failure, was on a care plan that included medications such as Lasix and Potassium Chloride. On December 12, 2023, the APRN decided to discontinue these medications after evaluating the resident and attempted to inform the resident's representative, Person #1, but was unable to reach them. Despite the facility's policy requiring repeated attempts to notify the resident representative, documentation showed no further attempts were made to contact Person #1 about the medication changes. The deficiency was further highlighted when the APRN discontinued Aspirin on December 13, 2023, again attempting to reach Person #1 without success. Interviews with the ADNS and DNS revealed that the expectation was for the nursing staff to continue trying to contact Person #1 and document these attempts. However, Person #1 was not informed of the medication changes until April 2024, when they discovered the discontinuation and expressed their dissatisfaction. The facility's Change of Condition Notification Policy mandates informing the resident, their representative, and the physician of any changes, which was not adhered to in this case.
Failure to Revise Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to consistently revise the care plan for a resident with a history and risk of falls, leading to multiple unwitnessed falls. The resident, who was admitted with diagnoses including breast cancer, heart failure, and obstructive sleep apnea, was initially assessed as low risk for falls. However, the resident experienced several falls, including incidents on 1/9/24, 4/12/24, 6/7/24, 6/15/24, and 7/2/24, without appropriate updates to the care plan to address the changing risk factors and implement effective interventions. Despite the resident's severely impaired cognition and occasional incontinence, the care plan interventions remained inadequate. After the fall on 1/9/24, the only intervention added was to remind the resident to call for assistance. No new interventions were implemented following the falls on 4/12/24 and 6/15/24, even though the resident continued to attempt self-transfers and experienced balance issues. The care plan was not revised until 7/8/24, three days after the resident returned from the hospital with a proximal humerus fracture, and even then, it failed to incorporate necessary interventions outlined in the APRN note from 7/5/24. The facility's policies on comprehensive care plans and fall prevention were not adhered to, as the care plan was not individualized or revised in response to the resident's condition changes and frequent falls. The DNS acknowledged that the care plan should have been reviewed and updated following the falls, but it was not done in a timely manner, contributing to the resident's continued risk and eventual injury.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident, leading to a deficiency in medication administration. The resident, who had a history of cerebrospinal fluid leak, nervous system surgery, and depression, was observed with a medicine cup containing seven pills at their bedside. The resident expressed a desire to wait until after breakfast to take the medications due to a previous incident of vomiting after taking them on an empty stomach. An LPN had left the medications at the bedside after the resident requested Hydromorphone for pain, intending to return after the resident had eaten. The LPN acknowledged that she should not have left the medications unattended and should have either stayed with the resident until the medications were taken or removed them to administer later. The facility's Medication Pass policy requires that medications be administered safely and timely, with the nurse observing the resident until all medications are swallowed. The policy also prohibits leaving medications at the bedside. The DNS confirmed that the resident was not evaluated or care planned to self-administer medications, and the expectation was for medications not to be left at the bedside.
Deficiencies in Monitoring and Medication Administration
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of vital signs and neurological checks for several residents, leading to deficiencies in care. For two residents, vital signs were not monitored monthly as required, and neurological checks were not completed following unwitnessed falls. This lack of monitoring and documentation was contrary to the facility's policies and the standard of care expected for residents with conditions such as heart failure and obstructive sleep apnea. Additionally, the facility did not adequately manage the care of a resident with Type 2 diabetes. The resident's blood sugar levels were not monitored, and there was a failure to administer insulin as directed by the hospital discharge summary. The facility did not have a policy in place for diabetic care and monitoring, which contributed to the oversight in managing the resident's diabetes effectively. The facility also failed to administer a specialty medication, Humira, consistently for a resident with Hidradenitis Suppurativa. The medication was missed three times and administered late on four occasions due to issues with pharmacy delivery and lack of timely reordering. This inconsistency in medication administration was not in line with the physician's orders and placed the resident at risk for treatment failure.
Failure to Properly Assess and Manage Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper assessment and documentation of pressure ulcers for a resident who was admitted with no pressure ulcers but was at risk due to decreased mobility and other health conditions. Initially, the resident was identified as having no pressure ulcers upon admission, but later developed deep tissue injuries on both heels. The facility's records did not show that a Registered Nurse completed an assessment of these new wounds or conducted weekly assessments as required by the facility's policy. Additionally, the facility did not properly set the resident's air mattress according to the manufacturer's recommendations. The mattress was observed to be set at the maximum weight setting and in a static mode, which is only intended for repositioning, rather than being adjusted to the resident's actual weight and set to alternating pressure. This oversight was acknowledged by the staff, who were unsure of the resident's current weight and failed to adjust the settings appropriately after a dressing change. The facility's policies on pressure injury prevention and support surfaces were not followed, as evidenced by the lack of comprehensive skin evaluations and incorrect air mattress settings. The Director of Nursing Services confirmed that complete and accurate wound assessments should be documented, and air mattresses should be set to the resident's weight, highlighting the facility's failure to adhere to its own protocols.
Failure to Provide Timely Feeding Assistance
Penalty
Summary
The facility failed to provide timely feeding assistance to a dependent resident, identified as Resident #26, who had a history of weight loss and was at risk for malnutrition. Resident #26 was admitted with diagnoses including dysphagia, vascular dementia, cerebral infarction, hemiplegia, and hemiparesis. The care plan for the resident included interventions for potential fluid deficit and nutritional diagnoses such as inadequate oral intake and swallowing difficulty. Despite these interventions, observations revealed that the resident's breakfast tray was delivered but left unattended for nearly an hour without any staff entering the room to assist with feeding. Interviews with facility staff indicated confusion among nurse aides regarding their assignments, which contributed to the delay in feeding Resident #26. The nurse aide assigned to the resident was unaware of her assignment due to this confusion. Additionally, the nurse aide who delivered the breakfast tray did not attempt to feed the resident, as she was preoccupied with other tasks. The facility's policies on nutrition and residents' rights emphasize the importance of timely and appropriate feeding assistance, which was not adhered to in this instance, leading to the deficiency.
Oxygen Therapy Deficiency for Two Residents
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered for two residents reviewed for respiratory care. Resident #79, who was admitted with diagnoses including anemia and syncope, had a physician's order for oxygen therapy to maintain oxygen saturation above 92%. However, during an observation, it was found that the resident's nasal cannula was not connected to the oxygen concentrator, as the tubing connector was on the floor and wrapped in surgical tape. The LPN was unaware of the disconnection and the DNS confirmed that the tubing should not have been taped and was unsure why it was disconnected. Similarly, Resident #82, admitted with interstitial pulmonary disease and chronic respiratory failure, had a physician's order for continuous oxygen therapy. An observation revealed that the resident's nasal cannula was also disconnected from the concentrator, with the tubing connector on the floor and taped. The DNS indicated that the tubing should fit properly without tape and was unsure of the reason for the disconnection. Interviews revealed that some tubing was not connecting properly, leading to the use of tape, and the issue was not widespread but affected the two residents identified.
Failure to Discontinue Unnecessary Nicotine Patch
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication, specifically a Nicotine patch. The resident, who was admitted with diagnoses including nicotine dependence, intellectual disabilities, anxiety, asthma, and COPD, was prescribed a Nicotine patch to address increased agitation and anxiety due to frustration from not being able to smoke. However, the resident's progress notes from May to July did not reflect a desire to smoke, and a pharmacy review recommended discontinuing the Nicotine patch after two weeks. Despite this recommendation being agreed upon by the APRN, the patch was not discontinued as expected. The APRN indicated that she was not aware of the resident's smoking status at the time of the initial prescription and relied on the facility's process for handling pharmacy recommendations. The facility's policy required the APRN to review and agree with the pharmacy's recommendations, which she did on June 13. However, the expectation was that the supervisor would execute the recommendation to discontinue the Nicotine patch, which did not occur. Interviews with the ADNS and DNS revealed a breakdown in the process of implementing pharmacy recommendations. The DNS missed the recommendation to discontinue the Nicotine patch, and there was confusion about who was responsible for updating the resident's electronic medical record. The facility's policies outlined the roles of the consultant pharmacist, DNS, and unit managers in ensuring timely action on pharmacy recommendations, but these were not followed, leading to the deficiency.
Delayed Resolution for Lost Dentures
Penalty
Summary
The facility failed to provide a timely resolution for a resident's lost dentures, which were reported missing on March 31, 2024. The resident, who was admitted with diagnoses including dementia, congestive heart failure, and dysphasia, required a therapeutic diet due to heart failure. Following the loss of the dentures, the resident's diet was downgraded to a mechanical soft texture on April 3, 2024, due to the missing upper partial denture. Despite a grievance being filed on April 12, 2024, and a dental follow-up scheduled, the resident had not received replacement dentures by the time of the survey on July 30, 2024. Interviews with facility staff revealed that there was a delay in addressing the issue due to a payment problem. The Assistant Director of Nursing Services (ADNS) and the Director of Nursing Services (DNS) both acknowledged that the resident had not been seen by a dentist because the facility had to pay for the replacement dentures. The DNS believed the issue had been resolved until informed otherwise during the survey. The facility's Administrator was aware of the grievance but was waiting for confirmation on whether the insurance or the facility would cover the cost of the new dentures. The facility's policies on lost property and dental services were not followed effectively. The Resident Lost Property Policy required a thorough search and potential reimbursement if the property could not be located, while the Dental Services Policy mandated a dental referral within three days of the facility being aware of lost dentures. The Grievance Policy required timely resolution of grievances, but the facility failed to ensure the resident received replacement dentures in a timely manner, resulting in a prolonged period without proper dental care.
Inaccurate Fall Risk Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate documentation of fall risk evaluations for a resident with a history of multiple falls. The resident, who was admitted with diagnoses including breast cancer, heart failure, and obstructive sleep apnea, was initially assessed as low risk for falls despite having severely impaired cognition and requiring assistance with daily activities. Over several months, the resident experienced multiple falls, yet subsequent fall risk evaluations continued to inaccurately categorize the resident as low risk, often noting it was unknown if the resident had fallen in the past six months. The facility's policy on fall prevention aimed to identify residents at high risk for falls based on evaluation scores, fall history, and nursing staff recommendations. However, the documentation did not reflect this policy, as evidenced by the repeated low-risk assessments despite the resident's fall history. An interview with the Director of Nursing Services confirmed that the fall risk evaluations were documented incorrectly. The facility was unable to provide a policy on maintaining clear and accurate clinical records, further highlighting the deficiency in documentation practices.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate incontinent care for a resident, identified as Resident #2, who was left without care from 12:30 AM until 5:30 AM. Resident #2 had a medical history that included subdural hemorrhage, aphonia, dysphonia, and seizures, and required extensive assistance with toileting and personal hygiene due to incontinence of bowel and bladder. The care plan for Resident #2 specified that incontinent care should be provided every two to four hours. However, due to a change in staff assignments, the nurse aide responsible for Resident #2 forgot to provide the necessary care. Interviews with staff revealed that the nurse aide assigned to Resident #2, NA #1, did not check on the resident throughout the shift, despite reminders from the charge nurse, LPN #1, about the need for frequent checks. At approximately 5:30 AM, Resident #2 was found on the floor in the bathroom with a saturated brief, indicating a lack of care for five hours. The facility's policy requires incontinent care every two hours, but this was not adhered to, leading to the deficiency. The Director of Nursing confirmed the lapse in care and the responsibility of charge nurses to ensure compliance with care policies.
Medication Reconciliation Failure on Readmission
Penalty
Summary
The facility failed to ensure proper medication reconciliation for a resident who was readmitted from the hospital. The resident, who had a history of pleural effusion, diabetes, congestive heart failure, atherosclerotic heart disease, and paroxysmal atrial fibrillation, was readmitted with new medication orders for Digoxin and Diltiazem. However, these medications were not reconciled and transcribed into the Medication Administration Records (MAR), resulting in the omission of four doses. Interviews with nursing staff revealed a breakdown in communication and responsibility. The nurse responsible for the admission assumed that another nurse had completed the medication reconciliation, while the second nurse acknowledged reactivating the resident in the electronic medical record but did not complete the reconciliation. The Director of Nursing confirmed that the facility's policy required the admitting nurse or the supervisor to reconcile medications, which was not done, leading to the resident missing critical cardiac medications.
Failure to Monitor IV Fluid Intake and Output
Penalty
Summary
The facility failed to ensure proper monitoring of intake and output for a resident receiving intravenous (IV) fluids. Resident #3, who was admitted with multiple diagnoses including congestive heart failure, atrial fibrillation, and myelodysplastic syndrome, required IV therapy due to poor nutritional intake. The resident's care plan highlighted the potential for fluid deficit and included interventions such as monitoring vital signs and signs of dehydration. Despite these directives, the facility did not provide documentation of intake and output monitoring during the administration of IV fluids on two separate occasions in December 2023. The facility's inability to produce a policy for intake and output monitoring or nursing care for residents receiving IV fluids further underscores the deficiency. Interviews with the Director of Nursing revealed an expectation for nursing staff to complete intake and output monitoring, yet this was not documented for Resident #3. The lack of documentation and policy indicates a failure in ensuring the safe and appropriate administration of IV fluids, as required by the resident's condition and physician's orders.
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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