Complete Care At Harrington Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Colchester, Connecticut.
- Location
- 59 Harrington Ct, Colchester, Connecticut 06415
- CMS Provider Number
- 075253
- Inspections on file
- 41
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Complete Care At Harrington Court during CMS and state inspections, most recent first.
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.
A resident with rheumatoid arthritis and multiple comorbidities was discharged from the hospital with Methotrexate ordered once weekly, but an RN transcribed the order as a daily dose, and the pharmacy filled it as written. Despite an EMR MAR dose warning that the daily Methotrexate regimen exceeded usual weekly dosing parameters, pharmacists reviewing the new admission orders did not identify or report the irregularity. The resident subsequently developed thrush, neutropenia, and altered respiratory status, was hospitalized with neutropenic fever, Methotrexate toxicity, and sepsis, required ICU care with intubation, and later died after extubation.
A resident with significant cardiac and respiratory diagnoses experienced respiratory symptoms and wheezing that prompted multiple APRN evaluations and orders, including a chest x-ray and IV Lasix. Staff notes later documented hypoxia, oxygen administration, and stat orders for labs and a chest x-ray on the day the resident died from heart failure related to sick sinus syndrome and COPD. However, the clinical record lacked documentation of an earlier chest x-ray order, any reason it was not performed, and respiratory assessments prior to the acute decline, despite staff recalling prior wheezing. Leadership acknowledged that nursing staff should have documented the change in condition and related assessments in accordance with the facility’s documentation policy.
A resident with multiple health conditions who was dependent on staff for ADLs repeatedly refused scheduled showers, but the care plan was not updated to reflect these refusals or to document alternative interventions such as bed baths. Staff reported the refusals verbally but did not document them, and the shower schedule was inconsistent with actual care provided. Facility policy requiring timely care plan updates and documentation of alternative interventions was not followed.
A resident with multiple risk factors for malnutrition did not have weekly weights obtained or documented as ordered, and after a significant weight loss was recorded, a re-weight was not performed promptly to confirm accuracy. Staff interviews revealed confusion about responsibilities and lack of a clear policy for re-weighing after significant changes, while the MAR allowed weights to be signed off without actual documentation.
A resident with dementia, depression, and other behavioral health issues, who was non-weight bearing after a toe amputation, repeatedly self-transferred and entered a roommate's space without assistance. Despite staff awareness and multiple observations of these behaviors, the care plan did not address them prior to a significant incident, and interventions were not formally documented or implemented until after the event.
A resident with mood disturbances and intact cognition reported being treated disrespectfully by an agency nurse aide, who entered the room without a name badge, responded with a false name, made inappropriate comments about the resident's belongings, and referenced race during their interaction. The incident was witnessed by another resident and reported to the night shift RN. Facility policies require staff to treat residents with dignity and respect, but these standards were not upheld in this case.
The facility failed to notify physicians and resident representatives as required when residents experienced missed medication doses, new pressure ulcers, and episodes of hypo- and hyperglycemia. In several cases, staff did not document or communicate these significant changes, delaying necessary assessments and interventions. Interviews revealed gaps in staff understanding and adherence to notification protocols.
Multiple residents with cognitive and behavioral disorders were involved in physical and verbal altercations, including incidents where a resident struck a roommate and a nurse aide verbally abused and handled a resident roughly. Staff and resident statements confirmed that abuse occurred, but there were delays in reporting and failure to immediately remove the staff member involved, as required by policy. Documentation also showed inconsistencies in care plans and monitoring, contributing to the failure to protect residents from abuse.
Three residents experienced incidents involving missing money or alleged abuse that were not reported to the Administrator or State Agency within required timeframes. In one case, a resident's missing money was treated as a grievance rather than a theft, delaying proper reporting. In another, an LPN witnessed a nurse aide verbally and physically mistreating a resident, but the incident was not escalated or acted upon according to policy. In the third case, a resident reported missing money, but the allegation was not promptly communicated to the DON or authorities.
A resident with cognitive impairment and incontinence was subjected to aggressive and inappropriate behavior by a nurse aide, including being yanked in a wheelchair and spoken to in a derogatory manner. Despite reports to supervisory staff, immediate protective actions were not taken, and the aide was not removed from the unit during the investigation, contrary to facility policy.
Two residents with significant or newly identified mental health conditions did not receive required PASARR rescreens, as facility staff failed to recognize or communicate the need for further screening and did not follow policy for coordinating assessments and referrals for Level II review.
A nurse prepared to administer a discontinued antibiotic instead of the currently prescribed one to a resident with multiple medical conditions, due to the discontinued medication not being removed from the medication cart. The error was identified before administration, and the correct medication was given after review of the orders. Facility policy requires adherence to physician orders and removal of discontinued medications from the cart.
The facility failed to follow physician orders and professional standards for several residents, including not ensuring the functionality of a cardiac remote transmission device, not administering scheduled medications due to unavailability without notifying the provider, and not documenting RN assessments or provider notification after multiple episodes of hyper- and hypoglycemia. Staff interviews revealed lack of awareness and confusion about responsibilities, and required documentation and communication were not completed.
A resident with severe cognitive impairment and mobility limitations developed a new pressure ulcer on the left heel that was not promptly recognized or assessed by nursing staff. The wound was not reported to the RN supervisor, and no treatment was initiated for several days. Additionally, the dietitian was not notified of the new wound, resulting in a significant delay in nutritional assessment and intervention to support wound healing.
Two residents requiring CPAP therapy did not have their equipment—including masks, tubing, and filters—cleaned or changed according to manufacturer and facility guidelines. Staff were unclear about responsibilities, documentation was inaccurate, and equipment was observed to be overdue for replacement, with some items not changed for over eight months.
A resident with multiple mental health diagnoses did not receive their prescribed Rexulti for several days because the facility failed to request a timely refill, resulting in missed doses and an exacerbation of anxiety. The facility did not follow its own policies for medication administration and timely pharmacy requests.
A resident was continued on Risperidone, an antipsychotic, without a documented psychiatric diagnosis to support its use. The medication was ordered for Bipolar disorder, but clinical records and screening did not confirm this diagnosis. The responsible APRN did not review hospital discharge paperwork or verify the diagnosis before continuing the medication, and a gradual dose reduction was not initiated as required by facility policy.
Two residents with cognitive and mental health diagnoses were subjected to verbal abuse by staff, including an LPN and a nursing assistant, who used profanities and derogatory language in response to care requests and behavioral challenges. These actions, witnessed by staff and a surveyor, violated facility policies requiring respectful and professional treatment of residents.
A resident with lymphedema and risk for skin breakdown did not receive timely ace wrap treatment as ordered by the practitioner because the order was incorrectly entered into the electronic medical record without a scheduled time, resulting in a five-day delay before the treatment was initiated.
A resident with a known pineapple allergy was served pineapple at dinner due to failures by dietary and nursing staff to follow established procedures for checking meal tickets and verifying tray contents. The resident ingested a small amount of the allergen, but no immediate allergic reaction was observed. Staff interviews confirmed lapses in protocol, including distractions and assumptions about responsibility for checking meals.
A resident with multiple sclerosis and psychiatric diagnoses was physically struck on the head by their roommate, who had a history of behavioral issues and cognitive impairment. The incident occurred after the resident told the roommate to leave the room, resulting in the roommate hitting the resident with a closed fist. The event was witnessed by another resident and confirmed by interviews and documentation, representing a failure to protect the resident from physical abuse as required by facility policy.
A LTC facility failed to prevent the misappropriation of narcotic medications for four residents, resulting in missing oxycodone tablets. The discrepancies were linked to a specific medication cart, where narcotic disposition sheets were soiled and later went missing. An LPN was found to have taken the medications for personal use, and the facility's medication destruction policy lacked a timeframe for removing narcotics after a resident's discharge or death.
A resident with insomnia and other conditions was prescribed Ambien 5 mg to be taken once daily as needed. However, an LPN administered the medication twice daily on several occasions, contrary to the physician's orders. The DNS was unaware of the error until informed by surveyors, and the resident confirmed the LPN's actions. The facility's policy on nursing documentation was not provided, and an interview with the LPN was not obtained.
A resident with chronic pain and insomnia was prescribed Ambien 5 mg as needed, but the facility failed to document its administration accurately. The Controlled Drug Receipt/Record/Disposition Form showed 28 administrations, while the MAR only documented 5. The DNS was unaware of the discrepancy, and the resident reported receiving the medication frequently from an LPN. The facility acknowledged the issue, but corrective actions are not detailed in the report.
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.
Failure to Identify and Report Methotrexate Dosing Irregularity During Pharmacy Review
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the consulting pharmacy identified and reported a significant medication irregularity involving Methotrexate dosing for a newly admitted resident. The resident’s hospital discharge orders specified Methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given once weekly. When the orders were transcribed at the facility, the Methotrexate frequency was incorrectly entered as once daily instead of once weekly, and these incorrect orders were sent electronically to the pharmacy. The pharmacy filled the Methotrexate as written on the incorrect daily orders. During the monthly drug regimen review for new admissions, the pharmacist did not identify the Methotrexate order as an irregularity, despite the EMR’s MAR dose warning indicating that the entered dose and daily frequency were outside the recommended regimen of one to ten tablets every seven days. Interviews with pharmacy personnel confirmed that two pharmacists reviewed and approved the order without recognizing the incorrect frequency, and the pharmacist in charge attributed the failure to human error. The resident had diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure, and was assessed as cognitively intact with moderate assistance needs for ADLs. Following the incorrect daily administration of Methotrexate, the resident developed thrush and later became neutropenic with altered respiratory status, as reflected in revisions to the resident’s care plan. Hospital records for a subsequent hospitalization documented admission for neutropenic fever, Methotrexate toxicity, and sepsis, during which the Methotrexate medication error was discovered. The resident required intubation and ICU care and ultimately expired after extubation.
Failure to Document Respiratory Change in Condition and Ordered Diagnostics
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for a resident with multiple cardiac and respiratory diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease. The resident’s care plan directed staff to administer medications as ordered and monitor for abnormal breath sounds, difficulty breathing, and signs of heart failure. An APRN evaluated the resident due to respiratory symptoms and increased wheezing and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from that period did not contain an order for the chest x-ray, nor any documentation explaining why the x-ray was not performed. Subsequently, the APRN again evaluated the resident at nursing’s request for a change in respiratory condition and documented that there were no signs of dyspnea, CHF, or glycemic issues, and that the resident was not in apparent distress. Later, the APRN documented another visit for increased respiratory distress, during which Lasix 40 mg IV was administered and a stat chest x-ray was ordered. Nursing notes documented that 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 ordered stat labs, a stat chest x-ray, and continuation of oxygen. The resident’s death was later pronounced the same day, with the death certificate listing heart failure due to sick sinus syndrome and COPD as the primary cause of death. Record review showed no documentation of the chest x-ray order on the earlier date, no documentation for the reason the chest x-ray was not performed, and no documentation of respiratory-related assessments prior to the later date, despite staff recalling episodes of wheezing and respiratory concerns in the week prior. The APRN confirmed she had ordered a chest x-ray and discussed the plan with a nurse but could not recall which staff member or why the order was not entered or carried out, and could not locate documentation explaining the omission. The ADON and the President of Clinical Services stated that nursing staff should have documented the change in condition and related assessments when the APRN was asked to see the resident for respiratory changes, and that the facility failed to follow its Documentation Policy requiring complete, accurate, and timely documentation by the end of the shift in which assessments or care occurred.
Failure to Revise Care Plan and Document Alternative Interventions for Refusal of Showers
Penalty
Summary
The facility failed to review and revise the care plan for a resident who consistently refused showers, and did not implement or document alternative interventions as required. The resident, who had diagnoses including adult failure to thrive, anorexia, type II diabetes mellitus, muscle weakness, and lack of coordination, was dependent on staff for transfers, personal hygiene, and bathing. Despite being scheduled for showers on specific days and shifts, documentation showed that the resident was not provided showers on multiple occasions over several months, with no follow-up documentation explaining the missed showers or indicating whether the resident had refused them. Interviews with nurse aides revealed that the resident had been refusing showers since admission but would accept bed baths instead. The aides reported notifying charge nurses when the resident refused showers, but these refusals were not documented in the clinical record. Additionally, the care plan was not updated to reflect the resident's ongoing refusal of showers or to include specific interventions addressing this behavior until after a family-initiated care conference. The shower schedule itself was inconsistent and confusing, listing showers for multiple shifts and days, which did not align with the actual care provided. Facility policy required that the comprehensive care plan be person-centered, include measurable objectives, and be updated to reflect refusals of care and alternative interventions. The policy also required documentation of attempts to provide care and discussions with the resident or their representative. However, these requirements were not met, as the care plan was not promptly revised, alternative interventions were not documented, and staff responsible for carrying out interventions were not adequately informed of changes.
Failure to Obtain and Document Weekly Weights and Prompt Re-Weight After Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document weekly weights for a resident at risk for weight loss, as ordered by the physician. The resident, who had diagnoses including adult failure to thrive, anorexia, dysphagia, and type II diabetes mellitus, was identified as being at risk for malnutrition due to poor intake and low albumin levels. Despite physician orders for weekly weights and care plan interventions to monitor weight, there was no documentation of weights being obtained on several scheduled dates, even though the Medication Administration Record (MAR) was signed off as if the weights had been taken. When a significant weight loss of 26.2 pounds in one week was documented, the facility failed to obtain a re-weight promptly to confirm the accuracy of this change. The re-weight was not performed until seven days later, and the dietician did not follow up on the significant weight loss until ten days after it was first identified. Interviews with staff revealed confusion and lack of clarity regarding responsibility for obtaining and documenting weights, as well as the absence of a facility policy on when to perform re-weights after significant changes. Further review showed that the MAR allowed nurses to sign off on weights without entering the actual measurement, and there was a period when the facility did not have a dietician on staff, resulting in a lack of interdisciplinary review of triggered weights. The facility's weight monitoring policy required timely recording and comparison of weights, but this was not followed, leading to a delay in identifying and responding to the resident's significant weight loss.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Needs
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan to address the behavioral needs of a resident with multiple diagnoses, including dementia, depression, anxiety disorder, obsessive-compulsive disorder, and insomnia. The resident was non-weight bearing on the right lower extremity following a toe amputation and required assistance from two staff members for transfers. Despite physician orders and nursing notes indicating the resident's confusion, restlessness, poor safety awareness, and need for close observation, the care plan did not address the resident's behaviors of self-transferring, wandering, or obsessive-compulsive actions. Clinical documentation and staff interviews revealed that the resident frequently got out of bed unassisted, transferred independently despite being non-weight bearing, and entered a roommate's space, sometimes rummaging through belongings or sitting on the roommate's bed. These behaviors were observed by multiple staff members and reported by the roommate, but were not formally addressed in the care plan prior to a significant incident. The Treatment Administration Record also failed to include all relevant behaviors, omitting restless and non-compliant transfer behaviors. Staff, including nurse aides and the nursing supervisor, acknowledged awareness of the resident's behaviors and described redirecting the resident or bringing them to the nurse's station, but did not update the care plan to reflect these interventions. The social worker, responsible for developing non-compliance care plans, confirmed that a care plan addressing these behaviors was not created until after an incident occurred. The Director of Nursing also indicated that a comprehensive care plan should have been developed collaboratively by nursing and social services to address the resident's specific behavioral and safety needs.
Failure to Ensure Resident Dignity and Respect by Agency Nurse Aide
Penalty
Summary
A resident with a history of atrial fibrillation, congestive heart failure, and encephalopathy, and who was identified as having intact cognition but experiencing mood disturbances, reported being treated in an undignified manner by an agency nurse aide during the night shift. The resident described that the nurse aide entered the room without a name badge, responded with a false name when asked, and made comments perceived as rude, including referencing the resident's personal items on the bed and suggesting the resident should have cleaned up. The resident also reported that the nurse aide made a comment about race, asking if the resident disliked her because of her voice or because she was black. The resident became upset, asked the nurse aide to leave, and subsequently reported the incident to the night shift nurse supervisor. Other residents and staff provided varying accounts of the incident. A nearby resident reported hearing an argument and the resident expressing that the nurse aide was hurting and being rude, while the nurse aide denied making disrespectful comments and stated that the resident was argumentative. The nurse aide also acknowledged asking the resident if race was a factor in their interaction. The nurse supervisor confirmed that the resident reported the incident and that the nurse aide did not have another staff member accompany her, despite the resident's care plan indicating a need for two staff due to a history of accusatory statements. The resident's roommate did not recall hearing any verbal abuse or rude behavior. Facility policies require staff to treat residents with dignity and respect, and to speak respectfully at all times. The incident demonstrated a failure to uphold these standards, as the resident was not treated in a dignified manner by the agency nurse aide, and the staff did not ensure adherence to the resident's care plan regarding the presence of two staff members during care.
Failure to Notify Physician and Resident Representatives of Significant Changes and Missed Medications
Penalty
Summary
The facility failed to ensure timely and appropriate notification of physicians and resident representatives in accordance with facility policy for multiple residents. For one resident admitted with complex medical needs including leg surgery, chronic kidney disease, and hypertension, several prescribed medications were not available and thus not administered as ordered. Nursing staff did not notify the physician or APRN about the missed doses, nor did they document such notifications, despite facility policy requiring immediate action and provider notification when medications are unavailable. Interviews confirmed that the responsible nurses did not follow the required procedures for reordering medications or for notifying the provider and documenting the event. Another resident, admitted with a history of falls and dementia, developed a new pressure ulcer that was first identified during a weekly skin check. The wound was not assessed by an RN, and neither the APRN nor the resident representative was notified until nine days after the initial finding. During this period, no treatment was initiated for the pressure ulcer, and the dietitian was not informed in a timely manner, delaying nutritional interventions that could support wound healing. Staff interviews revealed a lack of understanding or adherence to the protocol for new wound identification, assessment, and notification. A third resident with diabetes experienced multiple episodes of hypo- and hyperglycemia, some requiring emergency interventions such as IM Glucagon or glucose gel. Despite physician orders and facility protocols requiring provider and resident representative notification for blood glucose levels outside specified parameters, there was no documentation of such notifications for numerous incidents. Nursing staff often failed to document the events or communicate them to the appropriate parties, and in some cases, did not administer insulin as ordered or notify the provider when doses were held. Interviews with staff indicated confusion about roles and responsibilities regarding assessment, documentation, and notification in these situations.
Failure to Protect Residents from Abuse and Inadequate Staff Response
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident and staff-to-resident incidents. Several residents with cognitive impairments, psychiatric disorders, and behavioral disturbances were involved in physical altercations with each other. In one instance, a resident with paranoid schizophrenia and a history of combative behavior was observed striking a roommate, who had dementia and was identified as a wanderer. The care plans for these residents noted their behavioral risks, but conflicting documentation was found regarding their behaviors and interventions. Staff witnessed and documented physical altercations, and residents were found to have entered each other's rooms, leading to further incidents of aggression and distress. In another case, a resident with dementia and behavioral disturbances was reported by another resident to have been verbally abused by a nurse aide during the night shift. The nurse aide was overheard yelling at the resident to "shut up and be quiet" multiple times. Statements from staff and residents confirmed the occurrence of loud, inappropriate, and aggressive interactions between the nurse aide and both residents and other staff members. The nurse aide was also reported to have yanked a resident's wheelchair and made demeaning comments in the presence of the resident and others. These actions were witnessed by staff and reported by residents, but there was a delay in reporting the abuse to facility leadership, and the staff member was not immediately removed from the unit as required by facility policy. Documentation and interviews revealed that the facility's staff did not consistently follow established protocols for monitoring, redirecting, and protecting residents with known behavioral risks. There were lapses in communication and reporting among staff regarding incidents of abuse and altercations. The facility's failure to implement and adhere to its abuse prevention policies resulted in residents being subjected to physical and verbal abuse, as well as emotional distress, without timely and appropriate intervention.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to immediately report allegations of abuse and misappropriation of resident property to the Administrator and State Agency within the required timeframes for three residents. In the first case, a resident with chronic kidney disease and diabetes reported $150 missing from their wallet, which was last seen in their backpack. The wallet was found by a staff member in the laundry and returned to the resident, who immediately noticed the missing money. Despite the resident's insistence that the money was stolen, the Administrator treated the incident as a grievance rather than a theft, did not collect statements from involved staff, and did not report the incident to authorities until much later, stating she was not informed it was a theft until the day before the surveyor's interview. In the second case, a resident with Parkinson's disease and dementia was subjected to alleged verbal and physical abuse by a nurse aide, who was observed yanking the resident's wheelchair and making derogatory remarks. The incident was witnessed by an LPN, who reported it to the RN supervisor. However, the RN supervisor did not escalate the report to the Director of Nursing (DNS) or remove the alleged perpetrator from duty as required by facility policy. The DNS was unaware of the incident until the surveyor's inquiry and had not read the LPN's written statement. The facility's policy required immediate reporting and removal of staff in such cases, which was not followed. In the third case, a resident with cerebrovascular disease and dementia reported $80 missing from their purse, which was moved during the night without their knowledge. The resident informed the surveyor, who then notified the charge nurse. The charge nurse claimed to have reported the incident to the RN supervisor, who denied receiving the report. The DNS was not informed of the allegation until the following day, well beyond the required reporting timeframe. The facility's policy mandated immediate reporting of such allegations, but this was not adhered to in this instance.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
A deficiency occurred when the facility failed to take immediate steps to protect a resident from further potential abuse during an ongoing investigation. The incident involved a resident with multiple diagnoses, including Parkinson's disease, dementia, and mood disturbances, who was moderately cognitively impaired and required assistance with toileting. During a night shift, the resident was observed to have fallen, become restless, and subsequently urinated on the floor after requests for assistance were ignored by a nurse aide. The nurse aide was reported to have become agitated, yanked the resident's wheelchair, and made derogatory remarks to the resident in the presence of others. Multiple staff interviews confirmed that the nurse aide displayed aggressive and inappropriate behavior towards the resident and other staff, including yelling, cursing, and refusing to provide care when requested. The LPN on duty reported the incident to the RN supervisor, but the supervisor did not take immediate protective action or remove the nurse aide from the unit. Instead, the supervisor advised the staff to resolve their issues or take them to Human Resources, and did not escalate the report of potential abuse or ensure the safety of the resident. The Director of Nursing later confirmed that she was unaware of the full extent of the incident until prompted by surveyor inquiry and acknowledged that the facility's policy required immediate removal of staff accused of abuse. The facility's own policy mandates immediate protection of residents and removal of alleged perpetrators during investigations, but this was not followed, resulting in a failure to protect the resident from further potential harm while the investigation was ongoing.
Failure to Complete Required PASARR Rescreens for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that required Pre-admission Screening and Resident Review (PASARR) rescreens were completed for two residents with significant mental health histories or new mental health diagnoses. For one resident admitted with a history of chronic psychiatric illness, including bipolar disorder and executive deficits, the initial PASARR Level 1 screen did not identify a need for a Level II review. However, the clinical record and psychiatric notes documented a long-standing history of serious mental illness and the use of antipsychotic medication. Despite this, there was no documentation of a PASARR rescreen being initiated or completed after admission. The Social Work Director was unaware of the full extent of the resident's psychiatric history and did not initiate the required rescreen, as the psychiatric provider and facility staff did not communicate the relevant information to her. Another resident was admitted with diagnoses including anxiety disorder, dysthymic disorder, and PTSD. The initial PASARR Level 1 screen indicated no evidence of a PASARR condition, and no Level II was required at that time. Subsequently, the resident was diagnosed with major depressive disorder, a new mental health diagnosis. The clinical record did not show that a new PASARR Level 1 screen was submitted following this diagnosis. The Social Work Director confirmed that she was not the assigned social worker at the time of the new diagnosis and was unaware that a rescreen had not been completed, but acknowledged that a new PASARR should have been submitted upon identification of the new mental health condition. Facility policy requires coordination with the PASARR program to ensure that residents with mental disorders or related conditions receive appropriate care and services, including prompt referral for Level II review when a new or previously unidentified serious mental disorder is evident. The policy also assigns responsibility to the social services director for tracking PASARR screening status and making necessary referrals. In both cases, the facility did not follow its own policy, resulting in a failure to complete required PASARR rescreens for residents with significant or newly identified mental health conditions.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
A deficiency occurred when a nurse failed to administer medication in accordance with the physician's orders for a resident with a history of fractures, anemia, and bipolar disorder. The resident had a current order for Cephalexin 500mg to be given four times daily for cellulitis, but the nurse initially prepared Cefadroxil 500mg, a discontinued antibiotic, for administration. This error was identified during a medication pass observation, where the nurse was seen removing the incorrect medication from the resident's bubble pack and placing it into the medication cup. Upon inquiry, the nurse reviewed the orders again, realized the mistake, and replaced the Cefadroxil with the correct Cephalexin capsule. The nurse stated she was not usually assigned to that unit and expected discontinued medications to be removed from the cart. The facility's policy requires that medications be administered as ordered by the physician and in accordance with professional standards, including verifying the correct medication against the medication administration record (MAR) and ensuring discontinued medications are not available for administration. The Director of Nursing confirmed that the expectation is for nurses to follow the six rights of medication administration and for discontinued medications to be removed from the medication cart. The failure to remove the discontinued Cefadroxil from the cart and the nurse's initial selection of the wrong medication led to the deficiency.
Failure to Follow Physician Orders and Professional Standards in Medication Administration and Monitoring
Penalty
Summary
The facility failed to provide care and treatment according to professional standards, facility policy, and physician's orders for multiple residents. For one resident with a cardiac pacemaker, staff did not ensure the functionality of a remote cardiac transmission device. The device was found to be nonfunctional for over a month, with no documentation of daily checks or monitoring as required by the care plan and facility policy. Staff interviews revealed a lack of awareness regarding the device's status, and the last successful transmission was several months prior to the survey. The resident and staff were unaware of the device's malfunction, and there was no evidence that the physician or representative had been notified of the missed transmission. Another resident did not receive several scheduled medications, including Bumetanide, Gabapentin, and Lactobacillus, due to the medications being unavailable in the facility. Nursing staff failed to notify the physician or APRN of the missed doses, as required by facility policy. Documentation did not reflect any communication with the provider regarding the medication omissions, and the medications were not reordered in a timely manner. The facility's policy required immediate action and provider notification when medications were unavailable, but this was not followed. A third resident with insulin-dependent diabetes experienced multiple episodes of hyperglycemia and hypoglycemia, some requiring additional treatment such as glucose gel or IM Glucagon. The clinical record lacked documentation of RN assessments, provider notification, or notification of the resident's representative following these episodes, despite physician orders and facility policy requiring such actions. Staff interviews indicated confusion about roles and responsibilities for assessment and notification, with LPNs reporting that only RNs were allowed to contact providers or assess residents after a change in condition. The documentation did not reflect adherence to the hypoglycemia management protocol or communication requirements.
Failure to Provide Timely Pressure Ulcer Assessment and Nutritional Support
Penalty
Summary
A resident with a history of dementia, left femur fracture, and severe cognitive impairment was admitted and later readmitted to the facility. Upon readmission, the resident was identified as being at risk for pressure ulcers but had intact skin except for facial bruising. The care plan included interventions for skin integrity, such as barrier cream application and weekly skin checks. However, a new blister with slough was first documented on the resident's left heel during a weekly skin check, but it was not recognized as a new pressure ulcer by the nursing staff at that time. Both the RN and LPN who identified the left heel blister assumed it was an old injury and did not notify the RN supervisor or initiate a change of condition assessment as required by facility policy. As a result, no wound assessment or treatment was initiated for nine days after the initial identification of the pressure area. The first complete RN wound assessment and physician notification occurred only after the wound had deteriorated and was identified as an unstageable deep tissue injury (DTI). During this period, the resident did not receive appropriate wound care or interventions to address the new pressure ulcer. Additionally, the facility failed to notify the dietitian of the new pressure ulcer in a timely manner. The dietitian did not receive wound reports for the relevant period and was not made aware of the resident's new pressure ulcer until 49 days after its initial identification. Consequently, the resident did not receive a nutritional assessment or recommended protein supplementation to support wound healing until this late notification. These failures were contrary to the facility's policies on pressure injury prevention, management, and nutritional support.
Failure to Maintain and Change CPAP Equipment per Manufacturer Guidelines
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required CPAP therapy, as staff did not change or clean CPAP equipment—including tubing, filters, and masks—in accordance with manufacturer recommendations and facility policy. For one resident with sleep apnea and COPD, observations revealed that the CPAP mask was left unbagged, and the tubing and mask had not been changed for over eight months, despite orders and policy requiring more frequent changes. Staff interviews confirmed a lack of clarity regarding responsibility for equipment maintenance, with some nurses unaware of when equipment was last changed or cleaned, and one nurse admitting to signing off on cleaning tasks that were not performed due to lack of supplies and resident sleep schedules. For another resident with COPD and obstructive sleep apnea, similar deficiencies were observed. The CPAP tubing and mask had not been changed for over eight months, and the resident reported that no staff had cleaned the equipment in months. Staff interviews indicated confusion about the cleaning schedule and a lack of a system to ensure equipment was changed every three months as required. The facility's policy and physician orders referenced following manufacturer guidelines, but did not specify timeframes, contributing to inconsistent practices. Review of facility policy and manufacturer guidelines confirmed that CPAP masks and tubing should be changed every three months, with filters changed more frequently. However, both direct observation and staff interviews demonstrated that these protocols were not followed, and documentation of cleaning or changing equipment was inaccurate. The lack of adherence to established schedules and unclear staff responsibilities led to the failure to maintain respiratory equipment as required.
Failure to Administer Psychotropic Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of anxiety disorder, dysthymic disorder, major depressive mood disorder (MDD), and post-traumatic stress disorder (PTSD) did not receive their prescribed Rexulti medication for several days. The resident was admitted with these mental health diagnoses and had a care plan in place that included administering psychotropic medications as ordered and monitoring for adverse reactions. Despite a physician's order to administer Rexulti 1mg at bedtime for depression, the medication was not given on multiple consecutive days due to it not being available at the facility. The medication administration record (MAR) and interviews confirmed that the resident did not receive Rexulti as prescribed from 3/19 through 3/24, and the facility did not complete a timely refill request to the pharmacy during this period. The consulting pharmacist confirmed that the facility failed to request a refill for Rexulti in a timely manner, resulting in a gap in medication administration. The pharmacy policy required refill requests to be made 2-3 days before the medication ran out, but the facility did not follow this process, leading to missed doses. The resident experienced an exacerbation of anxiety due to the missed medication, as documented in a psychiatric evaluation. Facility policies required medications to be administered as ordered and in accordance with professional standards, but these were not followed, resulting in the deficiency.
Failure to Conduct Gradual Dose Reduction and Verify Indication for Antipsychotic Medication
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with a physician's order for Risperidone, an antipsychotic medication, without a documented psychiatric diagnosis to support its use. The resident's diagnoses included cerebrovascular disease and dementia, and the PASRR Level 1 screening indicated no known or suspected mental health diagnosis. Despite this, the psychiatric APRN continued the Risperidone order for a diagnosis of Bipolar disorder, which was not supported by the hospital or facility clinical records. The clinical record review and interviews revealed that the psychiatric APRN did not verify the presence of a psychiatric diagnosis before continuing the antipsychotic medication. The APRN admitted to not reviewing the hospital discharge paperwork and simply continued the medication based on the hospital orders. Another APRN noted that the resident was admitted on Risperidone without a diagnosis and expected a gradual dose reduction should have been initiated, as the only diagnosis present was dementia without behavioral disturbances. Facility policy requires that psychotropic medications only be used when necessary to treat a specific, documented condition and that gradual dose reductions be attempted unless contraindicated. In this case, the required gradual dose reduction was not initiated upon admission, and the use of Risperidone was not supported by an appropriate diagnosis, resulting in a failure to comply with facility policy and regulatory requirements regarding unnecessary medications.
Failure to Protect Residents from Verbal Abuse by Staff
Penalty
Summary
Two residents experienced incidents of verbal abuse by staff members, resulting in a failure to protect them from abuse as required. One resident, with diagnoses including cerebral infarction, legal blindness, anxiety disorder, and depression, approached an LPN at the nurse's station to request assistance with incontinent care. The LPN responded dismissively, telling the resident they were providing too many details and, after a verbal exchange, mumbled or stated profanities and derogatory remarks within the resident's hearing. Multiple staff interviews confirmed that the LPN used inappropriate language, which escalated the resident's agitation and led to a verbal altercation. The resident reported feeling upset and indicated that the LPN was unprofessional and rude. Another resident, diagnosed with anxiety disorder and schizoaffective disorder, was subjected to harsh and loud verbal remarks by a nursing assistant (NA) in a public area. The NA spoke to the resident in a derogatory tone, complained about the resident's repeated requests for water, and made disparaging comments about the resident's behavior and her own workload, all within earshot of other residents and staff. The NA further expressed frustration about her assignment and used inappropriate language to describe the resident, stating that the resident had been verbally abusive to her. The resident later reported that the NA had been mean throughout the day and delayed providing assistance with mobility. Both incidents were observed or corroborated by staff and, in the second case, by a surveyor. The facility's policies define such behavior as verbal abuse and require staff to treat residents with respect and professionalism at all times. The actions of the LPN and NA in these cases constituted verbal abuse and a failure to uphold residents' rights to be free from abuse, as outlined in facility policy and federal regulations.
Delayed Initiation of Practitioner-Ordered Treatment Due to Incorrect Order Entry
Penalty
Summary
A deficiency occurred when a resident with diagnoses including lymphedema, atherosclerotic heart disease, and anxiety did not receive timely treatment as ordered by the practitioner. The resident's care plan identified a risk for skin breakdown and required the use of ace wraps for bilateral lower extremity lymphedema. The APRN instructed that the resident's lower extremities be elevated while in bed and ace wraps be applied at 6:00 AM and removed at 6:00 PM daily. However, the order was entered incorrectly into the electronic medical record as an ancillary order without a scheduled time, preventing it from appearing on the Medication Administration Report (MAR) with the appropriate schedule. As a result, the treatment to wrap the resident's lower legs with ace wraps was not initiated until five days after the practitioner's directive. The Director of Nursing Services confirmed that the standard practice was for the nursing supervisor to verify new orders, but the missing treatment schedule was not identified until several days later, causing the delay in the initiation of the resident's prescribed care.
Resident Served Allergen Despite Documented Food Allergy
Penalty
Summary
A resident with a documented allergy to pineapple was served pineapple at dinner, despite clear indications in the care plan and electronic medical record regarding the allergy. The resident's care plan listed multiple allergies, including pineapple, and required that the allergy be noted in the electronic record and that staff monitor for allergic reactions. On the day of the incident, the resident, who had intact cognition and required assistance with personal care, was given pineapple with their meal. Nursing notes confirmed the resident ingested a small amount of pineapple, but no immediate allergic reaction was observed. Interviews revealed that the Food Services Director was aware of the incident and that a dietary aide initially removed the pineapple from the tray but inadvertently replaced it due to a distraction. The nursing assistant responsible for serving the meal did not check the tray against the meal ticket, assuming a family member would do so. Facility policies required dietary staff to check meal tickets for allergies and for nursing staff to verify trays before serving, but these procedures were not followed, resulting in the resident being exposed to an identified allergen.
Failure to Protect Resident from Physical Abuse by Roommate
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, schizoaffective disorder, and major depressive disorder was physically struck on the head by their roommate, who had diagnoses including respiratory failure with hypoxia, schizoaffective disorder, adjustment disorder, and dementia. The incident took place after the resident told their roommate to get out of the room, at which point the roommate walked over and hit the resident on the left side of the head with a closed fist. The roommate had a documented history of behavioral issues, including verbal and physical aggression, and required staff assistance for most activities of daily living due to severe cognitive impairment. The facility's policy states that each resident has the right to be free from abuse, including abuse by other residents. Despite this, the altercation occurred, and was witnessed by another alert and oriented resident who confirmed the physical assault. Interviews and documentation confirmed that the resident who was struck did not sustain physical injury and felt fine emotionally, but the event itself constituted a failure to protect the resident from physical abuse as required by facility policy.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation of controlled narcotic medications for four residents, leading to a significant deficiency. Resident #1, who had chronic pain syndrome and required oxycodone for pain management, was found to have 200 tablets missing from the facility's records. The discrepancy was discovered when staff attempted to reorder the medication, and the pharmacy indicated it was too soon for a refill. The facility's documentation showed that 360 tablets had been received, but only 160 were documented as administered. Resident #2, diagnosed with cancer and experiencing moderate pain, had 31 tablets of oxycodone missing. The facility had received 60 tablets, but only 29 were documented as administered before the resident's death. Similarly, Resident #3, who suffered from fibromyalgia and chronic pain, had 21 tablets missing from the 30 received by the facility. Resident #4, with chronic gout and diabetes, had 111 tablets missing from the 210 received. The discrepancies were linked to the West-1 medication cart, where the narcotic disposition sheets were reportedly soiled and later went missing. Interviews with staff revealed that LPN #7 was associated with the missing medications. The LPN had reported incidents of the narcotic book being soiled and was later found to have taken the oxycodone for personal use. The Director of Nursing Services (DNS) identified that the facility's medication destruction policy lacked a timeframe for removing narcotics after a resident's discharge or death, contributing to the oversight. The facility's failure to secure and accurately document the administration of narcotic medications resulted in the misappropriation of residents' medications.
Medication Administration Error Due to Non-Compliance with Physician's Orders
Penalty
Summary
The facility failed to adhere to physician's orders for medication administration for a resident diagnosed with insomnia, chronic pain syndrome, low back pain, and polyneuropathy. The resident, who had intact cognition and was independent in daily activities, was prescribed Ambien 5 mg to be administered once every 24 hours as needed for insomnia. However, the Controlled Drug Receipt/Record/Disposition Form revealed that the medication was administered twice daily on multiple occasions by an LPN, contrary to the physician's directive. The Director of Nursing Services (DNS) was unaware of the medication error until notified by the surveyor. Upon verification with the Advanced Practice Registered Nurse (APRN), it was confirmed that the resident was only supposed to receive the medication once per day. The resident corroborated that the LPN administered the medication more frequently, providing an additional dose if the initial dose was reported as ineffective. The DNS confirmed that borrowing narcotics from other residents' stock is prohibited and that the duplicate administrations were medication errors. An interview with the LPN involved was not obtained, and the facility's policy on nursing documentation was not provided.
Failure to Document and Evaluate As-Needed Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation and evaluation of as-needed narcotic administration for a resident diagnosed with chronic pain syndrome, low back pain, and polyneuropathy. The resident, who had intact cognition and frequently experienced moderate pain, was prescribed Ambien 5 mg as needed for insomnia. However, the Controlled Drug Receipt/Record/Disposition Form indicated that Ambien was administered 28 times over a period, while the Medication Administration Record (MAR) only documented administration on 5 occasions. This discrepancy suggests a failure in maintaining accurate records of medication administration. Interviews revealed that the Director of Nursing Services (DNS) was unaware of the discrepancy and confirmed that nurses are expected to document all as-needed medications in the MAR and follow up on their effectiveness. The resident reported receiving Ambien from an LPN every time she worked, and if the medication was ineffective, the LPN would administer another dose. The facility's Administrator acknowledged the issue and noted that a Plan of Correction was in place, but the report does not detail the corrective actions taken.
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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