Grandview Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Britain, Connecticut.
- Location
- 55 Grand Street, New Britain, Connecticut 06052
- CMS Provider Number
- 075182
- Inspections on file
- 56
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 40 (1 serious)
Citation history
Health deficiencies cited at Grandview Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with opioid dependence, anxiety, COPD, and other conditions, who was ordered Methadone 10 mg once daily for maintenance therapy, was given another resident’s Methadone dose of 120 mg after an RN removed two residents’ Methadone bottles from a locked cart at the same time and placed them on top of the cart. The RN verified the resident’s name and stated dose but then handed the wrong bottle without re-checking it at the bedside, despite the resident questioning the unusually large volume of liquid. The resident consumed the medication and was later confirmed, through clinical and hospital records, to have received an 1100% higher Methadone dose, requiring hospital admission and ICU-level care. This occurred in the context of a facility policy requiring adherence to the six rights of medication administration, including right resident and right dose, which were not followed.
Surveyors found that multiple residents’ physician orders were not reviewed and signed by the admitting physician at admission and monthly as required by facility practice. Record review showed that several newly admitted residents lacked timely physician signatures on their orders on expected review dates. The DON reported that the admitting physician is responsible for signing admission orders within 48–72 hours and then monthly, but was unaware that this was not occurring consistently. The Medical Director confirmed the expectation for timely signatures and noted that the electronic clinical record does not prompt physicians to sign orders, which may have led to missed signatures, and the facility could not provide a written policy specifying the frequency of physician order review.
The facility failed to complete required Methadone self-administration evaluations before two residents began supervised self-administration of this controlled substance. One resident with opioid dependence and moderately impaired cognition received multiple Methadone doses, including an incorrect 120 mg dose instead of 10 mg, without an updated self-administration evaluation completed on readmission or before new dosing. Another resident with chronic opiate use and a lumbar wedge compression fracture received daily Methadone 120 mg for many days before any self-administration evaluation was documented. The DON confirmed that evaluations were required on admission, readmission, and at initiation of Methadone, and facility policies specified that a successful self-administration evaluation must occur prior to the first administration and at defined intervals, which did not occur in these cases.
A resident with vascular dementia and multiple psychiatric and substance-related diagnoses experienced a progressive change in cognition and behavior, including increased confusion, wandering, exit-seeking, entering other residents’ rooms, and attempts to access an elevator. Nursing staff documented these changes over several weeks and placed the resident on every 15‑minute checks, but did not notify a provider of the significant mental and behavioral changes as required by facility policy. A psychiatric provider was only contacted after an incident in the dining room involving frustrated behavior, and later documented ongoing confusion, sundowning, wandering, and exit-seeking. Eventually, staff discovered the resident was no longer on the unit and had exited the building before being located and returning, with leadership interviews confirming that timely provider notification of the initial changes had not occurred.
A resident with a history of long‑term opiate use and a lumbar wedge compression fracture was started on high‑risk Methadone maintenance therapy without a baseline Resident Care Plan (RCP) addressing this medication. Nursing staff did not initiate an RCP for Methadone, and the MDS Coordinator did not identify the omission during the 72‑hour care plan meeting or while completing the admission MDS, even though Methadone was being administered and facility policy required a baseline care plan within 48 hours of admission that included admission orders and health and safety concerns.
Two residents with dementia and cognitive impairment did not receive complete or timely Wander Risk Evaluations as required by facility policy. One resident with vascular dementia, TBI history, substance dependence, and impaired cognition had only one Wander Risk Evaluation documented over more than a year, despite a care plan noting dementia, poor impulse control, fall risk, and every 15‑minute monitoring, and a nurse’s note documenting the resident’s expressed desire to leave the facility that did not trigger a new evaluation. Another resident with dementia, altered mental status, and a history of falls had a physician’s order for a Wanderguard and an incomplete Wander Risk Evaluation with only one of eight items answered, with no subsequent evaluations documented, even though the MDS and care plan identified severe cognitive impairment and risk for wandering/elopement. Facility policies required elopement/wander risk assessments on admission, readmission, quarterly, annually, and with significant changes in condition, and the DON acknowledged these evaluations were not completed as required.
A resident with chronic opioid use and a lumbar compression fracture received Methadone concentrate 120 mg/mL for maintenance therapy before a physician order was entered. The Methadone Chain of Custody Record documented administration of Methadone on multiple days, including two doses given prior to the date the prescriber’s order was written. The DON later acknowledged that medications should not be given without a physician’s order and that staff had been using the Methadone Chain of Custody Record as the administration record instead of relying on an order in the electronic medical record, contrary to facility policies on Methadone use and the six rights of medication administration.
A resident with vascular dementia, TBI history, generalized weakness, polyneuropathy, and documented fall and exit‑seeking risk was placed on q15‑minute safety checks per physician order and care plan. Over time, staff notes and psych provider documentation showed increasing confusion, wandering, sundowning, and repeated attempts to reach the elevator and exits. Despite this, the resident did not consistently have additional safeguards such as a Wanderguard, and a keypad‑secured stairwell on the unit led down multiple flights to an unsecured exterior door. On the incident day, the resident watched staff enter the keypad code, waited until the hallway was clear, opened the stairwell door, descended the stairs, exited to the street, and walked about half a mile away without staff awareness. The q15‑minute check sheet for that shift was later completed after the fact at the direction of an ADON, with NAs documenting checks they had not performed, including times when the resident was already off the unit, resulting in inaccurate medical record documentation and failure to provide the ordered level of supervision.
A resident with vascular dementia, substance use disorders, anxiety, depression, and chronic pain experienced a documented decline in cognition and behavior, including confusion, wandering, exit seeking, and attempts to reach the elevator, as recorded repeatedly by nursing staff and psychiatric providers. Although the care plan called for monitoring cognitive changes and the resident was placed on every 15‑minute checks for exit‑seeking behavior, social services did not meet with or assess the resident after the change in cognition, and no repeat BIMS assessment was completed over several weeks. The Director of Social Services acknowledged awareness of the decline but confirmed no reassessment occurred, and the DON stated that social services evaluation and a repeat BIMS should have been completed with the change in cognition, contrary to the facility’s Dementia Care policy.
A resident with dementia, substance dependence, psychiatric diagnoses, and a history of poor impulse control was care planned and ordered for every 15-minute monitoring after expressing a desire to leave. On one shift, the resident exited through a secured door and left the building, as later confirmed by camera footage. However, the 15-minute check sheet for that shift was fully completed, indicating the resident was on the unit at times when the resident was actually off the unit. Staff interviews revealed that the assigned NA did not perform the checks, another NA was not assigned to the resident and filled out the sheet only after being directed by the ADON, and times were estimated rather than based on actual observation. The DON and ADON acknowledged that the documentation was inaccurate and completed after the fact, contrary to facility policy requiring factual, timely, and truthful medical record entries.
A resident with cognitive and psychiatric diagnoses became upset after being denied permission to leave the facility, leading to a confrontation with staff. During the incident, a supervisor responded to the resident's verbal aggression by repeating foul language and threatening to pour water on the resident, actions that were acknowledged as inappropriate and contrary to facility policy prohibiting abuse and threats.
The facility did not ensure that agency RNs had completed background checks before starting work, as required by policy. Documentation confirming background screenings was not available, and interviews revealed confusion over responsibility for verifying these checks.
A resident with multiple fractures and anxiety, dependent on staff for care, was subjected to verbal abuse and an attempted physical assault by a nurse aide following a disagreement over care timing. The aide yelled, used inappropriate language, and attempted to throw objects at the resident, but was stopped by other staff who witnessed the incident.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident was not adequately protected from being separated from others, their room, or being confined to their room, resulting in a violation of their rights.
Several residents with personal funds accounts, including those with cognitive and mental health conditions, were unable to access their money outside of limited weekday banking hours. Facility staff confirmed that withdrawals were restricted due to posted hours, cash availability, and issues related to a change in ownership, resulting in delays and limits on resident access to their own funds.
The facility did not notify several Medicaid residents when their personal fund accounts approached the SSI resource limit and failed to distribute personal funds to discharged residents within the required timeframe. Some residents' account balances exceeded the allowable limit, and discharged residents experienced delays in receiving their remaining funds. The facility also lacked a specific policy for managing and distributing resident personal funds.
The facility did not update care plans or implement new interventions after falls for a resident with dementia, failed to complete required neurological checks, and did not ensure staff communicated or documented interventions. Another resident was allowed to leave the facility without a current LOA order, and the system for tracking LOAs was ineffective, making it impossible to account for residents during emergencies. Additionally, a resident with severe cognitive impairment was not provided required assistance for ambulation, resulting in multiple falls, and the facility failed to monitor hot water temperatures, exposing several cognitively impaired residents to unsafe conditions.
Facility administration failed to provide effective oversight, resulting in residents not being protected from verbal abuse and involuntary seclusion, delayed reporting and investigation of abuse allegations, improper management of personal needs accounts, lack of individualized activities for dependent residents, failure to follow physician's orders, unsafe water temperatures, and inadequate pest control. Actual harm occurred related to abuse, neglect, and exploitation.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of its investigation to the proper authorities as required.
Multiple residents experienced incomplete or delayed investigations into allegations of abuse, neglect, and misappropriation, with missing documentation, lack of staff and witness interviews, and failure to follow facility policy. In several cases, residents with cognitive and physical impairments were not adequately protected, and incidents were not reported or investigated as required, resulting in unaddressed allegations and continued staff access to affected residents.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions. Surveyors found that the care planning documentation was incomplete and did not meet regulatory requirements for individualized care.
The facility did not ensure that advance directive choices were properly completed and documented for several residents, including those with cognitive and physical impairments. In multiple cases, required signatures from residents, conservators, or physicians were missing, and staff failed to follow protocols for obtaining and recording advance directive decisions at admission. Efforts to contact responsible parties were not always documented, and some residents were not included in facility-wide audits of advance directive documentation.
A resident with diabetes, schizophrenia, and chronic kidney disease had a documented blood sugar level of 331, well above the normal range. Despite physician orders to notify the provider of elevated blood sugar results, staff did not inform the physician, and there was no documentation of such notification in the clinical record. Interviews with an LPN and an APRN confirmed that the required notification did not occur, and the facility's policy for notification of change was not followed.
A resident dependent on staff for ADLs, including bathing and personal hygiene, did not receive required fingernail care despite care plan directives and physician's orders. Observations confirmed the resident's nails were long and untrimmed, with debris present, and an LPN acknowledged that nail care should have been provided but was not.
A resident with diabetes did not receive a scheduled blood glucose check or insulin injection as ordered, due to a lapse in medication administration during a staff reassignment. The MAR showed the omission, and interviews confirmed that neither the LPN nor the RN supervisor completed the required tasks, resulting in a medication error that was later documented by the DON.
A resident did not receive the necessary care to maintain or improve ROM or mobility, and there was no documented medical reason for the decline.
A resident with schizophrenia, paranoia, and HIV did not receive pharmacy-recommended lab work for antiretroviral therapy after a missed appointment, and the lab was not rescheduled or completed. Additionally, the care plan for this resident included antipsychotic medication but lacked documentation of alternative, non-pharmacological interventions for behavioral symptoms.
A deficiency was cited when a resident was not protected from the wrongful use of their belongings or money, indicating a lapse in safeguarding personal property or funds.
A resident with heart failure and multiple comorbidities experienced significant, unmonitored weight gain due to the facility's failure to follow its own policies for daily assessment, weight monitoring, and dietary management. Required nursing assessments and physician orders for dietary and fluid restrictions were not documented, and key facility policies were not provided when requested.
A resident with a history of anxiety and recent hip replacement, who was alert and oriented, reported their debit card missing and unauthorized charges. Investigation revealed a nurse aide, despite having completed abuse prevention training, removed the card from the facility and used it at an ATM, failing to return it. The aide did not return to work after the incident, and the facility's policy prohibiting misappropriation of resident property was not followed.
A resident, who was cognitively intact and independent with eating, preferred personal snacks and meals over the facility's food. Despite a policy allowing food reheating, staff were unwilling to heat the resident's food, citing safety concerns. Interviews revealed confusion about the policy, and the lack of thermometers contributed to the issue, leading to the resident's dissatisfaction.
A resident with dementia had their feet run over by another resident using a wheelchair, who was agitated and not redirectable. Despite being aware of the other resident's presence, the agitated resident moved their wheelchair forcefully. No interventions were implemented to prevent further incidents, and the affected resident's care plan was not updated, contrary to the facility's policy on abuse prevention.
The facility failed to update care plans for two residents with pressure ulcers, leading to deficiencies in their care. One resident's care plan lacked an intervention for offloading pressure on the heel, while another resident's care plan did not reflect non-compliance with offloading boots and new pressure areas. Staff were unaware of these issues, and the facility's policy for care plan updates was not consistently followed.
The facility failed to provide accessible smoking receptacles during a supervised smoking break. Observations showed that residents, including one who needed assistance to dispose of a cigarette butt, were seated away from the receptacles. Staff interviews revealed that residents often required help to dispose of cigarette butts, and staff were unaware if the receptacles were movable, contrary to the facility's smoking policy.
A resident with COPD and other conditions was observed receiving oxygen therapy at a flow rate exceeding the prescribed 1-4 liters per minute. An LPN was unsure why the oxygen was set incorrectly and had not completed morning rounds to adjust it. This failure to follow the physician's order was identified during observations on two consecutive days.
A facility failed to monitor target behaviors for a resident on psychoactive medications, including an antipsychotic. Despite a pharmacist's recommendation, there were no physician's orders for monitoring, and no documentation of behaviors was found for 36 days. The resident, who was severely cognitively impaired, exhibited various behaviors, and a psychiatric visit later led to the discontinuation of the antipsychotic medication.
A resident with Alzheimer's disease was admitted to the facility without a functioning call bell system in their room, despite a care plan requiring its use for assistance. The absence of the call bell was not reported or addressed by staff, and the Maintenance Director was unaware of the issue. The facility's policy mandates that call bell systems be accessible and functioning, but this was not followed.
A resident with legal blindness and impulse disorder was involved in an incident where a Social Work Assistant raised her voice and made dismissive comments during a confrontation about missing personal items. The facility failed to ensure staff interacted with the resident in a dignified manner, as the Social Work Assistant did not follow the care plan's directive to de-escalate and walk away if the resident became aggressive.
A resident with dementia was physically abused by another resident who was agitated and verbally abusive. Despite being informed of the presence of the resident with dementia, the agitated resident forcefully moved their wheelchair, causing harm. The facility's policy on abuse and care planning was not effectively implemented.
A resident with a history of unsafe smoking practices and under 1:1 observation was found using a vape pen in their room. In response, the facility removed the privacy curtain from the resident's shared room, resulting in inadequate privacy compared to the roommate and a failure to maintain confidentiality of personal and medical records.
Two residents on 1:1 observation, both alert and oriented, were able to obtain and use vape pens and possess weapons such as knives and a machete within the facility. Despite direct staff supervision and facility policies prohibiting these items, the residents acquired and retained them, and staff were unable to determine how this occurred.
Facility administration did not prevent residents on 1:1 observation from accessing contraband, including vape pens and knives, and failed to stop residents from smoking vape pens inside. Interviews with the DON and Medical Director showed a lack of clear oversight processes and staff education, and no facility policy was provided to address these issues.
A resident with anxiety disorder and hypertension, who was cognitively intact and required supervision, was verbally abused and intimidated by a staff member following a disagreement during a smoke break. The staff member yelled, used profanities, and displayed threatening behavior toward the resident, including hitting the elevator door and attempting to enter while the resident was inside. Multiple staff witnessed the incident, and the resident was left visibly upset and shaken.
The facility did not ensure timely and documented social services follow-up for three residents after abuse incidents. In each case, either the initial social services contact was delayed, the incident was not referenced in documentation, or there was no evidence of ongoing follow-up as required by facility policy. Staff interviews confirmed that required follow-up and documentation did not occur as expected.
The facility did not ensure complete and accurate medical record documentation after abuse incidents involving three residents with various cognitive and physical impairments. In each case, initial notes were made, but required follow-up and monitoring entries were missing, despite facility policy and staff expectations for ongoing documentation after such events.
A resident at risk for pressure ulcers developed a wound on the coccyx that was not promptly assessed or treated, leading to its worsening. Despite being identified as at risk, the facility did not implement necessary preventive measures, and the wound was not properly documented or managed until two weeks after its discovery. Interviews revealed a lack of communication and adherence to the facility's wound management policy.
The facility failed to safeguard and reconcile controlled medications, resulting in 49 unaccounted-for medications. The DNS revealed that the CSDR were not reconciled after the ADNS left, and no narcotic audits were conducted. During audits, numerous CSDRs were found without corresponding white copies or bubble packs. The Medical Director was unaware of the issue, and the facility did not provide a policy on narcotic requisition, disposition, destruction, or audit.
The facility failed to administer medications on time and according to physician's orders for several residents. Medications were often given late, and some were crushed and mixed without proper orders. Staff interviews revealed a lack of awareness and communication regarding medication administration policies.
Significant Methadone Overdose Due to Failure to Follow Medication Administration Rights
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident receiving Methadone for substance use disorder was administered the medication according to the physician’s order, resulting in a significant medication error. The resident had diagnoses including opioid dependence, adjustment disorder, anxiety disorder, COPD, and a deviated nasal septum, and was care planned as being at increased risk for pain and using Methadone for treatment. A physician’s order directed that Methadone concentrate 10 mg/mL be given at a dose of 10 mg orally once daily for Methadone maintenance therapy. On the day of the incident, the RN responsible for medication administration opened the locked Methadone cart and removed Methadone bottles and chain-of-custody records for two residents at the same time, placing both bottles on top of the medication cart. With the cart positioned in the doorway of one resident’s room, the RN asked the resident to state their name and Methadone dose and verified the bottle and record, but then turned and picked up a Methadone bottle without confirming it was the correct one before handing it to the resident. The resident noted that the amount of liquid in the bottle was unusually large compared to their usual dose and questioned the RN, who initially affirmed it was correct. After the resident consumed the Methadone, the RN checked the bottle and discovered that the resident had been given another resident’s Methadone, which was a 120 mg dose instead of the prescribed 10 mg. The resident’s clinical record and hospital documentation confirmed that the resident received 120 mg of Methadone rather than the ordered 10 mg, constituting an 1100% higher dose. The resident was transferred to the hospital, where the discharge summary documented admission for accidental Methadone overdose, an ICU stay, and treatment with a Narcan drip, which was later weaned before the resident was restarted on Methadone 10 mg daily and discharged back to the facility. Interviews with the resident, the RN, the APRN, and the DON, along with review of the facility’s Medication Administration policy, showed that the RN did not follow the six rights of medication administration, including verifying the right resident and right dose at the bedside, and improperly removed and handled two residents’ Methadone bottles simultaneously, leading to the significant medication error.
Failure to Ensure Timely Physician Review and Signature of Orders
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for ensuring that physicians review, sign, and date resident orders at admission and on a monthly basis. For five of twelve sampled residents, clinical record review showed that physician orders were not reviewed and signed in accordance with facility practices. One resident admitted on 1/11/26 did not have orders reviewed and signed on 1/14/26 or 2/1/26, another admitted on 1/17/26 lacked signed orders on 1/20/26 and 2/1/26, and a third admitted on 1/18/26 had no evidence of order review and signature on 1/21/26 or 2/1/26. Two additional residents admitted on 2/3/26 and 2/15/26, respectively, did not have their orders reviewed and signed on 2/6/26 and 2/18/26 as expected. During interviews, the DON stated that the admitting physician is responsible for reviewing and signing admission orders when completing the initial history and physical within 48–72 hours of admission and then monthly, and reported being unaware that orders were not consistently signed. The Medical Director similarly stated that the admitting physician is responsible for signing admission orders within 72 hours and monthly thereafter, and explained that when the clinical record is accessed there is no prompt to sign orders, which may have contributed to orders being missed. When requested, the facility was unable to provide a policy specifying the required frequency for physician order review.
Failure to Complete Methadone Self-Administration Evaluations Prior to Dosing
Penalty
Summary
The deficiency involves the facility’s failure to complete required self-administration of medication evaluations before residents began self-administering Methadone, a controlled substance, as required by facility policy. For one resident with diagnoses including opioid dependence, adjustment disorder, and anxiety disorder, the quarterly MDS showed moderately impaired cognition with independence in ADLs, bed mobility, transfers, and ambulation. The resident’s care plan identified increased risk for pain due to a history of substance use disorder and use of Methadone for treatment, with interventions focused on anticipating pain needs and coordinating with the contracted treatment agency. Despite this, the clinical record showed that a Medication Self-Administration Evaluation had not been completed since several months prior. After a hospital discharge and readmission, a physician’s order directed Methadone 10 mg once daily with approval for supervised self-administration. The Methadone Chain of Custody Record showed the resident received Methadone from multiple dates, and a nurse’s note documented that a nurse inadvertently selected the wrong Methadone bottle, administering 120 mg instead of the prescribed 10 mg. The APRN was notified and the resident was transferred to the ED for evaluation and monitoring due to significant overdose risk. The record confirmed that no updated Medication Self-Administration Evaluation had been completed at that time. Following another hospital discharge and readmission, the resident again received Methadone doses before a new Medication Self-Administration Evaluation was completed, which occurred two days after readmission and after two doses had already been administered. A second resident, with diagnoses including long-term use of opiate analgesic and a wedge compression fracture of the first lumbar vertebra, was documented on admission as alert and oriented to person, place, time, and situation, requiring limited assistance with transfers and being independent with bed mobility. The Methadone Chain of Custody Record showed this resident received Methadone 120 mg daily over a span of about 20 days. A physician’s order approved supervised self-administration of Methadone, but the clinical record did not contain a Medication Self-Administration Evaluation until many days later, after approximately 20 doses had already been given. The care plan later identified risk for substance use disorder with a history of substance use and Methadone utilization. The DON stated that self-administration evaluations were required on admission, readmission, and upon initiation of new Methadone orders, and acknowledged that these evaluations should have been completed prior to any resident self-administering Methadone. Facility policies on residents receiving Methadone, self-medication, and the schedule of evaluations all directed that a self-administration evaluation be successfully completed prior to the first administration and at specified intervals, which did not occur for these residents.
Failure to Timely Notify Provider of Resident’s Cognitive and Behavioral Decline
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a provider of a resident’s significant change in behavior and cognition, as required by its Notification of Changes policy. The resident had multiple diagnoses including vascular dementia without behavioral disturbances, alcohol and opioid dependence, generalized anxiety disorder, depressive episodes, and chronic pain. A quarterly MDS showed moderately impaired cognition with independence in mobility and no wandering behaviors. The resident’s care plan, dated 1/22/26, identified impaired cognitive function/dementia, poor impulse control, a history of altercations, psychoactive drug use, fall risk, alcohol abuse, and risk for disorientation, confusion, unsteady gait, and slurred speech, with interventions including monitoring and reporting changes in cognitive function and behavior, and every 15‑minute monitoring per a physician’s order dated 1/23/26. Beginning on 1/23/26, nursing documentation reflected escalating behavioral and cognitive changes. A nurse’s note on 1/23/26 recorded the resident’s expressed desire to leave the facility and initiation of every 15‑minute checks. On 1/24/26, the resident was documented as confused, exit seeking, going into other residents’ rooms, and attempting to get to the elevator. On 1/29/26, notes again identified exit‑seeking behaviors, including the resident stating an intention to leave and not return and not wearing a Wanderguard. A psychiatric evaluation on 2/4/26 documented functional and cognitive decline that remained evident. However, review of the clinical record from 1/23/26 through 2/10/26 did not show that any provider had been notified of the increased confusion, wandering, or exit‑seeking behaviors during this period. Further nursing notes throughout February continued to document increased confusion, wandering, searching for family members, and repeated attempts to access the elevator and exit, including entries on 2/12/26, 2/13/26, 2/17/26, 2/20/26, 2/22/26, and 2/23/26. A psychiatric APRN was first asked to see the resident on 2/11/26 after an incident in the dining room where the resident threw something in frustration, and again on 2/13/26 for exit‑seeking behavior, increased confusion, and agitation, at which time new PRN medication was ordered. On 2/20/26, the psychiatric APRN documented staff reports of continued confusion, sundowning, wandering, and exit‑seeking and ordered additional medication. On 2/25/26, nursing documentation showed that staff discovered the resident was not in the room or on the unit, initiated a search, and later learned the resident had exited the building and was returning. Interviews with the psychiatric APRN, Medical Director, and DON confirmed that the psychiatric provider and Medical Director were not notified of the resident’s initial change in cognition and behaviors when first identified, despite the facility policy requiring notification for significant changes in mental or psychosocial condition.
Failure to Develop Baseline Care Plan for High‑Risk Methadone Therapy
Penalty
Summary
The deficiency involves the facility’s failure to develop a baseline Resident Care Plan (RCP) within 48 hours of admission for a resident receiving a high‑risk controlled substance, Methadone. The resident had diagnoses including long‑term use of opiate analgesic and a wedge compression fracture of the first lumbar vertebra, and the admission evaluation documented that the resident was alert and oriented, required limited assistance with transfers, and was independent with bed mobility. A Methadone chain of custody record showed the resident received Methadone 120 mg per mL over multiple days, and a physician’s order directed Methadone concentrate 120 mg per mL, 120 mg orally once daily for Methadone maintenance therapy. Despite these orders and administration of a high‑risk medication, review of the clinical record did not identify that an RCP had been developed for Methadone use. Interviews with the DON and the MDS Coordinator confirmed that Methadone is considered a high‑risk medication and that a baseline RCP should have been developed by nursing prior to the resident starting Methadone. The DON stated nursing was responsible for initiating the RCP and that the MDS Coordinator was responsible for reviewing RCPs at the 72‑hour care plan meeting and during completion of the admission MDS assessment, but the absence of an RCP for Methadone was not identified at those times. The MDS Coordinator acknowledged that a 72‑hour care plan meeting was held and that she signed the RCP as complete, yet an RCP for Methadone use had not been developed. This failure occurred despite a facility Baseline Care Plan policy directing that a baseline care plan be developed within 48 hours of admission, including initial goals based on admission orders and any health and safety concerns, and that a supervising nurse verify within 48 hours that a baseline care plan has been developed.
Failure to Complete Wander Risk Evaluations per Policy for Residents with Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to complete Wander Risk Evaluations according to its own policies for two residents with dementia and cognitive impairment. One resident with vascular dementia, substance dependence, generalized anxiety disorder, depressive episodes, and a history of traumatic brain injury had a Wander Risk Evaluation completed on 2/4/25 that identified a low risk for wandering, with no further Wander Risk Evaluations documented from 2/5/25 through 2/27/26. A quarterly MDS showed moderately impaired cognition and independence with mobility, and the resident’s care plan identified impaired cognitive function/dementia, poor impulse control, history of altercations, psychoactive drug use, fall risk, history of alcohol abuse, and risk for disorientation and confusion, with interventions including every 15‑minute monitoring. A nurse’s note documented that on 1/23/26 the resident expressed a desire to leave the facility and was placed on every 15‑minute checks, but no new Wander Risk Evaluation was completed at that time. The second resident had dementia without behavioral disturbances, altered mental status, a history of falls, and a physician’s order for a Wanderguard on the right wrist with placement and function checks every shift. A Wander Risk Evaluation dated 11/12/25 identified a low risk for wandering/elopement but was incomplete, with only one of eight questions answered, and no subsequent Wander Risk Evaluations were found in the clinical record. A quarterly MDS identified severely impaired cognition and memory problems, and the care plan documented that the resident was at risk for wandering and/or elopement with an intervention for a Wanderguard on the right wrist. Facility policies required elopement/wander risk evaluations on admission, readmission, quarterly, annually, and with significant changes in condition, and ongoing assessment for elopement and unsafe wandering throughout the stay. The DON confirmed that Wander Risk Evaluations should be completed in their entirety at least quarterly and acknowledged that required evaluations were not completed for these residents.
Methadone Administered Without Physician Order
Penalty
Summary
A resident with diagnoses including long-term use of opiate analgesics and a wedge compression fracture of the first lumbar vertebra was admitted alert and oriented, requiring limited assistance with transfers and being independent with bed mobility. The Methadone Chain of Custody Record showed that this resident received Methadone concentrate 120 mg/mL from 2/5/26 through 2/24/26. However, the physician’s order for Methadone concentrate 120 mg/mL, 120 mg orally once daily for Methadone maintenance therapy, was not entered until 2/7/26, after the resident had already received doses on 2/5/26 and 2/6/26. The DON stated that medications should not be administered without a physician’s order and reported being unaware that the resident did not have a physician’s order for Methadone until 2/7/26. The DON also identified that the facility used the Methadone Chain of Custody Record as the Methadone administration record, but a physician’s order should have been entered into the electronic medical record. Facility policy for residents receiving Methadone for opioid addiction required that the attending physician and pharmacy be notified of the resident’s participation in the Methadone maintenance program and that an order be obtained for self-administration after a self-administration evaluation. The undated Medication Administration policy directed staff to follow the six rights of medication administration and to compare the medication source with the Medication Administration Record to verify the resident’s name, medication name, form, dose, route, and time.
Failure to Supervise Exit-Seeking Resident on 15-Minute Checks Resulting in Elopement via Unsecured Stairwell
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an accident‑hazard‑free environment for a resident with known fall risk, cognitive impairment, and documented exit‑seeking behaviors. The resident’s diagnoses included generalized muscle weakness, lack of coordination, polyneuropathy, vascular dementia, history of TBI, alcohol and opioid dependence, anxiety, and depression. A fall risk evaluation identified the resident as a moderate fall risk, and the resident care plan documented a history of falls and risk for falls related to confusion, unawareness of safety needs, psychoactive and sedative/hypnotic medication use, impaired cognition, and poor impulse control. The care plan interventions included maintaining a safe environment, anticipating and meeting needs, monitoring for clinical and behavioral changes, and placing the resident on every 15‑minute monitoring for safety. The clinical record and progress notes showed a pattern of increasing confusion, wandering, and exit‑seeking behavior over several weeks. Multiple nursing notes documented the resident going into other residents’ rooms, attempting to get to the elevator, searching for exit doors, and looking for family members. Psychiatric provider notes identified functional and cognitive decline, ongoing confusion, agitation, sundowning, wandering, and exit‑seeking, and confirmed that the resident was on every 15‑minute checks for exit‑seeking behavior. Despite these documented behaviors and the physician’s order dated 1/23/26 for every 15‑minute observations each shift, there was no evidence that additional environmental safeguards, such as a Wanderguard, were in place, and the resident was noted at one point not to be wearing such a device. On the day of the elopement, the resident expressed a desire to leave and was told by a nurse that a leave of absence order was required. Later, camera footage showed the resident in the hallway looking around to ensure no one was present, then approaching a keypad‑secured stairwell door, entering the code observed from staff use, and exiting through the stairwell. The stairwell led down 4.5 flights of stairs to an unsecured exit door that opened directly to the street. The resident descended the stairs, exited the building, and walked approximately 0.5 miles along a main street without staff awareness. Staff did not realize the resident was missing until later, at which point a nurse documented that the last time she had seen the resident was at 1:00 PM. The resident was later located off premises and returned. Documentation related to the ordered every 15‑minute safety checks was found to be inaccurate and not reflective of actual monitoring. The 15‑minute check sheet for the day of the incident showed continuous checks from 7:00 AM through 1:15 PM, including entries indicating the resident was in the hallway at times when camera footage and staff accounts established the resident had already left the unit and the building. Nursing assistants interviewed reported they had not actually performed the 15‑minute checks but were directed by the ADON, after the resident was discovered missing, to complete the check sheet despite the checks not having been done. One NA stated she estimated times and signed the sheet, including for intervals when the resident was off the unit. The DON and Medical Director later acknowledged that the psychiatric provider had not been notified promptly of the resident’s increasing confusion and exit‑seeking, that the 15‑minute checks were not completed as ordered, and that the medical record documentation was inaccurate and not completed at the time of observation, contributing to the failure to supervise the resident adequately and prevent the elopement. Physical observation of the environment revealed that the stairwell door on the resident’s unit was secured only by a keypad and that the exit door at the bottom of the stairwell to the street was unsecured. The resident reported watching staff use the keypad until able to discern the code, then using it to open the door when staff were in other rooms. The DON confirmed that the keypad code remained unchanged after the incident and that staff were unsure how to change it. The facility’s fall prevention and documentation policies required individualized interventions based on fall risk and accurate, timely, factual documentation that reflects the resident’s actual experiences, and prohibited false information. However, there was no policy available for every 15‑minute checks, and the documented practice on the day of the incident did not align with the physician’s order or the facility’s documentation standards, resulting in the resident leaving the building and walking into the community without staff knowledge.
Failure to Provide Social Services and Repeat BIMS After Cognitive Decline and Wandering
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services and to repeat a Brief Interview for Mental Status (BIMS) after a documented change in cognition for one resident with dementia and substance use disorders. The resident had vascular dementia without behavioral disturbances, alcohol and opioid dependence, generalized anxiety disorder, depressive episodes, and chronic pain. A prior wander risk evaluation identified the resident as low risk for wandering, and a quarterly MDS assessment documented moderately impaired cognition with a BIMS score of 12, independence in mobility, and no wandering behaviors. The resident’s care plan identified impaired cognitive function/dementia, poor impulse control, a history of altercations, psychoactive drug use, fall risk, alcohol abuse, and risk for disorientation and confusion, with interventions including monitoring and documenting changes in cognitive function and behavior, reorientation, supervision, and every 15‑minute monitoring. Beginning in late January, multiple nursing notes documented a clear change in the resident’s cognition and behavior, including confusion, exit seeking, wandering into other residents’ rooms, and repeated attempts to reach the elevator and leave the facility. On one date, a nurse documented that the resident expressed a desire to leave and was placed on every 15‑minute checks. Subsequent notes over several weeks by various LPNs described increased confusion, wandering, searching for family members, and persistent exit‑seeking behaviors, including continuously checking the elevator. Psychiatric evaluations and APRN notes during this period identified functional and cognitive decline, increased confusion and agitation, exit‑seeking behavior, sundowning, and evidence of cognitive decline, and documented that the resident remained on every 15‑minute checks for exit‑seeking behavior. Despite these documented changes in cognition and behavior from late January through late February, review of the clinical record showed no evidence that social services met with or assessed the resident following the initial noted change in cognition. The record also lacked documentation of a repeat BIMS assessment from the time of the change through early March. The Director of Social Services acknowledged awareness of the resident’s cognitive decline, increased confusion, and wandering since January but confirmed he did not meet with the resident or reassess the BIMS as required with a change in cognition. The DON stated that social services should have evaluated the resident upon determination of a change in behavior and/or cognition and that a repeat BIMS should be completed with any change in cognition. The facility’s Dementia Care policy directed that appropriate treatment and services be provided to residents with dementia, that care plans be monitored and revised as necessary, and that appropriate referrals be made if current interventions were ineffective or if there was a decline in psychosocial, mood, or behavioral status.
Inaccurate 15-Minute Check Documentation After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate clinical record for a resident who had physician orders and care plan interventions for every 15-minute monitoring. The resident had vascular dementia without behavioral disturbances, alcohol and opioid dependence, generalized anxiety disorder, depressive episodes, chronic pain, a history of traumatic brain injury, poor impulse control, a history of altercations with another resident, and a history of alcohol abuse. The resident’s care plan identified impaired cognitive function and risk for disorientation, confusion, unsteady gait, and slurred speech, with interventions including every 15-minute monitoring. A physician’s order dated 1/23/26 directed that the resident be on every 15-minute observations every shift, and a nurse’s note on the same date documented that the resident expressed a desire to leave the facility and was placed on every 15-minute checks. On 2/25/26, an LPN documented that upon returning to the unit at 1:55 PM, she was informed by a nursing assistant and a housekeeper that the resident was not in the room or on the unit. She checked the room and unit, notified the nursing supervisor, and a building-wide search was initiated. The last time she reported seeing the resident was at 1:00 PM. The DON later reviewed camera footage and identified that at 12:36 PM the resident was seen looking around the hallway, approaching the keypad, and exiting a secured door into the stairwell, then going down 4.5 flights of stairs and exiting through an unsecured door to the outside. Despite this, the every 15-minute check sheet for that date showed continuous documentation from 7:00 AM through 1:15 PM indicating the resident was present on the unit, including entries at 12:45 PM, 1:00 PM, and 1:15 PM. Interviews revealed that the documentation on the every 15-minute check sheet was not based on actual observations. NA #2 stated she was not assigned to the resident on that shift and had not completed any 15-minute checks, but after the resident could not be located, the ADON directed her to fill out the sheet, and she did so despite knowing it was incorrect, estimating times for the checks. NA #3 reported that although her initials appeared as documenting on the resident for that shift, she did not complete any of the 15-minute checks due to a heavy assignment. The LPN confirmed that the ADON came to the unit, discovered the check sheet had not been filled out for the entire shift, and told NA #2 and the LPN they needed to figure out how to complete it. The ADON acknowledged directing staff to complete the sheet after the fact and stated the checks should have been documented at the time of observation. The DON confirmed that the clinical record should have been complete and accurate, that the resident was off the unit at the times documented as present, and that the documentation was therefore inaccurate and inconsistent with the facility’s policy requiring factual, objective, timely, and truthful entries, with late entries clearly identified as such.
Failure to Protect Resident from Verbal Abuse and Threats by Staff
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, schizoaffective disorder, and bipolar disorder was not protected from mistreatment by facility staff. The resident, who had a BIMS score indicating intact cognition and required assistance for ambulation, became upset after being told they could not leave the facility early in the morning. During the incident, the resident used foul language and slurs toward staff, followed a nursing assistant into another resident's room, and struck the nursing assistant on the arm. Multiple staff members, including a nurse and a supervisor, were involved in attempts to manage the situation. During the escalation, the supervisor responded to the resident's verbal aggression by repeating the same foul language and swearing back at the resident. The supervisor also threatened the resident by stating that they would be given a bath with a pitcher of water if they came any closer. These actions were confirmed through staff interviews and written statements, with the supervisor admitting to using inappropriate language and making the threat. The Director of Nursing and facility manager both acknowledged that the supervisor's response was inappropriate and constituted a threat to the resident. Facility policy prohibits abuse, including verbal and mental abuse, threats, and actions causing mental anguish. Despite this, the supervisor's conduct involved both verbal abuse and a threat of physical action, which failed to ensure the resident was free from mistreatment as required by policy. The facility's internal review did not substantiate the allegation of abuse, citing the resident as the aggressor, but the documented staff actions met the definition of mistreatment under facility policy.
Failure to Ensure Background Checks for Agency Staff
Penalty
Summary
The facility failed to ensure that staff working at the facility, specifically those employed through a nursing scheduling agency, were properly screened prior to beginning work. Review of personnel files and interviews revealed that two registered nurses from the agency began working at the facility before their background checks were completed. There was no documentation available to confirm that background checks had been conducted for these agency staff members. The facility's policy requires that all potential employees, including contracted temporary staff, undergo background, reference, and credentials checks, with documentation maintained as proof of screening. Interviews with facility personnel indicated confusion regarding responsibility for completing and reviewing background checks for agency staff. One staff member stated that the facility is responsible for background checks, while the HR representative believed the agency was responsible per their contract. Despite this, HR acknowledged that she had not reviewed all background checks for agency staff scheduled to work at the facility. As a result, the facility was unable to provide any documentation confirming that the required screenings had been completed for the agency staff in question.
Resident Subjected to Verbal and Attempted Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident, who had diagnoses including unspecified fractures of the left humerus and femur, acute pain due to trauma, and adjustment disorder with anxiety, was not protected from abuse by staff. The resident was alert, oriented, and dependent on staff for personal hygiene and dressing. An altercation took place after the resident requested morning care at a specific time, leading to a confrontation with a nurse aide. During the incident, the nurse aide spoke to the resident in an inappropriate manner, swore at the resident, and attempted to throw objects at the resident while providing care to the resident's roommate. The nurse aide also attempted to physically hit the resident but was stopped by other staff members who witnessed the event. Interviews and clinical record reviews confirmed that the resident became upset and threw a cup at the nurse aide, who then retaliated verbally and physically by yelling, swearing, calling the resident inappropriate names, and attempting to throw a plastic basin at the resident. The incident was witnessed by other staff, who intervened and removed the nurse aide from the room. The facility's policy prohibits abuse of any kind, but in this instance, the resident was subjected to verbal and attempted physical abuse by a staff member.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Resident from Unwarranted Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the protection of residents from separation, including separation from other residents, their own rooms, or confinement to their rooms. The report notes that at least one resident was not adequately protected from being separated or confined, which is a violation of resident rights. Specific details about the actions or inactions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to honor residents' rights to manage their personal financial affairs by restricting access to personal funds accounts. Three residents with varying cognitive abilities and medical conditions, including quadriplegia, anxiety, depression, chronic pain, PTSD, and bipolar disorder, reported being unable to withdraw funds from their accounts outside of posted banking hours, which were limited to Monday through Friday from 9:00 AM to 3:00 PM. Residents were not able to access their funds at night or on weekends, and in some cases, were told they could not withdraw any money for extended periods. Interviews with facility staff confirmed that residents' access to their personal funds was limited due to posted banking hours and ongoing difficulties related to a change in facility ownership, which affected the facility's ability to access bank accounts. The facility also imposed withdrawal limits based on available cash on hand, and if cash was unavailable, residents had to wait approximately 24 hours for a check to be generated and cashed. The facility did not have a specific personal funds policy, but the Resident's Rights Policy stated that residents have the right to manage their financial affairs.
Failure to Notify Residents of Account Balances and Timely Convey Personal Funds
Penalty
Summary
The facility failed to notify residents when their personal fund account balances were within $200 of the Social Security Income (SSI) resource limit, as required. Review of the facility's Trial Balance report and interviews with the Business Office Manager and Administrator revealed that several Medicaid residents had account balances exceeding the SSI resource limits. Specific account balances for these residents ranged from $1,611.98 to $2,234.64, all above the $1,600 threshold. The facility did not provide timely notification to these residents regarding their account status in relation to the SSI limit. Additionally, the facility did not convey personal funds to residents within 30 days of discharge, as required. It was identified that three discharged residents had not received their remaining personal fund balances within the mandated timeframe, with delays ranging from 14 to 73 days. The facility also lacked a specific policy addressing the management and timely distribution of resident personal funds, although their Resident's Rights Policy referenced the right to manage financial affairs and be informed of charges against their funds.
Failure to Prevent Accidents and Maintain Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents for multiple residents. For one resident with dementia and a high risk for falls, the care plan was not updated with new interventions following several falls, and neurological checks were not consistently completed as ordered after each incident. The care plan interventions were either delayed or not implemented, and documentation of post-fall assessments was incomplete or missing. Staff interviews confirmed that new interventions should have been added after each fall, but this was not consistently done, and communication of interventions to direct care staff was lacking. Another resident, who was dependent on a wheelchair and required maximal assistance, was allowed to leave the facility for non-medical reasons without a current physician's order for a leave of absence (LOA). The system for tracking residents on LOA was ineffective, with incomplete and illegible log entries, and staff were unable to confirm which residents were off the premises at any given time. Staff interviews revealed that verification of LOA orders was not consistently performed, and the facility could not account for residents in the event of an emergency due to the lack of an effective tracking system. Additionally, a resident with severe cognitive impairment and a physician's order requiring assistance for ambulation was observed ambulating independently without staff assistance or an assistive device. This was contrary to the care plan and physician's order, and the resident experienced multiple falls and injuries as a result. Furthermore, the facility failed to maintain an accident-free environment for several cognitively impaired residents by not monitoring hot water temperatures, resulting in water temperatures exceeding safe limits in multiple rooms. The facility had not conducted routine water temperature checks for several months, and the equipment used for monitoring was inappropriate, leading to inaccurate readings.
Failure in Administrative Oversight and Resident Protection
Penalty
Summary
The facility failed to administer its resources effectively and provide adequate administrative oversight, resulting in multiple deficiencies affecting resident care and safety. Specifically, the administration did not ensure residents were protected from verbal abuse and involuntary seclusion, and failed to notify the State Agency in a timely manner about reportable events. There were also failures to investigate allegations of abuse promptly and thoroughly, and staff accused of abuse were not removed from the schedule in a timely fashion. Additionally, the facility did not manage resident personal needs accounts according to requirements, did not provide individualized activities for bedbound or dependent residents, and did not update activity calendars to reflect actual activities provided. Further deficiencies included not following physician's orders, failing to maintain a safe environment due to high water temperatures, and not ensuring adequate pest control. These failures were identified through observation, clinical record review, facility documentation, policy review, and interviews. Actual harm occurred in the area of Freedom from Abuse, Neglect, and Exploitation. The administrator's job description outlined responsibilities for overall facility operations, compliance with laws and regulations, and protection of resident rights, but these duties were not fulfilled as required.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Failure to Conduct Complete and Timely Abuse and Incident Investigations
Penalty
Summary
The facility failed to ensure complete, thorough, and timely investigations into allegations of abuse, neglect, and misappropriation of resident property for multiple residents. In several cases, investigations were incomplete, lacked necessary documentation, or did not include statements from all relevant staff and witnesses. For example, in the case of a resident with mononeuropathy and diabetes, the investigation into a missing bank card and unauthorized bank charge did not include interviews with all staff who had access to the resident, the resident’s roommate, or the resident themselves, and failed to review video evidence or obtain bank statements. The Director of Nursing Services (DNS) admitted to not performing a complete investigation due to time constraints. Another resident with anxiety and depressive disorder reported missing money, but the DNS was unaware of the incident until informed by surveyors, and the subsequent investigation lacked statements from the nurse to whom the incident was reported and other staff on the unit. In the case of a resident with legal blindness and bipolar disorder, the investigation into allegations of verbal and physical abuse by a registered nurse was incomplete, missing the resident’s statement and signatures on staff statements, and the DNS was unable to produce the full investigation documentation. Additionally, a resident with multiple fractures reported being called a racial slur by a nurse aide, but the incident was documented as a grievance rather than abuse, not reported to the State Agency, and the aide continued to work in the facility after the allegation, failing to protect the resident from further potential abuse. For a resident with obstructive hydrocephalus and vision loss who sustained an injury of unknown origin, the facility’s investigation did not include statements from all staff who worked during the relevant period, as required by policy. The DNS and Assistant Director of Nursing Services (ADNS) could not account for missing investigation statements, and there was confusion among staff regarding the storage and responsibility for these documents. Across all cases, the facility did not follow its own policies for abuse, neglect, and exploitation investigations, including immediate initiation, comprehensive documentation, and protection of residents during and after the investigation.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized care planning as required.
Failure to Complete and Document Advance Directive Choices for Multiple Residents
Penalty
Summary
The facility failed to ensure that advance directive choices were properly completed and documented for multiple residents. For one resident with schizoaffective disorder and borderline intellectual functioning, the care plan did not include an advance directive, and there was no signed consent from the conservator, despite a physician order indicating full code status. The Director of Nursing Services (DNS) confirmed that the required consent should have been obtained and filed at admission, but it was missing from both the paper and electronic records. Another resident with diabetes, legal blindness, anxiety, and bipolar disorder had an unsigned advance directive in the chart, coded as Do Not Intubate/Do Not Resuscitate (DNI/DNR), and no physician order could be written without a completed and signed form. Staff interviews revealed that the conservator had not completed the necessary paperwork, and attempts to contact the conservator had been unsuccessful. The facility's protocol required the advanced directive to be signed on admission, but documentation of efforts to obtain the signature was lacking, and the resident was not properly included in a facility-wide audit of advance directive documentation. A third resident with cauda equina syndrome, COPD, and morbid obesity was identified as a full code in the care plan and social services notes, but the advance directive was missing both the resident's and physician's signatures. The admission nurse was responsible for ensuring completion of the advance directive, with social services reviewing the documentation at the 72-hour post-admission meeting. However, the required signatures were not obtained, and the social worker could not explain why the documentation was incomplete. Facility policy required determination and documentation of advance directive status on admission, but this was not consistently followed.
Failure to Notify Physician of Elevated Blood Sugar
Penalty
Summary
A deficiency occurred when staff failed to notify the physician of an elevated blood sugar level for a resident diagnosed with diabetes, schizophrenia, and chronic kidney disease. The resident's Medication Administration Record documented a blood sugar reading of 331, which is significantly above the normal range of 70-100. Physician orders in effect required staff to notify the physician of elevated blood sugar results, but did not specify exact parameters for notification. Review of the clinical record, nursing notes, and physician notes showed no evidence that the physician was informed of the elevated blood sugar. The resident's care plan included monitoring and documentation of side effects and effectiveness of treatment, as well as obtaining fasting serum blood sugar as ordered by the physician. During staff interviews, an LPN could not recall if he took the blood sugar reading but acknowledged that if he had, he should have notified the physician according to the order and facility policy. The LPN also stated that any provider notification would have been documented in the clinical record, but no such documentation was found. An APRN interviewed was unable to recall being notified of the elevated blood sugar and confirmed that no increased monitoring was directed following the abnormal result. The facility's Notification of Change policy required physician notification when a change occurred that required it, but this was not followed in this instance.
Failure to Provide Required Fingernail Care During ADL Assistance
Penalty
Summary
A deficiency was identified when a resident with diagnoses including dementia, anxiety disorder, and depression, who was dependent on staff for activities of daily living (ADLs) such as showering and personal hygiene, did not receive appropriate fingernail care. The resident's care plan specified the need for assistance with bathing due to self-care performance deficits related to deconditioning and multiple comorbidities. Physician's orders directed staff to provide showers on specific days. Despite these directives, observations on two consecutive days revealed that the resident's fingernails were long and not trimmed by choice, with the resident expressing a preference for having their nails cut. Further review of the Treatment Administration Record indicated that a shower had been documented as provided, but subsequent observation and interview with an LPN confirmed that the resident's fingernails remained long with dark brown debris underneath. The LPN acknowledged that nail care should have been performed during the shower and could not explain why it was omitted. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain good grooming and hygiene, which was not followed in this instance.
Failure to Follow Physician Orders for Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with diabetes and a history of ketoacidosis did not receive care according to physician orders. The resident required regular blood glucose monitoring and insulin administration before meals, with specific instructions to hold insulin if blood sugar was below 90 or if less than 25% of a meal was consumed. On the morning in question, the Medication Administration Record (MAR) showed that the 8:00 AM blood sugar check and insulin injection were not completed. The LPN assigned to the unit had been reassigned late and did not perform the required tasks, while the RN supervisor, who temporarily covered the unit, did not administer medications or conduct blood sugar testing before leaving the facility to obtain medication for another resident. The Director of Nursing was not aware of the omission until later, and the facility's policies required medications to be administered within a two-hour window and blood glucose monitoring to be performed as ordered. The failure to follow physician orders for blood glucose monitoring and insulin administration was confirmed through review of the MAR, interviews with nursing staff, and facility documentation. The resident's care plan specifically included diabetes management interventions, but these were not implemented as required on the day of the incident. The omission was later documented as a medication error by the facility.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care was provided to prevent a decline in these areas unless such decline was due to a documented medical reason. The report notes that the necessary interventions or services to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Complete Pharmacy-Recommended Lab Work and Lack of Non-Pharmacological Interventions in Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a pharmacy-recommended laboratory test for a resident receiving antiretroviral therapy was completed. The resident, who had diagnoses including schizophrenia, paranoia, and HIV, had a physician's order for Dolutegravir lamivudine and required regular lab monitoring as recommended by the pharmacy and agreed upon by the physician. The initial lab work was not drawn because the resident was at an appointment, and there was no evidence that the lab work was rescheduled or completed afterward. The Assistant Director of Nursing confirmed that the responsibility to reschedule the lab work fell to the Registered Nurse Supervisor, but there was no documentation or oversight to ensure this occurred. Additionally, the facility did not have a policy in place for laboratory work. The resident's care plan included the use of an antipsychotic medication but did not identify or document alternative interventions for managing behavioral symptoms aside from medication use. The care plan coordinator acknowledged that the care plan should have included non-pharmacological interventions as alternatives to medication, in accordance with facility policy. The facility's care plan policy required that care plans be modified with new or updated interventions, but this was not reflected in the resident's care plan documentation.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or improper use. Specific details about the actions or omissions that led to this event are not provided in the report excerpt. No additional information about the resident's medical history or condition at the time of the deficiency is included.
Failure to Adhere to Heart Failure Care Standards and Monitoring
Penalty
Summary
A deficiency was identified in the facility's failure to provide care in accordance with professional standards for a resident diagnosed with hypertensive heart disease with heart failure, diabetes mellitus, and hyperlipidemia. The resident's care plan included interventions such as encouraging a low fat, low salt diet and obtaining lab tests as needed. Despite this, the resident experienced a significant weight gain of over 10% in less than a month, which was not part of a physician-prescribed regimen. The facility's policy required daily assessment of residents with heart failure for lung sounds, respiratory status, and pedal pulses, as well as prompt provider notification of significant weight changes. However, the resident was only weighed monthly, and there was no documentation of daily or weekly weight monitoring, nor evidence of required nursing assessments for heart failure. Further review revealed the absence of physician orders for dietary restrictions, fluid restriction, intake and output monitoring, or daily weights, despite these being indicated in the care plan and facility policy. Interviews with facility staff confirmed that the necessary assessments and monitoring were not being conducted, and relevant policies such as the Heart Failure Policy and Resident Assessment Policy were not provided when requested. The lack of adherence to established protocols and missing documentation contributed to the deficiency in meeting professional standards of care for the resident with heart failure.
Failure to Protect Resident's Debit Card from Unauthorized Use by Staff
Penalty
Summary
A deficiency occurred when a resident, who was alert and oriented and had diagnoses including a left total hip replacement and anxiety, reported that their debit card was missing and unauthorized charges had been made. The resident last saw the debit card in their purse on the bureau, and it was documented as part of their personal belongings upon admission. Facility records show that the resident noticed $300 had been spent from their account without their authorization, and this was reported to the charge nurse and nursing supervisor. Subsequent investigation, including review of video footage from a local CVS, identified a nurse aide as the individual who used the resident's debit card to withdraw money from an ATM. The debit card was never returned to the resident, and the nurse aide failed to report to work for several scheduled shifts following the incident. The nurse aide in question had completed required training on abuse prevention and misappropriation of resident property. Despite this, the aide was identified by facility leadership and law enforcement as the person responsible for the unauthorized use of the resident's debit card. The facility's policy requires protection of residents' property and prohibits misappropriation, but in this case, the resident's debit card was removed from the facility and used without authorization, constituting a failure to safeguard the resident's belongings.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor Resident #27's choices regarding personal food preferences. Resident #27, who was cognitively intact and independent with eating, expressed a preference for personal snacks and meals over the facility's food. Despite having a physician's order for a consistent carbohydrate diet, the resident kept personal snacks, noodles, and canned soups in their room, which sometimes required heating. However, staff were unwilling to heat the resident's food, citing a facility policy that prohibited heating food or beverages for safety reasons. This policy was communicated to the resident on multiple occasions, leading to the resident's dissatisfaction. Interviews with staff revealed confusion and inconsistency regarding the policy on heating food. An LPN and a nursing aide both indicated they were informed that heating food was not allowed, but were unsure of the specifics or the duration of the policy. The facility's administrator later clarified that the policy did allow for food to be reheated in a microwave, provided it reached a temperature of 165 degrees Fahrenheit for 15 seconds. However, the lack of available thermometers on the nursing units at the time of the incident contributed to the staff's inability to comply with the policy, resulting in the resident's complaint and the facility's failure to support the resident's right to self-determination and choice regarding personal food preferences.
Failure to Implement Interventions Following Resident Altercation
Penalty
Summary
The facility failed to implement interventions to prevent further physical abuse from one resident towards another. Resident #86, who has diagnoses including unspecified dementia without behavioral disturbance and difficulty in walking, was involved in an altercation where their feet were run over by another resident, Resident #29. Resident #86 was cognitively impaired and dependent on staff for transfers and mobility. The incident occurred when Resident #29, who is cognitively intact and uses a wheelchair, became upset and agitated when a nursing assistant could not immediately assist them. Despite being informed that Resident #86 was behind them, Resident #29 forcefully moved their wheelchair, running over Resident #86's feet. The nursing progress notes and interviews with staff, including LPN #6, indicated that Resident #29 was aware of Resident #86's presence but was not redirectable due to their agitation. LPN #6 confirmed that no interventions were put in place following the incident to prevent further occurrences. Additionally, a review of Resident #86's care plan showed it was not updated with interventions to prevent further abuse or unintended altercations by Resident #29. The facility's policy on abuse, neglect, and exploitation requires ongoing assessment and care planning for appropriate interventions, which was not adhered to in this case.
Failure to Update Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to update and revise the care plans for two residents with pressure ulcers, leading to deficiencies in their care. Resident #17, diagnosed with diabetes mellitus and dementia, had a physician's order to use an offloading boot for pressure relief on the left heel. However, the care plan did not include this intervention, and the staff, including the LPN and wound nurse, acknowledged the omission. The facility's policy required care plan updates upon changes in status, but this was not adhered to in Resident #17's case. Resident #42, with paraplegia and pressure ulcers on the hips, also experienced deficiencies in care plan management. The care plan did not reflect the resident's non-compliance with offloading boots, and new pressure areas were discovered during a surveyor's observation. The resident had a DTI on the right heel and a calloused area on the plantar surface, which were not previously documented or addressed in the care plan. Interviews with staff revealed a lack of awareness and communication regarding these areas, and the resident's care plan was not updated to reflect the current status and interventions needed. The facility's failure to maintain accurate and updated care plans for these residents was attributed to inconsistent supervision of the care planning process. The INC acknowledged that care plans were not regularly updated and may not be accurate, citing recent changes in the MDS Coordinator and DNS positions. The facility's policy required care plan revisions upon status changes, but this was not consistently implemented, leading to deficiencies in resident care.
Inaccessible Smoking Receptacles During Supervised Break
Penalty
Summary
The facility failed to ensure that safe smoking receptacles were readily accessible for residents during a supervised smoking break. Observations revealed that the smoking break took place under a covered patio with seven residents present, all seated against the edges. Three metal cigarette disposal receptacles were also located at the edges, making them not readily accessible to the residents. Resident #32 was observed smoking a cigarette and, upon finishing, was unable to dispose of the cigarette butt independently. The resident handed the cigarette to the Smoking Monitor, who then disposed of it in a receptacle. Interviews with NA#4 and the Smoking Monitor indicated that residents often required assistance to extinguish and dispose of cigarette butts, and both staff members were unaware if the receptacles were movable. The facility's smoking policy required accessible metal containers with self-closing covers for ashtray disposal, which was not adhered to in this instance.
Failure to Follow Physician's Order for Oxygen Flow Rate
Penalty
Summary
The facility failed to adhere to a physician's order regarding the oxygen liter flow rate for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD), Pulmonary Fibrosis, and Type 2 diabetes mellitus. The resident, who was moderately cognitively impaired and required moderate assistance with personal hygiene and bed mobility, was observed receiving oxygen therapy at a flow rate of 5 liters per minute, which exceeded the prescribed range of 1-4 liters. This discrepancy was noted during observations on two consecutive days. An LPN interviewed was unsure why the oxygen was set at 5 liters and acknowledged that all nurses are responsible for ensuring physician's orders are followed correctly. The LPN had not completed her morning rounds, which delayed the adjustment of the oxygen setting to the prescribed range.
Failure to Monitor Target Behaviors for Resident on Psychoactive Medications
Penalty
Summary
The facility failed to ensure that target behaviors were monitored for a resident receiving psychoactive medications, including an antipsychotic. The resident, who was severely cognitively impaired, exhibited physical and verbal behaviors towards others and behaviors not directed towards others. Despite a pharmacist's recommendation for behavioral monitoring, there were no physician's orders for monitoring target behaviors, and no documentation of such behaviors was found for 36 days while the resident was on the antipsychotic medication Rexulti. The resident was readmitted to the facility and had physician's orders for Rexulti and Trazadone. The care plan included interventions for the resident's behaviors, but the lack of physician's orders for monitoring meant that these behaviors were not documented in the Medication Administration Kardex. A psychiatric visit later determined that the resident no longer required the antipsychotic, leading to a gradual dose reduction and eventual discontinuation of Rexulti. The facility was unable to provide a policy regarding the use of antipsychotic medications and monitoring of target behaviors.
Failure to Ensure Functioning Call Bell System for Resident
Penalty
Summary
The facility failed to ensure a functioning call bell system was in place for Resident #118 at the time of admission. Resident #118, diagnosed with Alzheimer's disease and severely cognitively impaired, was admitted with a care plan that included the use of a call bell for assistance due to a self-care deficit. However, upon observation, it was identified that Resident #118's room lacked a call bell and the call box on the wall was nonfunctioning. The regular charge nurse on the unit acknowledged the absence of a call bell and provided a manual handbell instead, but did not report the issue or implement a plan to address the lack of a call bell. The Maintenance Director, upon being informed, was unaware of the problem and confirmed the absence of a functioning call bell system in Resident #118's room. The Maintenance Director indicated that the room should have been checked for a functioning call bell system before admission, but was unable to identify who was responsible for this task. The Admissions Coordinator, who was new to the facility, did not have a checklist for Resident #118's admission, which would have included verifying the call bell system's functionality. The facility's policy requires that call bell systems be accessible and functioning, and any issues should be reported immediately, but this was not adhered to in this case.
Failure to Ensure Dignified Interaction with Resident
Penalty
Summary
The facility failed to ensure staff interacted with residents in a dignified manner, specifically in the case of a resident with legal blindness, bipolar disorder, and impulse disorder. The resident, who was cognitively intact but exhibited verbal behavioral symptoms, was involved in an incident where the Social Work Assistant became verbally disrespectful. The resident was yelling about a missing iPad and air-pods, and the Social Work Assistant raised her voice in response, telling the resident, 'Goodbye, have a good life.' This interaction was witnessed by the Human Resources Manager and the Business Office Manager, who confirmed the Social Work Assistant's raised voice but did not report any use of foul language. The incident was documented in an Accident and Incident report, but there was no corresponding documentation in the clinical record. Interviews with the Human Resources Manager and the Business Office Manager revealed that the Social Work Assistant attempted to continue the conversation despite the resident's agitation, contrary to the care plan's directive to de-escalate and walk away if the resident became aggressive. The Administrator acknowledged that the Social Work Assistant's behavior did not align with the facility's expectations for handling agitated residents, leading to her termination for customer service-related issues.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #86, who has diagnoses including unspecified dementia and is cognitively impaired, was involved in an incident with Resident #29. Resident #86 is dependent on staff for transfers and mobility. The care plan for Resident #86 included interventions for mood problems related to schizophrenia and dementia, with a focus on medication management and behavioral health consults. Resident #29, who is cognitively intact and uses a wheelchair, became agitated and verbally abusive when a nursing assistant (NA) could not immediately assist with a request. Despite being informed that Resident #86 was behind them, Resident #29 forcefully moved their wheelchair, running over Resident #86's feet. The incident was documented in nursing progress notes, and an LPN confirmed that Resident #29 was aware of Resident #86's presence but was not redirectable due to agitation. The facility's policy on abuse, neglect, and exploitation emphasizes ongoing assessment and care planning, which was not effectively implemented in this situation.
Privacy Curtain Removal Compromises Resident Confidentiality
Penalty
Summary
A deficiency occurred when the facility failed to maintain the privacy and confidentiality of a resident's personal and medical records by removing the privacy curtain from the resident's shared room. The resident, who had diagnoses including end stage renal disease, psychoactive substance abuse, and major depressive disorder, was alert and oriented, and required assistance for mobility. The resident was on 1:1 observation due to unsafe smoking practices and had a history of obtaining and using vape pens inside the facility, despite interventions such as supervision and searches. On two separate occasions, the resident was observed using a vape pen in the presence of staff assigned for 1:1 observation. In response, the facility removed the privacy curtain from the resident's room to prevent the resident from concealing vaping activity. During the survey, it was observed that the resident's roommate had a privacy curtain, while the resident in question had a curtain that did not provide full privacy. This action resulted in a failure to ensure the resident's privacy and confidentiality as required.
Failure to Prevent Residents on 1:1 Observation from Possessing Prohibited Items
Penalty
Summary
The facility failed to prevent residents on one-to-one (1:1) observation from possessing and using prohibited items, including vape pens and weapons, within the facility. One resident with diagnoses of end stage renal disease, psychoactive substance abuse, and major depressive disorder, who had a court-appointed conservator and was assessed as alert and oriented, was placed on 1:1 observation due to unsafe smoking practices. Despite these interventions, the resident was able to obtain and use a vape pen inside the facility on two separate occasions while under direct staff supervision. In both instances, the resident surrendered the vape pen when confronted, but staff were unable to determine how the resident acquired the device while on 1:1 observation. Another resident, also alert and oriented with a history of anxiety and depression, was found in possession of several vapes, empty cigarette boxes, a pocketknife, and a machete during a room change. This resident was subsequently placed on 1:1 observation, but additional specialty knives were discovered in the resident's belongings the following day. The resident admitted to ordering the knives online and refused a room search. Facility staff, including the DON, were unable to explain how the resident continued to obtain and retain prohibited items while under 1:1 supervision. Facility policy prohibits residents from carrying smoking materials or weapons, and requires reassessment and re-education for violations.
Failure to Prevent Contraband and Ensure Effective Oversight for Residents on 1:1 Observation
Penalty
Summary
Facility administration failed to ensure effective oversight and use of resources to maintain the highest practicable well-being of residents. Specifically, the facility did not prevent residents on one-to-one (1:1) observation from possessing contraband, such as vape pens and knives, including a machete, within the facility. There were multiple instances where residents were found with prohibited items, and the facility did not have a policy in place to address these issues. The administration also failed to prevent residents from smoking vape pens inside the facility. Interviews with the Medical Director and the DON revealed that while 1:1 observation and smoking cessation counseling were offered, there was no clear process for administrative oversight or staff education to prevent access to contraband. The DON was unable to explain how residents on 1:1 observation continued to obtain prohibited items without staff noticing. No facility policy was provided for review regarding these processes.
Resident Subjected to Verbal Abuse and Intimidation by Staff Member
Penalty
Summary
A deficiency occurred when a resident with anxiety disorder and hypertension, who was cognitively intact and required supervision for activities of daily living, was subjected to verbal abuse and intimidation by a staff member. The incident began during a scheduled smoke break when the resident became upset about the brand of cigarettes provided and confronted a nurse aide. The nurse aide, visibly irritated, followed the resident inside to the elevator, where she was observed yelling, using profanities, and displaying threatening behavior, including hitting the elevator door with closed fists and attempting to enter the elevator while the resident was inside. Multiple staff members witnessed the incident, and the resident reported feeling angry, upset, and threatened by the staff member's actions. Facility documentation and staff interviews confirmed that the nurse aide's conduct was inappropriate and constituted verbal and mental abuse, as defined by the facility's policy. The resident was visibly shaken and upset following the altercation, and support was provided by social services and psychiatric staff. The nurse aide refused to provide a statement regarding the incident and subsequently resigned. The facility's failure to prevent this abusive interaction resulted in a violation of the requirement to protect residents from all forms of abuse, including verbal and mental abuse by staff.
Failure to Provide Timely Social Services Support After Abuse Incidents
Penalty
Summary
The facility failed to provide timely and adequate social services support to residents following incidents of abuse. For three residents reviewed, there was a lack of documented follow-up by social services after abuse incidents occurred. One resident with anxiety disorder and hypertension was involved in a verbal altercation with a nursing assistant, after which social services documented an initial encounter but did not provide any further follow-up in the clinical record. Another resident with dementia and diabetes experienced resident-to-resident abuse and was not seen by social services until two days after the incident, with no subsequent follow-up documented. A third resident with multiple diagnoses, including bipolar disorder and PTSD, was involved in a resident-to-resident abuse incident and received a wellness check the following day, but the incident was not referenced in the note and no further follow-up was documented. Interviews with facility staff confirmed that the social worker is responsible for meeting with residents involved in abuse incidents on the day of the event or within 24 hours, and for conducting daily follow-ups for 72 hours, with documentation required in the medical record. However, the social worker was unable to provide evidence of these follow-ups, stating that notes were sometimes kept on paper and not transferred to the clinical record. Requested paper notes for the residents involved were not provided to surveyors. Facility policy and job descriptions require timely documentation of social service interventions and follow-up in the medical record, specifically at the time of service or by the end of the shift. Despite these requirements, the clinical records for the three residents did not reflect the expected ongoing social services support or documentation following the abuse incidents, resulting in a deficiency related to the provision of medically-related social services.
Incomplete Documentation Following Abuse Incidents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate following incidents of abuse involving three residents. For one resident with anxiety disorder and hypertension, after an altercation with a nursing assistant during a scheduled smoke break, there was no documentation in the clinical record detailing the incident or any follow-up monitoring, despite police involvement. Nursing staff assumed others would document the event, resulting in a lack of required entries in the resident's record. Another resident with dementia and diabetes experienced a resident-to-resident abuse incident when another resident entered their room and pulled their hair. Although an initial nursing note documented the event and a body audit, there was no further follow-up or monitoring documented in the clinical record for the remainder of the month. The lack of ongoing documentation failed to meet the facility's policy for post-incident monitoring. A third resident, with diagnoses including lack of coordination, cognitive communication deficit, and bipolar disorder, was struck on the back by another resident while ambulating in the hallway. The initial nursing note described the incident, the skin check, and notifications made, but no further follow-up documentation was found in the clinical record for the subsequent days. Interviews with staff and review of facility policies confirmed that required documentation and monitoring were not completed as expected after these incidents.
Failure to Prevent and Manage Pressure Ulcer
Penalty
Summary
The facility failed to implement timely interventions and treatments to prevent the development and worsening of a pressure ulcer for Resident #101. The resident, who was admitted with multiple diagnoses including dementia and decreased mobility, was identified as being at risk for pressure ulcers. Despite this, the facility did not ensure that appropriate preventive measures, such as a turning and repositioning program or a pressure-reducing device for the wheelchair, were in place. Additionally, the weekly skin monitoring ordered by the physician was not completed as required. On 8/2/24, a nurse's aide and the resident's responsible party reported a small open wound on the resident's coccyx. However, the nurse who documented this did not measure the wound, obtain a treatment order, or ensure further assessment. The wound was not properly documented or treated until 8/16/24, when it was found to have worsened into two small open wounds. The facility's failure to assess and treat the wound promptly contributed to its deterioration. Interviews with facility staff revealed a lack of communication and responsibility regarding the wound's management. The nursing supervisor and wound nurse were not informed of the wound's initial discovery, and the wound nurse only became aware of it two weeks later. The facility's policy on wound management was not followed, as the wound was not assessed, documented, or treated in a timely manner, leading to the worsening of the resident's condition.
Failure to Safeguard and Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were safeguarded and periodically reconciled to prevent diversion. The Director of Nursing Services (DNS) revealed that the Controlled Substance Disposition Records (CSDR) were not being reconciled after the Assistant Director of Nursing Services (ADNS) left over a month ago, and no one was assigned to this task. The facility had not conducted a narcotic audit for an undisclosed amount of time, and the DNS could not provide documentation of any audits completed in 2023 or 2024. The process for handling controlled medications involved the delivery person obtaining a signature from the supervisor, who checked the medication against the packing slip, but the facility did not maintain these slips until the surveyor's inquiry. During a house-wide narcotic audit conducted by the DNS and RN#6, numerous CSDRs were found without corresponding white copies or bubble packs of medication, indicating missing medications. The former ADNS, responsible for investigating missing narcotics, could not recall any instances of both the white CSDR and bubble pack being reported missing and admitted to losing the binder used for logging audits. The DNS, Administrator, and RN#6 conducted a second audit, finding additional missing medications, bringing the total to 49 unaccounted-for medications. The DNS speculated that the white CSDR sheets might have been discarded before reconciliation. The Medical Director was unaware of the missing medications and expected a thorough investigation. The facility's policy required discrepancies in controlled drug counts to be reported to the DNS, who would notify the administrator and consultant pharmacist. However, the facility did not provide a policy on narcotic requisition, disposition, destruction, or audit when requested.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were administered on time and according to physician's orders for eight sampled residents. Observations revealed that medications were administered late, and in some cases, medications were crushed and mixed together without specific orders to do so. For instance, Resident #13, who had a G-tube, received medications late and crushed together, contrary to the facility's policy that requires medications to be administered separately with flushing in between. The LPN responsible for administering these medications indicated that other duties took precedence, and she did not notify anyone about the delays or request assistance. Additionally, Resident #15's medications were administered outside the scheduled time, with all morning medications being given between 11:03 AM and 11:11 AM, despite being scheduled for 9:00 AM. Similar issues were observed with other residents, such as Resident #92 and Resident #51, where medications were crushed and mixed together without proper orders, and administration times were significantly delayed. Interviews with staff revealed a lack of awareness regarding the need for specific orders to crush medications and the importance of adhering to scheduled administration times. The facility's policy requires medications to be administered at specific times, with a one-hour window on either side of the scheduled time. However, the audit reports indicated that medications were consistently administered late, and there was no evidence of adjustments being made for subsequent doses. Interviews with the DNS and other staff highlighted a lack of communication and understanding of the facility's policies, contributing to the deficiencies observed in medication administration.
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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