Greentree Manor Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterford, Connecticut.
- Location
- 4 Greentree Drive, Waterford, Connecticut 06385
- CMS Provider Number
- 075113
- Inspections on file
- 36
- Latest survey
- December 22, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Greentree Manor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and a history of wandering, who used a wheelchair and wore a wanderguard, exited the facility through an emergency exit door not equipped with a wanderguard alarm. Staff heard the alarm but did not immediately check outside or witness the resident leaving, resulting in the resident being found unattended outside by an off-duty staff member.
The facility failed to properly account for and secure controlled medications, resulting in missing narcotic blister packs and absent disposition records for several residents with significant medical needs. Despite documentation showing that pain medications were administered as ordered, required records for the receipt, administration, or destruction of these medications were not provided, and some residents did not receive their prescribed narcotics upon discharge.
The facility failed to maintain accurate records for the receipt and disposition of controlled medications, resulting in missing documentation and unaccounted-for blister packs for several residents who were prescribed pain medications such as Oxycodone and Hydromorphone. A DEA investigation confirmed the absence of required records and medication, and staff interviews revealed discrepancies in medication documentation and storage.
A resident with dementia and a history of falls sustained a scalp laceration that was treated with staples, but the facility failed to ensure timely removal due to a physician's order lacking a stop date. The issue was only identified after a family grievance, and the nurse involved was not educated on the incident as required by the facility's grievance resolution process.
A resident with dementia, a history of falls, and high fall risk experienced an unwitnessed fall after being assisted to bed. Despite the incident, no new interventions were added to the care plan, and documentation failed to reflect the fall or any changes. Staff interviews confirmed that required updates to the care plan were not made, contrary to facility policy.
A resident with dementia and a history of falls sustained a scalp laceration that was treated with staples in the ED. Upon return, nursing staff entered an order to monitor the staples but failed to include a stop date or instructions for removal, resulting in the staples remaining in place for an extended period. Required chart checks and order reconciliation procedures were not followed, leading to a delay in staple removal.
Two cognitively intact residents requiring ADL assistance were subjected to verbal abuse by nursing assistants, who yelled and used profanity when one resident requested help with a bedpan. The staff member left without providing care, and both residents' accounts were consistent in describing the mistreatment. Facility investigation confirmed that the actions violated the abuse policy prohibiting verbal abuse and mistreatment.
A resident with dementia and morbid obesity, who required a mechanical lift for transfers, was manually transferred by staff without a gait belt, resulting in a fall and a fractured leg. Staff did not conduct a thorough RN assessment after the fall, nor did they promptly notify the physician of the incident and change in condition, as required by facility policy. The resident was sent to a medical appointment before the injury was identified at the hospital.
A resident with multiple health conditions and a high fall risk was transferred by staff without a gait belt or mechanical lift, despite prior recommendations. The resident expressed pain and inability to stand during multiple transfer attempts, resulting in a fall and a significant leg fracture. Staff did not conduct a thorough assessment or notify the physician promptly, and standard transfer protocols were not followed.
A resident with hemiplegia, aphasia, and diabetes who used a power wheelchair was unable to independently exit a shared room due to obstructive furniture placement. Staff were aware that the resident required assistance to move the roommate's bed each time the resident wanted to leave, and an attempt to adjust the furniture did not clearly resolve the issue. No facility policy on accommodation of resident needs was provided.
The facility did not consistently develop or update care plans to address residents' individualized needs, including missing documentation of interventions after a reported misappropriation, lack of care planning for CHF and respiratory issues in a resident with recent hospitalization, and failure to include smoking-related interventions for a resident who resumed smoking. These omissions resulted in care plans that did not reflect current conditions or practices.
The facility did not ensure timely review and revision of care plans within 7 days of MDS assessments and failed to hold or properly document quarterly care plan meetings with full interdisciplinary team participation. For several residents with complex medical needs, care plans were not updated to reflect changes in condition or interventions, and meetings often lacked attendance from required clinical staff, resulting in incomplete care planning.
A deficiency occurred when multiple residents did not receive their scheduled medications within the required timeframe due to significant staffing shortages and the reassignment of a newly hired RN unfamiliar with the unit. Medications were administered late or early, affecting residents with a range of medical conditions and cognitive abilities. The delays were primarily caused by multiple nurse call-outs and the inability to secure replacements, resulting in a late and prolonged medication pass.
A resident with diabetes and hemiplegia, who was cognitively intact, was not provided with meals that matched their stated food preferences, including cultural foods and bone-in meats, despite these being documented in their care plan. The Food Services Director was aware of the preferences but refused to provide bone-in meats and could not show that other requested foods were available. The DON was not aware that the preferences were not being met, and the facility could not provide a policy for accommodating food preferences.
Surveyors found that food service staff failed to properly label, date, and dispose of expired and open food items, and did not maintain sanitary conditions in food preparation and serving areas. Expired milk and undated foods were found in storage, and the steam table and chafing dishes were observed with food debris, dirty water, and evidence of pests. The Director of Food Services confirmed lapses in cleaning and sanitizing procedures, contrary to facility policy.
Surveyors found that the dumpster area was not maintained in a clean and sanitary manner, with large items such as a couch, tables, and various trash—including used incontinence pads and medical waste—littered on the ground. Facility staff acknowledged the ongoing presence of these items, a rodent problem, and the lack of a clear policy or adequate resources for proper refuse removal.
The facility did not obtain or document required consents for care and treatment for three residents, including consents for psychoactive medications, potassium iodide, mental health services, and vaccinations. Despite being cognitively intact, these residents' consent forms remained unsigned, and care plans did not reflect permissions for these treatments. The DON confirmed that LPNs or supervisors were responsible for obtaining consents within two days of admission, but this was not done, and admission documentation was incomplete.
A resident with dementia, cancer, and morbid obesity, who was dependent on staff for transfers and identified as a fall risk, experienced a fall with major injury when staff failed to use a mechanical lift as directed. The physician was not notified immediately after the incident, contrary to facility policy, and only learned of the injury after the resident was diagnosed with a fracture in the emergency department the following day.
A resident requiring substantial to total assistance with ADLs, including bathing, did not receive scheduled showers on multiple occasions. Documentation was lacking for both the provision of showers and any refusals or equipment issues, despite facility policy requiring such records. The DON confirmed that missed showers were not documented and could not explain the lapses.
Two residents experienced deficiencies in care when staff failed to follow physician orders for wound care and weekly weight monitoring. One resident received an unauthorized wound treatment and had multiple undocumented wounds that were not reported or assessed as required. Another resident was not weighed weekly as ordered, with staff unaware of the order and responsibilities. Facility protocols for skin assessments and weight monitoring were not followed, leading to lapses in care.
Two residents experienced deficiencies in weight monitoring: one with dysphagia and multiple comorbidities was not reweighed after a significant weekly weight loss, and another receiving G-tube feedings did not have an admission weight obtained promptly and was not reweighed after a notable weight loss. In both cases, required notifications to the dietician and adherence to facility policy for weight confirmation were not followed.
Two residents with complex medical needs did not receive appropriate respiratory care: one was not properly assessed or monitored for CHF and respiratory distress, leading to hospitalization, while another did not have their oxygen tubing changed as ordered, despite staff documentation indicating otherwise. These deficiencies were identified through record review, observation, and staff interviews.
A resident dependent on hemodialysis missed two consecutive treatments due to transportation failures, and facility staff did not notify the dialysis center or reschedule the missed appointments as requested. Despite being ready for transport, the resident was not picked up, and the facility did not communicate the issue or arrange make-up sessions, resulting in missed treatments and elevated vital signs.
An LPN was observed disposing of unused medications for a resident with thyroid disease and heart failure into a garbage can attached to the medication cart, instead of following facility policy requiring secure storage and proper disposal. The LPN acknowledged the error when questioned, noting the safety concern of medication accessibility to residents.
A resident with severe cognitive impairment and multiple diagnoses had repeated pharmacy recommendations to update an acetaminophen order to include a maximal daily dose, but the physician failed to address or sign these recommendations despite facility policy requiring such action.
A medication cart was found unlocked and unattended, allowing access to resident medications, and expired IV fluids, heparin flushes, and Covid vaccines were discovered in the emergency supply box. The DON confirmed the cart was left unsecured and that expired medications remained due to oversight.
Surveyors found that staff failed to follow infection control protocols, including handling medications with ungloved hands, not wearing required PPE during direct care for residents on Enhanced Barrier Precautions, and not maintaining a clean medication room. These deficiencies involved multiple residents with complex medical needs and were observed among nursing, therapy, and hospice staff.
The facility did not obtain or document immunization status, offer vaccinations, or secure consent for flu and pneumonia vaccines for multiple residents. Clinical records lacked completed consent forms, and care plans did not note any contraindications or allergies. Staff interviews confirmed that required procedures for immunization documentation were not followed.
A resident with no contraindications and intact cognition was not offered a COVID-19 vaccine, and consent forms remained unsigned for over six months after admission. The LPN or Nurse Supervisor did not ensure timely completion of consent, and the DON could not explain the delay. The facility also lacked a COVID-19 vaccination policy.
Surveyors found that the facility failed to maintain a clean and homelike environment, with observations of sticky handrails, dirty kickboards, missing shower room tiles, peeling wallpaper, and rust-like substances on door jams and bed rails. Leadership interviews confirmed that cleaning schedules existed but renovations and equipment replacements had not been completed, and no maintenance or cleaning policy was provided.
A resident with dementia, depression, and anxiety was punched in the chest by another resident with a history of depression and chronic illness after attempting to pick up the aggressor's thermos. The aggressor had a known pattern of verbal and physical threats toward others, which staff were aware of, but the facility did not prevent the altercation, resulting in a failure to protect residents from abuse.
Staff did not follow the care plan for a resident with psychiatric diagnoses who was dependent on staff for daily care and known to be non-compliant. Despite the resident's agitation and repeated refusals during incontinence care, staff continued with care and failed to notify the charge nurse as required. The incident resulted in the resident sustaining a swollen lip and alleging rough treatment, with documentation not reflecting the refusals or resistance.
A resident with cognitive impairment and mobility issues, who required assistance with ambulation per physician's order and care plan, was left unsupervised and able to leave the facility grounds independently. Staff interviews revealed that supervision was inadequate, with the receptionist unable to monitor residents effectively while performing other duties, and nursing staff unaware of the resident's specific ambulation requirements. The lack of adherence to the care plan and physician's orders led to the resident's unsupervised elopement.
Failure to Respond to Door Alarm Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to respond appropriately to a door alarm, resulting in a resident at risk for elopement exiting the facility unattended. The resident, who had diagnoses including dementia, depression, and anxiety disorder, was non-ambulatory but able to self-propel in a wheelchair and wore a wanderguard daily. The care plan identified the resident as a wander and elopement risk, with interventions in place such as checking the wanderguard function and placement regularly. Despite these measures, the resident was able to push open an emergency exit door that was not equipped with a wanderguard alarm, exit the building, and was found outside by an off-duty staff member. Staff heard the emergency door alarm but did not witness the resident leaving or immediately check the surrounding area outside the door. The investigation revealed that staff did not exit through the door to search for the resident after the alarm sounded, and some staff were unaware of the code needed to reset the exit door alarm. Facility policies for missing residents and secured exits were requested but not provided. The incident was confirmed through interviews, facility documentation, and review of the resident's clinical records.
Failure to Account for and Secure Controlled Medications
Penalty
Summary
The facility failed to ensure that residents' controlled medications, specifically narcotics such as Oxycodone and Hydromorphone, were properly accounted for and not removed from the premises by staff. For five of eight sampled residents, there was a lack of documentation for the Control Disposition Records and missing blister packs of medication. The Drug Enforcement Agency (DEA) conducted an investigation following a complaint regarding missing narcotics and found that six blister packs for five residents, along with the corresponding disposition records, were unaccounted for. Residents involved had significant medical conditions, including osteomyelitis, diabetes with polyneuropathy, pressure ulcers, congestive heart failure, metabolic encephalopathy, rheumatoid arthritis, chronic obstructive pulmonary disease, neuropathy, rectal cancer, and dementia. Physician orders for these residents included as-needed administration of narcotic pain medications. Medication Administration Records indicated that the medications were administered as ordered, but upon review, the facility could not provide documentation for the receipt, administration, or destruction of several controlled substances. Interviews with staff and residents revealed that at least one resident was informed by a nursing supervisor that pain medication could not be released upon discharge, and the contracted pharmacist confirmed the delivery of the medications in question. The facility's abuse policy defines misappropriation of resident property as a form of abuse, and the absence of required records and missing medications constituted a failure to protect residents' property as required.
Failure to Account for Receipt and Disposition of Controlled Substances
Penalty
Summary
The facility failed to establish and maintain a system for accurately recording the receipt and disposition of controlled medications for multiple residents. For five of eight sampled residents, including individuals with diagnoses such as osteomyelitis, diabetes with polyneuropathy, pressure ulcers, congestive heart failure, metabolic encephalopathy, rheumatoid arthritis, chronic obstructive pulmonary disease, rectal cancer, and dementia, the facility was unable to provide documentation accounting for the administration and destruction of controlled substances, specifically Oxycodone and Hydromorphone. Pharmacy shipment records confirmed delivery of these medications, but the corresponding Control Disposition Records and blister packs were missing. A Drug Enforcement Agency (DEA) investigation was initiated following a complaint regarding missing narcotics. The DEA's review revealed that six blister packs for five residents, along with the required Control Disposition Records, were unaccounted for. Interviews with facility staff, including the contracted pharmacist and the Regional Director, confirmed that the facility could not produce documentation for the controlled substances delivered and that discontinued drugs were not removed from units or disposed of in a timely manner. In one instance, a resident was discharged without receiving their prescribed pain medication, and staff informed the resident that the medication could not be released to them. Further interviews with the Medical Director and review of facility documentation indicated discrepancies between Medication Administration Records, Controlled Substance Disposition sheets, and the actual presence of medications. The Medical Director noted that medication carts were overfilled and that some medications were missing or not properly documented. The facility was unable to provide a policy regarding the receipt and disposition of controlled substances that was in place prior to the incident, further highlighting the lack of an effective system for managing controlled medications.
Failure to Implement and Document Grievance Resolution for Timely Staple Removal
Penalty
Summary
A deficiency occurred when the facility failed to implement and document the resolution of a grievance related to the timely removal of scalp staples for a resident with dementia, a history of falls, and anxiety disorder. The resident experienced an unwitnessed fall resulting in a scalp laceration, which was treated in the emergency department with five staples and an order for antibiotic therapy. Upon return to the facility, a physician's order was entered to monitor the staples and report any signs of infection, but the order did not specify a stop date or a timeline for staple removal. The staples remained in place beyond the expected timeframe, and the omission was not identified or corrected until a grievance was filed by the resident's family member. The facility's grievance investigation revealed that the nurse responsible for entering the physician's order did not include a stop date for staple removal and was not educated on the incident. Interviews with staff indicated that the education of the nurse, which was listed as a corrective action in the grievance resolution, was neither documented nor completed. The facility was unable to provide evidence of the required education or disciplinary action, and the grievance form was found to be incomplete and inaccurate, contrary to facility policy.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the care plan to include a new intervention following a resident's fall. The resident, who had diagnoses including dementia with agitation, a history of falling, and anxiety disorder, experienced an unwitnessed fall after being assisted to bed. The clinical record showed that the resident had severely impaired cognition, required moderate assistance for transfers and ambulation, and was at high risk for falls as identified by a recent Fall Risk Evaluation. Despite these risk factors and the occurrence of a new fall, the Accident and Investigation documentation and the Resident Care Plan did not reflect the addition of any new interventions after the incident. Interviews with facility staff revealed that no new interventions were added to the care plan following the fall, and the responsible LPN was unaware that an intervention needed to be added for falls without injury. The Director of Nursing Services confirmed that an appropriate intervention should have been added to the care plan after the fall, and that the RN supervisor was responsible for ensuring the Accident and Investigation was fully completed. The facility's policy directed staff to implement additional or different interventions if falls recurred, but this was not followed in this case.
Failure to Obtain Timely Physician Order for Staple Removal After Fall
Penalty
Summary
A resident with dementia, a history of falls, and severely impaired cognition experienced an unwitnessed fall resulting in a scalp laceration. The resident was transferred to the emergency department, where the laceration was treated with five staples. Upon return to the facility, a physician's order was entered to monitor the staples and report any signs of infection or bleeding, but the order did not specify a stop date or include instructions for staple removal. The omission of a stop date and removal instructions was not identified during routine chart checks by nursing staff, as required by facility policy. As a result, the staples remained in place for 13 days, exceeding the typical duration for such wound closures. The facility's documentation and interviews revealed that the responsible nurse was unaware of the missing stop date and had not received education on the incident. Additionally, the facility was unable to provide evidence of education or disciplinary action related to the failure to ensure timely staple removal. Facility policies required orders to include start and stop dates and for nurses to reconcile and verify orders upon a resident's return from another care setting, but these procedures were not followed in this case.
Failure to Protect Residents from Verbal Abuse by Nursing Assistants
Penalty
Summary
Two residents, both cognitively intact and requiring assistance with activities of daily living, experienced verbal abuse from nursing assistants during the evening shift. One resident, with diagnoses including depression and anxiety, requested assistance with a bedpan by using the call bell. When a staff member entered the room, she began yelling and using profanity, accusing the other resident of ringing the bell excessively. The resident who had called for help clarified it was their request, but the staff member did not respond and left without providing care. The second resident, who has congestive heart failure and a pressure ulcer requiring wound management, corroborated the account, stating that the staff member yelled, swore, and left the room without assisting the first resident. The incident was reported by the first resident to the facility administrator the following day. Both residents were interviewed as part of the facility's investigation, and their statements were consistent regarding the verbal abuse and lack of care provided during the incident. Staff interviews revealed that the nursing assistant involved denied the allegations, citing being overwhelmed by workload, while another staff member reported hearing similar language from a different nursing assistant but could not confirm the context. The facility's investigation substantiated the allegations of verbal abuse based on resident interviews and staff statements. Facility documentation and policy review confirmed that the actions of the nursing assistants violated the facility's abuse policy, which prohibits any form of mistreatment, including verbal abuse. The policy defines verbal abuse as the use of disparaging or derogatory language within hearing distance of residents. The failure to provide care and the use of profane, aggressive language toward the residents constituted mistreatment and a breach of the residents' right to be free from abuse.
Failure to Use Proper Transfer Techniques and Notify Physician After Resident Fall
Penalty
Summary
Staff failed to follow professional standards of practice during the transfer and post-fall care of a resident with dementia, morbid obesity, and a history of falls who was receiving chemotherapy. Despite a care plan and physical therapy evaluation directing the use of a mechanical lift for all transfers, staff attempted to transfer the resident manually without a gait belt, instead lifting under the resident's arms. The resident expressed pain and inability to stand during multiple transfer attempts, but staff continued to try to move the resident, ultimately resulting in the resident being lowered to the floor after the legs gave out and the left leg became twisted underneath. After the fall, staff did not immediately notify a Registered Nurse (RN) to assess the resident, nor did they conduct a thorough assessment of the resident's condition prior to further movement. The resident was transferred from the floor to a wheelchair using a mechanical lift, but only after the incident had occurred. The RN who eventually assessed the resident only changed a dressing on a pre-existing skin tear and did not perform a comprehensive assessment of the resident's new complaints or injuries. The resident was then sent to a scheduled medical appointment, where further symptoms were noted, and was subsequently transferred to the Emergency Department, where a tibia/fibula fracture was diagnosed. Facility leadership and staff interviews confirmed that the use of a gait belt is standard practice for transfers and that staff should have stopped the transfer and used a mechanical lift when the resident was unable to stand. The facility also failed to notify the resident's physician of the fall and change in condition in a timely manner, as required by facility policy. The physician only became aware of the incident after being contacted by the hospital. The facility did not have a transfer policy available for review.
Failure to Ensure Safe Transfer and Timely Assessment After Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to appropriately transfer a resident with multiple complex medical conditions, including dementia, morbid obesity, and active chemotherapy treatment. The resident was identified as a high fall risk, but the facility did not assign a total score on the Fall Risk Evaluation to indicate the resident's risk level. Additionally, recommendations from a recent physical therapy evaluation, which specified the use of a mechanical lift for transfers, were not implemented in the resident's care plan or orders. On the day of the incident, multiple nursing assistants attempted to transfer the resident from bed to wheelchair without a gait belt and did not use a mechanical lift, despite the resident expressing pain and inability to stand. The staff made three attempts to transfer the resident, during which the resident's leg became twisted and the resident was lowered to the floor. After the fall, the staff used a mechanical lift to move the resident to a wheelchair, but a thorough assessment, including range of motion, was not conducted by a registered nurse prior to the transfer. The resident continued to complain of pain, but was sent to a scheduled medical appointment, where further symptoms were noted and the resident was transferred to the emergency department, where a significant leg fracture was diagnosed. The facility also failed to notify the resident's physician of the fall and injury in a timely manner. The physician was not informed until the hospital contacted the facility the following day. Interviews with staff and leadership confirmed that standard transfer procedures, such as the use of a gait belt and mechanical lift, were not followed, and that communication regarding changes in the resident's condition and care needs was inadequate. The facility did not have a transfer policy available for review.
Failure to Accommodate Resident's Mobility Needs in Shared Room
Penalty
Summary
A deficiency was identified when the facility failed to reasonably accommodate the mobility needs and preferences of a resident with hemiplegia, aphasia, and diabetes, who used a motorized wheelchair and required assistance with activities of daily living. The resident was previously in a private room without mobility concerns but was moved to a shared room, where the arrangement of the roommate's bed and dresser created a barrier, preventing the resident from independently exiting the room. The resident reported feeling confined due to the inability to leave the room without staff assistance to move furniture. Staff interviews confirmed awareness of the issue, with the social worker acknowledging that staff needed to move the roommate's bed each time the resident wanted to exit. An observation with the DNS showed that even after adjusting the furniture, it was unclear if the new setup provided sufficient clearance for independent wheelchair access. The facility did not provide a policy on accommodation of resident needs when requested.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents, resulting in deficiencies related to individualized resident needs. For one resident with hemiplegia, aphasia, and diabetes, the care plan did not address the resident's report of misappropriation of funds. Although the resident reported $2,000 missing and an investigation was conducted, the care plan was not updated to reflect the allegation, the offer of a lock box, or any new interventions related to the incident. The Director of Nursing Services acknowledged that the care plan should have been updated to include these elements. Another resident with a history of respiratory failure, deep vein thrombosis, pulmonary emboli, and congestive heart failure had a care plan that failed to include problems, interventions, goals, or monitoring parameters related to congestive heart failure or respiratory distress. Despite documentation of these conditions in the resident's medical history and a recent hospitalization for related issues, the care plan did not reflect these significant diagnoses or the necessary care approaches. A third resident with anxiety, right-sided hemiplegia, and hemiparesis was not identified as a smoker in the care plan, nor were there interventions related to smoking such as supervision, staff assistance, or safety measures. The resident was observed smoking in the designated area, and the Director of Nursing Services confirmed that the care plan was incomplete and did not reflect the resident's current smoking status or staff practices. The facility's policy required comprehensive and individualized care plans, but these were not consistently developed or implemented for the residents reviewed.
Failure to Timely Review, Revise, and Conduct Interdisciplinary Care Plan Meetings
Penalty
Summary
The facility failed to develop, review, and revise comprehensive care plans within the required timeframes and did not ensure the participation of the full interdisciplinary team (IDT) in resident care plan meetings. For multiple residents, care plans were not updated within 7 days of the completion of quarterly Minimum Data Set (MDS) assessments, and required quarterly Resident Care Plan (RCP) meetings were either not held or lacked documentation of attendance. In several cases, only the social worker and the resident attended these meetings, with no participation from nursing, dietary, or other required disciplines, despite facility policy mandating their involvement. Specific deficiencies were observed for several residents. One resident with seizure disorder and chronic obstructive pulmonary disease did not have RCP meetings held after a certain date, and their care plan was not reviewed or revised following MDS assessments. Another resident with epilepsy and depression had no documentation of any RCP meetings during their stay. A resident with hemiplegia and diabetes also lacked RCP meeting attendance records, and their care plan was not updated after multiple MDS assessments. In another case, a resident with chronic pain and opioid dependence experienced a significant change in condition involving outside narcotic prescriptions and the implementation of 1:1 observation, but the care plan was not updated to reflect these changes. Additional findings included a resident with morbid obesity and lymphedema whose care plan focused on discharge planning, but whose RCP meetings were attended only by the social worker and administrator, with no input from nursing or dietary staff. Another resident dependent on hemolytic treatment had RCP meetings attended solely by the social worker, with no participation from other IDT members, despite ongoing issues requiring multidisciplinary input. Interviews with staff confirmed awareness of the requirements but revealed ongoing noncompliance and an inability to explain the lack of IDT participation and timely care plan updates.
Medication Administration Delays Due to Staffing Shortages
Penalty
Summary
A deficiency was identified in the administration of medications, where the facility failed to ensure that medications scheduled to be given more than once daily were administered at the correct times as ordered by physicians. Multiple residents across one of four units reviewed experienced significant delays or early administration of their scheduled medications. The facility's policy required medications to be administered within 60 minutes of the scheduled time, except for those tied to mealtimes, but this standard was not met for numerous residents. The report details that on a specific date, a large number of residents with various diagnoses—including chronic obstructive pulmonary disease, diabetes, heart failure, schizophrenia, hypertension, and others—did not receive their scheduled 9:00 AM medications within the required timeframe. Delays ranged from over an hour to more than four hours past the scheduled time, and in some cases, medications were administered more than an hour before the scheduled time. The affected residents had a range of cognitive abilities, from severe impairment to no impairment, as indicated by their BIMS scores. The medications involved included critical treatments such as anticoagulants, insulin, antihypertensives, and other essential therapies. The primary cause of the deficiency was a staffing shortage due to three nurse call-outs on the morning shift, which left the facility unable to find replacements. An RN who was new to the facility and had not received orientation on the unit was reassigned from her infection prevention role to perform the medication pass. She began the medication pass late and was unfamiliar with the unit, resulting in further delays. The RN communicated her concerns about the delay to the DNS, who acknowledged the situation but instructed her to continue as best as she could. The CCSO later became aware of the issue and attempted to reallocate staff, but by that time, significant delays had already occurred.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
A resident with diagnoses including right-sided hemiplegia, aphasia, and diabetes, and who was assessed as cognitively intact, was not provided with meals that accommodated their stated food preferences. The resident was on a low calorie sweetener (LCS) diet with regular texture and was to receive large portions and a bedtime snack daily. Despite documentation in the care plan and nutrition assessment that the resident's food preferences, including cultural foods and bone-in meats, should be honored, the facility failed to provide these items. The resident reported receiving bland meals and boneless chicken instead of preferred bone-in chicken legs and thighs, leading them to purchase and store their own food in their room. The clinical record showed that the Director of Food Services had previously been made aware of the resident's preferences and had ordered some culturally appropriate foods, but refused to provide bone-in meats, citing concerns about choking hazards. The Director of Food Services could not provide evidence that the requested cultural foods were currently available in the facility. The Director of Nursing Services was aware of the resident's preferences but was not aware that these preferences were not being accommodated as outlined in the resident's care plan. The facility was unable to provide a policy for accommodating resident food preferences when requested.
Failure to Maintain Food Safety and Sanitation Standards
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's food service operations during a kitchen and dining area inspection. Expired food items, including two half gallons of milk past their expiration date and a soup bowl of tuna salad, as well as trays and containers of cranberry jelly/sauce with outdated or missing dates, were found in storage areas. Open bags of non-dairy topping and shredded cheese were also undated, and a bag of frozen egg patties was left open and undated in the freezer. The Director of Food Services was unaware of the expired milk and confirmed that these items were intended for resident use. Further observations revealed unsanitary conditions in the dining area, including a steam table with crusted food on the sneeze guard, food crumbs, dirty plates, and discolored water with floating food particles in chafing dishes. An ant was observed crawling in and out of a chafing dish. The Director of Food Services acknowledged that the water in the chafing dishes had not been changed for several days and that the steam table and side table were not cleaned with sanitizing spray, but rather with a scouring powder. Subsequent inspections confirmed that cleaning and sanitizing procedures were not consistently followed, and the facility's food policy requiring proper labeling, dating, and timely disposal of prepared foods, as well as maintenance of sanitary conditions, was not adhered to.
Improper Disposal and Containment of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary condition and did not ensure that refuse was properly contained. During an observation with the Director of Food Service, multiple items were found littered on the ground in front of two dumpsters, including a water-stained couch, a decomposing wood table, a tabletop with disintegrating foam, several cardboard boxes, a pedestal table, a snow shovel, a used incontinence disposable under pad, and various used face masks, bandages, paper scraps, plastic bags, and Styrofoam cups. The Director of Food Service stated that he had recently swept the area but noted that wind often blew trash against the fence and acknowledged a rodent problem, with pest control traps set outside the dumpster area. He also indicated that the large furniture items had been present for about a year and that the Director of Maintenance was responsible for their removal. The Director of Maintenance confirmed awareness of the garbage and used furniture, explaining that his request for an additional dumpster was denied by corporate and that local haul-away services were too expensive. The Chief Clinical Officer was informed of the trash issue but had not seen it personally until an observation confirmed the extent of the problem. The Chief Clinical Officer was uncertain about the specifics of the facility's policy on refuse disposal but stated that garbage bags should be tied and medical/procedure gloves bagged and tied. The facility was unable to provide a policy on refuse and garbage storage and disposal when requested.
Failure to Obtain and Document Resident Consents for Care and Treatment
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided with the opportunity to make decisions regarding their care and treatments upon admission. For three of four sampled residents reviewed for advance directives, there were unsigned consent forms for psychoactive medications, emergency use of potassium iodide, mental health services, and vaccinations. Despite residents being cognitively intact and capable of making their own decisions, the required consents were not obtained or documented, and the care plans did not reflect that permissions for these treatments had been secured. In one case, a resident was administered an antipsychotic medication without a signed consent, and the facility acknowledged that, in the event of a nuclear emergency, potassium iodide would have been administered without consent. Interviews with the Director of Nursing Services revealed that it was the responsibility of the LPN or nurse supervisor to ensure that consent forms were signed within two days of admission, but this process was not followed, resulting in unsigned forms remaining in the residents' charts for extended periods. Additionally, the facility was unable to provide a policy for obtaining resident consent prior to treatment, and admission documentation and checklists were incomplete, with blank areas for vaccine dates and missing signatures from residents or their responsible parties.
Failure to Notify Physician After Resident Fall with Major Injury
Penalty
Summary
The facility failed to notify the physician immediately following a fall with major injury for a resident with multiple complex medical conditions, including dementia, cancer, and morbid obesity, who was actively receiving chemotherapy. The resident, identified as a fall risk and dependent on staff for mobility and transfers, was being assisted by three staff members from bed to wheelchair when their legs became weak, resulting in a fall. Despite the care plan and physical therapy directives requiring the use of a mechanical lift for all transfers, the staff did not utilize the lift during this incident. After the fall, the resident was assessed, reported no complaints at the time, and was transferred to a scheduled medical appointment. Facility documentation initially indicated that the physician was notified shortly after the incident; however, an investigation revealed that no such notification occurred. The Director of Nursing Services confirmed that the nurse did not use the required encrypted provider notification system, and the physician only became aware of the incident the following day after being contacted by the Emergency Department, where the resident was diagnosed with a tibia/fibula fracture. The facility's policy required immediate notification of the physician and responsible parties in the event of an accident resulting in injury, which was not followed in this case.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
A resident with diagnoses including Parkinson's disease, anxiety disorder, and spinal stenosis, who was moderately cognitively impaired and required substantial to total assistance with activities of daily living (ADLs), did not receive scheduled showers as required. The resident's care plan specified assistance with bathing, dressing, and hygiene, and the resident was scheduled for showers twice weekly. However, documentation and interviews revealed that showers were not provided on multiple scheduled dates, as indicated by blank entries on the shower record. The Director of Nursing Services (DNS) confirmed that if there was no documentation, the shower was not given, and was unable to explain the missed showers. The DNS also noted that the resident sometimes refused the mechanical lift required for safe transfers into the shower bed, preferring an unsafe alternative, and that the shower bed had been broken in the past. However, there was no documentation to support that the resident refused transfers or that the shower bed was unavailable on the missed dates. Facility policy required that if care was declined, staff should document the refusal, notify a supervisor, and reoffer care, but no such documentation was provided. Additionally, the facility was unable to provide a policy for shower scheduling when requested.
Failure to Follow Physician Orders for Wound Care and Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders and established protocols for wound care and weight monitoring for two residents. For one resident with multiple diagnoses including epilepsy, bullous pemphigoid, and pressure ulcers, staff did not adhere to physician orders for wound care. During wound care observation, Xeroform was applied to a left foot wound without a physician's order, and both the LPN and RN involved could not explain the deviation from the prescribed treatment. The RN acknowledged that it was not within her scope to change a physician's order and that she had not contacted the physician to update the treatment plan. The Director of Nursing confirmed that staff should not alter treatments without proper orders and that a process existed for obtaining new orders if needed. Further deficiencies were identified when a resident was found with multiple undocumented wounds, including an open wound on the coccyx and two wounds on the right buttock, none of which were recorded in the clinical records or reported to the physician. The RN responsible for weekly head-to-toe skin assessments admitted she had not performed these assessments as required, focusing only on the resident's heel ulcers. The facility's weekly skin check documentation did not identify the new wounds, and the Director of Nursing was unaware of these issues until notified by another nurse. Facility policy required daily skin checks by CNAs and weekly audits by nurses, with new findings to be reported and evaluated, but these protocols were not followed. For another resident with morbid obesity and chronic kidney disease, the facility failed to obtain weekly weights as ordered by the physician. The resident was weighed only seven times over a fourteen-week period, and staff interviews revealed a lack of awareness and communication regarding the weekly weight order. The nurse aide was not informed of the need for weekly weights, and the dietitian was unaware of the order, having missed it during her reviews. The Director of Nursing confirmed that weights should have been obtained weekly and that the charge nurse was responsible for ensuring compliance, but could not explain the missed weights. Facility policy required multidisciplinary monitoring and intervention for weight changes, but this was not implemented as ordered.
Failure to Timely Obtain and Confirm Weights for Residents with Significant Weight Changes
Penalty
Summary
For one resident with dysphagia, dementia, diabetes, and anxiety, the facility failed to reweigh the individual after a significant weight loss. The care plan required weekly weights and the physician's order specified weekly weights on a particular shift. Documentation showed a loss of 10.2 lbs. in one week, but there was no evidence in the clinical record that a reweight was performed or refused after this significant loss. Nursing staff confirmed that the resident was not reweighed and could not provide a reason for this omission. The dietician was not notified of the weight loss until approximately two weeks later, and the Director of Nursing Services (DNS) was unable to confirm if any attempts to reweigh the resident were made. For another resident with a gastrostomy tube and a diagnosis of malignant neoplasm of the tongue and adult failure to thrive, the facility failed to obtain a timely admission weight and did not reweigh the resident after a significant weight loss. The care plan and physician's order required an admission weight and weekly weights for four weeks. However, the admission assessment did not include a weight, and the dietician's nutrition assessment noted the admission weight as pending. Nursing staff were unaware that the admission weight had not been obtained until prompted by surveyors, and the weight was only recorded three days after admission, showing a 6.95% loss from the hospital weight. There was no documentation of a reweight after this significant loss. Facility policy required weights to be obtained on admission, the next day, and weekly for four weeks, with any weight change of 5% or more to be retaken the next day for confirmation and immediate notification of the dietician. In both cases, these procedures were not followed, as weights were not obtained or confirmed in a timely manner, and appropriate notifications were not made.
Failure to Provide Safe and Appropriate Respiratory Care and Adhere to Oxygen Protocols
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents with significant medical histories. For one resident with diagnoses including respiratory failure, deep vein thrombosis, pulmonary emboli, and congestive heart failure (CHF), the care plan did not address the resident's CHF, asthma, or recent pulmonary emboli, and lacked interventions, goals, or monitoring parameters related to CHF or respiratory distress. Documentation showed a decline in oxygen saturation over several days, with readings dropping as low as 72%. Despite the resident expressing concerns of shortness of breath and lower extremity edema, nursing staff did not perform a thorough assessment, such as auscultation of lung sounds, nor did they escalate the change in condition to a registered nurse or notify the provider in a timely manner. The resident was eventually found to be hypoxic and tachypneic, requiring emergency intervention and hospitalization for acute hypoxic respiratory failure and an acute onset of CHF. For another resident with diabetes, hypertension, and anxiety who required continuous oxygen, the care plan did not include oxygen use. Physician orders specified that oxygen tubing should be changed weekly, but observations revealed that the tubing had not been changed for 44 days, despite staff signing off on the treatment administration record that it had been changed weekly. The Director of Nursing confirmed that the tubing should have been changed according to the order and facility policy, and that the failure to do so could compromise infection control and oxygen delivery. Both deficiencies were identified through review of clinical records, facility policy, and staff interviews. The failures included lack of appropriate assessment and escalation for a resident with respiratory symptoms and CHF, and failure to follow physician orders and facility policy for oxygen tubing changes for a resident on continuous oxygen therapy.
Failure to Notify and Reschedule Missed Dialysis Appointments
Penalty
Summary
The facility failed to ensure safe and appropriate dialysis care for a resident dependent on hemodialysis by not notifying the dialysis center when the resident missed scheduled treatments due to transportation issues, and by not rescheduling missed appointments as requested by the dialysis center. The resident, who had end stage renal disease, anemia, and an amputation, was scheduled for hemodialysis three times per week per physician orders. On two consecutive occasions, the resident missed treatments because the transportation company did not pick up the scheduled rides, despite the resident being ready and waiting at the designated times. The scheduler confirmed that the transportation company failed to provide the rides, and that the resident had not refused transportation. The Director of Nursing Services (DNS) and other staff were informed of the missed rides, but the facility did not notify the dialysis center of the missed appointments. The dialysis center nurse reported that the facility did not communicate about the missed treatments and did not arrange for make-up sessions, even though the center had requested rescheduling. Clinical records showed that after missing the second treatment, the resident experienced elevated blood pressure and blood sugar levels, prompting physician notification and orders for lab work. The facility's policy required timely arrangement of transportation and communication of issues affecting the resident's care plan, but these steps were not followed in this instance, resulting in missed dialysis treatments and lack of coordination with the dialysis center.
Improper Disposal of Unused Medications by LPN
Penalty
Summary
A deficiency occurred when unused medications for a resident with thyroid disease and heart failure were improperly disposed of by an LPN during a medication pass. The LPN was observed placing unused medications into a garbage can attached to the medication cart, rather than following facility policy which requires medications to be stored in a locked area until destruction and hazardous medications to be placed in appropriate containers. The LPN acknowledged that medications should not have been placed in the trash due to safety concerns, as they would be accessible to residents. The facility's policy on medication destruction and disposal was not followed during this incident.
Failure to Act on Pharmacy Recommendations for Medication Regimen
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were reviewed and acted upon as required. Specifically, a resident with diagnoses including non-Alzheimer's dementia, anxiety, and depression had a physician order for acetaminophen, but the order did not specify a maximal daily dose. The pharmacy made repeated recommendations over several months to update the order to include the maximum daily dose of 4000 mg, but these recommendations were not addressed or signed by the physician, despite being presented multiple times. The resident's care plan included regular evaluation of the drug regimen by the physician, and the facility's policy required that pharmacy recommendation forms be addressed and signed by the physician to make any medication changes. However, the physician failed to act on the pharmacy's recommendations, and the facility was unable to provide a policy on pharmacy recommendations when requested. This inaction resulted in the deficiency identified during the review of clinical records, facility policy, and staff interviews.
Unsecured Medication Cart and Expired Medications Found
Penalty
Summary
A medication cart on the South Wing was observed with its lock in the open position and left unattended at the end of a hallway, allowing unrestricted access to all drawers containing residents' medications. The cart was not attended by staff at the time of observation, and the drawers could be easily opened. The Director of Nursing Services (DNS) confirmed the cart was unsecured and unattended and was unable to explain why the responsible nurse had left it in that state. Additionally, expired medications were found in the emergency intravenous (IV) supply tackle box, including a liter of Normal Saline with potassium chloride, a bag of heparin IV flushes, and two Covid vaccines, all past their expiration dates. The DNS acknowledged that these medications were expired and stated that it was her responsibility to check the emergency medication box, attributing the presence of expired medications to an oversight. The facility's Medication Administration policy required medication carts to be kept closed and locked when out of sight of the medication nurse but did not address the storage of expired medications.
Infection Control and PPE Deficiencies During Medication Administration and Resident Care
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. During medication administration, a nurse dropped a tablet of Levothyroxine for a resident with thyroid disease and heart failure, picked it up with an ungloved hand, and placed it back into the medication cup, contrary to facility policy and infection control standards. The facility's policy directed that gloves should be worn when handling tablets to prevent contamination, but this was not followed. For a resident with epilepsy, bullous pemphigoid, and a Foley catheter, staff failed to adhere to Enhanced Barrier Precautions (EBP) as ordered by the physician. Observations revealed that staff and hospice personnel did not consistently wear required PPE, such as gowns and gloves, when providing direct care. In one instance, a nurse replaced a dirty glove that had fallen off during wound care without performing hand hygiene or changing to a clean glove, despite being aware of the correct procedure. Hospice staff also failed to don appropriate PPE, either due to not noticing posted signage or not following instructions, even when providing direct care to the resident. Additionally, a resident with a wound and indwelling urinary catheter was observed receiving care from an occupational therapist who did not wear a gown as required by EBP, only donning gloves. The therapist was unaware that a gown was necessary for direct care. The medication room was also found to be cluttered and dirty, with items stored in the sink's splash zone and insufficient space for medication preparation. Facility policies did not specify procedures or responsibilities for maintaining a clean medication room, contributing to the unsanitary conditions observed.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to obtain and document current immunization status, offer immunizations, and secure consent for flu and pneumonia vaccinations for four out of five residents reviewed. For each resident, clinical records lacked completed and signed consent forms for influenza, pneumococcal, and Covid-19 vaccines. Care plans did not identify any contraindications or allergies to immunizations, and there was no documentation of immunization status in the residents' records. Physician orders for vaccination were not followed up with proper documentation or administration, and the required consent forms remained blank and unsigned. Interviews with nursing staff and the Director of Nursing Services revealed that the facility's process required completion of immunization documentation within 48 hours of admission, with subsequent review and follow-up for missing items. However, this process was not carried out as intended, resulting in missing documentation for immunization status and consent. Facility policies assigned responsibility for informing residents and responsible parties about vaccinations to the Admissions Coordinator, but these procedures were not followed, and no policy for Covid-19 vaccination was provided when requested.
Failure to Offer and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to offer a COVID-19 vaccine to a resident who was admitted with diagnoses including epilepsy, dysphagia, and depression. The resident's care plan did not identify any contraindications to vaccination, and the quarterly MDS assessment indicated the resident had intact cognition and was independent in personal care and mobility. A review of the clinical record showed that consent forms for vaccination were unsigned, and the resident was not up to date with the COVID-19 vaccine, with the last administration occurring several years prior. The Director of Nursing Services confirmed that it was the responsibility of the LPN or Nurse Supervisor to ensure consent forms were signed within two days of admission, but could not explain why the forms remained unsigned for over six months. Additionally, the facility was unable to provide a COVID-19 vaccination policy as required.
Failure to Maintain a Clean, Comfortable, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's environment across two nursing units, including sticky handrails with debris, plastic kickboards on resident room doors with noticeable streaks, and missing wall tiles in a shower room that were covered with plastic. Additional findings included peeling wallpaper on the North and South wings, door jams in several resident rooms with a reddish-brown rust-like substance, and bed rails in multiple rooms with a similar reddish-brown substance. These observations were made during facility tours at various times throughout the day. Interviews with facility leadership revealed that although there were daily and weekly cleaning schedules in place, and quotes had previously been obtained for renovations and equipment replacement, these updates had not been completed. The facility was unable to provide a policy for maintenance or cleaning when requested. The combination of these factors resulted in the failure to provide a clean, comfortable, and homelike environment for residents, as required.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. One resident, who had diagnoses including dementia, depression, and anxiety, was punched in the chest by another resident with a history of depression, cardiomyopathy, and chronic kidney disease. The incident occurred when the first resident bent over to pick up a thermos belonging to the second resident, who then verbally threatened and physically struck the first resident. Staff observed the altercation and intervened immediately, removing the first resident from the situation and notifying nursing staff. Documentation indicated that the first resident did not sustain visible injuries or pain and quickly forgot the incident due to significant memory deficits. Prior to this event, the second resident had exhibited verbally aggressive and threatening behaviors toward other residents, including raising a cane and using profane language. Staff interviews confirmed awareness of these behaviors, and the social worker had previously addressed the resident's conduct. Despite these known behavioral issues, the facility did not prevent the physical altercation, resulting in a failure to ensure the safety and protection of all residents as required by facility policy.
Failure to Follow Care Plan and Respect Resident Refusals During Incontinence Care
Penalty
Summary
Staff failed to follow the care plan for a resident with bipolar disorder, anxiety, and delusional disorder who required assistance with activities of daily living and was known to be non-compliant with care. The care plan specified that if the resident became agitated during care, staff should stop and attempt care again later, and notify the charge nurse of any refusals. On the evening in question, the resident became agitated and resisted incontinence care, but staff continued to provide care despite the resistance and did not notify the charge nurse as required. Documentation did not reflect the resident's refusals of care during this period. Multiple interviews confirmed that the resident was combative and had refused care several times, yet care was still provided against the resident's wishes. The charge nurse was unaware of the resistance until after the incident, when the resident complained of being abused and was found to have a swollen lip. The Director of Nursing acknowledged that the aides' actions in persisting with care despite the resident's refusals did not align with the facility's standard of care. Facility policy states that residents have the right to be free from abuse, including the right to refuse care.
Failure to Supervise Resident Requiring Assisted Ambulation Resulting in Elopement
Penalty
Summary
A resident with diagnoses including alcohol abuse, muscle weakness, difficulty walking, and a history of falls was admitted to the facility and assessed as alert but with some forgetfulness and short-term memory loss. The resident required assistance with activities of daily living, including ambulation, as documented in the care plan and supported by a physician's order specifying ambulation with a rolling walker and the assistance of one staff member. Occupational therapy also noted the need for 24/7 supervision and assist of one with ADLs due to cognitive concerns. Despite these documented needs, the resident was left unsupervised and was able to leave the facility grounds independently. On the day of the incident, the resident was observed by a physician walking away from the facility towards an intersection, unaccompanied. The physician notified the facility, prompting staff to locate and return the resident. Interviews with staff revealed that the receptionist was tasked with watching residents on the front porch but found it difficult to do so while managing other duties. Nursing and aide staff reported the resident enjoyed walking the halls and sitting outside but had not previously attempted to leave the facility. The DNS confirmed that the resident should not have been outside unattended and that staff were expected to follow the physician's order for assisted ambulation, which was not done in this case. Facility documentation did not provide a policy for following physician's orders when requested. The failure to supervise the resident according to the care plan and physician's orders resulted in the resident leaving the facility grounds unsupervised, constituting a deficiency in providing appropriate treatment and care according to orders and the resident's needs.
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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