Greenwich Woods Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenwich, Connecticut.
- Location
- 1165 King Street, Greenwich, Connecticut 06831
- CMS Provider Number
- 075309
- Inspections on file
- 20
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Greenwich Woods Rehabilitation during CMS and state inspections, most recent first.
The facility did not replace Nephros water filters according to manufacturer guidelines after a presumptive Legionella case and failed to notify the state Department of Public Health when water samples tested positive for Legionella. Several faucets lacked required filters, and staff were unaware of missing or expired filters. The Infection Preventionist and Medical Director were not informed of positive results, and there was no specific monitoring of residents in affected rooms, resulting in Immediate Jeopardy.
Two residents were found with medications left at their bedside despite not having orders or assessments for self-administration. In both cases, nursing staff left medications, including a liquid cough medicine and an albuterol inhaler, for the residents to take on their own, contrary to facility policy and physician orders. Documentation in the MAR was also inaccurate or incomplete regarding actual administration.
Second-floor windows in the secured dementia unit were found without safety devices, allowing them to open fully and creating a hazard for residents. Staff admitted to opening windows due to heat and not reporting missing safety devices, while maintenance relied on nursing staff to report issues rather than conducting regular checks. Facility policy required windows to be secured after air conditioner removal, but this was not followed, resulting in multiple unsecured windows.
The facility did not ensure that all licensed nurses and nurse aides completed required education, training, and competency assessments for IV therapy, with documentation missing for annual competencies and IV certificates for a significant portion of staff. Leadership was unaware of these deficiencies, and no facility policy was provided when requested.
The facility did not consistently complete shift-to-shift controlled drug counts, as evidenced by missing signatures on narcotic audit sheets across multiple units and shifts. Nursing staff interviews confirmed that all nurses were responsible for signing the count sheets at the start and end of each shift, but this process was not reliably followed, resulting in incomplete documentation for controlled substances.
Several residents with varying medical conditions and cognitive statuses were not offered or administered influenza and pneumococcal vaccines as required, with documentation missing in their clinical records. Issues included lack of consent form follow-up, delays in vaccine delivery from the pharmacy, and unawareness of the problem by the DNS, despite facility policy mandating that all eligible residents be offered these immunizations.
The facility did not offer or administer COVID-19 booster vaccines to several eligible residents, despite having signed consents and documentation indicating the vaccines were not up to date. Issues included missing consents from representatives, lack of follow-up, and delays in vaccine delivery from the pharmacy, with no evidence that boosters were given during the review period.
Two residents were not provided with timely assistance or their preferred choices: one was left waiting for hours before being assisted to bed at their requested time, and another did not receive the specific meal items they had selected, despite clear communication of their preferences. These failures reflect a lack of support for resident self-determination and choice in daily care and meals.
A resident with multiple medical conditions was admitted without a signed advance directive or code status consent form in the clinical record. Nursing staff relied on hospital discharge paperwork for code status and did not complete the required documentation at admission, contrary to facility policy.
A resident with a history of bipolar disorder and other medical conditions remained in the facility beyond the approved 30-day PASRR Level 1 period without a timely Level 2 determination. The responsible social worker did not submit the required PASRR rescreen before the approval expired, and only did so after surveyor intervention, despite facility policy requiring earlier submission.
Two residents did not receive care as ordered by their physicians: one did not have required orthostatic blood pressure monitoring documented while on antipsychotic medication, and another did not receive prescribed COPD medication due to pharmacy and communication issues, with delayed provider notification. Facility staff failed to follow policies for executing and documenting orders and for timely provider notification when medications were unavailable.
Two residents with significant risk factors for skin breakdown did not receive weekly skin audits as ordered by physicians, with multiple weeks missing documentation and no evidence of refusals. Nursing staff and supervisors were unaware of the missed audits, and facility policy requiring weekly audits on shower days was not followed, resulting in a failure to monitor and document skin integrity as required.
A resident with severe cognitive impairment and bilateral hand contractures did not consistently have hand rolls or rolled washcloths in place as ordered by the physician and outlined in the care plan. Multiple observations found the resident without these devices, and staff interviews revealed inconsistent application and difficulty placing them due to contractures and soiling. Facility policy required consistent use and communication with rehab for issues, but these procedures were not reliably followed.
A resident receiving enteral feeding was observed with an unlabeled feeding container and uncapped tubing, which was later reconnected to the resident. An LPN confirmed the feeding was not labeled as required and should have been discarded, while the DNS stated that facility policy mandates proper labeling and capping of enteral feeding supplies.
A resident with chronic pain did not receive prescribed Tramadol for pain management as ordered, after staff incorrectly believed the order had expired. The resident's pain was not assessed using a pain scale, and Tylenol was given instead, which did not relieve the pain. Staff did not contact a provider to renew the order overnight, and the facility's pain management policy for timely and appropriate intervention was not followed.
Two residents did not have their pain medication administration accurately documented in the MAR, despite records elsewhere indicating the medications were given. Nursing staff sometimes recorded administration only in shift reports or on controlled substance logs, but not in the official MAR, contrary to facility policy. This resulted in incomplete and inaccurate medical records for pain management.
A resident with metastatic breast cancer and a complex wound did not receive updated wound care as recommended by an APRN, specifically the addition of calcium alginate with silver for increased drainage. Despite clear documentation and communication of the new treatment plan, charge nurses did not implement the changes, and facility records did not reflect the updated orders or care provided.
A resident with multiple wounds and complex medical needs did not have complete and accurate documentation of wound care treatments. Nursing staff failed to consistently record the administration of wound treatments in the medical record, particularly when treatments were given after the resident was initially asleep or refused care. Facility policy required all treatments to be documented, but this was not followed by the staff involved.
Failure to Replace Water Filters and Report Legionella Results
Penalty
Summary
The facility failed to follow the manufacturer's recommendations for replacing Nephros water filters after a presumptive positive case of Legionella in a resident. Nephros filters, which are certified for 90 days of use, were installed on all faucets and shower heads but were not replaced as required. Observations revealed that several resident rooms and utility areas lacked the required filters, and interviews with the Maintenance Director and Administrator confirmed that filters were only replaced when they broke or fell off, not according to the recommended schedule. The Maintenance Director was unaware of missing filters, and there was no record-keeping of filter replacements. Additionally, the facility did not ensure timely notification to the state Department of Public Health when positive Legionella water sample results were identified, as required by their water management plan. Multiple water samples from various locations in the facility tested positive for Legionella, with results ranging from 1.2 to 31.9 CFU/ml. Despite these findings, documentation failed to show that the state agency was notified when results exceeded the threshold for reporting. The water management committee met regularly but did not document in detail how positive Legionella results were addressed. Interviews with key staff, including the Infection Preventionist and Medical Director, revealed gaps in communication and monitoring. The Infection Preventionist did not review water sample results or maintain a line list for Legionella monitoring, and residents in rooms with positive water samples were not specifically monitored. The Medical Director was unaware of the positive Legionella results and indicated that he would have ordered additional testing if informed. These failures resulted in a finding of Immediate Jeopardy, as the facility did not implement required infection prevention and control measures following the identification of Legionella.
Removal Plan
- Replace the water filters on all shower heads and previous resident care areas that tested positive.
- Ship 35 water filters overnight and replace.
- WC #2 adjusted chlorine levels per WC #1's guidance (from 1.0mg to 2.2mg).
- Order and install 115 additional water filters to be delivered and installed.
- Replace all water filters in the kitchen.
- Provide bottled water for drinking and oral care until the water filters are replaced/changed.
- Provide staff education on the use of bottled water for drinking and providing oral care.
- Continue to perform bi-weekly water sampling testing to be conducted by WC #1.
- Provide hand sanitizer for hand hygiene and disposable wipes for use in resident rooms.
- Mark sinks for non-use until water filters are replaced.
- Notify residents and families of the concern with the water.
- Continue to monitor residents and obtain physician orders to conduct further testing if indicated.
- Bag faucets and post signs identifying not to use in rooms without new water filters.
- Place wipes and hand sanitizers in every room.
- Place signs to not use the water on the front door and on the units.
- Educate every resident regarding the wipes and hand sanitizer in the affected rooms.
- Allow staff to use the shower room, staff bathroom, and soiled utility room sinks for hand washing.
- Deliver water bottles to all units.
Medications Left at Bedside Without Self-Administration Orders
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards and that medications were not left at the bedside for residents without an order or assessment for self-administration. In one instance, a resident with severe cognitive impairment and a physician's order prohibiting self-administration was observed with a cup containing cough medicine left on the overbed table. The nurse responsible admitted to leaving the medication for the resident to take unsupervised and had already documented administration in the Medication Administration Record before confirming ingestion. In another case, a resident with chronic obstructive pulmonary disease and a physician's order against self-administration was found with an albuterol inhaler left at the bedside. The medication was not documented as administered in the Medication Administration Record, and the nurse confirmed that the medication should not have been left in the resident's room. The resident indicated that the nurse had left the medication for them. Facility policy requires that residents are observed after medication administration to ensure ingestion and that self-administration is only permitted with specific physician authorization and an interdisciplinary team assessment. In both cases, these policies were not followed, resulting in medications being left at the bedside for residents without proper orders or assessments for self-administration.
Failure to Secure Second-Floor Windows Creates Safety Hazard
Penalty
Summary
The facility failed to ensure that second-floor windows in the secured dementia unit were equipped with mechanisms to prevent them from fully opening, creating a safety hazard for residents. During an observation, a window in a resident room was found fully open without a screen, and staff interviews revealed that nursing assistants had been opening windows fully due to heat, despite knowing that windows were only supposed to open a little. One nursing assistant admitted that the window had been able to open fully for at least a month and had not reported the issue for repair or informed anyone. The Director of Maintenance (DOM) confirmed that it was maintenance's responsibility to ensure windows had safety devices limiting their opening to no more than 6 inches, but stated he relied on nursing staff to report issues rather than conducting regular checks himself. A tour of the secured dementia unit revealed that 8 out of 17 rooms had windows without the required safety devices, with window openings measured between 17 to 22 inches high and 33 inches wide. The DOM acknowledged that when air conditioners were removed from the windows, safety devices were not reinstalled, and he had not instructed his staff to do so or checked the windows afterward. Interviews with facility leadership, including the Administrator and VP of Clinical Services, confirmed that there was no system in place for routine checking and monitoring of window safety devices, and that maintenance checks were only performed if nursing staff reported an issue. The facility's policy required that windows in resident-accessible areas not open more than 6 inches and that safety devices be installed when air conditioning units were removed, but this policy was not followed, resulting in unsecured windows in multiple resident rooms.
Failure to Ensure IV Therapy Competencies and Certification Among Nursing Staff
Penalty
Summary
The facility failed to ensure that licensed nurses and nurse aides had completed required education, training, and competency assessments related to intravenous (IV) therapy. Documentation for annual IV competencies for 2023 was not provided, and for 2024, only a portion of the nursing staff had received competency training in IV therapy. Specifically, only 15 of 29 licensed nurses and 17 of 43 nurse aides had documented IV therapy competency for 2024. Interviews with the Infection Preventionist and the Director of Nursing Services revealed a lack of awareness regarding the incomplete education and competency records, and the responsible staff member was unable to locate or provide the necessary documentation for both years. Additionally, the facility was unable to provide a policy regarding IV therapy competencies when requested. Further review showed that 11 of 29 licensed nurses did not have documentation of an IV therapy certificate, as required for the facility's IV therapy program. The Infection Preventionist was not aware of this deficiency and had not ensured that all licensed nurses possessed the necessary certification. The Director of Nursing Services also indicated unawareness of the missing certificates and confirmed that oversight of staff development and review of IV certificates was the responsibility of the Infection Preventionist. The facility assessment identified the need for staff competencies in IV therapy, including establishing peripheral venous routes and central line dressing changes, but annual training and documentation were not consistently completed or provided.
Failure to Consistently Complete Shift-to-Shift Controlled Drug Counts
Penalty
Summary
The facility failed to ensure that shift-to-shift controlled drug counts were consistently completed for all four medication carts. Observations and review of narcotic drug change of shift audit sheets revealed missing signatures on multiple dates and shifts across several units, including significant gaps in both February and March. The missing signatures indicated that the required process of both on-coming and off-going nurses counting and signing for controlled substances at each shift change was not consistently followed. Interviews with nursing staff confirmed that all nurses were responsible for signing the narcotic count sheets at the beginning and end of each shift, but this was not consistently done. The Director of Nursing Services acknowledged awareness of the issue and stated that education was being provided to licensed nurses regarding this responsibility. Facility documentation and policy also required compliance with federal, state, and other applicable laws and regulations for the handling, storage, and record keeping of controlled substances.
Failure to Offer and Administer Influenza and Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and provide influenza and pneumococcal vaccinations to several residents as required. Clinical record reviews and interviews revealed that five residents with various diagnoses, including diabetes mellitus, hypertension, multiple sclerosis, schizophrenia, and dementia, did not have documentation showing that the influenza vaccine was offered or administered. These residents had varying levels of cognitive impairment, and their quarterly MDS assessments indicated that their influenza vaccinations were not up to date. Similarly, four residents with diagnoses such as atherosclerotic heart disease, hemiplegia, cerebral palsy, and subarachnoid hemorrhage were found to be lacking documentation that the pneumococcal vaccine was offered or administered. Their MDS assessments also showed that their pneumococcal vaccinations were not current. In some cases, residents had severe cognitive impairment, while others had intact cognition. Interviews with the Infection Preventionist revealed issues with obtaining consent forms from resident representatives and delays in vaccine delivery from the pharmacy. The Infection Preventionist was unable to verify if follow-up with resident representatives occurred and could not locate previous vaccination records. The Director of Nursing was not aware of the issue and indicated that the Infection Preventionist was responsible for ensuring timely vaccination of all residents. The facility's policy stated that all eligible residents should be offered these vaccines unless medically contraindicated, and that residents or their legal representatives should receive vaccine information prior to administration.
Failure to Offer and Administer COVID-19 Booster Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer and provide COVID-19 booster vaccinations to all eligible residents as required, as evidenced by clinical record reviews, facility documentation, and staff interviews. For five residents with various diagnoses and cognitive statuses, documentation did not show that the COVID-19 booster vaccine was offered or administered, despite signed consents being present in the records. The Minimum Data Set (MDS) assessments for these residents indicated that their COVID-19 booster vaccinations were not up to date, and there was no evidence in the clinical records that the vaccine had been offered or given. Interviews with the Infection Preventionist (RN) revealed that some consents from resident representatives were not received, and there was no verification of follow-up with these representatives. Additionally, the RN stated that no COVID-19 booster vaccines had been administered in 2024 or 2025. Delays in vaccine delivery from the pharmacy were also noted, with issues related to communication, payment profiles, and insurance coverage. The Director of Nursing was unaware of these issues, and facility policy required that all eligible residents be offered the vaccine with appropriate education and documentation.
Failure to Honor Resident Choices in Care and Meal Preferences
Penalty
Summary
Two residents were not provided with the opportunity to exercise their choices regarding daily care and meal preferences, resulting in deficiencies related to resident rights and self-determination. One resident, who had diagnoses including muscle weakness, difficulty walking, and required extensive assistance with activities of daily living, was not assisted to bed at their preferred time. Despite the resident's established care plan and physician orders requiring assistance with transfers, documentation was missing for the relevant shifts, and the resident was left waiting for four hours before being put to bed, fully clothed, at midnight. The resident's call light was not answered, and the assigned nurse aide did not provide care, later stating she was unaware the resident was on her assignment. Another resident, with chronic obstructive pulmonary disease, atrial fibrillation, and heart failure, did not receive the meal items they had specifically requested. The resident was alert and oriented, and their care plan indicated independence with meal setup. However, the lunch tray provided did not include the requested tomato and mayonnaise on the BLT sandwich, and the resident reported ongoing issues with receiving incorrect meal trays since admission. The dietary staff confirmed that tomatoes were unavailable and that the resident's preferences were not fully accommodated, despite being communicated on the meal ticket. Facility policies reviewed indicated that residents should receive assistance with activities of daily living and be encouraged to make choices regarding their care, including timing and meal preferences. The failure to accommodate these choices, as evidenced by the lack of timely assistance with bedtime and the incorrect meal tray, demonstrates a lack of adherence to these policies and the residents' rights to self-determination.
Failure to Obtain and Document Advance Directive Consent at Admission
Penalty
Summary
The facility failed to obtain and document the resident's wishes regarding advance directives and code status upon admission for one resident with multiple medical conditions, including COPD, respiratory failure, and cellulitis. Although the resident was assessed as having moderately impaired cognition and required significant assistance with daily activities, there was no signed Acknowledgement of Receipt Advance Directive/Medical Treatment Decisions form in either the physical or electronic clinical record at the time of review. The physician's order and care plan indicated a full code status, but this was not supported by a signed consent from the resident or their representative. Interviews with nursing staff revealed that the admitting nurse did not complete the advance directive paperwork at admission, instead relying on the code status from the hospital discharge paperwork. The nurse reported that the resident was capable of signing the form but was asleep at the time, and the task was passed on to the next shift. Facility policy requires that advance directives be discussed and documented at admission, with the appropriate form signed and maintained in the clinical record, but this process was not followed for the resident in question.
Failure to Complete Timely PASRR Level 2 Determination
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a Level 2 Pre-Admission Screening and Resident Review (PASRR) determination was completed for a resident whose 30-day approval stay had expired. The resident, who had diagnoses including anxiety disorder, type 2 diabetes mellitus, squamous cell carcinoma, and a history of bipolar disorder, was admitted with a 30-day PASRR Level 1 approval. The facility's policy required that a request for continued approval be submitted no later than 10 days prior to the expiration of the current approval. However, the social worker responsible for submitting PASRR requests did not submit the Level 2 PASRR request before the expiration date, and only did so after being prompted by the surveyor during the review. The social worker acknowledged being behind in her duties and had communicated her need for assistance to the Director of Nursing Services (DNS) and the Administrator, but they were only aware of her being behind on MDS assessments and not on PASRR-related tasks. The resident remained in the facility beyond the approved 30-day period without the required Level 2 PASRR determination, despite having a diagnosis that warranted such a review. Facility documentation and interviews confirmed that the required process for timely PASRR rescreening was not followed.
Failure to Implement and Document Physician Orders for Medication Administration and Monitoring
Penalty
Summary
For one resident with diagnoses including anxiety disorder, diabetes, and squamous cell carcinoma, the facility failed to ensure that physician orders for orthostatic blood pressure (BP) monitoring were implemented and documented as prescribed. The resident was receiving antipsychotic medication, and the order required weekly orthostatic BP checks with documentation in the progress notes and notification to the provider if significant changes were observed. Review of the clinical records did not identify any documentation of the required BP readings, despite nurses signing off on the Medication Administration Record (MAR) as if the order had been completed. Interviews with nursing staff revealed confusion about where to document the readings and indicated that the order may have been inputted incorrectly in the electronic health record, resulting in the required monitoring not being performed or recorded. For another resident with chronic obstructive pulmonary disease (COPD) and respiratory failure, the facility failed to ensure that prescribed medication (Trelegy Ellipta) was administered as ordered. The medication was not available for administration on several days, and the provider was not notified of the missed doses until several days after the medication became unavailable. The MAR reflected that the medication was not given due to pharmacy delivery issues and later due to the drug being unavailable, but there was no documentation that the provider was informed in a timely manner. Interviews with nursing staff and the pharmacist confirmed that the medication was delayed due to a duplicate order warning and billing issues, and that multiple notifications were sent to the facility requesting authorization, but no timely response was received. Facility policy required that all physician orders be executed and documented according to current standards of nursing practice, and that the provider be notified if three consecutive doses of a vital medication were withheld or unavailable. In both cases, the facility did not follow its own policies or the specific physician orders, resulting in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Complete and Document Weekly Skin Audits for Residents at Risk for Pressure Ulcers
Penalty
Summary
The facility failed to ensure that weekly skin audits were completed and documented as ordered by physicians for two residents with significant risk factors for skin breakdown and pressure ulcers. For one resident with dementia, severe cognitive impairment, incontinence, and a stage 4 pressure ulcer, physician orders required weekly body audits to be performed and documented on specific days and shifts. However, review of the clinical record revealed that body audits were missing for six out of twelve weeks, and there was no documentation to support that the audits had been completed during those periods. Interviews with the Director of Nursing Services (DNS) confirmed that the audits were not documented and that the expectation was for charge nurses to complete and record these audits on the designated days. Another resident, admitted for short-term rehabilitation with diagnoses including hemiplegia, incontinence, and fragile skin, also had physician orders for weekly body audits. Documentation review showed that body audits were not completed or documented for several weeks, and there was no evidence in the nurse's notes that the audits were performed or that the resident refused them. Interviews with nursing staff, including the RN Supervisor and charge nurse, indicated a lack of awareness regarding the missed audits and confirmed that refusals would have been documented and reported if they had occurred. Facility policy required weekly body audits to coincide with shower days, to be performed and documented by the assigned licensed nurse. Despite this policy, both the clinical record and staff interviews confirmed that the required weekly skin audits were not consistently completed or documented for the two residents, resulting in a failure to follow physician orders and facility protocol for pressure ulcer prevention and monitoring.
Failure to Consistently Apply Hand Rolls as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with multiple sclerosis, bilateral hand and wrist deformities, and right-sided weakness consistently had bilateral hand rolls or rolled washcloths in place as ordered by the physician. The resident was identified as severely cognitively impaired and dependent on staff for bed mobility, transfers, bathing, and personal hygiene. The care plan and physician's orders required that hand rolls or rolled washcloths be in place at all times, except during skin checks or hygiene, to address the resident's risk for skin breakdown due to contractures. However, during multiple observations on different days, the resident was found without the required hand rolls or washcloths in place. Staff interviews revealed inconsistencies in the application of the hand rolls, with explanations including removal for care or due to soiling, and difficulty placing them because of contractures and resident resistance. Nursing staff were sometimes unable to locate the hand rolls or splints in the resident's room, and there was a lack of clarity regarding their consistent use. Occupational therapy staff confirmed ongoing challenges with placement due to worsening contractures and staff difficulty, despite previous education on the matter. Facility policy required nursing staff to apply and remove such devices as scheduled and to notify rehabilitation if devices were ill-fitting or refused, but these procedures were not consistently followed.
Failure to Properly Label and Handle Enteral Feeding Supplies
Penalty
Summary
A deficiency was identified regarding the management of enteral feeding for a resident with a history of hemiplegia, hemiparesis, dysphagia, and a gastrostomy. The resident required extensive assistance with eating and received Jevity 1.5 calories via enteral feeding tube, as ordered by the physician. Observations revealed that the enteral feeding container was not properly labeled with the date and time, and the tubing was left uncapped and exposed when not connected to the resident. The same bottle of enteral feeding was later reconnected to the resident, and the label on the bottle indicated it had been changed the previous evening, not during the current shift. Interviews with staff confirmed that facility policy required enteral feeding containers to be labeled with the date, time, and rate, and that tubing should be capped when not in use. The LPN acknowledged that the feeding was not labeled that morning and that the undated container should have been discarded and replaced. The DNS also confirmed that enteral feeding should be replaced if not properly labeled or if the cap was missing, in accordance with facility policy. The facility's enteral feeding policy further specified the need for proper labeling and timely discarding of supplies and equipment.
Failure to Administer Prescribed Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of chronic pain, including diagnoses of lumbar vertebra compression fracture, pancreatic cancer, and myelodysplastic syndrome, did not receive prescribed pain medication as ordered. The resident had an active physician's order for Tramadol 50mg every 12 hours as needed for pain, but when the resident requested the medication at night, it was not administered. Instead, the resident was told the nurse would return, but no one did, and the resident was later given Tylenol, which did not relieve the pain. The resident reported ongoing pain in the head, mouth, and ribs, and stated that the nurse did not assess the pain at the time of the request. Staff interviews and record reviews revealed that the LPN believed the Tramadol order had expired and did not assess the resident's pain using a pain rating scale. The LPN provided Tylenol and documented a request for order renewal in the APRN notification book but did not contact a provider overnight to renew the order. The RN supervisor was notified of the situation but was not informed that the resident's pain was unrelieved after Tylenol. The APRN and DNS both indicated that a pain assessment should have been completed and the provider contacted if the order had expired and the resident was experiencing pain. The facility's pain management policy requires regular pain assessment, belief in resident reports, and timely intervention, which were not followed in this instance.
Failure to Accurately Document Pain Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of pain medication administration for two residents reviewed for pain management. For one resident with a history of lower back pain, arm pain, and dementia, there were discrepancies between the 24-Hour Shift Report and the Medication Administration Record (MAR). The 24-Hour Shift Report indicated that as-needed (PRN) acetaminophen was administered on several dates, but the MAR did not reflect these administrations. Interviews with nursing staff revealed that medications were sometimes documented only in the shift report and not in the MAR, contrary to facility policy, which requires immediate documentation in the MAR after administration. For another resident with diagnoses including lumbar vertebra fracture, pancreatic cancer, and myelodysplastic syndrome, there were similar documentation failures. The resident had a PRN order for Tramadol for pain, and the Control Substance Disposition Record showed that doses were dispensed on multiple dates. However, the MAR and progress notes did not document the administration of Tramadol on several of those dates. Nursing staff acknowledged that they sometimes failed to document medication administration in the MAR, especially when working double shifts or multiple units, despite being aware of the requirement to do so. Facility policies for both general medication administration and controlled substances require that the nurse administering the medication immediately document the administration in the MAR and, for controlled substances, also on the accountability record. The observed failures to document medication administration in the MAR, while sometimes recording it elsewhere, resulted in incomplete and inaccurate medical records for the residents involved.
Failure to Implement Updated Wound Care Recommendations
Penalty
Summary
The facility failed to implement wound treatment recommendations for one resident with a complex medical history, including metastatic breast cancer, a fungating breast mass, secondary bone malignancy, severe protein-calorie malnutrition, and adult failure to thrive. Upon admission, the resident was noted to have a cancerous wound on the right breast with erythema and sanguineous drainage. Initial physician orders directed specific wound care, including cleansing with Dakins solution, application of Xeroform gauze, and covering with a stockinette, to be performed daily. The care plan also required weekly skin assessments, monitoring for healing, and notification of the physician if there was no improvement. On a subsequent wound evaluation, an APRN recommended a change in the wound care regimen to address moderate sanguineous drainage, specifically adding calcium alginate with silver to the base of the wound. However, a review of physician orders and the Treatment Administration Record for the relevant period showed that this updated recommendation was not implemented. Interviews confirmed that the charge nurses, who were responsible for carrying out the APRN's recommendations during the wound nurse's absence, did not ensure the new treatment was ordered or provided. Facility policy required documentation of wound rounds and implementation of new treatments, but no evidence was provided to show the APRN's recommendations were followed.
Incomplete and Inaccurate Documentation of Wound Treatments
Penalty
Summary
The facility failed to ensure that the clinical record for a resident with multiple complex wounds was complete and accurate, specifically regarding the administration and documentation of wound treatments. The resident had significant medical conditions, including metastatic breast cancer with a fungating mass, multiple pressure ulcers, severe malnutrition, and failure to thrive. Physician orders were in place for specific wound care regimens for the resident's lower legs, right breast, buttocks, and coccyx, with instructions for daily dressing changes and documentation of treatments provided. Review of the Treatment Administration Record (TAR) and nurse notes revealed multiple instances where wound treatments were either not administered as ordered or not documented. On several occasions, treatments were missed during overnight shifts, with reasons such as the resident being asleep or refusing care. In some cases, nurses reported verbally to the oncoming shift that the resident had refused treatment or that care was provided later, but failed to document these actions in the medical record as required by facility policy. Interviews with nursing staff confirmed that treatments were sometimes given after the initial refusal or missed opportunity, but documentation was not consistently completed. The facility's documentation policy required that all services provided to residents, including wound treatments, be recorded in the medical record. Despite this, there were repeated failures by nursing staff to document wound care interventions, particularly when treatments were administered after a missed or refused dose. The Director of Nursing Services (DNS) confirmed the expectation for nurse notes to be written whenever wound treatments were provided, especially in cases of as-needed care or when a resident initially refused treatment.
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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