Lord Chamberlain Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Stratford, Connecticut.
- Location
- 7003 Main Street, Stratford, Connecticut 06614
- CMS Provider Number
- 075412
- Inspections on file
- 28
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Lord Chamberlain Manor during CMS and state inspections, most recent first.
A resident with a history of stroke, atrial fibrillation, and antiphospholipid syndrome did not receive Coumadin therapy as ordered, with missed doses and delayed or missing INR monitoring. Documentation was inconsistent, and staff did not act on subtherapeutic INR results in a timely manner, resulting in significant medication errors and failure to maintain the therapeutic INR range.
Two residents with significant medical histories, including atrial fibrillation and recent hospitalizations, were prescribed Coumadin and received the medication for several weeks. Despite physician orders for anticoagulation therapy and required INR monitoring, the facility did not develop or document care plans addressing anticoagulation therapy or bleeding risk for either resident, as required by facility policy. Interviews with the DON, Administrator, and an RN confirmed the omission and the lack of explanation for why the care plans were not completed.
A resident with atrial fibrillation and a history of TIA did not consistently receive Coumadin as ordered, due to multiple transcription errors by LPNs and incorrect dosing entries by an APRN. Missed doses and delays in obtaining new orders led to the resident's INR frequently falling outside the therapeutic range, contrary to physician instructions and facility protocol.
A resident with confusion and a recent femur fracture, identified as an elopement risk and wearing a wander guard, was able to leave the facility unsupervised after a Dietary Aide opened a non-alarmed cafe door without consulting nursing staff. The resident was later found at a nearby gas station without the wander guard and refused to return, requiring EMS intervention.
A resident with dementia and a high fall risk exhibited increased agitation and combative behavior, including medication refusal and the need for constant redirection. Although a physician was notified of agitation on admission and a PRN medication was ordered, there was no evidence that the physician was informed of the resident's further behavioral escalation during the night shift, contrary to facility policy. This lapse occurred prior to the resident experiencing an unwitnessed fall and subsequent hospital transfer.
A resident with multiple chronic conditions experienced vaginal bleeding and repeatedly refused to use an ordered AVAP device at bedtime. Nursing staff documented these events and communicated among themselves and to respiratory therapy, but failed to notify the medical provider in a timely manner as required. This resulted in a delay in provider awareness and intervention for significant changes in the resident's condition.
A resident with a surgical abdominal wound was transferred to the hospital for infection and was not allowed to return to the facility after the hospital cleared them for discharge. Nursing staff reported being instructed not to readmit the resident, though the supervisor did not recall giving this direction. The facility's administrator confirmed that residents should be permitted to return within 48 hours, and the facility's policy supports resident return after hospitalization.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube and a PICC line, despite the resident's diagnoses of severe sepsis and infection due to an orthopedic prosthetic device. The resident required substantial assistance and was receiving intravenous therapy. There was no EBP signage or PPE outside the resident's room, and the nursing assistant was unaware of the need for additional precautions. The oversight was acknowledged by the LPN and DNS, who confirmed that the resident should have been on EBP due to the presence of indwelling medical devices.
A resident with a history of leg amputation and other medical conditions was not treated with dignity when requesting wheelchair leg rests before a dialysis appointment. Despite the resident's request, an LPN attempted to transport the resident without the leg rests, contrary to facility protocol. The facility's policy required leg rests unless the resident requested otherwise, and the Administrator acknowledged the importance of listening to residents' requests.
A resident with a fracture and muscle weakness was unable to use the standard call bell due to stiff buttons, despite being alert and oriented. The facility had alternative call bell options, but they were not provided, and the policy did not address procedures for residents unable to use a standard call bell. This led to the resident attempting to get out of bed without assistance.
A facility failed to include dialysis needs and medication monitoring in a baseline care plan for a resident with end-stage renal disease and bipolar disorder. Despite physician orders for dialysis and mood stabilization medication, the care plan omitted these critical elements due to staff oversight. The Director of Nursing acknowledged the oversight, which contravened the facility's policy requiring comprehensive care plans within 48 hours of admission.
A resident with congestive heart failure and muscle weakness required two-person assistance for bed mobility, as per physician's orders. However, a nurse aide assisted the resident alone, leading to discomfort and dissatisfaction. The aide believed the resident could assist themselves, despite the care plan specifying total dependence. The facility's policy mandates adherence to care plans, which was not followed in this case.
A facility failed to ensure correct medication administration for a resident with NPO status and a gastrostomy tube. Despite the resident's condition requiring all medications to be administered via the tube, several orders were incorrectly transcribed as 'by mouth' in the EHR. Staff interviews revealed a lack of clarification and correction of these orders, contrary to facility policy.
The facility failed to implement physician-ordered safety measures for two residents. One resident with a history of seizures was observed without required bumper guards and floor mats, despite orders and a care plan specifying these precautions. Another resident, with multiple health issues, was not wearing heel booties as ordered to offload heels, despite staff signing off on compliance. Facility policies on seizure precautions and physician orders were not effectively followed, leading to these deficiencies.
A facility failed to provide appropriate assistance during a resident's transfer, leading to a fall, and did not conduct a smoking assessment for another resident, who continued to smoke on the premises. The facility also failed to enforce its no-smoking policy, resulting in cigarette waste accumulation.
A resident with acute respiratory failure and heart failure did not receive oxygen as per physician orders, leading to a deficiency in care. Despite orders for continuous oxygen at 2 liters via nasal cannula, the resident was observed without oxygen on multiple occasions. Staff, including an LPN and the DNS, were unable to explain the presence of multiple conflicting oxygen orders or why continuous oxygen was signed off when not administered. The facility's policy for reviewing physician orders was not followed, resulting in the deficiency.
A facility failed to identify and monitor a resident's AV fistula, essential for dialysis care. The resident, dependent on dialysis, was not assessed for the fistula upon admission, and the baseline care plan lacked documentation of its presence. Facility policies require monitoring of AV fistulas every shift, but this was not done due to oversight in entering batch orders and MAR instructions.
A facility failed to ensure a resident receiving Zyprexa had an appropriate diagnosis and monitoring. The resident, admitted with anxiety/depression disorder, was prescribed Zyprexa for anxiety, which is not an appropriate diagnosis. Orthostatic BP monitoring was delayed, and AIMS testing was not conducted. The resident was unaware of the medication's purpose, and the DNS confirmed anxiety disorder was not a valid diagnosis for antipsychotic use.
A facility failed to provide a resident with the requested alternative menu option, despite the resident's care plan identifying nutritional status and diet as a concern. The resident, who had dysphagia, depression, and gastro-esophageal reflux disease, reported not receiving requested menu substitutions. An observation confirmed the resident received pudding instead of yogurt. Interviews revealed that dietary and nurse aides did not consistently check dietary slips and meal tray contents, with one aide stating she was often too busy to verify trays.
A resident admitted with sepsis, chronic kidney disease, and type 2 diabetes was not offered an influenza vaccine, nor was there documentation of refusal or prior immunization. The facility's policy required offering the vaccine to all eligible residents, but this was not adhered to, as revealed in an interview with an RN.
Failure to Maintain Therapeutic INR Levels and Timely Coumadin Management
Penalty
Summary
The facility failed to ensure that a resident receiving Coumadin (Warfarin) therapy had their INR levels maintained within the physician-ordered therapeutic range of 2.5 to 3.5. The hospital discharge summary specified Coumadin dosing and required INR monitoring every other day, with dose adjustments as needed. However, clinical record review revealed that INR tests were not consistently performed as ordered, and Coumadin doses were not always administered according to the prescribed schedule. There were multiple days when the resident did not receive any Coumadin, and INR results were frequently below the therapeutic range without timely intervention or dose adjustment. Documentation on the Coumadin Tracking Form was inconsistent and sometimes contained conflicting information regarding current doses, new orders, and next INR test dates. There were also instances where new orders were not obtained or acknowledged by a physician or APRN, and INR results were not acted upon in a timely manner. Interviews with clinical staff confirmed that the resident's INR levels were not maintained within the therapeutic range, and that the management of Coumadin therapy was not efficient or consistent with the facility's own Coumadin protocol policy. The resident had significant medical conditions, including cerebral infarct with hemiplegia, atrial fibrillation, and antiphospholipid syndrome, all of which increased the importance of maintaining therapeutic anticoagulation. Despite these risks, the facility did not provide adequate monitoring or management of the resident's Coumadin therapy, resulting in significant medication errors as identified by both facility staff and external reviewers. The deficiency was cited as Immediate Jeopardy due to the failure to maintain the ordered therapeutic INR range and to ensure timely and appropriate medication administration and monitoring.
Failure to Timely Develop Care Plans for Residents on Anticoagulation Therapy
Penalty
Summary
The facility failed to develop and implement timely care plans for anticoagulation therapy for two residents who were prescribed Coumadin (Warfarin) following their admission. Both residents had medical histories that included conditions such as atrial fibrillation, cerebral infarct with hemiplegia/hemiparesis, antiphospholipid syndrome, and transient ischemic attack, and were ordered to receive daily Coumadin with specific instructions for INR monitoring and dose adjustments. Despite these orders and the administration of Coumadin over several weeks, review of the clinical records and resident care plans revealed that neither resident had a care plan addressing anticoagulation therapy or the associated risk for bleeding, as required by facility policy and the Coumadin protocol. Interviews with the DON, Administrator, and an RN confirmed that it was the responsibility of the nursing or MDS team to ensure care plans reflected resident needs and treatment plans, and that comprehensive care plans should be completed within the required timeframe after admission. The facility was unable to provide documentation of care plans for anticoagulant use for either resident and acknowledged that such care plans should have been in place. The reason for the omission could not be identified during the interviews.
Failure to Accurately Administer and Manage Coumadin Therapy
Penalty
Summary
The facility failed to ensure that Coumadin was administered and managed according to physician orders and the resident's therapeutic INR goal. A resident with a history of atrial fibrillation and transient ischemic attack was admitted with orders for Coumadin and a target INR range of 2.0 to 3.0. Multiple errors were identified in the transcription and administration of Coumadin orders, resulting in missed doses on several occasions. Specifically, LPNs transcribed Coumadin orders to start on incorrect dates, causing the resident to miss scheduled doses on three separate days. Additionally, there were inconsistencies and delays in obtaining new Coumadin orders when INR results were outside the therapeutic range. On several occasions, the resident's INR was either above or below the target range, but no new orders were documented or implemented in a timely manner. There was also a documented instance where an APRN intended to increase the Coumadin dose but incorrectly entered a lower dose, which was then administered to the resident. Facility documentation and interviews confirmed that the resident's Coumadin therapy was not consistently managed to maintain the INR within the prescribed range. The facility's Coumadin protocol required accurate logging of INR results, current and new orders, and timely physician notification, but these procedures were not consistently followed. Both the APRN and physician acknowledged that Coumadin doses should not have been missed and that orders should have been transcribed accurately.
Failure to Prevent Elopement of At-Risk Resident Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident identified as being at risk for elopement was able to leave the facility without staff knowledge or supervision. The resident, who had a history of confusion and was assessed as a fall and elopement risk, was admitted with a left femur fracture and had a wander guard bracelet placed on their wrist. Despite these precautions, the resident expressed a desire to leave the facility, was noted to be exit-seeking, and required standby assistance for mobility. On the day of the incident, the resident entered the facility's cafe and requested to go outside. A Dietary Aide, unaware of the resident's elopement risk and without confirming with nursing staff, assisted by opening the cafe side door, which was not equipped with a wander guard alarm system. The resident exited through this door and was later found at a gas station across a four-lane road, approximately 0.3 miles from the facility. At the time of discovery, the resident no longer had the wander guard bracelet and refused to return to the facility, requiring EMS intervention for transport. Facility documentation and staff interviews confirmed that the Dietary Aide did not check for the presence of the wander guard or consult with nursing staff before allowing the resident outside. The lack of adequate supervision and the absence of an alarm system on the cafe door directly contributed to the resident's unsupervised exit from the facility.
Failure to Notify Physician of Resident's Increased Agitation
Penalty
Summary
The facility failed to ensure timely physician notification regarding a resident's increased agitation. The resident, who had dementia with behavioral disturbance and a history of falls, was admitted following a recent hospitalization for a fall and was identified as a high fall risk. Nursing documentation showed that the resident exhibited increased agitation, restlessness, and combative behavior during the night shift, including refusing medications and requiring constant redirection. Although the physician was notified of agitation on the day of admission and a PRN Trazodone order was obtained, there was no evidence that the physician was notified of the further increase in agitation and combative behavior observed during the early morning hours of the following day. Facility policy required that the physician, resident, and family/legal representative be informed of changes in condition. Interviews with staff and the physician confirmed that the physician was not notified of the resident's increased agitation on the morning in question, despite expectations and policy. The lack of timely notification occurred prior to an unwitnessed fall, after which the resident was found on the floor with a head injury and transferred to the hospital.
Failure to Notify Medical Provider of Change in Condition and Treatment Refusals
Penalty
Summary
The facility failed to ensure timely notification of a medical provider regarding a resident's change in condition. The resident, who had multiple diagnoses including COPD, sleep apnea, chronic cellulitis, morbid obesity, and congestive heart failure, was admitted with orders for continuous oxygen and use of an AVAP (a type of CPAP) device. The resident also had an unstageable pressure injury and required mechanical lift transfers. On one occasion, the resident experienced vaginal bleeding, which was noted by nursing staff and assessed by an RN, but there was no documentation that the MD or APRN was notified of this change until over eight hours later, when a PA was finally contacted and orders were obtained. Additionally, the resident repeatedly refused to use the AVAP device at bedtime and overnight, as documented by multiple LPNs. Although these refusals were communicated among nursing staff and to the respiratory therapist, there was no evidence that the APRN or MD was notified of the refusals, despite facility expectations and physician orders requiring such notification. Interviews with staff confirmed that refusals of the AVAP device were not consistently reported to the medical provider, and the acting DON stated that such refusals should have been communicated to the APRN. The lack of timely notification to the medical provider regarding both the vaginal bleeding and the repeated refusals to use the AVAP device constituted a failure to inform the provider of significant changes in the resident's condition and non-compliance with physician orders. This deficiency was confirmed through clinical record review, facility documentation, and staff interviews.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
A resident with a diagnosis of abdominal wound due to intestinal perforation and small bowel obstruction was transferred to the hospital for a wound infection. The resident had a physician's order for specific wound care and was noted to be alert and oriented with a surgical wound requiring ongoing treatment. Documentation showed that the wound was stable at the time of the last evaluation, and the care plan included instructions to provide wound care per treatment orders. Following the hospital transfer, the resident was not readmitted to the facility despite the hospital indicating the resident was ready for discharge back to the facility. An RN reported receiving instructions during shift change not to accept the resident's return, although the supervisor did not recall giving such a directive. The facility's administrator stated that residents are permitted to return within 48 hours per federal guidelines and was unaware of the reason for the denial. The facility's bed hold policy allows residents to return after hospitalization, but the resident was not permitted to do so in this instance.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Devices
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube and a peripherally inserted central catheter (PICC). The resident, who was cognitively intact, required substantial assistance with mobility and was dependent on toileting. Diagnosed with severe sepsis, septic shock, and an infection due to an internal orthopedic prosthetic device, the resident was receiving intravenous therapy and had a feeding tube. Despite these conditions, there was no posted signage for EBP outside the resident's room, and the nursing assistant providing care was unaware of the need for additional precautions, as the care card did not indicate EBP, and no personal protective equipment (PPE) was available outside the room. The oversight was further confirmed by a Licensed Practical Nurse (LPN) and the Director of Nursing Services (DNS), who acknowledged that the resident should have been on EBP due to the presence of indwelling medical devices. The facility's policy required an order for EBP and the implementation of signage and PPE for residents with such devices. However, the necessary steps were not taken upon the resident's admission, and the charge nurse responsible for the admission did not obtain a physician's order or ensure the placement of EBP signage and PPE. This lapse in protocol was identified as an oversight by the DNS and the Infection Preventionist.
Failure to Provide Dignified Care for Resident Requesting Wheelchair Leg Rests
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity when requesting wheelchair footrests. Resident #374, who had a medical history including acquired absence of the left leg below the knee, generalized muscle weakness, end-stage renal disease, and hypertension, was observed sitting in a wheelchair without leg rests. The resident, who was alert and oriented but forgetful, requested the surveyor to inform the nurse about the need for leg rests before being transported to a dialysis appointment. Despite the request, LPN #5 attempted to push the wheelchair forward without informing the resident, intending to transport the resident to the physical therapy room to obtain the leg rests. LPN #5 acknowledged that the resident should have had the leg rests applied before being transported. The facility's protocol, as confirmed by the Administrator and Occupational Therapist, required that residents in wheelchairs have leg rests applied unless the resident requested otherwise. The facility policy also stated that extremities should be supported once a resident is transferred to a wheelchair. The Administrator recognized that residents have a right to be listened to and treated with dignity, and LPN #5 should have adhered to the resident's request for leg rests.
Failure to Provide Appropriate Call Bell for Resident
Penalty
Summary
The facility failed to accommodate the physical limitations of Resident #525 by not providing an appropriate call bell system. Resident #525, who had a fracture of the right femur, a history of falling, and muscle weakness, was unable to use the standard call bell due to the stiffness of the buttons. Despite being alert and oriented, the resident could not press the call bell to call for assistance, as observed during multiple interviews and observations with staff. The facility had alternative call bell options, such as manual handheld bells and soft touch pads, but these were not provided to the resident. The deficiency was further highlighted by the fact that the facility's policy did not address procedures for residents unable to use a standard call bell. Interviews with staff revealed that while the call bell's functionality was checked upon admission, there was no assessment of the resident's ability to use it. Despite the availability of alternative call bells, they were not stocked on the unit and required a request to Maintenance for delivery. The failure to provide an appropriate call bell led to Resident #525 attempting to get out of bed without assistance, as noted in a nursing progress note.
Failure to Address Dialysis Needs in Baseline Care Plan
Penalty
Summary
The facility failed to implement a baseline care plan that addressed the immediate needs of a resident with end-stage renal disease who was dependent on renal dialysis. Upon admission, the resident had diagnoses including type 2 diabetes with diabetic chronic kidney disease and bipolar disorder. Physician orders indicated that the resident required dialysis at an outpatient facility three times a week and was prescribed Lamotrigine for mood stabilization. However, the Baseline Resident Care Plan (RCP) did not include the resident's dialysis needs or medication monitoring, despite addressing other categories such as activities of daily living, elimination, pain, falls, and behavior. Interviews and record reviews revealed that the omission of dialysis and psychotropic medication evaluation in the Baseline RCP was due to staff oversight. The Director of Nursing Services acknowledged that the Baseline RCP should have included goals, weights, diet, and other elements specific to dialysis. The facility's policy mandates that a baseline care plan be completed within 48 hours of admission, including resident goals, services, treatments, and a summary of medications and dietary instructions. The failure to include these critical elements in the care plan represents a deficiency in meeting the resident's immediate needs.
Failure to Provide Required Assistance for Bed Mobility
Penalty
Summary
The facility failed to ensure that a resident, who was admitted with diagnoses including congestive heart failure, respiratory failure, muscle weakness, and obesity, received the required assistance with bed mobility according to physician's orders. The resident, who was non-ambulatory and bed/chair-bound, was identified as needing the assistance of two staff members for bed mobility. However, during an observation, a nurse aide assisted the resident alone, contrary to the physician's order and the care plan, which specified the need for two-person assistance. The resident expressed discomfort and dissatisfaction with the assistance provided, noting that the inconsistency in the number of aides assisting made them feel annoyed. Interviews with the nurse aide and the physical therapist revealed that the aide was aware of the resident's need for assistance but chose to assist alone, believing the resident could help themselves by holding onto the bed rails. The physical therapist emphasized the importance of following care plans and orders to prevent potential injury to the resident. The facility's policy for positioning and repositioning residents requires staff to check the care plan and follow the specified number of staff required for assistance, which was not adhered to in this instance.
Failure to Ensure Correct Medication Administration Route for NPO Resident
Penalty
Summary
The facility failed to ensure that medication orders for a resident with a gastrostomy tube and NPO (nothing by mouth) status were correctly documented with the appropriate route of administration. The resident, who was admitted with conditions including dysphagia and GERD, had multiple physician orders indicating medications to be given by mouth, despite the NPO status. These discrepancies were found in the electronic health record (EHR) and were not corrected by the nursing staff responsible for transcribing the orders. Interviews with the resident and staff, including an APRN and an LPN, confirmed that the resident was aware of their NPO status and that all medications and nutrition should be administered via the gastrostomy tube. The APRN acknowledged that the orders were transcribed incorrectly into the EHR and that the original handwritten orders did not specify a route of administration. The LPN admitted to not realizing the error due to being accustomed to oral administration of medications and did not seek clarification from the prescriber. The Director of Nursing Services (DNS) also confirmed the oversight and emphasized that all medication orders should specify a route of administration. The facility's policy requires that any discrepancies in medication orders be clarified and corrected by the nursing supervisor. However, this protocol was not followed, leading to the incorrect transcription of medication orders for the resident.
Failure to Implement Physician-Ordered Safety Measures
Penalty
Summary
The facility failed to implement physician-ordered safety measures for a resident with seizure precautions. The resident, who had a history of seizures, encephalopathy, and hemiplegia following a stroke, was observed multiple times without the required bumper guards on bed rails and floor mats at the bedside. Despite a care plan and physician's orders specifying these precautions, staff did not ensure their implementation. Observations revealed that the necessary equipment was either misplaced or not used, and the nurse aide care card lacked the updated information about these safety measures. Additionally, a Licensed Practical Nurse (LPN) admitted to signing off on the Treatment Administration Record (TAR) without verifying the presence of the safety equipment. Another deficiency involved a resident with acute respiratory failure, congestive heart failure, and chronic kidney failure, who was supposed to have heel booties applied to offload heels while in bed or a recliner chair. Observations showed that the resident was not wearing heel booties as ordered, despite staff signing off on the Medication Administration Record (MAR) indicating compliance. An LPN acknowledged the oversight and admitted to not checking the application of heel booties before signing the MAR. The Director of Nursing Services (DNS) confirmed the requirement for heel booties but could not explain the staff's failure to apply them. The facility's policies on seizure precautions and physician orders were not effectively followed, leading to these deficiencies. The seizure precautions policy directed the use of padded side rails for residents at risk, while the policy on physician orders lacked specificity regarding the application of heel booties. These lapses in following physician orders and facility policies resulted in the failure to provide appropriate care and safety measures for the residents involved.
Deficiencies in Resident Transfer Assistance and Smoking Policy Enforcement
Penalty
Summary
The facility failed to provide appropriate assistance during the transfer of a resident, identified as Resident #374, who had significant mobility and cognitive impairments. The resident, who required maximum assistance of two staff members for pivot transfers due to conditions such as acquired absence of the left leg below the knee and generalized muscle weakness, was transferred by a single nurse aide. This resulted in the resident's right leg giving out and the resident falling to the floor. The nurse aide did not adhere to the care plan and occupational therapy recommendations, which specified the need for two staff members during transfers. Another deficiency was identified concerning Resident #624, who was admitted with conditions including sepsis and type 2 diabetes mellitus. The facility failed to conduct a smoking assessment as part of the initial admission assessment, despite the resident's regular smoking activity. The resident informed staff of their smoking habits, yet the facility, which was a non-smoking environment, was unaware of the resident's smoking until it was brought to their attention during the survey. The smoking assessment form was left blank, and the resident continued to smoke on facility grounds without proper supervision or intervention. Additionally, the facility did not ensure the proper disposal of cigarette materials, as evidenced by the observation of over 100 cigarette butts in the mulch surrounding the seating area by the water fountain. The facility's policy stated it was a non-smoking environment, yet the grounds were littered with cigarette waste, indicating a lack of enforcement of the no-smoking policy and inadequate maintenance of the designated smoking area.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to administer oxygen to a resident as per physician orders, leading to a deficiency in respiratory care. The resident, who had diagnoses including acute respiratory failure with hypoxia, heart failure, and muscle weakness, had multiple physician orders for oxygen administration. These orders included applying oxygen as needed to maintain oxygen saturations over 92%, applying oxygen at 15 liters via nasal cannula or non-rebreather mask if oxygen saturation fell below 90%, and administering oxygen at 2 liters via nasal cannula at baseline every shift. However, observations on multiple occasions identified the resident sitting without oxygen, despite the order for continuous oxygen at 2 liters via nasal cannula. Staff, including an LPN and the DNS, were unable to explain why the resident had three different oxygen orders or why staff was signing off that the resident was on continuous oxygen when they were not. The LPN indicated a misunderstanding of the orders, believing the resident was on an as-needed basis and did not require continuous oxygen. The DNS confirmed the presence of three different current oxygen orders and noted that staff should have consulted with the Nursing Supervisor or Respiratory Therapist to clarify and discontinue unnecessary orders. The facility's policy required physician orders to be reviewed every 24 hours for accuracy, but discrepancies were not addressed, leading to the deficiency.
Failure to Monitor Dialysis Fistula
Penalty
Summary
The facility failed to properly identify and monitor a resident's arteriovenous (AV) fistula, which is crucial for dialysis care. The resident, who has end-stage renal disease and relies on dialysis, was not properly assessed for the presence and condition of the AV fistula upon admission. The baseline care plan and admission nursing assessment did not document the existence of the AV fistula, nor did they include any monitoring or assessment protocols for it. This oversight was confirmed through interviews with the resident, nursing staff, and the Director of Nursing Services (DNS), who acknowledged that the necessary batch orders for dialysis residents were not entered due to staff oversight. The facility's policies require that AV fistulas be monitored every shift for bruit and thrill, with documentation on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, these assessments were not conducted or documented for the resident. The Nursing Supervisor and DNS both confirmed that the lack of documentation and assessment was due to the MAR not indicating the need to check the fistula, and the batch orders not being entered. This failure to adhere to the facility's Hemodialysis and A-V Fistula Policies resulted in the deficiency noted in the report.
Inappropriate Use and Monitoring of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving an antipsychotic medication, Zyprexa, had an appropriate diagnosis and monitoring. Resident #674 was admitted with diagnoses including anxiety/depression disorder, chronic obstructive pulmonary disease, and breast cancer. Despite being alert, oriented, and having a pleasant mood with no unwanted behaviors, a physician's order was made to administer Zyprexa for anxiety disorder, which is not an appropriate diagnosis for its use. The facility did not conduct orthostatic blood pressure monitoring as ordered until seven days after the initial order. Additionally, progress notes from APRNs failed to identify an appropriate diagnosis for Zyprexa, and the attending physician's review did not address the reason for its use. The facility also neglected to perform an Abnormal Involuntary Movement Scale (AIMS) test as recommended by a pharmacy consultant and did not document behavior monitoring. Interviews with the Director of Nursing Services (DNS) and Resident #674 revealed that the resident was unaware of the reason for taking the antipsychotic medication, and the DNS acknowledged that anxiety disorder was not a supporting diagnosis for its use. The facility's policy on antipsychotic medication use specifies that such medications should only be used when necessary to treat specific conditions and should not be used for symptoms like mild anxiety or restlessness.
Failure to Provide Requested Menu Substitutions
Penalty
Summary
The facility failed to provide the requested alternative menu option for Resident #625, who had diagnoses including dysphagia, depression, and gastro-esophageal reflux disease. The resident's care plan identified nutritional status and diet as a concern, with interventions to provide diet and fluids as ordered. However, during an interview, the resident reported not receiving the menu substitutions they had requested. An observation confirmed that the resident received pudding instead of the requested yogurt. Interviews with dietary and nurse aides revealed a lack of consistent checking of dietary slips and meal tray contents, with one nurse aide stating she was often too busy to verify the trays, leading to the resident not receiving the correct meal items.
Failure to Offer Influenza Vaccine to Resident
Penalty
Summary
The facility failed to offer an influenza vaccine to Resident #624, who was admitted in October 2024 with diagnoses including sepsis, chronic kidney disease, and type 2 diabetes. The Baseline Resident Care Plan identified the resident as being at risk for falls, with interventions such as the use of a call bell. The admission nursing assessment noted the resident was alert and oriented, with a right hip incision. Physician orders included administering the Pneumovax 23 vaccine for pneumonia prophylaxis, but there was no order for an influenza vaccine. An interview with RN #1 revealed that the admitting nurse, charge nurse, and infection preventionist were responsible for offering the influenza vaccine and documenting the resident's acceptance or refusal. However, there was no documentation of the resident being offered the vaccine, declining it, or having previous immunization evidence for the 2024-2025 flu season. The facility's policy required offering the influenza vaccine to all residents without medical contraindications or previous immunization evidence between October 1st and March 31st, which was not followed in this case.
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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