Lord Chamberlain Nursing & Rehabilitation Center
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
- 075339
- Inspections on file
- 31
- Latest survey
- March 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Lord Chamberlain Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Alzheimer's and osteoporosis suffered a left hip fracture, which was not reported to the State Agency within the required timeframe. The facility delayed reporting the injury of unknown origin by five days, despite policy requiring immediate notification. The DON confirmed the delay and stated the injury was naturally occurring, but this conclusion was not reached within the mandated two-hour period.
The facility failed to notify physicians of critical changes in resident conditions, leading to hospitalization and potential health risks. A resident did not receive necessary immunoglobulin infusions due to administrative issues, resulting in hospitalization. Two other residents with CHF experienced significant weight gains without proper notification to their medical providers, which could have prompted necessary evaluations and treatment adjustments.
The facility failed to develop comprehensive care plans for two residents: one receiving anticoagulant therapy and another with a urinary catheter. The first resident, with dementia and other conditions, was on Lovenox, but their care plan lacked bleeding precautions. The second resident had a Foley catheter due to urinary retention, yet their care plan did not document the catheter. The facility's policy requires updates to care plans by the nursing or interdisciplinary team, which was not followed.
The facility failed to update care plans for several residents, including changes in code status and wound care interventions. Additionally, a resident was not invited to care plan meetings, and there was a lack of documentation regarding resident involvement. Staff interviews revealed confusion about care plan updates and resident invitations, contributing to the deficiencies.
A resident with limited ROM did not receive physician-ordered hand splints due to a lack of communication and incorrect order entry. The resident, who was severely cognitively impaired, was observed without the splints, which were supposed to be applied at bedtime and removed in the morning. Staff interviews revealed that the orders were not properly communicated or documented, leading to the oversight.
The facility failed to maintain a clean kitchen and dry storage area, with several open and unlabeled food items found. Personal items were inappropriately stored, and expired milk was discovered. Additionally, food thermometers were not properly sanitized between uses, and opened supplements were unlabeled. The facility's policies on food storage and sanitation were not followed.
A resident with depression and anxiety reported disrespectful behavior by nurse aides to an RN, but no investigation was conducted. The facility's policy requires such incidents to be documented and investigated, but this process was not followed, resulting in a deficiency.
A resident with severe cognitive impairment and Stage 3 pressure ulcers did not receive proper infection control during wound care. Nursing staff failed to perform hand hygiene between glove changes and used non-standard practices like double gloving, contrary to facility policies. The infection prevention RN confirmed these practices were against the facility's hand hygiene and dressing technique policies.
A facility failed to ensure safe transfers, maintain a hazard-free environment, and provide adequate supervision for residents. A resident with dementia fell during an incomplete transfer, resulting in severe injuries and death. Another resident's room had a hazardous radiator cover, and a third resident on aspiration precautions was left unsupervised while eating, contrary to physician orders.
A facility failed to provide trauma-informed care for a resident with PTSD and dementia. The resident's care plan and psychiatric consultations lacked documentation of trauma history, triggers, or stressors, and no initial PTSD assessment was conducted. Staff interviews revealed that the PTSD diagnosis was acknowledged but not adequately addressed, and the facility lacked a specific trauma-informed care policy.
A facility failed to ensure timely signing of physician's orders for a resident with multiple diagnoses, including CHF and chronic kidney disease. The facility had recently adopted an electronic medical record system, but only the Medical Director was using it, leading to overdue orders by 55 days. Staff interviews revealed a lack of training and awareness regarding the new system and the process for ensuring timely signing of orders.
A facility failed to train staff on using the electronic physician order system, resulting in overdue orders for a resident. The staff were unable to locate signed orders, which were overdue by 55 days, due to a lack of training on the new system. The Medical Director was the only physician using the electronic system, while others used paper. No training was provided to staff on their responsibilities in ensuring timely signing of orders.
A resident was administered naloxegol oxalate daily for gastrointestinal upset despite not being on opioid medications, which the medication is intended to counteract. The APRN and MD were unaware of the unnecessary prescription until surveyors highlighted the issue, indicating a lapse in medication management and oversight.
A facility failed to implement a stop date for a PRN psychotropic medication for a resident with depression, anxiety disorder, and insomnia. The resident received multiple doses of trazodone beyond the 14-day limit without a documented rationale. Interviews revealed a misunderstanding of the requirement for a stop date for all PRN psychotropics, and the consultant pharmacist did not recommend adding a stop date.
The facility failed to secure medications during administration and properly manage medication storage. An LPN left medication blister packs unsecured on a cart, and expired heparin flushes were found in storage. A broken lock box in a refrigerator contained a narcotic, and expired and unlabeled medications were found on a cart. Facility policies on medication security and labeling were not followed.
A resident with dysphagia, hypertension, and hyperlipidemia did not receive their preferred food items, such as avoiding chicken on a bun and hamburgers, and sometimes missed their requested toast for breakfast. The facility's process for determining food preferences was not effectively implemented, as there was no dedicated dietary aide to ensure meals matched the resident's choices, leading to a deficiency in meeting the resident's dietary needs.
Two residents did not receive the complete breakfast meals as specified on their meal tickets. A resident with diabetes and heart failure received only toast instead of a heart-healthy diet, while another resident with dementia and malnutrition received an incomplete meal with missing drinks. The Dietary Director acknowledged the shortage of egg whites but could not explain the omission of other items.
A facility failed to provide appropriate food consistency for a resident on a pureed diet. The resident, with a history of tongue cancer, was observed receiving a meal of pureed peas, baked beans, and spinach that were runny and mixed together on the plate. The Dietary Manager confirmed the meal should not have been of thin consistency. The Dietary Director noted that cornstarch was used to thicken food, but the baked beans were not thickened to avoid reducing protein intake. Facility policy required pureed meals to be pudding-like in consistency.
A facility staff member failed to follow Enhanced Barrier Precautions (EBP) for a resident with a feeding tube, leading to a deficiency in infection control. The resident, with a history of dysphagia and aphasia, required EBP due to the feeding tube. Despite signage and available PPE, an LPN entered the room and handled the feeding tube without wearing a gown, violating the facility's EBP policy.
A facility failed to provide a dignified dining experience for residents with cognitive impairments and medical conditions requiring meal assistance. Due to staffing constraints, residents were lined up in a hallway for breakfast instead of being supervised in the dining room. Staff interviews revealed that previous staffing levels allowed for better supervision, but current levels were insufficient, and the facility lacked documentation and a dining policy.
The facility failed to post interest to the Resident Trust Accounts of two residents, despite having balances, due to a procedure that favored residents with higher balances. This led to a deficiency in honoring the residents' rights to manage their financial affairs.
The facility did not have a Surety Bond in place for Resident Trust Accounts before a certain date, as revealed by the Business Office Manager and confirmed by the underwriter assistant. The bond was only effective from a later date, leaving a gap in coverage.
The facility failed to provide written notice of the bed hold policy during transfers for two residents. One resident with gastroenteritis and dementia was transferred to a hospital without the responsible party receiving the bed hold policy. Similarly, another resident with enterocolitis and COPD was transferred without receiving the policy. Interviews revealed confusion over responsibility for providing this information, and it was determined that no one was completing the bed hold form or notifying residents or representatives of their rights.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of abuse, specifically an injury of unknown origin, to the State Agency within the required timeframe. A resident with Alzheimer's disease, dementia, and osteoporosis was identified to have a left hip acute sub capital fracture. The resident's care plan noted an increased risk for spontaneous fractures due to osteoporosis. On the day of the incident, the resident complained of leg pain and was unable to move the left leg, prompting an x-ray that confirmed the fracture. Despite the injury being identified, the facility delayed reporting the incident to the State Agency by five days. The Director of Nursing (DON) acknowledged that the facility did not report the injury within the mandated two-hour window. The facility's investigation concluded that the injury was naturally occurring and not a result of abuse, but this determination was not made within the required timeframe. The facility's undated Abuse Prevention Policy mandates immediate reporting of any injury of unknown origin to the Department of Public Health, which was not adhered to in this case.
Failure to Notify Physicians of Critical Changes in Resident Conditions
Penalty
Summary
The facility failed to notify the physician or APRN of the unavailability of a critical medication for a resident, leading to hospitalization. Resident #42, diagnosed with chronic inflammatory demyelinating polyneuritis and other conditions, had a physician's order for immunoglobulin infusions every four weeks. However, the facility did not administer the medication for three months due to difficulties in finding an infusion center and insurance restrictions. The resident eventually requested to go to the hospital due to symptoms of an immune response, where they received the necessary treatment. The facility's policy on medication errors requires immediate notification of the physician and supervisor, which was not followed in this case. For Resident #33, who had a diagnosis of congestive heart failure (CHF), the facility failed to notify the physician or APRN of significant weight gains, which are critical indicators of CHF exacerbation. The resident's care plan included monitoring and reporting weight changes, but documentation showed three instances of weight gain exceeding five pounds in one week without proper notification to the medical team. The APRN confirmed not being informed of these weight changes, which would have prompted further evaluation and potential medication adjustments. Similarly, Resident #38, also diagnosed with CHF, experienced weight gains that should have been reported according to the care plan and physician's orders. Despite documentation in the medication administration record, there was no evidence in the nurses' progress notes of notifying the physician or APRN about these changes. The APRN stated that if informed, they would have assessed the resident's condition and potentially adjusted treatment. The facility's policies on CHF management and weight assessment did not provide clear directives for handling weight gain related to the resident's disease process.
Failure to Develop Comprehensive Care Plans for Anticoagulant Therapy and Urinary Catheter
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident receiving anticoagulant therapy and another resident with a urinary catheter. The first resident, diagnosed with dementia, hypertension, and respiratory failure, was prescribed Lovenox, an anticoagulant, to be administered daily. Despite this, the resident's care plan did not include interventions for bleeding precautions, which was confirmed by both a registered nurse and the Director of Nursing Services (DNS). The facility lacked a specific policy for Lovenox, although a policy for another anticoagulant, Coumadin, was available, which required monitoring for signs and symptoms of bleeding. The facility's care planning policy mandates that changes in a resident's status should be updated by the nursing or interdisciplinary team, which was not adhered to in this case. The second resident, with diagnoses including neuromuscular dysfunction of the bladder and urinary retention, had a physician's order for a Foley catheter due to urinary retention. Despite the resident's condition and the presence of a catheter, the care plan did not reflect documentation for the urinary catheter. The MDS Manager confirmed that a care plan should have been in place for the urinary catheter, and it was the responsibility of the interdisciplinary team to ensure appropriate monitoring. The facility's care planning policy also requires that ongoing changes in residents' status be updated by the nursing or interdisciplinary team, which was not followed in this instance.
Deficiencies in Care Plan Updates and Resident Involvement
Penalty
Summary
The facility failed to update the care plans for several residents in a timely manner, leading to deficiencies in care planning. For one resident, the care plan was not revised when the resident's code status changed from Full Code to Do Not Resuscitate (DNR). Despite the change being documented in the physician's orders, the care plan remained unaltered for several months. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the care plan should have been updated immediately following the change in advance directives. Another resident's care plan was not updated to reflect the discontinuation of a wound vac, despite a physician's order to do so. The care plan continued to list the wound vac as an intervention, even though it had been discontinued months earlier. Nursing staff interviews revealed that care plans are expected to be updated with changes in condition, but this was not done in this case. Additionally, the care plan for a resident who experienced an unwitnessed fall was not updated to include the fall or any new interventions to prevent future falls. Furthermore, a resident was not invited to participate in care plan meetings, and there was no documentation to indicate that the resident had been informed or had declined to attend. Interviews with staff revealed confusion about the process for inviting residents to care conferences, and there was a lack of documentation to confirm whether meetings had occurred as scheduled. The facility's policy did not adequately address how residents are encouraged to participate in care planning, contributing to the deficiency.
Failure to Apply Physician-Ordered Hand Splints
Penalty
Summary
The facility failed to apply hand splints for a resident with limited range of motion as per the physician's orders. The resident, who had diagnoses including congestive heart failure, obesity, and diabetes, was severely cognitively impaired and dependent on assistance for upper body dressing and transfers. Physician orders directed the application of a left resting hand splint and a right grip roll hand splint at bedtime, to be removed in the morning. However, observations revealed that the resident was not wearing the splints as ordered, and one splint was found stored on the dresser. Interviews with staff indicated a lack of communication and awareness regarding the splint orders, leading to the splints not being applied. The Rehabilitation Director and Occupational Therapist were unaware of the specific administration directions for the splints, resulting in the orders not appearing on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). This oversight meant that nursing staff were not directed to apply the splints. Additionally, a Registered Nurse admitted to entering the order incorrectly, which contributed to the failure to implement the physician's orders. The facility's policy for monitoring residents with splints was not followed, as the schedule for splint application and removal was not maintained.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen and dry storage area, as well as properly label and store food items. During a tour of the kitchen and dry storage area, several open and unlabeled food items were found, including cornstarch, rice, brown sugar, powdered cheese, breadcrumbs, and brownie mix. Additionally, personal items were found in the storage area, and expired milk was discovered in the walk-in refrigerator. The Dietary Manager acknowledged these issues and indicated that opened food items should be placed in covered containers, labeled, and dated. Furthermore, the facility lacked documentation of staff completing daily tasks related to food storage and cleanliness. The facility also failed to properly sanitize food temperature thermometers between uses. An observation revealed that a dietary aide was using a paper towel to wipe the thermometer instead of using alcohol wipes as required by facility policy. Additionally, opened bottles of a liquid high-calorie supplement were found unlabeled in a refrigerator on the 3rd floor, which should have been dated when opened and discarded after 48 hours. The facility's policy requires all food items to be stored in a clean and dry area, labeled, and dated to ensure proper rotation and prevent contamination.
Failure to Investigate Allegation of Mistreatment
Penalty
Summary
The facility failed to investigate an allegation of mistreatment involving a resident diagnosed with depression, anxiety, and breast cancer. The resident, who was cognitively intact and mostly independent in daily activities, reported to a registered nurse (RN) that some nurse aides were disrespectful, telling the resident to 'get it yourself' when requests were made. Despite this report, the grievance log did not reflect any filed grievances regarding the incident, and the RN admitted to not completing an investigation. The Director of Nursing Services (DNS) confirmed that facility policy requires any incident reported to a supervisor to be formally investigated. However, the DNS was unsure why this particular incident was not investigated. The facility's policy mandates that concerns or complaints be documented and submitted to the Director of Social Services for investigation, with findings reviewed by the Administrator. This process was not followed in the case of the resident's complaint, leading to a deficiency in addressing the reported mistreatment.
Inadequate Infection Control During Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure pressure ulcer treatments for a resident were performed in accordance with infection control standards. The resident, who was severely cognitively impaired and dependent for daily activities, had two Stage 3 pressure ulcers and was at risk for developing more. The care plan required adherence to facility protocols for skin breakdown prevention and treatment, including specific wound care orders from the physician. However, during an observation of the treatment process, it was noted that the nursing staff did not follow proper hand hygiene protocols. The LPN and RN involved in the treatment did not perform hand hygiene between glove changes, and the RN used a non-standard practice of double gloving. The LPN did not wash hands between glove changes, citing inconvenience, and failed to change gloves when moving from dirty to clean areas during the dressing change. The RN also did not perform hand hygiene when changing gloves, believing it was unnecessary. The facility's infection prevention RN confirmed that the policy required hand washing between glove changes and that double gloving was not practiced. The facility's policies on hand washing and clean dressing techniques were not followed, as hands should be washed after removing gloves and before applying new ones, and gloves should be changed when transitioning from dirty to clean tasks.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to provide a safe and complete transfer for a resident, resulting in a fall with major injury. Resident #232, who had dementia with psychotic disturbance and was severely cognitively impaired, required moderate assistance with transfers. On the evening of the incident, a nurse aide assisted the resident to a sitting position on the bed but left the resident unattended to move a chair. During this time, the resident fell, sustaining multiple severe injuries, including a subarachnoid hemorrhage and fractures, which ultimately contributed to the resident's death. Interviews with staff revealed that the transfer was not completed as the resident was left sitting instead of being laid down, contrary to facility policy. Another deficiency involved Resident #71, who had a history of falls and was cognitively intact. The resident's room had a radiator cover with sharp, protruding metal edges, posing a hazard. Despite maintenance attempts to fix the issue, the cover remained dangerous, and the resident reported it had been in this condition since admission over a year ago. The Director of Maintenance acknowledged the hazard and indicated the need for replacement rather than repair. Additionally, the facility failed to provide appropriate supervision for Resident #24, who was on aspiration precautions due to dysphagia and other conditions. The resident was observed self-feeding in a prone position without supervision, contrary to physician orders requiring line-of-sight supervision during meals. Staff interviews revealed a lack of adherence to the aspiration precautions policy, with some staff unaware of the specific requirements for supervising the resident during meals.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD) and dementia. The resident's care plan and psychiatric consultations did not document the resident's personal history of trauma, triggers, or stressors, nor did they outline how care was managed to prevent re-traumatization. The resident's diagnoses included PTSD, depression, and anxiety, and they required assistance with activities of daily living. Despite these needs, the facility did not conduct an initial assessment for PTSD upon admission or thereafter, relying instead on psychiatric services to support PTSD-related care. Interviews with facility staff, including an Advanced Practice Registered Nurse (APRN) and a Social Worker (SW), revealed that the resident's PTSD diagnosis was acknowledged but not adequately addressed in psychiatric evaluations or care plans. The APRN noted that a history and identification of triggers should be part of a psychiatric evaluation, even for residents with dementia. The Social Worker admitted that an initial PTSD assessment was never completed, and the Director of Nursing Services (DNS) indicated that history and triggers should be assessed by social services and managed by psychiatric services. The facility lacked a specific policy for trauma-informed care, and their educational materials emphasized the importance of understanding trauma and preventing re-traumatization, which was not reflected in the care provided to the resident.
Failure to Ensure Timely Signing of Physician's Orders
Penalty
Summary
The facility failed to ensure that electronic physician's orders for a resident with diagnoses including Congestive Heart Failure, acute respiratory failure, and chronic kidney disease were signed in a timely manner. During a review of the resident's clinical records, it was found that the physician's orders were overdue by 55 days. The facility had recently transitioned to an electronic medical record system, but only the Medical Director was using it, while other physicians continued to sign orders on paper. There was no evidence of educational training provided to the staff on how to use the new system or ensure timely signing of orders. Interviews with staff revealed a lack of awareness and training regarding the new electronic system and the process for ensuring physician's orders are signed within the required time frames. The Director of Nursing Services and the Staff Development Nurse were unaware of the issue and acknowledged the absence of training for licensed staff. Despite attempts to verify the status of the orders, it was confirmed that the orders for the resident were not signed, and the facility could not provide a report of the Medical Director's residents' orders.
Lack of Training on Electronic Physician Order System
Penalty
Summary
The facility failed to ensure that staff were adequately trained in using the electronic physician order system, which led to a deficiency in managing physician orders for a resident. During an observation and record review, it was found that a registered nurse and a unit secretary were unable to locate signed physician orders for a resident, which were overdue by 55 days. The facility had recently transitioned to an electronic system, but no educational training was provided to the staff on how to use it effectively. This lack of training resulted in the staff being unaware of their responsibilities in ensuring timely signing of physician orders. Further interviews revealed that the Medical Director was the only physician using the electronic system, while other physicians continued to sign orders on paper. The corporate staff nurse acknowledged the oversight and mentioned that the Medical Director had requested the use of the electronic system and was already familiar with it, hence no training was deemed necessary for the physician. However, the staff development nurse confirmed that no training had been provided to the licensed staff regarding their role in ensuring timely signing of physician orders and understanding the duration for which the orders are in effect.
Unnecessary Medication Administration for Non-Opioid Resident
Penalty
Summary
The facility failed to prevent the administration of an unnecessary medication for a resident who was not receiving opioid medications. The resident, who was cognitively intact and required assistance with mobility, was prescribed naloxegol oxalate for gastrointestinal upset, despite not having an active order for opioid medications. This medication is typically used to treat constipation due to opioid use. The resident's care plan identified a risk for constipation related to decreased mobility and pain management, but there was no indication of opioid use that would necessitate naloxegol oxalate. Interviews with the Advanced Practice Registered Nurse (APRN) and the Medical Doctor (MD) revealed a lack of communication and oversight regarding the resident's medication regimen. The APRN stated that the administration of naloxegol oxalate was unnecessary without opioid medication, and the MD was unaware of the prescription in the absence of opioid use. The MD had reviewed the resident's medications but did not identify the unnecessary prescription until it was brought to her attention by surveyors. The facility's policy required a comprehensive medical history and examination within 48 hours of admission, but this oversight in medication management led to the deficiency.
Failure to Implement Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to implement a stop date for a psychotropic medication for a resident diagnosed with depression, anxiety disorder, and insomnia. The resident was cognitively intact and required assistance with daily activities. Upon re-admission, the physician's orders included trazodone 50 mg at bedtime for sleep and 25 mg three times a day as needed for anxiety, but these orders lacked a stop date. The resident's care plan noted the use of psychotropic medications and included interventions to monitor anxiety and consult with the physician for medication adjustments. Despite the facility's policy requiring a stop date for PRN psychotropic medications, the order for trazodone was renewed without a stop date by an APRN. The resident received multiple doses of PRN trazodone beyond the 14-day limit without a documented rationale for the extended order. Interviews with the APRN and the attending physician revealed a misunderstanding of the requirement for a stop date for all PRN psychotropics, not just antipsychotics. The consultant pharmacist's review also failed to recommend adding a stop date to the PRN trazodone order.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications during administration and storage. During medication administration, an LPN was observed leaving medication blister packs unsecured on top of a medication cart while entering a resident's room. This occurred twice, and the LPN admitted to not securing the medications due to nervousness during the surveyor's observation. Additionally, the facility's Director of Nursing Services expected nursing staff to secure medications and lock the cart before leaving the area, which was not adhered to in these instances. Further deficiencies were identified in the storage of medications. In the 4th floor medication storage room, 50 expired heparin lock flushes were found, and an RN was unaware of their presence. The facility's policy required outdated medications to be immediately removed from inventory. On the 3rd floor, a medication refrigerator was found with a broken lock box containing a narcotic medication, which was not securely stored. An open bottle of Cetirizine past its expiration date and an unlabeled Lantus insulin bottle were also found on a medication cart. The facility's policy required medications to be stored securely, labeled with the resident's name, and dated when opened, which was not followed in these cases.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food choices, leading to a deficiency in providing a nourishing, palatable, well-balanced diet that meets the resident's daily nutritional and special dietary needs. The resident, who is cognitively intact and requires assistance with eating, reported not receiving preferred food items, such as not liking chicken on a bun and never having eaten a hamburger, both of which were served to them. Additionally, the resident did not always receive their requested two slices of toast for breakfast, and during an observation, the resident's lunch ticket noted extra gravy on the side, which was not provided. The Dietary Manager explained that the process for determining food preferences involves interviewing the resident and using a menu system where residents circle their choices, which are then entered into a software system. However, there was no dedicated dietary aide to ensure the meal matched the ticket, leading to discrepancies in the resident's meal service. The Dietary Director was unsure why the resident's menu choices were not honored, attributing it to the dietary aide not checking the ticket. The facility's policy directed that food preferences should be identified upon admission or within 24 hours, but this was not effectively implemented for the resident in question.
Failure to Follow Meal Tickets Results in Missing Food Items
Penalty
Summary
The facility failed to follow the meal tickets for two residents, resulting in missing food items during breakfast. Resident #67, who has diabetes mellitus and heart failure, was served only two slices of toast instead of the heart-healthy regular-textured diet specified on the meal ticket. The meal ticket indicated that the resident should have received apple juice, diet jelly or margarine, skim milk, scrambled egg whites, cream of wheat, rye toast, and coffee. The Dietary Director acknowledged that the facility had run out of egg whites and that the resident should have been asked if they were agreeable to receiving regular scrambled eggs. However, the Dietary Director could not explain why other items were omitted from the tray. Resident #146, who has dementia, severe protein-calorie malnutrition, and insomnia, was also affected by the facility's failure to follow the meal ticket. The resident's breakfast plate contained only one slice of French toast and one slice of white toast, with no drinks provided. The meal ticket specified two slices of French toast, cranberry juice, milk, Maypo, and coffee. Although staff provided a cup of apple juice and encouraged the resident to eat, the other items listed on the meal ticket were never provided during the breakfast meal.
Inadequate Food Consistency for Pureed Diet
Penalty
Summary
The facility failed to provide appropriate food consistency for a resident on a pureed diet. Resident #82, who was admitted with diagnoses including tongue cancer and a hip replacement, was cognitively intact and independent with eating. Despite not having a swallowing disorder, the resident was on a mechanically altered diet and had requested pureed food. Observations during the noon meal revealed that the resident's meal consisted of pureed peas, baked beans, and spinach, all of which were runny and mixed together on the plate. The Dietary Manager confirmed that the meal should not have been of thin consistency and that the pureed items should not have been running into each other. The Dietary Director explained that cornstarch was added to thicken the food, but the pureed baked beans were not thickened to prevent the resident from getting fuller faster and consuming less protein. The facility's policy for pureed meals stated that they should be blended to a pudding-like consistency and not be runny unless specified for an unthickened diet. A review of the resident's dietary note indicated that the resident's protein supplement had been discontinued, their weight was stable, and no new dietary recommendations were made.
Failure to Follow Enhanced Barrier Precautions for Resident with Feeding Tube
Penalty
Summary
The facility staff failed to adhere to the Enhanced Barrier Precautions (EBP) protocol for a resident with a feeding tube, leading to a deficiency in infection prevention and control. Resident #38, who had a history of dysphagia, aphasia, and a feeding tube following a stroke, was identified as requiring EBP due to the presence of the feeding tube. The resident's care plan and physician's orders specified the need for EBP, which included wearing a gown and gloves during high-contact activities such as device care for indwelling medical devices. On the observed date, signage indicating the need for EBP was posted on the resident's door, and a cart with appropriate PPE was available outside the room. However, LPN #1 entered the room without wearing a gown, handled the feeding tube, and connected it to the feeding pump without the required PPE. The LPN acknowledged awareness of the EBP requirement and admitted to not wearing the necessary PPE during the procedure. This oversight was a direct violation of the facility's Enhanced Barrier Precautions policy, which mandates the use of gown and gloves during specific resident care activities.
Inadequate Dining Experience Due to Staffing Constraints
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, as observed during a breakfast meal. Residents with various diagnoses, including dementia, dysphagia, and Alzheimer's disease, were lined up in a train-like formation in the hallway with their meals on overbed tables in front of them. This arrangement was due to staffing constraints on the 4th floor, where more residents required assistance with feeding than on other units. The residents involved had significant cognitive impairments and various medical conditions that necessitated assistance with eating and monitoring for aspiration risks. For instance, one resident with Alzheimer's and dysphagia required supervision during meals to prevent aspiration, while another with dementia and diabetes needed assistance with meal setup. Despite these needs, the facility's staffing levels did not support the assignment of a nurse aide to the dining room for breakfast supervision. Interviews with facility staff revealed that the 4th floor previously had more nurse aides, allowing for dedicated supervision in the dining room. However, the current staffing level of seven nurse aides was deemed insufficient to provide the necessary care. The facility was unable to provide documentation of when the staffing levels were reduced, nor could they provide a policy on facility dining, indicating a lack of formal procedures to ensure a dignified dining experience for residents.
Failure to Post Interest to Resident Trust Accounts
Penalty
Summary
The facility failed to ensure that interest was provided to the Resident Trust Accounts for two residents, leading to a deficiency in honoring the residents' rights to manage their financial affairs. Resident #94, who was admitted in March 2023 and has Medicaid as a payor source, did not receive interest on multiple occasions despite having a balance in their account. Interest was posted to other Resident Trust Accounts within the facility, but Resident #94 was excluded from receiving interest on several dates, including December 2023, February 2024, March 2024, April 2024, May 2024, and October 2024. Although Resident #94 did receive minimal interest in July, August, and September 2024, the pattern of exclusion from interest postings was evident. Similarly, Resident #100, admitted in January 2024 with Medicaid pending, also did not receive interest on their Resident Trust Account on several occasions. Despite having a balance, interest was not posted to Resident #100's account on dates when other residents received interest, including March 2024, April 2024, May 2024, June 2024, July 2024, August 2024, and September 2024. The Business Office Manager revealed that the procedure for posting interest favored residents with higher balances, which led to the exclusion of these two residents. The Facility Account Specialist confirmed that interest was allocated based on daily accrual and posted only to residents with the highest balances, indicating a systemic issue in the interest allocation process.
Lack of Surety Bond for Resident Trust Accounts
Penalty
Summary
The facility failed to ensure a Surety Bond was in place for the Resident Trust Accounts prior to October 24, 2024. During an interview on October 25, 2024, the Business Office Manager revealed that the Resident Trust Account balance exceeded $94,759.89. A review of the Resident Trust Fund Surety bond showed it was effective from October 24, 2024, for $100,000. However, the Business Office Manager could not provide evidence of a Surety Bond in effect before this date. Further investigation with the underwriter assistant confirmed that there was no record of a previous Surety Bond for the facility before October 24, 2024.
Failure to Provide Bed Hold Policy During Resident Transfers
Penalty
Summary
The facility failed to provide the responsible party with written notice of the bed hold policy at the time of transfer for two residents. Resident #63, who had diagnoses including gastroenteritis, Type II diabetes mellitus, and dementia, was transferred to a community hospital after being noted to be sleepy with poor intake. Despite the transfer, the clinical record did not reflect that the bed hold policy, detailing the reason for transfer and duration of the bed hold, was provided to the responsible party. Interviews with the Admissions Director, Social Worker, and DNS revealed a lack of clarity regarding who was responsible for providing this information, and it was discovered that the provision of the bed hold policy at the time of admission was not being done. Similarly, Resident #167, with diagnoses including enterocolitis due to clostridium difficile and COPD, was transferred to a hospital without receiving the bed hold policy. The clinical record review failed to identify that the policy was given to the resident at the time of transfer. Interviews with the Admissions Director and Social Worker confirmed that they did not provide the bed hold policy during transfers, and the DNS identified that either social services or admissions was supposed to oversee this process. However, it was determined that no one was completing the bed hold form or notifying the resident or representative of the right to hold the bed and return to the facility.
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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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