Mansfield Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Storrs Mansfield, Connecticut.
- Location
- 100 Warren Circle, Storrs Mansfield, Connecticut 06268
- CMS Provider Number
- 075402
- Inspections on file
- 22
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Mansfield Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments, requiring two-person assistance for mechanical lift transfers, was transferred by a single nurse aide who failed to secure all sling loops and did not follow safety protocols. The resident, who was restless and on anticoagulant therapy, tipped forward during the transfer and sustained a head injury. The incident was not immediately reported, and other staff confirmed they did not assist or witness the transfer.
A resident with severe dementia and mobility impairments was injured during a mechanical lift transfer when a nurse aide, working alone, failed to follow the care plan's behavioral interventions and did not request assistance despite the resident's agitation. The resident struck their head on the lift after a sling loop detached, and the incident was not reported to nursing staff until injuries were later discovered.
Multiple residents were transferred using mechanical lifts by only one staff member, despite care plans and facility policy requiring two staff for such transfers. In one case, a resident sustained a leg fracture due to improper use of the lift and lack of required safety measures. Staff interviews and documentation confirmed awareness of the two-person requirement, but it was not consistently followed.
Surveyors found that food items in the kitchen were not labeled with expiration or open dates, and staff with facial hair, including the Dietary Manager and a Dietary Aide, plated food without wearing required beard restraints. Facility policy requires proper labeling of food and the use of hair and beard restraints during food handling.
Staff did not consistently use required PPE when providing care to a resident on Enhanced Barrier Precautions for a chronic wound, and infection control surveillance reports were found to be incomplete, lacking key data and analysis. Despite clear care plans and facility policies, observations and staff interviews confirmed lapses in both PPE use and infection documentation.
The facility did not complete or review required antibiotic surveillance reports at medical staff meetings, and a resident received antibiotics for a UTI despite lab results indicating colonization or contamination and not meeting McGeer's criteria. Staff interviews confirmed that antibiotic stewardship protocols were not consistently followed, and antibiotics were administered without proper indication.
The facility did not maintain a complete and accurate system for recording the receipt and disposition of controlled medications. Audits were performed, but reconciliation between yellow and white Controlled Substance Disposition Records was incomplete and delayed, and audit sheets were missing. The ADNS did not audit records until receiving documentation from nursing units, resulting in inadequate reconciliation and failure to meet the facility's policy for controlled drug record keeping.
A resident with significant mobility deficits and multiple diagnoses required two-person assistance for mechanical lift transfers. During a transfer performed by a single aide, the resident's foot slipped, resulting in an incident that was not followed by a registered nurse assessment or proper documentation, despite facility policy requiring such action. The resident was later found to have a leg fracture after reporting pain and swelling.
A controlled medication prescribed for a resident with anxiety and depressive disorder was found missing after a shift change. The medication was last verified during a count by two nurses, but one nurse left the medication cart keys unsecured and the incoming nurse did not immediately take possession of them. This lapse in medication security and accountability resulted in the loss of nearly all tablets from the resident's supply.
A resident's controlled medication, Ativan, was discovered missing, and the facility failed to report the incident to state authorities within the required two-hour window. The delay occurred despite internal awareness of the missing medication and an ongoing investigation, with external agencies not notified until several days after the initial discovery.
A resident with a history of stroke and dysphagia developed worsening respiratory symptoms, including a productive cough and abnormal lung sounds, over several days. Nursing staff documented these changes but did not notify the provider until the resident experienced further decline, including altered mental status and hypoxemia, resulting in hospitalization for probable aspiration pneumonia. Facility policy required prompt provider notification for changes in condition, which was not followed in this case.
A resident with hemiplegia and intact cognition submitted a grievance requesting more frequent care checks, timely linen changes, and specific hygiene assistance. Although the facility discussed these concerns in a care plan meeting, the resident's care plan and care card were not updated to reflect the preferences, and there was no documentation of staff education on the new care needs.
A resident with left-sided weakness and a history of falls was provided with a new mattress and bed frame, but necessary fall prevention measures, such as bolsters, were not included with the new equipment. The omission led to the resident falling from bed and sustaining shoulder pain.
A resident with essential tremor did not receive medications as per physician orders due to transcription errors and supply issues. Propranolol was given in a non-extended-release form, and Bupropion was omitted because it was not available. The DNS confirmed these errors during an interview.
Failure to Ensure Two-Person Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe dementia, hemiplegia, hemiparesis, muscle weakness, and a history of subarachnoid hemorrhage, who was dependent on staff for all activities of daily living and required two-person assistance for mechanical lift transfers, was transferred by only one nurse aide using a mechanical lift. The resident was noted to be fidgety, anxious, restless, and flailing arms at the time of the transfer. Despite these behaviors, the nurse aide proceeded with the transfer alone, contrary to the resident's care plan and facility policy, which required two staff members for such transfers. During the transfer, one of the loops on the lift sling became detached from the hook, causing the resident to tip forward in the sling and strike their head on the mast of the lift. The nurse aide admitted to being in a rush and failing to ensure all loops were securely attached before lifting the resident. After the incident, the nurse aide lowered the resident back into the wheelchair, secured the loop, and completed the transfer to bed without notifying a nurse or reporting the incident at that time. The resident was later found by an LPN to have a raised, discolored area above the right eye and minor bleeding near the right ear, which had not been present earlier. Due to the resident's cognitive impairment, they were unable to communicate what had happened. The incident was initially treated as an injury of unknown origin until the nurse aide later reported the accident. Interviews with other staff confirmed that no one assisted the nurse aide during the transfer, and the required safety checks and reporting procedures were not followed.
Failure to Follow Care Plan During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan during a mechanical lift transfer, resulting in the resident sustaining an injury. The resident had severe dementia with agitation, hemiplegia, hemiparesis, muscle weakness, and required substantial assistance with mobility and transfers. The care plan specified interventions for behavioral symptoms, including offering diversion, redirection, calm communication, step-by-step explanations, stopping care if the resident became combative or resistive, and notifying the provider if behaviors increased or persisted. On the evening of the incident, a nurse aide attempted to transfer the resident from a wheelchair to bed using a mechanical lift while the resident was visibly anxious, restless, and flailing their arms. Despite these behaviors, the aide proceeded with the transfer alone, without reporting the behaviors to nursing staff or requesting assistance, as required by the care plan and facility policy. During the transfer, a loop on the lift became detached, causing the resident to tip forward and strike their head on the lift's mast. The aide then completed the transfer without notifying nursing staff of the incident or the resident's behaviors. Later, nursing staff discovered injuries to the resident's head and ear, which were not present earlier in the day. The resident was sent to the emergency department for evaluation, where a forehead hematoma was diagnosed. The incident was initially treated as an injury of unknown origin until the aide reported the details of the transfer. Interviews confirmed that the aide did not follow the prescribed interventions for managing the resident's behaviors and did not adhere to the requirement for two staff during mechanical lift transfers.
Failure to Ensure Required Staff Assistance During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that required staff assistance was utilized during mechanical lift transfers for multiple residents, as observed and documented in the clinical records and through staff interviews. For one resident with metabolic encephalopathy, dementia, and renal failure, staff were observed transferring the resident from the bathroom to a wheelchair using a mechanical lift with only one staff member present, despite care plans, physician orders, and facility policy requiring two staff for such transfers. The nurse aide involved acknowledged awareness of the two-person requirement but proceeded alone, and this was confirmed by interviews with other staff and review of facility policy. Another resident with Alzheimer's disease, aphasia, muscle weakness, and chronic kidney disease suffered a left tibia and fibula fracture following a mechanical lift transfer performed by a single nurse aide. The aide did not use the required leg support straps and failed to ensure the resident's feet remained on the lift platform, resulting in the resident's leg slipping and subsequent injury. Documentation and interviews confirmed that the resident required two staff for transfers and that the lift's safety features were not properly used. The incident was not initially acknowledged in the facility's reportable event documentation, and the aide admitted to performing the transfer alone due to lack of available assistance. A third resident with dementia, diabetes, anemia, and hemiplegia was also transferred using a mechanical lift by a single staff member, contrary to care plan instructions and facility policy. The staff member stated she was trained by other staff that only one person was needed, despite documentation and interviews with the DNS, staff development nurse, and physical therapist confirming the two-person requirement. These failures to follow established protocols and care plans for mechanical lift transfers resulted in unsafe conditions and, in one case, resident injury.
Failure to Label Food and Use Beard Restraints in Kitchen
Penalty
Summary
Surveyors observed multiple instances where food items stored in the facility's refrigerators and freezers were not labeled with expiration or open dates. Specifically, an open package of waffles, a partially consumed Starbucks mocha drink, shredded cabbage, Parmesan cheese wrapped in saran wrap, a box of pizza slices, a package of beef patties, an opened package of hot dogs, and oatmeal raisin cookie dough were all found without proper labeling. The Dietary Manager confirmed during interviews that these items should have been labeled with both the date they were opened and their expiration dates, in accordance with facility policy. Additionally, staff members, including the Dietary Manager and a Dietary Aide, were observed plating food without wearing required beard restraints, despite having facial hair. The facility's policies mandate that hair restraints, including beard guards, must be worn at all times in the kitchen and that facial hair should be fully covered. The Dietary Manager acknowledged during interviews that beard restraints should have been worn during food preparation.
Failure to Ensure PPE Use and Complete Infection Surveillance Documentation
Penalty
Summary
The facility failed to ensure that staff consistently used appropriate personal protective equipment (PPE) when providing care to a resident on Enhanced Barrier Precautions (EBP) and did not maintain complete infection control surveillance data. During the review of the infection control program for April 2023 to January 2024, it was found that monthly surveillance infection reports and analysis of infection trends were incomplete. The facility relied on monthly Antibiotic Reports for surveillance, but these reports lacked critical information such as whether infections were healthcare-associated or community-acquired, if McGeer's criteria were met, and details on new prophylactic treatments. Interviews with facility staff confirmed that the infection control surveillance reports were incomplete during this period, and it was the responsibility of the Infection Preventionist at the time to complete and analyze these reports. A resident with a history of neurocognitive disorder, Lewy bodies dementia, trigeminal neuralgia, and a sacral pressure ulcer was identified as requiring EBP due to a chronic wound. The care plan specified the use of gown and gloves during high-contact care activities. However, observations revealed that staff did not consistently follow these precautions. On multiple occasions, staff members provided wound care and incontinence care to the resident without donning the required PPE, such as gowns and masks, despite clear indicators (blue dots on name plaques) that the resident was on EBP. Staff interviews confirmed awareness of the EBP requirements, but they could not explain the failure to use PPE during care. Facility policy required maintaining separate infection records for each resident with an infection, analyzing clusters, and monitoring the infection control program quarterly or as indicated at quality improvement meetings. Despite these policies, the facility did not ensure complete documentation or consistent PPE use, as evidenced by direct observation and staff interviews. The lack of adherence to EBP protocols and incomplete infection surveillance documentation constituted the identified deficiencies.
Failure to Implement and Monitor Antibiotic Stewardship Program
Penalty
Summary
The facility failed to ensure that its antibiotic stewardship program was properly implemented and monitored, as required by policy. During a review of the program, it was found that the antibiotic surveillance tracking report, which should include data on antibiotic use, patterns, and resistance trends, was not completed or reviewed at quarterly medical staff meetings for the period of April 2023 to January 2024. Monthly antibiotic reports were also found to be incomplete, missing key information such as infection source, whether McGeer's criteria were met, and details on new prophylactic use. Quarterly reports lacked any information regarding the antibiotic stewardship program, and staff interviews confirmed that the responsibility for completing these reports was not fulfilled during the period in question. For one resident reviewed for unnecessary medications, the facility did not follow its antibiotic stewardship protocols. The resident, who had diagnoses including metabolic encephalopathy, chronic kidney disease stage 4, and altered mental status, was administered antibiotics for a urinary tract infection (UTI) despite laboratory results suggesting colonization or contamination rather than infection. The resident's care plan included both treatment and prophylactic antibiotics, and medication administration records confirmed that these were given as ordered. However, progress notes and lab results indicated that urine cultures showed multiple organisms with no predominant species, and the resident did not exhibit classic symptoms of UTI. Staff interviews revealed that antibiotics were continued even when McGeer's criteria were not met, and the process for reviewing these criteria was not consistently followed. Further interviews with clinical staff and the medical director highlighted inconsistencies in the application of antibiotic stewardship practices. The infection preventionist noted an increase in antibiotic prescribing for UTIs that did not meet established criteria, and the APRN acknowledged not always using McGeer's criteria, citing altered mental status as a justification. The medical director stated that antibiotics should not be continued without culture sensitivity and suggested alternative treatments. The facility's own policy requires oversight and monitoring of antibiotic use to minimize resistance, but these procedures were not adhered to, resulting in the administration of antibiotics without proper indication.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a complete and accurate system for recording the receipt and disposition of all controlled medications. During a review of the bi-monthly narcotic drug audit, it was found that while audits were being conducted to check for locked medication carts, proof of use sheets, correct narcotic counts, signed shift change count sheets, correct labeling, and removal of expired medications, there was a lack of comprehensive reconciliation between the yellow and white Controlled Substance Disposition Records (CSDR). The oldest yellow CSDR sheet had not been reconciled with the corresponding white CSDR, nor had the medications been documented as destroyed, and audit sheets were missing from the record book. An interview with the ADNS revealed that she was responsible for the controlled drug audits, which were performed twice a month. However, she stated that she did not audit the yellow CSDR sheets until she received the white CSDR sheets from the nursing units, resulting in incomplete and delayed reconciliation. The facility's own policy required special record keeping for all controlled drugs, but the current practice did not ensure adequate medication reconciliation, leaving the system vulnerable to medication diversion.
Failure to Complete RN Assessment After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, aphasia, muscle weakness, and chronic kidney disease, who required maximal assistance for mobility and transfers, was not assessed by a registered nurse following an incident during a mechanical lift transfer. The resident's care plan and aide care card specified the need for two staff members to assist with transfers using the Sara or Hoyer lift. However, on the day of the incident, a nurse aide performed the transfer alone due to lack of available assistance. During the transfer, the resident's left foot slipped off the lift platform, and the resident reported leg weakness. The aide stopped the transfer and sought help from a nurse. The charge nurse, an LPN, responded and assisted in transferring the resident back to bed, then to a wheelchair using the Hoyer lift. The LPN checked the resident for pain, bruising, or deformity, and found none at that time. No immediate documentation or assessment by a registered nurse was completed following the incident, and no accident/incident report was initiated. The following day, the resident complained of pain, and swelling and redness were observed, leading to further evaluation and discovery of a left tibia fracture. Interviews with facility staff confirmed that the incident was not documented as required by facility policy, which mandates that a licensed nurse or supervisor complete and document an evaluation of the resident's condition after an incident. The nursing supervisor and LPN both acknowledged that a nursing assessment and note should have been completed, and the administrator and DNS agreed that the event constituted an incident requiring such documentation.
Failure to Protect Resident's Controlled Medication from Misappropriation
Penalty
Summary
A controlled medication, Ativan, prescribed for a resident with diagnoses including cerebral infarction, anxiety, and depressive disorder, was found missing from the facility. The medication, delivered in a bubble pack containing thirty tablets, was last verified as present during a shift change count by two nurses. Subsequently, it was discovered that twenty-nine tablets were missing. Documentation and interviews revealed that the nurse responsible for the 3-11PM shift left the medication cart keys on top of the cart and proceeded to another unit, while the incoming 11PM-7AM nurse did not immediately take possession of the keys or access the cart, despite both nurses having signed off on the controlled medication count. The incident was reported to the Director of Nursing and the Drug Enforcement Agency, and an internal investigation was conducted, including audits and staff interviews. The facility's abuse policy defines misappropriation of resident property as the wrongful use of a resident's belongings without consent. The investigation was unable to determine how the Ativan went missing, but the failure to maintain proper control and accountability of the medication, as well as lapses in the handoff process and medication cart security, led to the loss of the resident's controlled medication. The resident was alert and oriented at the time, with a care plan in place for medication administration and monitoring.
Failure to Timely Report Missing Controlled Medication
Penalty
Summary
The facility failed to report the misappropriation of a resident's controlled medication, Ativan, to the state agency within the required two-hour timeframe. A resident with diagnoses including cerebral infarction, anxiety, and depressive disorder was prescribed Ativan 1 mg as needed for anxiety. On a specified date, it was discovered that 29 tablets of Ativan were missing from the resident's medication supply. The missing medication was identified during a shift change count, and subsequent investigation revealed discrepancies in the medication count process and handling of the medication cart keys by nursing staff. The incident was reported to the Director of Nursing, but there was a delay in notifying the Administrator and external authorities. The Administrator was informed of the missing medication two days after it was reported to the Director of Nursing, and the incident was not reported to the Department of Consumer Protection, Drug Enforcement Division, Department of Public Health, or local law enforcement until four days after the initial discovery. The facility's abuse policy requires immediate reporting of alleged violations, including misappropriation of resident property, to the Administrator and Director of Nurses. However, the delay in reporting the missing medication constituted a failure to comply with this policy and regulatory requirements.
Failure to Timely Notify Provider of Resident's Change in Condition Leading to Hospitalization
Penalty
Summary
The facility failed to notify the healthcare provider in a timely manner regarding a resident's change in condition, which ultimately led to a hospitalization. The resident, who had a history of hemiplegia, hemiparesis, and dysphagia following a cerebral infarction, was documented as having diminished lung sounds upon admission. Over several days, nursing notes recorded the development and progression of respiratory symptoms, including a non-productive cough, crackles on auscultation, and later a productive cough with moderate white secretions. Despite these documented changes in respiratory status from 8/30/24 through 9/2/24, there was no evidence that the provider was notified during this period. On 9/3/24, the resident exhibited further decline, including altered mental status, increased confusion, a low-grade fever, and a decreased oxygen saturation level. At this point, the provider was notified, and the resident was transferred to the emergency department. Hospital records indicated that the resident arrived with hypoxemia, fever, and tachycardia, and was subsequently diagnosed with probable aspiration pneumonia and treated with antibiotics. Interviews with facility staff and the APRN confirmed that the expectation was for immediate provider notification upon the initial observation of a productive cough and abnormal lung sounds, which did not occur. Facility policy required that any change in condition be promptly communicated to the provider, the resident, and the family or responsible party. The review of documentation and staff interviews revealed that this policy was not followed, as the provider was not informed of the resident's respiratory changes until several days after the initial symptoms were observed. This delay in notification was confirmed by both the APRN and the previous DNS, who stated that provider notification should have occurred immediately upon the identification of the change in lung sounds and cough.
Failure to Update Care Plan and Communicate Resident Preferences After Grievance
Penalty
Summary
A resident with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, anxiety, and gait abnormalities, who was cognitively intact, required moderate assistance with activities of daily living such as toileting, bathing, and dressing. The resident submitted a grievance requesting more frequent care checks, prompt changing of soiled linens, and specific attention to scalp and jawline hygiene during bathing due to dry skin. Although the facility received these care requests and held a care plan meeting with the interdisciplinary team, the resident, and the resident's spouse to discuss the concerns, the care plan and care card were not updated to reflect the resident's preferences and requests. Additionally, there was no documentation provided to show that staff had been educated on the resident's specific care concerns and preferences. The facility's Resident Rights policy requires prompt efforts to resolve grievances and reasonable accommodation of individual needs and preferences, but the failure to update the care plan and care card, as well as the lack of staff education, demonstrated noncompliance with these requirements.
Failure to Provide Fall Prevention Measures with New Bed Equipment
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a new piece of equipment, specifically a mattress and bed frame, had the necessary fall prevention measures in place for a resident with a history of hemiplegia, hemiparesis, and mobility impairments. The resident required moderate assistance for bed mobility and transfers and was identified as being at risk for falls due to left side weakness and use of psychotropic medications. The care plan included interventions such as keeping the bed in a low position and using non-skid footwear, as well as the use of bolsters to prevent falls from bed. After an initial fall, a mattress with bolsters was ordered, but when a larger replacement mattress and bed frame were subsequently ordered, bolsters were not included or specifically ordered for the new equipment. The facility administrator did not verify whether the new mattress came with bolsters and assumed that pillows placed under the sheet would suffice as a preventive measure. As a result, the resident experienced another fall from bed, sustaining left shoulder pain, though without serious injury.
Medication Administration Errors Due to Transcription and Supply Issues
Penalty
Summary
The facility failed to administer medications in accordance with physician orders for a resident diagnosed with essential tremor. The hospital discharge orders specified the administration of Propranolol 60 mg 24-hour capsule daily, but the facility administered a non-extended-release Propranolol HCL oral tablet 60 mg instead. This discrepancy was identified when the resident was being discharged and reported the error. The Director of Nursing Services (DNS) confirmed that the error was due to a transcription mistake, and the incorrect medication was sourced from the facility's emergency supply. Additionally, the facility did not administer Bupropion HCL ER (XL) 150 mg oral tablet extended release as ordered by the physician. The medication was omitted because it had not been received from the pharmacy, and there was none available in the facility's emergency supply. These incidents highlight a failure in the medication administration process, specifically in transcribing and ensuring the availability of prescribed medications.
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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