Masonicare Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wallingford, Connecticut.
- Location
- 22 Masonic Avenue, Wallingford, Connecticut 06492
- CMS Provider Number
- 075135
- Inspections on file
- 32
- Latest survey
- December 9, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Masonicare Health Center during CMS and state inspections, most recent first.
The facility failed to ensure proper food safety and hygiene practices in the kitchen. Staff with facial hair, including the Executive Chef, were not wearing beard guards while preparing food, as the facility had not provided them. Additionally, several food items in the kitchen were improperly stored, not dated, or exceeded their storage life, contrary to the facility's policy.
The facility failed to document and obtain consent for advance directives for three residents. One resident had conflicting code status documentation, another lacked a signed Advance Directives Summary form despite a CPR order, and a third resident with a terminal prognosis had no documented advance directive form. Staff acknowledged the absence of necessary documentation and consent, which should have been completed during the admission process.
The facility failed to maintain a safe and clean environment, as evidenced by drywall residue left in hallways and deficiencies in a resident's room, including a partially attached window curtain, a soiled privacy curtain, and an exposed cable wire. Despite acknowledgment of these issues, they remained unaddressed, compromising the resident's environment.
Three residents with dementia were placed in a secured unit without proper documentation of clinical criteria or evidence that it was the least restrictive setting. The facility failed to document the involvement of responsible parties or the interdisciplinary team's assessment of the impact of the placement. Observations showed residents were calm and cooperative, yet their care plans did not reflect the necessity of the secured unit.
The facility failed to follow its Water Management Plan by not conducting monthly Legionella testing and not reporting positive results to the State Agency. Missing testing results for 2022, 2023, and 2024 were identified, and multiple positive Legionella samples were not reported. The Director of Maintenance and Administrator were unaware of all positive results, despite the facility's policy to report them.
A resident with dementia and mobility issues sustained a skin tear during a transfer, but the facility failed to update the care plan to include accident prevention measures. The ADNS admitted the care plan should have included re-education for the nursing assistant involved, but this did not occur.
The facility did not complete an annual performance evaluation for a nurse aide hired in 2010, with missing evaluations for 2022, 2023, and 2024. The administrator confirmed that annual reviews should occur on the hire date anniversary, but no documentation was found. The unit manager was responsible for these evaluations, and the facility lacked a policy for performance evaluations.
The facility failed to document and act on pharmacy consultant recommendations for two residents. One resident was prescribed Seroquel without a clear diagnosis, and the recommendation to review this was not addressed. Another resident had a delayed TSH level check recommendation following a Levothyroxine dosage change. Delays in forwarding recommendations to APRNs led to untimely reviews, contrary to the facility's policy requiring action within 30 days.
The facility was found to have a medication error rate of 12%, exceeding the acceptable threshold of 5%. This was determined through a review of clinical records and facility policies, highlighting a significant issue in medication administration practices.
In a dementia unit, an LPN left a medication cart unsecured while attending to a resident, leaving it unattended and out of sight. Interviews confirmed that the cart should have been secured, as per facility policy, especially given the cognitive deficits of the residents on the floor.
The facility failed to administer the pneumococcal vaccine to two residents as per their requests and CDC guidelines. One resident, who was cognitively intact, did not receive the vaccine despite giving consent. Another resident, with severely impaired cognition, was not offered the PCV20 vaccine upon admission, despite being eligible. The facility's policy required offering pneumococcal immunizations as recommended by the CDC, but this was not followed, and necessary documentation was not completed.
A resident with multiple medical conditions did not have Social Security funds deposited into their personal fund account in a timely manner. The Business Manager, responsible for transferring funds from the trust account, failed to do so due to confusion over a check, despite being aware of the expected payment. This resulted in the resident not having timely access to their funds as required by facility policy.
A resident with cognitive impairment and mobility deficits, requiring a two-person assist for transfers, sustained a skin tear to the lower leg during a transfer to bed. Facility records and staff interviews indicated uncertainty about whether wheelchair leg rests were removed prior to the transfer, and the facility could not provide an accident prevention policy when requested.
A resident dependent on staff for transfers and at high risk for falls was improperly transferred using a mechanical lift when a nurse aide inadvertently pressed the remote, causing the sling to recline and a strap to disconnect. The resident fell, sustaining a head laceration and subdural hematoma, due to failure to follow proper two-person transfer technique.
A resident with dementia and anxiety was administered Trazodone for agitation, which proved ineffective. The LPN did not notify the physician or supervisor about the ineffectiveness, leading to the resident falling and sustaining a head injury. The facility's policy required notifying the physician of a change in condition, which was not followed.
A facility failed to create a comprehensive care plan for a resident with urinary incontinence. The resident, diagnosed with urinary retention and benign prostatic hyperplasia, was frequently incontinent after the removal of an indwelling urinary catheter. Despite this, no care plan was developed to address the incontinence, as confirmed by the DON. The facility's policy requires a patient-specific care plan, which was not followed.
A facility failed to conduct a continence assessment for a resident after removing an indwelling urinary catheter. The resident, with severe cognitive impairment and a history of urine retention, was frequently incontinent post-catheter removal. The facility's policy required a bowel and bladder assessment, which was not completed, as confirmed by the DON.
A resident with dementia and anxiety experienced increased agitation and restlessness, which were not effectively managed by the facility. Despite being administered Trazodone, the medication was ineffective, and staff failed to notify the physician or take further action. The resident fell from a wheelchair, sustaining a head injury. Additionally, the facility did not consistently document the resident's behaviors, contributing to inadequate management.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a survey. Several staff members, including the Executive Chef and other kitchen staff with facial hair, were found not wearing beard guards while preparing food. The Executive Chef acknowledged that the facility did not have beard guards available, although they were ordered but not yet received. Interviews with staff revealed that the facility had not offered beard guards, and some staff believed that keeping their beards short negated the need for a guard. The facility's policy required all facial hair to be restrained with a beard net or restraint. Additionally, the facility failed to adhere to its food storage policy. Observations in the kitchen identified several food items that were either not dated, improperly covered, or had exceeded their storage life. Prepared foods such as cheese blitzes, stuffed peppers, meatballs, and ground meat were found in the walk-in refrigerator beyond the three-day limit for use. The Executive Chef confirmed that these items should have been discarded and acknowledged that the weekend staff should have removed the out-of-date food. The facility's policy required refrigerated foods to be discarded after three days from being opened or prepared.
Failure to Document and Obtain Consent for Advance Directives
Penalty
Summary
The facility failed to ensure proper documentation and consent for advance directives and code status for three residents. Resident #18 was admitted with severe cognitive impairment and had conflicting documentation regarding their code status. The electronic record indicated a DNR status, while the physical record had an incomplete DNR form. The responsible party initially wished for a DNR status but later confirmed a full code status after the facility sought clarification. Resident #22, who was cognitively intact, did not have a signed Advance Directives Summary form in either the physical or electronic records, despite a physician's order indicating a CPR code status. The resident did not recall any discussion about advance directives or code status upon admission. The facility's staff acknowledged the absence of the necessary documentation and consent, which should have been completed during the admission process. Resident #128, with severe cognitive impairment and a terminal prognosis, also lacked a documented advance directive form in both the electronic and physical records. The physician's orders indicated a DNR status, but there was no written consent from the responsible party. The facility's staff confirmed the absence of the required documentation and noted that the advance directive should have been verified and documented within the first three days of admission.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by observations and interviews conducted during the survey. On the 3 Ramage unit, a hole in the wall was noted due to a water leak, and maintenance staff were present but not actively working on repairs. The base molding was missing throughout the unit. Additionally, drywall residue from preparation for painting was found clumped on the floors, spread across hallways, and tracked by residents, indicating inadequate cleanup by the work crew. The facility manager acknowledged that the staff should have cleaned up the mess at the end of the day. Resident #80's room was observed to have several deficiencies, including a window curtain that was only partially attached, exposing metal hooks, a soiled bedside privacy curtain with brownish, reddish splatters, and a cable wire protruding from the wall without a cover. Despite the LPN's acknowledgment of the issues and the intention to address them, subsequent observations showed that the deficiencies remained unaddressed, indicating a lack of timely action to ensure a safe and homelike environment for the resident.
Lack of Documentation for Secured Unit Placement
Penalty
Summary
The facility failed to ensure proper documentation and criteria for placing residents in a secured unit, affecting three residents with dementia. Resident #13, diagnosed with dementia, bipolar disorder, and liver cancer, was placed in a secured unit without documented clinical criteria or evidence that it was the least restrictive setting. Despite being pleasant and without unwanted behaviors, the resident's care plan included a wander guard, and there was no documentation of the resident's or responsible party's involvement in the decision. Resident #38, with dementia and a history of combative behaviors, was also placed in the secured unit without proper documentation. The resident's clinical record lacked evidence of the interdisciplinary team's assessment of the impact of the placement or the involvement of the responsible party. Observations showed the resident was calm and cooperative, yet the facility did not document the necessity of the secured unit as the least restrictive environment. Similarly, Resident #82, with dementia and heart failure, was placed in the secured unit without documented clinical criteria or evidence of the least restrictive setting. The resident's care plan did not reflect the secured unit placement, and there was no documentation of the responsible party's involvement. The facility's assessment failed to identify criteria for placement in secured units, and the interdisciplinary team's discussions were not adequately documented in the residents' clinical records.
Failure to Report Positive Legionella Results
Penalty
Summary
The facility failed to adhere to its Water Management Plan, which required monthly Legionella testing, and did not report positive Legionella water sampling results to the State Agency. The facility's documentation review revealed missing Legionella testing results for several months in 2022, 2023, and 2024. Interviews with the Director of Maintenance and the Administrator confirmed that they were unable to provide the missing testing results and the water management plan binder. The Director of Maintenance was responsible for obtaining and maintaining copies of the Legionella water sampling results, but failed to do so. The facility's Water Management Plan identified multiple instances of positive Legionella water sampling results that were not reported to the State Agency. These results included several months in 2023 and 2024 where testing locations showed Legionella pneumophila and other species above the threshold of 10 colony-forming units per milliliter or swab. Despite the facility's policy to report positive results to the State Agency, the Administrator was not aware of all positive results, and the Director of Maintenance failed to communicate these results to the Administrator. The Water Management Contractor, who conducted the monthly testing, confirmed that the facility was responsible for reporting positive results to the State Agency. The contractor provided recommendations for addressing positive results, which were followed by the facility. However, the facility did not maintain a complete record of testing results and failed to report positive findings as required. The Administrator and Director of Maintenance acknowledged the facility's practice of reporting positive results but did not provide a policy or plan related to the water management plan and reporting requirements.
Failure to Revise Care Plan After Resident Injury
Penalty
Summary
The facility failed to review and revise the care plan for a resident following an incident where the resident sustained a skin tear during a transfer. The resident, who had diagnoses including dementia and muscle wasting, was dependent on staff for transfers and used a wheelchair for mobility. On a specific date, a nurse noted an open area on the resident's lower right leg after a transfer, which was later identified as a skin tear. The facility's investigation determined that the injury occurred during the transfer to bed, but the care plan was not updated to include interventions for accident prevention, such as re-educating the nursing assistant involved in the transfer. The Assistant Director of Nursing Services (ADNS) acknowledged that the care plan should have been updated to include education for the nursing assistant on safe transfer techniques. However, this re-education did not occur. Additionally, a registered nurse could not recall specific details about the incident, and attempts to interview the nursing assistant involved were unsuccessful. The facility's policy requires that care plans be developed and revised as appropriate, but this was not adhered to in this case, leading to the deficiency.
Failure to Complete Annual Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to complete an annual performance evaluation for one of its nurse aides, identified as NA #4. NA #4 was hired on January 18, 2010, and there was no documentation of a performance evaluation for the years 2022, 2023, or 2024 in their personnel file. During an interview on December 3, 2024, the administrator confirmed that each employee should receive a performance review annually on their hire date anniversary. The unit manager was responsible for ensuring these evaluations were completed, but no documentation was found for NA #4's evaluations. Additionally, the facility could not provide a policy for performance evaluations when requested.
Failure to Document and Act on Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure proper documentation and timely action on pharmacy consultant recommendations for two residents. Resident #120, diagnosed with unspecified dementia, anxiety disorder, and heart failure, was prescribed Seroquel for agitation without a clear supporting diagnosis. A pharmacy consultant recommended a review of this medication, but the recommendation was not addressed by the APRN/Physician and was not included in the resident's clinical record. The APRN for Resident #120's unit indicated that she only reviews paperwork provided to her and does not receive pharmacy recommendations directly, leading to delays in addressing these recommendations. Similarly, for Resident #135, who had diagnoses including unspecified dementia with agitation and psychotic disorder, a pharmacy consultant recommended a TSH level check following a Levothyroxine dosage change. This recommendation was not documented in the clinical record until requested by a surveyor. The ADNS and unit managers receive pharmacy recommendations via email, but there are delays in forwarding these to the APRNs, resulting in untimely reviews. The facility's policy requires prescribers to act on recommendations within 30 days, but this was not adhered to, as evidenced by the delayed actions and incomplete documentation in the clinical records.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below the required threshold of 5%. Upon review of clinical records and facility policies, it was found that the observed medication administration had a calculated error rate of 12%. This indicates a significant deviation from the acceptable standards for medication administration within the facility.
Medication Cart Security Lapse in Dementia Unit
Penalty
Summary
The facility failed to ensure the security of the medication administration cart in the locked down dementia unit. During an observation, an LPN was seen preparing medication and then leaving the cart unsecured as he walked into the dining room to administer medication to a resident. The cart was positioned near the entrance to the dining room, and all drawers were accessible. The LPN then left the cart unattended and out of his line of sight as he escorted a confused resident down the hallway to their room, approximately 50 feet away. Interviews with the LPN and the Assistant Director of Nursing Services (ADNS) confirmed that the medication cart should have been secured whenever the nurse was not in attendance. The facility's policy on Medication Ordering, Scheduling, and Administration also stipulated that medication carts must be maintained securely on the nursing unit, with main locks engaged when unattended. The ADNS acknowledged that the residents on this floor had cognitive deficits, emphasizing the importance of securing the cart even if it was within the nurse's view.
Failure to Administer Pneumococcal Vaccines as Requested
Penalty
Summary
The facility failed to administer the pneumococcal vaccine to two residents as per their requests and CDC guidelines. Resident #25, who was admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and Wernicke's encephalopathy, was cognitively intact and had given consent for the pneumococcal vaccine. However, the vaccine was not administered, and the Infection Preventionist nurse could not provide a reason for this oversight. The Director of Quality confirmed that it was the Infection Preventionist nurse's responsibility to track the resident's vaccine status. Resident #144, admitted with Alzheimer's disease, dementia, and depression, had severely impaired cognition. The legal representative of Resident #144 was provided with an incorrect consent form, and the resident was not offered the PCV20 vaccine upon admission, despite being eligible based on prior vaccination history. The facility's policy required offering pneumococcal immunizations as recommended by the CDC, provided there were no medical contraindications and consent was obtained. However, the policy was not followed, and the necessary documentation was not completed in the resident's medical record.
Failure to Timely Deposit Resident Personal Funds
Penalty
Summary
A deficiency occurred when the facility failed to deposit a resident's Social Security funds into the resident's personal fund account in a timely manner. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, major depressive disorder, and Wernicke's encephalopathy, was identified as cognitively intact but dependent on staff for several activities of daily living and used a wheelchair for mobility. The responsible party for the resident reported that the resident was owed money from Social Security, and the Business Manager initially stated that the delay was due to the Social Security office. However, a review of the resident's accounts revealed that a deposit from the US Treasury had been received by the facility but was not transferred to the resident's fund account as required. Interviews with the Business Manager and the corporate Cash Specialist clarified that the Business Manager was responsible for transferring funds from the facility's trust account to individual resident accounts. The Business Manager admitted confusion regarding the check, despite being aware of the expected amount for the resident. The facility's policy required individual accounts for each resident with monthly reconciliation, but this process was not followed, resulting in the resident not having timely access to their funds.
Failure to Ensure Safe Transfer Results in Resident Skin Tear
Penalty
Summary
A deficiency occurred when a resident with dementia, muscle wasting, atrophy, atrial fibrillation, and anxiety, who was dependent on staff for transfers and used a wheelchair for mobility, sustained a skin tear during a transfer to bed. The resident's care plan required a two-person assist for transfers, and the incident happened while a nursing assistant was assisting the resident back to bed. The skin tear was discovered on the resident's lower right leg, and the cause was determined to be related to the transfer process. Facility documentation and interviews revealed uncertainty about whether the wheelchair leg rests were removed prior to the transfer, which may have contributed to the injury. The facility was unable to provide a policy for accident prevention when requested. Staff interviews could not confirm the exact circumstances of the injury, and the nursing assistant involved was unavailable for interview. The incident was documented in the resident's clinical record and facility reports, and the wound was subsequently treated according to physician orders.
Improper Mechanical Lift Transfer Results in Resident Fall and Head Injury
Penalty
Summary
A deficiency occurred when a resident with dementia, impaired mobility, and a high risk for falls was improperly transferred from bed to wheelchair using a mechanical lift. The resident was dependent on staff for all transfers and required two-person assistance with a Hoyer lift, as documented in the care plan. During the transfer, the nurse aide operating the lift held the remote in her hand while maneuvering the device, inadvertently pressing a button that caused the sling to recline. This action led to a strap disconnecting from the lift, resulting in the resident falling and striking their head on the lift. Clinical records and staff interviews confirmed that the transfer was not performed according to proper technique, as the second staff member was not in position to guide or support the resident during the maneuver. The resident sustained a scalp laceration, a bump on the head, and was diagnosed at the hospital with a subdural hematoma and bifrontal petechial hemorrhages, requiring admission for treatment and monitoring. The incident was attributed to improper handling of the lift controls and failure to follow established transfer protocols.
Failure to Notify Physician of Ineffective Medication
Penalty
Summary
The facility failed to notify a physician when a resident exhibiting behaviors was administered an as-needed medication that was ineffective. The resident, diagnosed with dementia and anxiety, was severely cognitively impaired and required extensive assistance. The care plan included administering medications as ordered and reporting restlessness and agitation. A physician's order directed the administration of Trazodone for anxiety, restlessness, or agitation. However, on a specific date, the medication was ineffective, and the staff did not notify the physician or take further action. On the day of the incident, the resident was agitated, self-propelling in a wheelchair, and calling out loudly. Despite attempts to calm the resident with food and redirection, the agitation persisted. An LPN administered Trazodone, which was ineffective, but did not notify the supervisor or physician about the ineffectiveness. Later, the resident fell from the wheelchair, sustaining a head injury, and was transferred to the hospital. The nursing staff had not communicated the ineffectiveness of the medication to the physician, missing an opportunity for further intervention. Interviews with staff and the psychiatric provider revealed that the facility had been managing the resident's behaviors with medication adjustments. The psychiatric provider indicated that if notified of the continued agitation, he could have adjusted the medication dosage. The facility's policy required notifying the physician of a change in condition, which was not followed in this case. The DNS and Administrator acknowledged that the nurse should have reported the medication's ineffectiveness to the supervisor, who could have contacted the physician for further direction.
Failure to Develop Comprehensive Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with urinary incontinence. The resident, who had a diagnosis of urinary retention and benign prostatic hyperplasia, was identified as having severe cognitive impairment and required extensive assistance with Activities of Daily Living (ADLs). An admission Minimum Data Set (MDS) assessment noted the presence of an indwelling urinary catheter, which was later discontinued per physician's orders. Subsequent assessments and ADL flow sheets indicated that the resident was frequently incontinent of urine. However, a review of the clinical record revealed that no care plan was developed to address the resident's urinary incontinence. An interview with the Director of Nurses confirmed that a comprehensive care plan should have been created once the resident's incontinence was identified. The facility's care plan policy mandates the development of a patient-specific care plan to meet the resident's needs, which was not adhered to in this case.
Failure to Conduct Continence Assessment Post-Catheter Removal
Penalty
Summary
The facility failed to ensure a proper assessment for continence was completed for a resident after the discontinuation of an indwelling urinary catheter. The resident, who had a diagnosis of urine retention and benign prostatic hyperplasia, was identified as having severe cognitive impairment and requiring extensive assistance with activities of daily living. A physician's order directed the discontinuation of the indwelling urinary catheter, but the clinical record did not show that a bladder assessment was conducted to evaluate the resident's continence status post-catheter removal. Subsequent assessments and flow sheets indicated that the resident was frequently incontinent of urine. An interview with the Director of Nurses confirmed that a bowel and bladder assessment should have been completed following the catheter's removal, as per the facility's bowel and bladder management program policy.
Failure to Address and Document Resident Behaviors Leads to Fall
Penalty
Summary
The facility failed to adequately address and document the behaviors of a resident diagnosed with dementia and anxiety, leading to an incident where the resident fell and sustained a head injury. The resident, who was severely cognitively impaired and required extensive assistance, exhibited increased agitation and restlessness, which were not effectively managed. Despite a physician's order to administer Trazodone for anxiety and agitation, the medication was ineffective, and the staff did not notify the physician or take further action to address the resident's continued agitation. On the day of the incident, the resident was observed to be agitated, self-propelling in a wheelchair, and calling out for a spouse. The Trazodone administered by an LPN was ineffective, and the resident continued to exhibit agitated behaviors. The LPN did not report the ineffectiveness of the medication to the supervisor or seek further intervention, as she was occupied with other tasks. Consequently, the resident fell from the wheelchair, resulting in a laceration to the forehead and requiring hospital evaluation. Additionally, the facility failed to document the resident's behaviors consistently, as required by the physician's order. The behavior monitoring flow sheets did not reflect the resident's agitation and restlessness, particularly during the night shift, despite the administration of Trazodone on several occasions. This lack of documentation and communication contributed to the inadequate management of the resident's behaviors and the subsequent fall.
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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