Monsignor Bojnowski Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in New Britain, Connecticut.
- Location
- 50 Pulaski Street, New Britain, Connecticut 06053
- CMS Provider Number
- 075374
- Inspections on file
- 18
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Monsignor Bojnowski Manor during CMS and state inspections, most recent first.
A resident with dementia, multiple comorbidities, and moderate cognitive impairment exhibited escalating agitation, continuous yelling, and restlessness that staff were unable to redirect. Despite a care plan and dementia policy requiring physician or mental health referral when behaviors declined or interventions were ineffective, staff did not notify the physician of the behavioral change. Instead, a supervising RN directed that the resident be brought to the nurse’s station, then placed the resident in the medication room behind the nurse’s station with the door closed for about one and one-half hours for "close observation," while other staff later described the situation as solitary confinement.
A resident with dementia, multiple comorbidities, and total dependence for care, who frequently yelled out and was sometimes calmed when near the nurse’s station, was placed in the medication room with the door closed for about one and one-half hours due to agitation, yelling, and attempts to get out of bed. A CNA brought the resident to the nurse’s station for anxiety and restlessness, and the supervising RN, unable to fit the wheelchair behind the nurse’s station, directed that the resident be placed in the medication room and shut the door so other residents could sleep, stating it was easier to watch the resident there. Staff later described the situation as “solitary confinement,” confirmed the door was shut though unlocked, and documented that the resident remained there until after midnight before being returned to their room. This conduct conflicted with the facility’s abuse policy, which prohibits involuntary seclusion defined as separating a resident from others or from their room against the will of the resident or representative.
A resident with dementia, ESRD, failure to thrive, depression, and moderate cognitive impairment, fully dependent for care and wheelchair bound, was placed in a medication room with the door shut by an RN after the resident had been screaming, anxious, and trying to get out of bed. Multiple staff, including an NA and LPNs, observed the resident in the closed medication room, questioned the practice, and one LPN referred to it as solitary confinement, but none reported it as suspected abuse at the time despite prior abuse/neglect training and awareness that involuntary seclusion is a form of abuse. The DON only became aware of the incident days later during conversations with staff, and the facility’s abuse policy requiring immediate reporting of suspected abuse to the Administrator within two hours was not followed.
The facility failed to secure medications designated for destruction or return to the pharmacy, as observed in the DNS office, which was found open and unoccupied on multiple occasions. Various medications were visible and accessible, contrary to the facility's policy. Interviews revealed that the DNS did not secure the office door, believing residents and visitors would not enter, leading to unsecured medications.
The facility failed to administer pneumococcal and influenza vaccines to residents, despite consents being given. A resident with hypertension and another with dementia were not offered the influenza vaccine, and there was no record of pneumococcal vaccine administration for five residents. The DNS confirmed the oversight, indicating a lapse in the facility's vaccination program.
A resident with vascular dementia and anxiety frequently refused care and medications, particularly Trazodone, but the facility failed to update the care plan to address these refusals. Interviews with staff revealed that the resident was redirectable, yet the care plan lacked interventions for reapproaching the resident. The facility did not have a specific policy on refusals, and the care plan was not updated despite the resident's transition to hospice care.
A resident with dementia and a history of wandering eloped to a courtyard patio due to inadequate supervision and staff's failure to respond to door alarms. The resident, who was at risk for elopement, managed to exit the building unnoticed, despite having a wander guard. Staff interviews revealed that alarms were not promptly investigated, leading to the resident being found outside and brought back inside by an LPN.
An LPN failed to follow hand hygiene procedures during medication administration and resident care, as observed in a facility. The LPN did not sanitize hands between resident interactions or after glove removal, despite the facility's policy requiring hand hygiene between resident contacts and before handling medications. The LPN was unfamiliar with the facility's hand hygiene policy, which was confirmed through interviews.
A resident with epilepsy and dementia missed three doses of prescribed Clobazam because the medication was not available, despite refills remaining. The MAR and EMR showed the medication should have been refilled, but the pharmacy's records did not reflect this, leading to a lapse in administration. The resident developed symptoms and was sent to the hospital for evaluation, where it was confirmed that the medication had not been given as ordered. Staff interviews revealed confusion and miscommunication regarding the refill process for controlled substances.
A facility failed to notify the Ombudsman of a resident's transfer to the hospital, as required. A resident with osteomyelitis and other conditions was found unresponsive and transferred to the ER. The Social Worker, responsible for reporting transfers, was unaware of this duty, resulting in a lack of notification for several months. The Administrator confirmed the oversight, as the Social Worker was on leave and he lacked access to the reporting portal.
The facility failed to properly label and store food, and did not ensure kitchen staff adhered to hygiene standards. Observations revealed unlabeled and uncovered food items in storage, and staff not wearing required hair and beard guards while preparing food. Interviews confirmed these actions were against facility policy.
The facility failed to accurately encode MDS assessments for five residents, leading to discrepancies in their immunization records. Residents were reported as having up-to-date vaccinations, but records showed no documentation of recent pneumococcal or influenza vaccines. Interviews with an LPN revealed that the assessments were not accurately coded, and the clinical records lacked necessary information. The DNS acknowledged signing off on the assessments but emphasized the MDS Coordinator's responsibility for accuracy.
Two residents in a facility sustained injuries due to improper transfers. One resident, with osteoarthritis, was not transferred using a rolling walker as required, resulting in a leg laceration. Another resident, with Alzheimer's, was transferred without a rolling walker, leading to a leg injury from a bed rail. Both incidents occurred due to staff not following care plans.
The facility failed to provide required orientation, including emergency procedures and abuse training, to three agency NAs before they began working. The Administrator confirmed the absence of documentation for these orientations, which is against the facility's policy.
Failure to Notify Physician of Behavioral Change and Inappropriate Use of Medication Room for Observation
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in a resident’s behavior and the subsequent placement of the resident in a medication room with the door closed for an extended period. The resident had diagnoses including dementia, insomnia, end stage renal disease, failure to thrive, and depression, and was identified as moderately cognitively impaired, dependent for all care, and wheelchair bound. The resident’s care plan directed staff to assess mood every shift and obtain psychiatric services if mood declined. In the days leading up to the incident, nurse’s notes documented that the resident often yelled out continuously and was sometimes calmed when brought near the nurse’s station. An FNP note indicated recent falls, increased confusion, anxiety, and a discussion with family about starting Trazodone, which the family declined. On the date of the incident, staff reported that the resident was anxious, trying to get out of bed, and screaming throughout the shift, with usual redirection attempts unsuccessful. NA #1 brought the resident to the nurse’s station due to restlessness and high fall risk. RN #2, the nursing supervisor, determined the resident should be kept under direct observation and attempted to position the resident behind the nurse’s station, but the custom wheelchair would not fit. RN #2 then placed the resident in the medication room located directly behind the nurse’s station and shut the door. Written statements and interviews indicated that the resident remained in the medication room in the wheelchair with the door shut for approximately one and one-half hours, and that staff referred to this as “solitary confinement.” Review of the clinical record and nurse’s notes for the 24 hours preceding the incident showed no documentation that the physician was notified of the resident’s increased agitation and behavioral escalation, despite the facility’s dementia care policy directing appropriate referrals to the physician or mental health provider when current interventions were ineffective or when there was a decline in psychosocial, mood, or behavioral status. Interviews confirmed that staff were unable to de-escalate the resident’s behaviors and that the family member was not contacted for assistance until early the following morning. The facility documentation and staff interviews collectively demonstrated that the resident’s significant change in behavior was not reported to the physician and that the resident was instead placed in the medication room with the door closed for close observation.
Involuntary Seclusion of a Cognitively Impaired Resident in Medication Room
Penalty
Summary
The deficiency involves the involuntary seclusion of a resident with dementia and multiple comorbidities who was placed in the facility’s medication room with the door closed for approximately one and one-half hours due to agitated behaviors and continuous yelling. The resident had diagnoses including dementia, insomnia, end-stage renal disease, failure to thrive, and depression, and was assessed as moderately cognitively impaired, unable to make reasonable and consistent decisions, dependent for all care, and wheelchair bound. The resident’s care plan addressed self-care deficits and mood concerns but did not include interventions involving separation from other residents or placement in a medication room. In the days leading up to the incident, nursing notes documented that the resident frequently yelled out continuously throughout shifts, with some decrease in yelling when brought near the nurse’s station. On the day of the incident, staff reported the resident was anxious, trying to get out of bed, and screaming throughout the shift. A nursing assistant brought the resident to the nurse’s station, and the supervising RN directed that the resident be brought there for closer observation. When the resident’s wheelchair could not be accommodated behind the nurse’s station, the supervising RN placed the resident in the medication room and shut the door, stating it was easier to watch the resident there and to allow other residents to sleep. Written statements and interviews confirmed that the resident remained in the medication room with the door shut, with staff referring to the situation as “solitary confinement” and acknowledging the resident had been yelling all evening. The medication room door was unlocked and had clear glass panels, allowing visual observation, and at some point after midnight, vital signs were obtained and the resident was returned to their room, where they slept for the remainder of the night. The facility’s abuse policy stated that residents would be protected from involuntary seclusion, defined as separation from other residents or the resident’s room against the will of the resident or the resident’s representative. The placement of the resident in the medication room with the door closed for behavioral reasons constituted the separation that led to the cited deficiency.
Failure to Timely Report Allegation of Involuntary Seclusion
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of involuntary seclusion involving one resident. The resident had dementia, insomnia, end stage renal disease, failure to thrive, depression, was moderately cognitively impaired with a BIMS score of 9, unable to make reasonable and consistent decisions, dependent for all care, and wheelchair bound. The resident’s care plan called for assessment every shift, medication administration as ordered, encouragement to participate in care, and psychiatric services and emotional support if mood declined or the resident self-isolated. On the evening in question, the resident was reportedly screaming, anxious, trying to get out of bed, and attempting to climb out of bed. Multiple staff members, including nursing assistants and nurses, observed that the resident was placed in the medication room with the door shut for close observation and to prevent disruption to other residents. Staff accounts documented that an RN directed that the resident be brought to the nurse’s station and then placed the resident in the medication room with the door shut, referring to the situation as a way to watch the resident and allow others to sleep. Other staff, including an NA and LPNs, noted they had never seen a resident placed in the medication room in this manner, questioned the appropriateness of the action, and one LPN described it as “solitary confinement.” Despite having received abuse and neglect training and being aware that involuntary seclusion is a form of abuse, these staff did not report the incident as suspected abuse at the time it occurred, citing reasons such as not realizing it was wrong or believing the resident was not their patient. The DON later learned of the incident only when speaking with staff about interactions with the RN involved, at which point the facility initiated an investigation and completed a Reportable Event Form several days after the incident, contrary to the facility’s abuse policy requiring suspected abuse to be reported to the Administrator immediately and no longer than two hours after an allegation is made.
Unsecured Medications in DNS Office
Penalty
Summary
The facility failed to ensure that medications designated for destruction or return to the pharmacy were secured, as observed during multiple instances. On several occasions, the Director of Nursing Services (DNS) office door was found open and unoccupied, with a yellow basket containing various medications visible on top of the medication safe. This office is located on a nursing unit that opens to the resident corridor, where residents and visitors were present. The medications included Eliquis, Amox-Clav, Cephalexin, Ciprofloxacin, Prednisone, and others, which were not secured as per the facility's policy. Interviews with RN#2 and the DNS revealed that discontinued and expired medications are typically stored in a cabinet in the medication storage room until they are taken by the DNS for destruction or return to the pharmacy. However, the DNS admitted that the medications in the office were supposed to be destroyed but had not yet been processed. Despite the presence of ambulatory residents and visitors near the open office, the DNS did not secure the door, believing that residents and visitors would not enter the office. This oversight led to the medications being unsecured and accessible, contrary to the facility's policy for medication storage.
Failure to Administer Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal and influenza vaccines were assessed and administered to residents, as evidenced by the review of clinical records, facility policy, and interviews. Five residents were reviewed for immunizations, and it was found that the pneumococcal vaccine was not offered or administered to any of them. Specifically, Resident #12 and Resident #31 were not offered the influenza vaccine. The DNS, who was covering for the Infection Preventionist, confirmed that these residents should have been offered and given the PCV 20 vaccine based on their pneumococcal history. Resident #12 had diagnoses including hypertension, osteoarthritis, and hypercholesterolemia. Despite giving consent for the pneumococcal vaccine, there was no record of administration. Similarly, Resident #31, with diagnoses of dementia, depressive disorder, and gastrointestinal hemorrhage, had no documentation of receiving the pneumococcal vaccine, nor was there evidence of refusal. The DNS identified that the responsibility for reviewing and assessing vaccination status, obtaining consents, and ensuring administration within 30 days lies with the infection control nurse. The facility's policies for pneumococcal and influenza vaccinations were not followed, as evidenced by the lack of documentation and administration of vaccines. The DNS acknowledged that the influenza vaccine should have been offered to Resident #12 and Resident #31 during the facility's vaccination clinic. The report highlights a systemic issue in the facility's vaccination program, as the DNS was only made aware of the oversight during a COVID-19 clinic, indicating a lapse in the facility's adherence to its vaccination policies.
Failure to Address Resident's Refusal of Care in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive care plan addressed a resident's consistent refusals of care and medication. The resident, who was admitted in October 2024, had diagnoses including vascular dementia with agitation, anxiety disorder, and insomnia. Despite having intact cognition, the resident frequently refused care and medications, particularly Trazodone, which was refused 26 times in December 2024 and 23 times in January 2025. The care plan dated January 3, 2025, did not address these refusals, nor did it include interventions for reapproaching the resident. Interviews with facility staff revealed that the resident was redirectable but often refused care depending on the staff and their mood. The Director of Nursing Services (DNS) and other staff members indicated that refusals should be addressed in the care plan, and the RN Supervisor and APRN should be notified of consistent refusals. However, the facility lacked a specific policy on refusals of care or medications, and the care plan was not updated to reflect the resident's behavior of refusing care, treatments, and medications. The MDS Coordinator acknowledged that the care plan should have included interventions for refusals, such as reapproach strategies. Despite the resident's transition to hospice care, the care plan did not adequately address the resident's refusals, which were documented in nursing notes and the medication administration record. The facility's care planning policy requires that care plans be reviewed and updated to reflect changes in the resident's status, but this was not done in the case of this resident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving Resident #16, who had a history of dementia, poly-osteoarthritis, restlessness, and agitation. The resident was identified as being at risk for elopement, with a physician's order for a wander guard to be checked every shift. Despite these precautions, the resident managed to elope to the courtyard patio without staff noticing, as the door alarm was not responded to in a timely manner. On the day of the incident, Resident #16 was last seen in the dining room and later observed sitting near the nurses' station. The resident then walked towards the dining room, opened a door leading to the courtyard, and exited the building. The nursing supervisor was on the phone and did not notice the resident leaving. The door alarm was activated, but staff did not respond immediately. The resident was eventually found knocking on a window outside and was brought back inside by an LPN who had not heard the alarm. Interviews with staff revealed that the door alarms were functioning, but staff failed to investigate the alarm signals. One nursing aide admitted to hearing the alarm but did not check which door was opened. The facility's policy on elopement and wandering residents emphasized the need for adequate supervision and timely response to alarms, which was not adhered to in this case.
Failure to Follow Hand Hygiene Procedures
Penalty
Summary
The facility failed to ensure proper hand hygiene procedures were followed by staff involved in direct resident contact. During medication administration, an LPN was observed taking a resident's blood pressure and exiting the room without performing hand hygiene. The LPN then prepared and administered medications to the resident without sanitizing hands. The resident had a new complaint of a rash on both arms. The LPN continued to interact with multiple residents, including taking blood pressure and providing care, without performing hand hygiene between tasks or after glove removal. The LPN, who was from an agency but had been working regularly at the facility, admitted to being unfamiliar with the facility's hand hygiene policy. The facility's policy requires hand hygiene to be performed between resident contacts, before and after glove use, and before preparing or handling medications. The policy also specifies that hand hygiene should be performed with an alcohol-based hand rub or by washing with soap and water when hands are visibly soiled. The failure to adhere to these procedures was confirmed through interviews with the LPN and an RN, who reiterated the importance of hand hygiene in preventing infection.
Failure to Administer Ordered Medication Due to Refill and Communication Errors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including epilepsy, dementia, and anxiety did not receive their prescribed Clobazam 10mg for three consecutive days, as ordered by the physician. The medication administration record (MAR) showed that the doses were missed because the medication was not available in the facility, despite a 30-day supply having been delivered and refills remaining. The pharmacy's records incorrectly indicated that no refills were available, while the facility's electronic medical record (EMR) showed otherwise. Multiple staff interviews confirmed that the medication was not administered due to this discrepancy, and the pharmacy was contacted several times without resolution. During the period when the medication was missed, the resident exhibited symptoms including not feeling well, difficulty pronouncing words, and labored breathing with an expiratory wheeze. The advanced practice registered nurse (APRN) and the resident's family were notified, and the resident was sent to the hospital for evaluation. The hospital confirmed that the resident had not received three doses of Clobazam, and laboratory results showed the medication level was within the normal range. The resident was evaluated for a stroke, and the facility did not notify the family about the missed doses until after the hospital evaluation. Interviews with facility staff and the pharmacist revealed confusion and miscommunication regarding the medication refill process, particularly for controlled substances. The facility's policy required medications to be administered as ordered and for discrepancies to be reported and corrected, but this was not followed in this instance. The failure to ensure the medication was available and administered as ordered led to the resident missing three doses and being hospitalized for evaluation.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure the Ombudsman's office was notified of a resident's transfer to the hospital, as required by regulations. Resident #34, who had diagnoses including osteomyelitis, anemia, and osteoarthritis of the knee, was found unresponsive and was subsequently transferred to the emergency room for evaluation. The facility's policy mandates that the Ombudsman be notified of such transfers, but this was not done in this case. The Social Worker, who was responsible for sending the monthly report of transfers and discharges to the Ombudsman's office, was unaware of this responsibility and did not complete the report. The facility's records showed multiple transfers and discharges over several months, but the required notifications were not sent to the Ombudsman. The Administrator acknowledged that the Social Worker was on leave and that he did not have access to the Ombudsman's reporting portal. The Social Worker, who started working at the facility in September 2024, admitted to not being aware of the responsibility to complete the report. This oversight resulted in the Ombudsman not being informed of the transfers and discharges from September 2024 through January 2025, including the emergency transfer of Resident #34.
Deficiencies in Food Labeling and Kitchen Hygiene
Penalty
Summary
The facility failed to adhere to proper food labeling and storage protocols, as well as personal hygiene standards in the kitchen. During an observation, it was noted that bologna in the refrigerator was wrapped in plastic without a label indicating the date it was opened or a discard date. A tray of pasta with meat sauce in the walk-in freezer was found partially uncovered, exposing the food to open air. Additionally, bags of fish squares and yellow cake mix in the freezer and dry storage were not labeled with open or expiration dates. Interviews with supervisors confirmed that these items should have been properly labeled and covered according to facility policy. Furthermore, the facility did not ensure that kitchen staff adhered to personal hygiene standards. A dietary aide was observed preparing food without a beard guard, despite having a full beard. Another supervisor was seen placing food into the steam table without a head covering, only putting on a hat after noticing the surveyor. The facility's policy requires staff to wear hair and beard guards while preparing food, which was not followed in these instances. The dietary manager confirmed that the facility's policy mandates proper labeling of food and the use of hair restraints in the kitchen.
Inaccurate MDS Assessments for Resident Immunizations
Penalty
Summary
The facility failed to ensure accurate encoding of Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their immunization records. Resident #12, diagnosed with hypertension, osteoarthritis, and hypercholesterolemia, was reported as having received an influenza vaccine and being up-to-date with the pneumococcal vaccine, but records showed no documentation of these vaccinations. Resident #31, with dementia and depressive disorder, was also inaccurately reported as having up-to-date vaccinations, with no evidence of recent pneumococcal or influenza vaccines. Resident #43, who has type 2 diabetes mellitus and peripheral vascular disease, was noted as having an up-to-date pneumococcal vaccine, but records did not support this claim. Similarly, Resident #46, with sepsis and sleep apnea, and Resident #49, with dementia and hypercholesterolemia, were both inaccurately reported as having up-to-date pneumococcal vaccinations, despite lacking documentation of recent vaccinations. Interviews with the MDS Coordinator, LPN #4, revealed that the assessments were not accurately coded, and the clinical records did not contain the necessary information to support the MDS assessments. The Director of Nursing Services (DNS) acknowledged signing off on the assessments but emphasized that it was the MDS Coordinator's responsibility to ensure accuracy. The facility's policy requires comprehensive and accurate assessments, with each section attested to by the responsible staff member.
Improper Resident Transfers Result in Injuries
Penalty
Summary
The facility failed to ensure that Resident #1 was transferred according to the plan of care, resulting in an injury. Resident #1, who had diagnoses including osteoarthritis and required partial/moderate assistance with transfers, was supposed to be transferred with the assistance of one staff member using a rolling walker and gait belt. However, on 12/28/2024, NA #1 did not use the rolling walker during the transfer from a wheelchair to a bed, leading to Resident #1's leg grazing the metal part of the wheelchair and sustaining a laceration that required hospital treatment and sutures. NA #1 admitted to not being aware of the need for a walker and did not consult the care card for transfer instructions. Resident #2, diagnosed with Alzheimer's disease and requiring substantial/maximal assistance with transfers, also experienced an improper transfer. On 9/2/2023, two NAs were involved in transferring Resident #2 without using the required rolling walker, as per the care plan. During the transfer, Resident #2's leg got caught on the bed's side rail, resulting in a skin cut that required stitches. The NAs involved did not provide physical assistance during the transfer, and the walker was not listed on the care card, leading to the improper execution of the transfer. Both incidents highlight the facility's failure to adhere to the established care plans and transfer protocols, resulting in injuries to the residents. The facility's documentation and interviews with staff confirmed that the proper use of assistive devices, such as rolling walkers, was not followed, contributing to the accidents. The Director of Nursing and Administrator acknowledged that the injuries could have been prevented if the care plans had been followed correctly.
Failure to Provide Orientation to Agency Staff
Penalty
Summary
The facility failed to ensure that agency nursing assistants (NAs) received proper orientation, including emergency procedures and abuse training, before commencing work. This deficiency was identified through a review of clinical records, facility documentation, and agency staff files for three agency NAs. Specifically, the files for Agency NA #1, #2, and #3 lacked documentation of a general orientation that included facility emergency procedures and abuse training. These NAs worked shifts at the facility without the required orientation, which is a violation of the facility's orientation policy. During an interview and review of facility documentation and policies, the Administrator confirmed that the medical records/scheduler is responsible for orienting agency staff, which includes providing a tour and training on emergency procedures and abuse. However, the facility did not have documentation to confirm that this orientation was provided to the three agency NAs in question. The Administrator was unable to explain the absence of this documentation, indicating a lapse in the facility's adherence to its own orientation policy, which mandates that all new staff and contractual service providers complete a general orientation before having formal contact with residents.
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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