Montowese Center For Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in North Haven, Connecticut.
- Location
- 163 Quinnipiac Avenue, North Haven, Connecticut 06473
- CMS Provider Number
- 075017
- Inspections on file
- 33
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Montowese Center For Health & Rehabilitation during CMS and state inspections, most recent first.
A resident with a seizure disorder, anoxic brain injury, and a brain tumor had an order for Brivaracetam 100 mg twice daily and a care plan requiring seizure medications to be given as ordered. During an evening med pass, an LPN could not locate the resident’s scheduled Brivaracetam dose and documented that the drug was unavailable but did not notify the supervising RN, provider, or pharmacy as required by facility policy. The resident later had a seizure, was evaluated by a provider via telemedicine, and was subsequently transferred to the hospital for seizure-related symptoms, where the event was assessed as a breakthrough seizure; later review by nursing leadership confirmed the lack of required notifications when the medication was unavailable.
A resident with neurofibromatosis, hypertension, and pain returned from outside physician consultations with new medication orders, including changes to Gabapentin and Dexamethasone and the addition of a Lidoderm patch. These orders were not reviewed, reconciled, or transcribed onto the MAR for several weeks, despite facility policy and staff responsibilities for order reconciliation and transcription. The DON was unaware of the missed orders until notified by the hospital, and staff did not follow up to obtain or verify the new orders.
A resident who returned from a hospital stay was not evaluated by a provider within the required 48-hour timeframe, despite significant changes in their condition and care needs. Facility policy and state regulations mandate timely assessment by a physician or APRN after readmission, but the evaluation was delayed by five days.
A resident with severe cognitive impairment and dependent on staff for mobility was not adequately protected from sexual abuse by another resident with dementia and behavioral disturbances. Staff had not previously observed wandering or aggressive behaviors in the perpetrator, and the incident occurred when the resident was found in another's room engaging in inappropriate contact. Immediate staff intervention followed, but the event highlighted a failure to ensure resident safety from abuse.
A resident with COPD, acute respiratory failure, and nicotine dependence was admitted with orders for nicotine replacement and oxygen therapy. Despite being identified as an active smoker and educated on the facility's non-smoking policy, no baseline care plan addressing smoking was developed within 48 hours of admission. The care plan was only created after the resident was found smoking while on oxygen, contrary to facility policy and expectations.
The facility failed to document the administration of evening medications for several residents and did not notify their representatives. Additionally, a resident's wound deterioration was not communicated to the physician, and COVID-19 related changes were not reported to resident representatives. These deficiencies highlight lapses in communication and adherence to facility policies.
A LTC facility failed to ensure proper medication administration and documentation for 20 residents when an LPN left without completing the medication pass. Additionally, the facility did not conduct necessary RN assessments following changes in residents' conditions, such as a positive COVID-19 test and urinary catheter issues. The facility also neglected required neurological checks after unwitnessed falls and failed to assess a deteriorating wound, violating its policies on medication administration, change of condition, and fall management.
A resident with Alzheimer's and contractures did not receive prescribed splinting care as per OT recommendations and physician's orders. Observations and interviews revealed that the splints were not applied, and staff were unaware of the orders. The splints were found in the resident's closet, suggesting they were not used, and the right palm guard was missing for months. The facility's policy on splinting was not followed, leading to this deficiency.
The facility failed to ensure that the physician or APRN signed and dated orders and wrote signed and dated progress notes for two residents over a nine-month period. One resident had unsigned monthly orders from January to September 2024, while another had both unsigned orders and missing progress notes. Interviews revealed that the Medical Director was unaware of how to sign orders electronically, leading to a lapse in compliance with facility policy.
A facility failed to respond to pharmacy recommendations for a resident with dementia, diabetes, and depression. The resident's medication regimen, including antipsychotic and antidepressant drugs, was not reviewed or adjusted as recommended by the pharmacist. Despite repeated requests to taper Risperidone and reduce Celexa dosage due to heart risks, the facility did not act on these recommendations. Interviews revealed a lack of communication and follow-through among staff, leading to continued inappropriate medication regimens.
The facility failed to maintain proper infection control techniques, including hand hygiene and PPE use, during a COVID-19 outbreak. A resident with shingles was cohorted without confirming a roommate's varicella immunity. Additionally, soiled linen handling and vaccination refrigerator temperature monitoring were inadequate.
The facility did not designate a qualified individual to oversee the Infection Control Program. An LPN was primarily handling the program, while an RN with an inappropriate OSHA certification was infrequently involved. The DNS and ADNS lacked specialized infection control certification, and the LPN had only remote support from a Corporate Clinical Infection Control Nurse.
The facility's 2-way call bell system was found to be non-functional, with the entire second floor's system only allowing one-way communication. The Director of Maintenance, new to the position, acknowledged the issue and indicated that parts were unavailable, requiring a full system replacement. An audit revealed two beds on the first floor with completely non-functional systems. The Administrator was unaware of the problem specifics, and there was no policy regarding the call light system.
A resident with multiple diagnoses did not have quarterly care plan meetings or updates as required. The facility failed to ensure the resident's participation in care planning, and the care plan was not updated following hospitalizations. Staff interviews revealed scheduling confusion and lack of adherence to policy.
A resident with dementia and dysphagia experienced a fall with major injury due to missing floor mats and was left unsupervised during meals despite a physician's order for 1:1 supervision. Staff were unaware of the resident's care plan requirements, and the facility lacked documentation on aspiration and fall risk policies.
A resident's rights were not honored when their Leave of Absence (LOA) was restricted due to contraband. The resident, with a history of Traumatic Brain Injury and paraplegia, was found with lighters and vape pens, leading to safety concerns. Despite having no cognitive impairment, the facility limited the resident's LOA to medical appointments only, following facility policies on contraband and smoking.
A resident with traumatic brain injury and paraplegia was not transferred according to physician orders, leading to a deficiency. The resident attempted to enter a vehicle with assistance from a receptionist and an Uber driver, neither of whom were aware of the transfer requirements. A popping sound was heard during the attempt, and the resident was returned to the wheelchair. The facility failed to adhere to the resident's care plan and physician orders.
A long-term care facility failed to follow medication administration policies, resulting in omissions and delays for multiple residents with serious medical conditions. The facility did not complete required documentation or investigate the causes of these issues, and a resident received an incorrect medication, leading to a hospital transfer.
The facility failed to administer medications as per physician orders, leading to significant errors for multiple residents. A resident with atrial fibrillation missed doses of Eliquis and Lasix, while another received incorrect Warfarin doses due to transcription errors. Other residents experienced missed or late medication administration, including a case where incorrect insulin was given, prompting an emergency response. The facility's medication administration policy was not adhered to, potentially impacting residents' health.
The facility failed to conduct required medication self-administration assessments for seven residents self-administering Methadone, despite their policy mandating evaluations of cognitive, physical, and visual abilities. This oversight occurred across residents with various medical conditions, including opioid dependence and diabetes, and was confirmed by the nursing supervisor. The assessments were either incomplete or not conducted, potentially impacting safe medication management.
The facility failed to make recent survey results accessible to residents and the public. Initially, a note instructed individuals to ask the receptionist for the survey results, which the DNS acknowledged should be freely available. Although the note was removed, subsequent observations found the survey results were covered by folders at the receptionist desk, hindering access.
The facility failed to notify the physician and responsible parties of significant condition changes in two residents. One resident with CHF experienced multiple weight gains without physician notification, and another resident with cognitive impairment had significant weight loss and behavioral changes without informing the responsible person.
The facility failed to provide a safe discharge plan for two residents, leading to deficiencies. One resident was discharged without adequate communication with family and friends, resulting in homelessness and hospital admission. Another resident received incorrect medications upon discharge, with the error identified by a family member. The facility's discharge planning policy was not adequately followed, highlighting deficiencies in communication and medication management.
A facility failed to ensure timely approval and signing of doctor's orders for a newly admitted resident with multiple diagnoses, including metabolic encephalopathy and acute kidney failure. The Order Summary Report did not show physician approval, and there was no admission documentation by the physician or APRN within forty-eight hours. An interview with an RN confirmed the absence of this documentation, indicating a deficiency in the admission process.
A facility failed to conduct a fall risk assessment for a resident upon admission, despite the resident's history of falls and recent cervical fractures. The resident was later found on the floor after independently transferring out of bed. A nurse confirmed that the assessment should have been completed as per the facility's policy.
The facility failed to follow physician orders and document necessary assessments for residents with non-pressure skin conditions, leading to missed wound documentation and follow-up appointments. Additionally, multiple residents experienced medication administration errors, including missed or delayed doses, and incorrect Warfarin dosing due to transcription errors. Interviews with staff confirmed the lack of adherence to facility policies and procedures.
The facility failed to follow physician orders and its own policy for managing pressure ulcers for two residents. One resident's coccyx pressure injury was not documented weekly, and another resident at moderate risk for pressure ulcers was not consistently repositioned every two hours as required. These deficiencies were confirmed by the Corporate Wound Nurse and the DNS.
The facility failed to monitor and document the nutritional and hydration needs of several residents, leading to deficiencies in care. Residents experienced inadequate monitoring of intake and output, non-compliance with physician orders for fluid restrictions, and missed weight checks. These issues were identified through clinical record reviews and staff interviews, revealing a pattern of non-compliance with facility policies.
A resident with chronic shoulder pain reported high pain levels, but the facility failed to contact the provider for further intervention in a timely manner. Despite the care plan and pain management policy requiring evaluation and physician notification for worsening pain, these steps were not documented, leading to inadequate pain management.
The facility did not provide sufficient staffing, resulting in significant medication errors for eight residents. On a day with a census of 107 residents, the 7:00 AM to 3:00 PM shift had three nurses and one nursing supervisor, yet medications were either late or omitted.
The facility failed to conduct performance appraisals for two RNs since their hire date, contrary to its policy requiring reviews within the first three months, before the employment anniversary, and six months post-transfer or promotion. This deficiency was identified during a review with the Chief Administrative Officer.
A facility failed to obtain a repeat Basic Metabolic Panel (BMP) for a resident with anemia, dementia, atrial fibrillation, and hypertension, as ordered by a physician. The Director of Nursing could not verify the test was completed, and an RN indicated it was the nursing supervisor's responsibility to ensure labs are drawn. The facility's policy requires diagnostic services to be performed only on physician orders.
A facility failed to ensure that a resident's laboratory results were available in their medical record, as required by physician orders. The resident, admitted with conditions including anemia and dementia, had orders for lab work that were not filed in their record. An RN confirmed the results should have been present but could not explain their absence. Facility policy mandates that all resident record forms be kept in the medical record.
A resident with multiple health issues and a high fall risk experienced an unwitnessed fall, resulting in bruising around the eyes. An APRN ordered a head CT scan to rule out hemorrhage, but the facility failed to obtain the scan as per the order. The Regional Nurse confirmed the oversight, acknowledging that provider orders should be followed according to the facility's Diagnostic Services Policy.
A facility failed to conduct an initial nutritional assessment for a resident with specific dietary needs and preferences, as required by their policy. Despite physician orders for a low fat, low sodium diet and weight monitoring, the clinical record lacked documentation of a completed nutritional assessment or resident preferences. The Director of Nursing confirmed these omissions, which were contrary to the facility's policy requiring assessment by a dietitian within seven days.
A facility failed to document weekly skin assessments for a resident with multiple wounds, including the coccyx and toes, as required by physician orders. Despite the resident's complex medical history, the facility did not maintain accurate or consistent documentation of the wounds in the electronic health record. Interviews with the Corporate Wound Nurse confirmed that wound measurements were not documented weekly, and the documentation was deemed inaccurate.
The facility failed to secure the pool area in the rehabilitation gym, which was busy and had a drained pool with a 4-5 foot drop. This was observed over several days and confirmed through staff interviews.
A resident with a history of substance abuse and liver cirrhosis received an extra dose of Methadone due to multiple lapses in medication administration protocols. The resident was hospitalized for Accidental Methadone Ingestion and treated with Narcan. Interviews revealed failures in transcribing orders, verifying medication dates, and documenting administration.
A resident with multiple diagnoses, including alcohol and polysubstance abuse, received an extra dose of Methadone due to a failure in following the new physician's order. The error occurred because the previous order was not discontinued, and the medication was administered at both 6:00 AM and 9:30 AM. The resident was sent to the Emergency Department and subsequently admitted to the hospital for treatment.
Failure to Notify Supervisor When Anticonvulsant Medication Was Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff followed policy to notify the supervisor when a prescribed anticonvulsant medication was not available for administration. A resident with diagnoses including epilepsy, anoxic brain injury, and a meningioma had a care plan directing that seizure medications be given as ordered, seizure precautions maintained, and seizure activity monitored. A physician’s order required Brivaracetam 100 mg by mouth twice daily for seizures, and the controlled substance disposition record showed that tablets were on hand earlier in the day. On the evening in question, the 3–11 PM charge nurse could not locate the resident’s scheduled 8:30 PM dose of Brivaracetam in the medication cart and documented in a nurse’s note that the medication was not available. However, the nurse’s note did not reflect that the nursing supervisor, provider, or pharmacy were contacted about the missing dose, despite facility policy requiring the charge nurse to notify the supervisor when a medication is unavailable so that the supervisor can contact the provider and pharmacy. The LPN later acknowledged that although she spoke with the supervisor during the shift about another issue, she did not inform the supervisor that the Brivaracetam dose was missed. Subsequently, the resident experienced seizure activity lasting two minutes, after which the provider was notified and the resident was evaluated via telemedicine and remained at the facility. Later that morning, the resident developed sudden right extremity paralysis and was transferred to the hospital, where the event was assessed as a breakthrough seizure. Clinical record review by supervisory nursing staff and the DON confirmed that the nurse’s documentation from the prior evening did not show required notifications to the supervisor or provider when the Brivaracetam dose was unavailable, and that this omission was contrary to the facility’s Medication Pass Policy and Unavailable Medication Policy, which direct that medications be administered safely and timely per physician order and that unavailable medications prompt immediate notification of pharmacy and appropriate practitioners.
Failure to Reconcile and Transcribe Physician Orders After Resident's Consultation
Penalty
Summary
The facility failed to review, reconcile, and transcribe physician orders for a resident who returned from consulting physician appointments. The resident, who had diagnoses including neurofibromatosis, elevated blood pressure, and pain, was alert and oriented at the time of the incident. After a hospital discharge, the resident's medication orders were correctly reconciled and transcribed onto the Medication Administration Record (MAR). However, subsequent consultation forms from the resident's oncologist, which included changes to the medication regimen, were not reviewed, reconciled, or transcribed onto the MAR for several weeks. This included changes to the dosing and frequency of Gabapentin and Dexamethasone, as well as the addition of a Lidoderm patch. Interviews with facility staff revealed that the process for handling new orders after outside appointments involved review and reconciliation by an Advanced Practice Registered Nurse, followed by transcription into the electronic health record by a supervisor, charge nurse, or unit manager. Despite this process, the orders from the consulting physician were not entered into the MAR, and staff did not follow up to obtain or verify the new orders. The Director of Nursing was unaware of the missed orders until notified by the hospital, and could not explain why the required follow-up did not occur. The facility's policy required orders from outside providers to be transcribed by licensed staff, but this was not followed in this instance.
Failure to Timely Evaluate Resident After Hospital Readmission
Penalty
Summary
A deficiency was identified when a resident who had recently returned to the facility following a hospitalization was not evaluated by a provider within the required timeframe. The resident, admitted with diagnoses including transient ischemic attacks, cerebral infarction, alcoholic cirrhosis of the liver, and depression, was noted to be cognitively intact and independent with activities of daily living prior to the hospitalization. Upon return, therapy documentation indicated the resident now required substantial assistance with daily activities, and the resident was on anticoagulant therapy with specific monitoring interventions outlined in the care plan. Despite these changes and the facility's policy requiring evaluation by a physician or APRN within forty-eight hours of admission or readmission, the resident was not seen by a provider until five days after returning from the hospital. The Director of Nursing confirmed the facility's policy and was unable to explain the delay. Review of the Public Health Code also confirmed the requirement for a comprehensive medical history and examination within forty-eight hours of admission.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and dependence on staff for mobility was not protected from sexual abuse by another resident. The resident's care plan identified impaired cognition and the need for supervision, but this was not sufficient to prevent the incident. The resident was found by staff to be teary and confirmed inappropriate touching by another resident, who was observed standing over the resident and touching their genitalia with the resident's brief open. The resident who committed the abuse had a history of dementia with behavioral disturbances and was assessed as having severely impaired cognition. Prior to the incident, there were no documented behaviors of wandering or aggression, and staff had not observed or reported any such behaviors. On the night of the incident, staff observed the resident leaving another room and subsequently found them in the victim's room engaging in inappropriate contact. The staff immediately intervened, but the event had already occurred. Interviews with staff confirmed that neither the resident's history nor prior observations indicated a risk for such behavior, and the facility's abuse policy required individualized care plans and staff training to identify and protect residents at risk. Despite these policies, the lack of prior identification of risk factors and insufficient supervision allowed the incident to occur, resulting in a failure to ensure the resident was free from sexual abuse.
Failure to Develop Timely Baseline Care Plan for Active Smoker
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission to address the needs of a resident who was an active smoker. The resident, who had diagnoses including chronic obstructive pulmonary disease with exacerbation, acute respiratory failure with hypercapnia, and anxiety disorder, was identified as a current smoker upon admission. The hospital referral and medication orders included nicotine replacement therapy and oxygen use. The nursing admission assessment and subsequent notes confirmed the resident's smoking status and use of oxygen, and the resident was educated on the facility's non-smoking policy. However, no care plan addressing smoking was created within the required timeframe. Despite documentation of the resident's smoking history and the presence of smoking materials, the facility did not implement a care plan for smoking until after an incident occurred in which the resident was found smoking while on oxygen. The Director of Nursing confirmed that the expectation was to have a care plan in place prior to the incident, but this was not done. Facility policy required a baseline care plan to be developed within 48 hours of admission, but this was not followed in this case.
Deficiencies in Medication Administration and Resident Notification
Penalty
Summary
The facility failed to ensure proper notification and documentation regarding medication administration and changes in resident conditions. For multiple residents, there was a lack of documentation indicating that evening medications were administered on a specific date after the charge nurse left the facility without reporting off. This failure extended to notifying resident representatives about the missed medications, which is a critical aspect of resident care and communication. In another instance, the facility did not notify the physician or the resident's family when a resident's non-pressure wound deteriorated significantly. Despite the wound worsening over several days, there was no documentation of an RN assessment or notification to the healthcare provider until the resident was eventually sent to the hospital. This lack of timely communication and documentation could have potentially delayed necessary medical interventions. Additionally, the facility failed to notify resident representatives about changes in condition related to COVID-19 and other medical issues. For example, residents who tested positive for COVID-19 or had new medication orders did not have their representatives informed, as required by the facility's policy. This oversight in communication and documentation highlights significant deficiencies in the facility's adherence to its own policies and procedures regarding resident care and safety.
Medication Administration and Assessment Failures in LTC Facility
Penalty
Summary
The facility failed to ensure proper medication administration and documentation for 20 residents on a specific date. The charge nurse left the facility without notifying the Nursing Supervisor or completing the medication pass, resulting in multiple residents not receiving their prescribed medications. This lapse in protocol was identified through a review of the Medication Administration Record (MAR), which showed that medications were not signed off as administered. The facility's policy requires medications to be administered safely and timely, per the physician's orders, and emphasizes the importance of the ten rights of medication administration. In addition to medication administration issues, the facility failed to conduct necessary RN assessments following changes in residents' conditions. For instance, a resident with a urinary catheter experienced bleeding and catheter issues, but no RN assessment was documented. Similarly, another resident tested positive for COVID-19, yet there was no RN assessment recorded following the positive test result. The facility's policy on change of condition mandates that a licensed nurse conduct a complete evaluation and document the findings in the clinical record. The facility also neglected to perform required neurological checks and assessments following unwitnessed falls. One resident experienced an unwitnessed fall, but the clinical record lacked documentation of neurological monitoring or post-fall assessments. The facility's policy on fall management requires neurological checks to be documented for 72 hours following an unwitnessed fall. Additionally, a resident with a deteriorating wound did not receive timely RN assessments or notifications to the healthcare provider, as required by the facility's change of condition notification policy.
Failure to Apply Splints as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to ensure that splints for a resident with contractures were applied according to occupational therapy (OT) recommendations and physician's orders. The resident, who was admitted with Alzheimer's disease, dysphagia, and weakness, had a physician's order to apply a right palm guard during morning care and remove it with evening care. Additionally, resting hand splints were to be applied to both upper extremities at bedtime and removed with morning care. However, observations and interviews revealed that these splints were not being applied as required. Interviews with a visitor, identified as Person #1, indicated that the splints were consistently found in the same position in the resident's closet, suggesting they were not being used. Person #1 also noted that the right palm guard had not been seen on the resident for a couple of months. Further interviews with nursing staff, including an LPN and a nurse aide, confirmed that they were unaware of the orders for the splints and had not seen them applied. Observations on a specific date showed the resident without any splints while sleeping, and the splints were found in the closet, hidden behind a glove box. The Assistant Director of Nursing Services (ADNS) and the Assistant Physical Therapy Director were also interviewed. The ADNS was unaware of the splint application requirements and could not locate the right palm guard. The Assistant Physical Therapy Director confirmed the necessity of the splints for preventing further loss of range of motion and was unaware that they were not being applied. The facility's policy on splinting required nursing staff to be instructed on the wearing schedule and application, but this was not adhered to, leading to the deficiency.
Failure to Sign and Date Physician Orders and Progress Notes
Penalty
Summary
The facility failed to ensure that the physician or APRN signed and dated orders and wrote signed and dated progress notes for two residents over a period of nine months. Resident #9, who was admitted in July 2021 with diagnoses including dementia, heart failure, and diabetes, had monthly physician's orders from January 2024 through September 2024 that were neither signed nor dated by the physician or APRN. Similarly, Resident #30, readmitted in January 2024 with conditions such as epilepsy, heart failure, and chronic obstructive pulmonary disease, also had unsigned and undated monthly physician's orders for the same period. Additionally, for Resident #30, there were no signed or dated progress notes from January to March 2024 and from May to July 2024. Interviews with the Director of Nursing Services (DNS) and the Medical Director (MD #1) revealed a lack of compliance with the facility's policy requiring physicians to sign admission orders within 48 hours and to review, sign, and date interim and monthly orders every 30 days for the first 90 days, and then alternating every 60 days with the APRN. The DNS and MD #1 acknowledged that the orders were not printed for signing and were to be signed electronically. MD #1 admitted to not knowing how to sign off orders in the electronic medical record system until the surveyor's inquiry, despite the system being in place for over a year. This oversight resulted in a failure to sign orders for all current residents until the issue was addressed during the survey process.
Failure to Address Pharmacy Recommendations for Resident Medications
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were responded to by the physician or APRN for a resident with dementia, diabetes, and depression. The resident was receiving antipsychotic, antidepressant, and diuretic medications, with a physician's note indicating that a gradual dose reduction (GDR) was contraindicated. However, the clinical record did not reflect a medication regimen review by the pharmacist for November and December 2023, and pharmacy recommendations for tapering Risperidone and adjusting insulin doses were not addressed by the physician. Further reviews of the medication regimen in 2024 showed continued neglect in addressing pharmacy recommendations. The pharmacist recommended tapering Risperidone and adjusting blood sugar monitoring parameters, but these were not acted upon. Additionally, recommendations to reduce the Celexa dosage due to potential heart risks were not implemented, despite repeated requests. The APRN signed some recommendations but did not ensure changes were made or documented reasons for not following them. Interviews with facility staff, including the DNS, MD, and APRNs, revealed a lack of communication and follow-through on pharmacy recommendations. The DNS was responsible for distributing recommendations but did not ensure they were filed in the resident's clinical records. The APRNs and MD acknowledged the need to respond to recommendations but failed to do so in a timely manner. This lack of action resulted in the resident continuing on potentially inappropriate medication regimens without documented justification or necessary adjustments.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control techniques and hand hygiene procedures, particularly for residents requiring transmission-based and enhanced barrier precautions. During a survey, it was observed that a nursing assistant did not adhere to the required personal protective equipment (PPE) protocols while assisting residents under special precautions. The assistant was seen entering and exiting rooms without performing hand hygiene or donning the necessary PPE, despite the facility being in an active COVID-19 outbreak. This lapse in protocol was acknowledged by the Assistant Director of Nursing Services (ADNS), who noted the need for re-education on these procedures. The facility also failed to ensure that a resident's immunity status was obtained following an identified infection control issue. A resident with shingles was cohorted with another resident without confirming the latter's varicella immunity status. The infection preventionist did not assess the risk of exposure, assuming that the resident's limited mobility reduced the risk. However, the medical director later confirmed that the resident should not have been cohorted without verifying immunity status, as shingles can spread the varicella virus to those who have never had chickenpox or the vaccine. Additionally, the facility did not adhere to proper procedures for handling soiled linen and monitoring vaccination refrigerator temperatures. Soiled laundry was left inappropriately in the corridor, and there were gaps in the temperature logs for the vaccination refrigerator, with no alternative access to the refrigerator when the infection preventionist was unavailable. These oversights indicate a lack of adherence to infection prevention and control policies, as well as inadequate monitoring and documentation practices.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual to oversee the Infection Control Program, as required by their policy. An LPN was identified as the Infection Control Nurse since February 2024, but the oversight was infrequent and primarily handled by the LPN, despite an RN being designated as the responsible party. The RN had chosen an OSHA certification for infection prevention, which was not specifically tailored to nursing home settings, and was selected due to its lower cost. The Corporate Clinical Infection Control Nurse was unfamiliar with the OSHA certification's applicability to nursing homes. The Director of Nursing Services (DNS) and Assistant Director of Nursing Services (ADNS) acknowledged that neither they nor the RN had specialized infection control certification. After a change in ownership, the LPN received remote support from the new Corporate Clinical Infection Control Nurse, but lacked in-house support. The facility's policy required the Infection Preventionist to have primary professional training in relevant fields, be qualified by education, training, experience, or certification, and work at least part-time at the facility, which was not met in this case.
Non-Functional 2-Way Call Bell System
Penalty
Summary
The facility failed to ensure that the 2-way call bell system was functioning properly, as observed on multiple occasions throughout the day. The Director of Maintenance, who had been in the position for three weeks, acknowledged the issue, stating that parts for the system were no longer available, necessitating a complete replacement. The entire second floor's 2-way call bell system was non-functional, with residents able to communicate to the nurses only as a muffled sound, and unable to hear the nurses at all. An audit revealed that on the first floor, two beds had completely non-functional call bell systems, while the second floor's system was only one-way. The Director of Maintenance communicated with the DNS and Admissions, ensuring that the two beds with non-functional systems would remain unoccupied until repairs were made. The Administrator was unaware of the specifics of the call bell system's issues, which had been identified at the end of August 2024, and there was no policy in place regarding the call light system. The DNS confirmed the necessity of a 2-way system for effective communication between residents and nursing staff, but was unaware of the second floor's system failure.
Failure to Conduct Quarterly Care Plan Meetings and Updates
Penalty
Summary
The facility failed to ensure that resident care conferences were completed quarterly, and that the resident was invited and attended these meetings. This deficiency was identified for a resident who was admitted with diagnoses including hemiplegia, hemiparesis, aphasia, cognitive communication disorder, and adjustment disorder. The interdisciplinary care planning meeting documents did not consistently indicate the resident's participation, and the resident expressed feeling uninformed about their care plan and future at the facility. The care plan for the resident was not updated quarterly as required. The last care plan review was completed in May, and there was no update following the resident's hospitalization and subsequent admission MDS in July. The MDS Coordinator acknowledged that the care plan should have been updated quarterly and as needed, but it was not done due to the resident's hospitalizations and the absence of a scheduled MDS in August. Interviews with facility staff revealed a lack of coordination in scheduling and conducting care plan meetings. The Care Plan Meeting Scheduler admitted to confusion due to the resident's hospitalizations, and the Director of Nursing Services confirmed that the care plan meeting had not occurred since May. The facility's policy requires the comprehensive care plan to be reviewed and revised quarterly and following significant changes, but this was not adhered to in the case of the resident.
Failure to Implement Fall and Aspiration Prevention Measures
Penalty
Summary
The facility failed to ensure that interventions were in place for a resident after a fall with a major injury and did not provide 1:1 supervision during meal times as per the physician's order. The resident, who had diagnoses including dementia, dysphagia, and difficulty walking, was at risk for aspiration and had a history of falls. Despite a care plan that required floor mats to prevent falls and 1:1 supervision during meals, these interventions were not consistently implemented. On one occasion, the resident was found on the floor with injuries after attempting to get up to the bathroom, indicating that the fall prevention measures were not in place. Observations revealed that floor mats, which were supposed to be around the resident's bed, were missing, and staff were unaware of their location. Additionally, during meal times, the resident was left unsupervised despite having an order for 1:1 supervision to prevent aspiration due to impaired cognition and dysphagia. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan and physician's orders. The LPN assigned to the resident's unit was unaware of the 1:1 supervision order and the resident's risk for aspiration. The facility also failed to provide policies related to aspiration risk and fall risk assessments, highlighting a gap in the implementation of safety measures for the resident.
Resident's LOA Restricted Due to Contraband
Penalty
Summary
The facility failed to honor a resident's rights by limiting their Leave of Absence (LOA) due to contraband. The resident, admitted with diagnoses including Traumatic Brain Injury, paraplegia, and cognitive communication deficit, was found with contraband items such as lighters and vape pens on multiple occasions. Despite having a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment, the resident was restricted from LOA due to safety concerns for themselves and other residents. The facility's policies, including a Non-Smoking Policy and a Safe Unsupervised LOA Policy, were cited in the decision to restrict the resident's LOA. The Director of Nursing Services (DNS) and the Medical Director confirmed that the resident's LOA was limited to medical appointments only, following the discovery of contraband. The facility's policies prohibit items like cigarettes, vape pens, and lighters, and violations can lead to eviction notices. The interdisciplinary team and physician reviewed the resident's behavior and determined the need for changes in the resident's care plan and physician orders, resulting in the restriction of LOA privileges.
Failure to Follow Transfer Protocols for Resident
Penalty
Summary
The facility failed to ensure that a resident was transferred in accordance with physician orders, leading to a deficiency. The resident, who had a traumatic brain injury, paraplegia, and a cognitive communication deficit, required substantial assistance for transfers as per their care plan. The physician's order specified minimal assistance with slide board transfers and assistance with bilateral lower extremity positioning. However, on the day of the incident, the resident attempted to get into a vehicle with the help of a receptionist and an Uber driver, neither of whom were aware of the resident's transfer requirements. During the attempt, a popping sound was heard, and the resident was lowered back into the wheelchair. The receptionist, who had previously worked as a nursing assistant at the facility, admitted to not knowing the resident's transfer status and not using the available slide board due to the height difference between the wheelchair and the vehicle seat. The physical therapist confirmed that slide board transfers should be performed from a higher to a lower surface or between surfaces of the same height. The Director of Nursing Services acknowledged that the receptionist should not have attempted the transfer and should have called nursing staff to complete it. This incident highlights a failure in adhering to the resident's care plan and physician orders, resulting in a deficiency.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to its medication administration policies, resulting in omissions and delays in medication administration for 11 out of 12 residents reviewed. These residents had various medical conditions, including diabetes, hypertension, heart failure, and depression, which required timely and accurate medication administration. The facility did not complete the necessary reporting documentation, investigate the reasons for these omissions or delays, or report the incidents to the state survey agency as required by their policies. For instance, one resident did not receive their scheduled dose of Cyanocobalamin, and another resident's medications were administered significantly outside the permitted administration window. In another case, a resident's medications, including insulin, were not administered at all during the scheduled times. Additionally, a resident received an incorrect medication, Novolog instead of Semglee, which led to the resident calling emergency services and requesting a hospital transfer. Interviews with facility staff, including the Regional Nurse and Medical Director, confirmed that the medication administration policy was not followed, and medication error reports were incomplete. The Medical Director acknowledged that the omissions and delays could have potentially harmful effects on the residents' health and management of their medical conditions.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications in accordance with physician orders, resulting in significant medication errors for several residents. Resident #24, who was admitted with conditions including atrial fibrillation and congestive heart failure, did not receive their prescribed doses of Eliquis and Lasix on time, with one dose of Eliquis being missed entirely. This pattern of missed and late medications was acknowledged by the Regional Nurse during an interview. Resident #25 experienced a critical medication error involving Warfarin, an anticoagulant, due to incorrect transcription of hospital discharge orders. The resident received a total of 9 mg of Warfarin instead of the alternating doses of 4 mg and 5 mg as intended. This error was compounded by a similar mistake upon readmission, where the resident received an incorrect total dose of 12 mg of Warfarin, despite being scheduled to receive only 3 mg. The errors were attributed to failures in the medication reconciliation process and transcription of physician orders. Other residents, including Resident #45, #46, #50, #52, #53, and #40, also experienced medication administration errors. These included missed doses, late administration, and incorrect medication being given. For instance, Resident #40 received Novolog instead of the prescribed Semglee insulin, leading to an emergency response. The facility's policy for medication administration was not followed, as confirmed by the Regional Nurse, and the Medical Director noted that these omissions and delays could have potentially harmful effects on the residents' health and management of their medical conditions.
Failure to Conduct Medication Self-Administration Assessments
Penalty
Summary
The facility failed to conduct medication self-administration assessments for seven residents who were self-administering Methadone, as required by their policy. Each resident had various medical conditions, including opioid dependence, diabetes, and hypertension, and were receiving Methadone for either opioid dependence or pain management. Despite the facility's policy requiring an evaluation of cognitive, physical, and visual abilities to ensure safe medication management, these assessments were either incomplete or not conducted at all. For instance, one resident was self-administering Methadone despite a self-administration assessment indicating they did not desire to self-administer medications. Another resident's assessment was noted as in progress but had not been completed. In all cases, the nursing supervisor confirmed that the residents were provided Methadone by a nurse and then self-administered the medication without the necessary assessments being documented. The lack of proper assessments was consistent across all seven residents, regardless of their cognitive status as indicated by their BIMS scores, which ranged from 8 to 15. This oversight in conducting and documenting the required assessments represents a failure to adhere to the facility's policy, potentially impacting the safe and effective management of medications for these residents.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that recent survey activities were accessible to residents and the public. During a tour of the facility, a note was observed taped on the counter of the reception desk, instructing individuals to see the receptionist for Connecticut's Department of Public Health Annual Survey results. An interview with the Director of Nurses (DNS) revealed that survey results should be available to all without needing to ask. The DNS subsequently removed the sign from the counter. Further observations on subsequent days identified that the survey results were placed on the wall at the receptionist desk but were covered by folders, making them inaccessible.
Failure to Notify Physician and Responsible Parties of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician and responsible parties of significant changes in the conditions of two residents, leading to deficiencies in care. Resident #5, who was admitted with diagnoses including congestive heart failure, experienced multiple instances of weight gain that exceeded the thresholds set by physician orders. Despite orders to notify the physician of a 2-pound daily or 5-pound weekly weight increase, the facility did not inform the physician of a 2-pound gain on 10/14/19, a 4.2-pound gain on 10/17/19, and a 2.4-pound gain on 10/21/19. Additionally, daily weights were not recorded on 10/26, 10/27, and 10/28/19, and the care plan was not followed, as evidenced by the lack of notification to the physician about these weight changes. Resident #13, admitted with conditions including hemiplegia and cognitive impairment, experienced a significant weight loss of 13.4 pounds over two months, as documented by the APRN and dietician. Despite this, the responsible person was not notified of the resident's condition changes, which included fatigue and constipation. On 1/27/22, the resident exhibited disorganized thoughts and nearly fell out of bed, prompting a report to nursing. However, the clinical record did not show that the responsible person was informed of these changes, which was necessary given the resident's cognitive impairment.
Deficiencies in Discharge Planning and Medication Management
Penalty
Summary
The facility failed to provide a safe and comprehensive discharge plan for two residents, leading to deficiencies in their discharge process. Resident #21, who had a history of cerebral vascular accident, myocardial infarction, and other conditions, was discharged without adequate communication and planning with the family and friends who were supposed to support the resident post-discharge. The discharge packet included necessary information, but there was no evidence that the resident's friend was informed about the level of care needed. This lack of communication resulted in the resident being found homeless and without support shortly after discharge, leading to a hospital admission. Resident #26, who had diagnoses including difficulty walking and diabetes, was discharged with a significant error in the medication provided. The discharge packet included medications that belonged to another resident, Resident #61, instead of the correct medications for Resident #26. This error was identified by a family member, who notified the facility, but the regional nurse was unaware of the situation. The facility's discharge planning policy requires interdisciplinary plans to ensure safe and orderly discharges, but these were not adequately followed for the two residents. The lack of proper communication and medication management highlights deficiencies in the facility's discharge planning process, which could have serious implications for the residents' safety and well-being.
Failure to Timely Approve and Sign Admission Orders
Penalty
Summary
The facility failed to ensure timely approval and signing of doctor's orders for a resident admitted with multiple diagnoses, including metabolic encephalopathy, syncope and collapse, anemia, acute kidney failure, and basal cell carcinoma of the skin. The Order Summary Report for the period from 10/1/2022 to 10/31/2022 did not show that the physician had approved and signed the orders. Additionally, the clinical record review revealed a lack of admission documentation completed by the physician or APRN within forty-eight hours of the resident's admission. An interview with RN#4 confirmed the absence of this documentation, indicating a deficiency in the facility's admission process.
Failure to Conduct Fall Risk Assessment on Admission
Penalty
Summary
The facility failed to conduct a fall risk assessment for a resident upon admission, as required by their policy and procedures. The resident, who had a history of falls and was diagnosed with weakness, systemic lupus, and recent cervical fractures, was admitted to the facility. Despite these conditions, an initial fall risk assessment was not completed at the time of admission. The resident's care plan, dated shortly after admission, identified a risk for falls and included specific interventions. However, the resident was later found on the floor of their room, having independently transferred out of bed. A facility investigation noted that the resident had last been checked over an hour before the fall occurred. During an interview, a nurse confirmed that a fall risk assessment should have been conducted upon admission, in accordance with the facility's fall management policy.
Failure to Follow Physician Orders and Medication Administration Errors
Penalty
Summary
The facility failed to follow physician orders and document necessary assessments for two residents with non-pressure skin conditions. Resident #19, who was admitted with multiple diagnoses including COVID-19 and end-stage renal disease, had specific physician orders for weekly wound documentation that were not followed. The facility's records lacked weekly documentation of wound measurements for the resident's toes and coccyx, as required by the facility's policy. The Corporate Wound Nurse confirmed the absence of documentation and expressed concerns about the accuracy of the electronic health record. Resident #36, who was admitted with conditions such as cellulitis and chronic venous hypertension, missed scheduled follow-up appointments due to the facility's failure to ensure access and proper documentation. The resident's care plan included monitoring and documenting signs of infection, but the facility did not document attempts to reschedule a canceled appointment. Additionally, the facility failed to document wound care treatments for the resident's chronic non-healing wounds, as confirmed by interviews with nursing staff. The facility also failed to administer medications in accordance with physician orders for multiple residents. Resident #3 did not receive a scheduled dose of Cyanocobalamin, leading to the resident's transfer out of the facility. Other residents, including #44, #47, #48, and #49, experienced delays or missed doses of their prescribed medications. The facility's policy for medication administration was not followed, as confirmed by the Regional Nurse. Furthermore, Resident #25 experienced medication errors related to Warfarin dosing due to inaccurate transcription of orders upon admission and readmission, resulting in incorrect dosages being administered. Interviews with facility staff highlighted the lack of proper medication reconciliation and transcription processes, contributing to these deficiencies.
Failure to Document and Manage Pressure Ulcers
Penalty
Summary
The facility failed to adhere to physician orders and its own policy regarding the management and documentation of pressure ulcers for two residents. Resident #19, who was admitted with multiple diagnoses including COVID-19 and end-stage renal disease, had a pressure injury on the coccyx that was not documented weekly as required by physician orders and facility policy. Despite the presence of a care plan that included interventions for wound management, the facility did not maintain accurate and consistent documentation of the wound's measurements and condition, as confirmed by the Corporate Wound Nurse. Resident #28, admitted with a right hip fracture and other conditions, was identified as being at moderate risk for pressure ulcers. Physician orders and the care plan required regular repositioning and skin assessments, yet the facility failed to document that the resident was turned and repositioned every two hours as needed. This lack of documentation was confirmed during an interview with the Director of Nursing Services, indicating a failure to follow the facility's policy on the prevention and management of pressure injuries.
Failure to Monitor Nutrition and Hydration
Penalty
Summary
The facility failed to adequately monitor and document the nutritional and hydration needs of seven residents, leading to deficiencies in care. For Resident #1, the facility did not adhere to physician orders for fluid restriction and failed to monitor intake on the day and evening shifts over a period of 93 days. The Director of Nurses acknowledged that the physician orders should have been followed, and the facility's policy required intake and output to be monitored per physician orders. Resident #5 experienced a lack of monitoring for intake and output over 20 days, despite physician orders for daily weight monitoring and fluid restrictions. The clinical record did not show weights being obtained on specific dates, and the Regional Nurse confirmed that the plan of care was not followed. Similarly, Resident #9's intake was not monitored as required by physician orders, despite the presence of a Foley catheter and IV antibiotics, which necessitated strict intake and output monitoring. Other residents, including Residents #18, #23, #29, and #42, also experienced failures in monitoring intake and output, as well as adherence to fluid restrictions. These deficiencies were identified through clinical record reviews and staff interviews, revealing a pattern of non-compliance with physician orders and facility policies. The facility's policies on intake and output monitoring and fluid restrictions were not consistently followed, leading to gaps in care for residents with complex medical needs.
Failure in Timely Pain Management for a Resident
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident who was admitted with diagnoses including acute respiratory failure, influenza, pneumonia, and chronic shoulder pain. The resident was identified as cognitively intact and reported experiencing constant pain that affected sleep and daily activities. The care plan included administering pain medication as ordered and assessing pain characteristics, but the facility did not adequately address the resident's complaints of pain. Despite the resident reporting high pain levels, including a level 7 on the pain scale, the clinical record did not show that the provider was contacted for further intervention until several days later. The facility's pain management policy required a pain evaluation and physician notification for new or worsening pain, which was not followed. The Director of Nursing Services confirmed that the expectation was to administer as-needed medication and contact the provider if pain relief was not achieved, which was not documented in the resident's case.
Insufficient Staffing Leads to Medication Errors
Penalty
Summary
The facility failed to ensure sufficient staffing on January 28, 2023, between 7:00 AM and 11:30 AM, which resulted in significant medication errors for eight residents. The daily census on this date was 107 residents, and the staffing for the 7:00 AM to 3:00 PM shift included three nurses and one nursing supervisor. Despite this staffing, significant medications were either late or omitted for the residents involved.
Failure to Complete Performance Appraisals for RNs
Penalty
Summary
The facility failed to complete performance appraisals for two registered nurses, RN #8 and RN #9, in accordance with its policy. Both nurses had an effective employment date of September 29, 2022, but their personnel files lacked any performance reviews since their hire date. The facility's policy requires performance appraisals to be completed by the end of the first three months of employment, prior to the anniversary date of employment, and six months after an employee is transferred or promoted to a new job. This deficiency was identified during an interview and review of the personnel files with the Chief Administrative Officer on May 5, 2024.
Failure to Obtain Ordered Laboratory Test
Penalty
Summary
The facility failed to ensure a laboratory test was obtained in accordance with physician orders for Resident #12, who was admitted with diagnoses including anemia, dementia, atrial fibrillation, and hypertension. A care plan dated 12/29/20 identified the resident as a fall/safety risk and included interventions such as monitoring for complications. Physician orders dated 1/8/21 directed a repeat Basic Metabolic Panel (BMP) to be obtained. However, a review of the clinical record with the Director of Nursing (DON) on 5/9/24 confirmed that the facility did not verify the completion of the laboratory test as ordered. The DON was unable to provide documentation verifying the test was performed. An interview with RN #5 indicated that the lab order should have been drawn and it was the nursing supervisor's responsibility to ensure labs are drawn, but could not explain why it was not done. The facility's Diagnostic Services Policy requires all diagnostic services to be performed only on the order of a physician.
Missing Laboratory Results in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that laboratory results for Resident #12 were available in the resident's medical record, as required by physician orders. Resident #12, who was admitted with diagnoses including anemia, dementia, atrial fibrillation, and hypertension, had an initial Resident Care Plan that identified them as a fall/safety risk and noted conditions such as anemia and a COVID-19 infection. Physician orders dated 12/30/20 and 1/11/21 directed that laboratory work, including a complete blood count and a basal metabolic panel, be completed on 12/31/20 and 1/12/21. However, upon review of the clinical record with the Director of Nursing, it was found that the laboratory results were not filed in the resident's medical record. An interview with RN #5 confirmed that the laboratory results should have been in the medical record, but the nurse could not explain their absence. The facility's policy for Nursing Documentation requires that all resident record forms be kept in the resident's medical record.
Failure to Obtain Ordered Diagnostic Test for Resident
Penalty
Summary
The facility failed to obtain a diagnostic test in accordance with provider orders for a resident who had a fall. The resident, who was admitted with multiple diagnoses including congestive heart failure, atrial fibrillation, bradycardia, difficulty walking, and chronic obstructive pulmonary disease, was identified as being at risk for falls. Despite interventions such as a bed alarm, chair alarm, and gripper socks, the resident experienced an unwitnessed fall and reported hitting their head. Subsequent observations noted periorbital ecchymosis, prompting an APRN to order a head CT scan without contrast to rule out hemorrhage. However, the facility did not follow through with the APRN's order for the CT scan. A review of the clinical record and an interview with the Regional Nurse confirmed that the scan had not been obtained. The Diagnostic Services Policy of the facility mandates that all diagnostic services are performed only on the order of a physician, yet this order was not executed. The Regional Nurse acknowledged that provider orders should be adhered to, indicating a lapse in following the established protocol for diagnostic testing.
Failure to Conduct Initial Nutritional Assessment
Penalty
Summary
The facility failed to conduct an initial nutritional assessment for a resident, identified as cognitively intact and requiring extensive assistance with bathing and dressing, who was admitted with diagnoses including cellulitis, congestive heart failure, and atrial fibrillation. Despite a physician's order for a low fat, low sodium diet and instructions to obtain a weight on admission and for four consecutive weeks post-admission, the clinical record did not reflect that a nutritional assessment was completed. This assessment should have included the resident's dietary preferences, as per the facility's policy. Additionally, the resident's care plan noted the need to monitor labs, weight, and update preferences as needed, yet there was no documentation of these actions being taken. The Director of Nursing Services confirmed the absence of a nutrition assessment and resident preferences documentation during an interview. The facility's Food First Nutrition policy requires that a resident be assessed by a registered dietitian or diet technician within seven days, which was not adhered to in this case.
Failure to Document Weekly Wound Assessments
Penalty
Summary
The facility failed to document weekly skin assessments for a resident with multiple wounds, including the coccyx, right 2nd toe, and left 4th toe, as required by physician orders. The resident, who was admitted with diagnoses including COVID-19, End Stage Renal Disease, atherosclerotic heart disease, and hypertension, had a hospital discharge summary noting necrosis and ulceration on the toes and a pressure injury on the coccyx. Despite these conditions, the facility did not maintain accurate or consistent documentation of the resident's wounds in the electronic health record, as evidenced by missing weekly wound documentation from late April to late June. Interviews with the Corporate Wound Nurse revealed that wound measurements were not documented or tracked weekly, contrary to expectations. The nurse also indicated that the wound documentation in the electronic health record was inaccurate. The facility's policy from February 2016 emphasized that nursing notes should be clear and concise, yet the documentation for this resident did not meet these standards, failing to provide an accurate assessment of the resident's clinical progress and changes in condition related to skin integrity.
Unsecured Pool Area in Rehabilitation Gym
Penalty
Summary
The facility failed to ensure a safe environment in the rehabilitation gym area. Observations on multiple days identified that the pool area within the gym was unsecured, despite the gym being very busy. The pool was drained, creating a 4-5 foot drop to the bottom, posing a potential safety hazard. This issue was identified through observations and interviews with facility staff, including a discussion with the Maintenance Director.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to follow established professional standards when transcribing a physician's order, documenting medication administration, and administering the correct dose of Methadone for a resident. The resident, who had a history of alcohol and polysubstance abuse, dependence on renal dialysis, cirrhosis of the liver, and chronic viral hepatitis, was prescribed Methadone HCL oral solution 105 mg daily. However, discrepancies were found in the Medication Administration Record (MAR) and the Individual Controlled Drug Record, indicating that the resident received an extra dose of Methadone on a specific date. The MAR failed to reflect a licensed staff's signature for the 6:00 AM dose, and the resident was administered Methadone again at 9:30 AM, leading to an overdose and subsequent hospitalization for Accidental Methadone Ingestion. The resident was treated with Narcan and other interventions at the hospital before being discharged with a recommendation to discontinue Methadone and start Suboxone due to liver cirrhosis. Interviews with the Regional Director of Nursing (DON), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) revealed multiple lapses in protocol. The 3PM-11PM Nursing Supervisor failed to discontinue the existing Methadone order before transcribing the new order. Additionally, the Methadone Clinic's protocol to destroy any Methadone not used while the resident was in the hospital was not followed. LPNs and RNs involved in the medication administration process did not verify the correct dates on the Methadone bottles and failed to document the administration accurately. These actions and inactions led to the resident receiving an extra dose of Methadone, resulting in severe lethargy and the need for emergency medical intervention.
Failure to Administer Methadone According to New Physician's Order
Penalty
Summary
The facility failed to administer Methadone in accordance with the new physician's order for a resident with diagnoses including alcohol and polysubstance abuse, dependence on renal dialysis, cirrhosis of the liver, and chronic viral hepatitis. The physician's order dated 11/4/23 directed the administration of Methadone HCL oral solution 105 mg by mouth daily at 9:00 AM. However, upon the resident's return from the hospital on 11/11/23, a new order directed the administration of Methadone at 6:00 AM. The Medication Administration Record (MAR) showed that Methadone was administered at both 6:00 AM and 9:30 AM on 11/12/23, resulting in an extra dose being given to the resident. This error was identified when the 7AM-3PM Nursing Supervisor noticed the discrepancy in the controlled substance book. Interviews with various staff members revealed that the 3PM-11PM Nursing Supervisor did not follow the correct protocol when entering the new medication order, failing to discontinue the previous order. The 11PM-7AM Nursing Supervisor and charge nurse also did not verify the correct date on the Methadone bottle before administration. As a result, the resident was sent to the Emergency Department for evaluation and was subsequently admitted to the hospital with a principal diagnosis of Accidental Methadone Ingestion. The resident was treated with Narcan and had their medication regimen adjusted due to their liver condition.
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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