Mystic Healthcare & Rehabilitation Center, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mystic, Connecticut.
- Location
- 475 High St, Mystic, Connecticut 06355
- CMS Provider Number
- 075271
- Inspections on file
- 21
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Mystic Healthcare & Rehabilitation Center, Llc during CMS and state inspections, most recent first.
A facility failed to maintain a safe environment when a dirty meal tray cart with uncovered leftover food and an open garbage was routinely left overnight in a hallway outside a locked kitchen, accessible to cognitively impaired, wandering residents on modified diets, including pureed and mechanical soft textures with thin liquids. One resident with dementia, dysphagia, severe memory deficits, and dependence on staff for eating accessed a peanut butter sandwich from the unattended cart and choked, requiring an LPN to perform the Heimlich maneuver. Staff interviews revealed that this resident habitually wandered at night seeking food and had previously attempted to take food from the cart, but these behaviors were not reported to licensed staff. The Director of Food Service and DON were aware that the cart was not consistently locked in the kitchen, and a new RN supervisor on duty had not been oriented to the meal tray collection and cart storage process. The facility lacked a specific policy on food cart storage or food disposal, despite having general policies on safe environment and management of wandering and elopement risk, resulting in an Immediate Jeopardy finding.
A resident with dementia, COPD, dysphagia, severe memory deficits, and dependence on staff for eating had a care plan and Resident Care Card directing a regular pureed diet with thin liquids, aspiration monitoring during meals, and removal of accessible food due to food-seeking behavior. Staff failed to follow these directives when the resident, who habitually wandered at night looking for food, accessed a peanut butter sandwich from a food cart and choked, requiring an LPN to perform the Heimlich maneuver. A NA had previously seen the resident attempt to take and eat food from the cart, did not report these incidents to nursing staff, was unaware of the prescribed pureed diet, and provided snacks at night without knowledge of dietary restrictions, while the DON was unaware of the prior food cart incidents.
A resident with dementia, dysphagia, severe memory deficits, and dependence on staff for eating was care planned and ordered for a regular, pureed diet with thin liquids and had a Wanderguard for wandering risk. During a night shift, the resident, who habitually wandered the halls seeking food, accessed a food cart outside the locked kitchen, took a peanut butter sandwich inconsistent with the prescribed diet, and began choking. A NA observed the choking and alerted an LPN, who performed the Heimlich maneuver. The NA reported having previously seen the resident attempt to take and eat food from the food cart but did not report these behaviors to licensed staff and was unaware of the resident’s pureed diet, while the DON was unaware of the prior unsafe eating incidents.
A resident with significant physical and mental health needs was subjected to loud and derogatory remarks by a nursing assistant during toileting care. Two other NAs witnessed the incident and reported that the staff member questioned the resident's need for care and expressed frustration about being assigned to the resident, in violation of facility policies on resident rights and abuse prevention.
A resident with significant care needs was subjected to disparaging and vulgar remarks by a nursing assistant regarding incontinence and food intake. Although two staff members reported the incident to supervisory staff, the nursing supervisor did not escalate the allegation, initiate an incident report, or remove the accused staff member from duty. The DON was not informed until the next day, resulting in a delay in addressing the abuse allegation as required by facility policy.
A resident with cognitive impairment and muscle weakness sustained significant burns to the thigh and genital area after spilling hot chocolate, due to the facility's failure to implement an ordered sippy cup intervention and lack of communication among staff. The resident continued to receive hot beverages in open cups, and required assessments and investigations into the injuries were not completed as per facility policy.
A resident with dementia, muscle weakness, and polyneuropathy developed new wounds that were not promptly addressed in the care plan, with a delay of 10 days before updates were made. Additionally, the care plan did not include interventions for the resident's frequent refusals of care, despite staff being aware of this behavior. Facility policy required timely updates to care plans for changes in resident status, but this was not followed.
A resident with dementia and polyneuropathy experienced injuries of unknown origin, but staff failed to perform a timely full body skin assessment after the initial wound was discovered, and did not document nursing notes every shift as ordered by the physician. Facility policy requiring immediate assessment and documentation of unexplained injuries was not followed, as confirmed by staff interviews and record review.
Several residents with cognitive and physical impairments reported mistreatment and fear related to a staff member, but the facility failed to document grievances, provide required follow-up, or offer timely support as outlined in its own policy. Staff interviews and record reviews confirmed that complaints were not properly recorded or resolved, and administrative staff were unaware of key incidents.
Multiple residents with cognitive and physical impairments reported verbal and physical mistreatment by a staff member, but staff failed to document, investigate, and report these abuse allegations to the State Agency as required by facility policy. Despite some immediate actions, such as staff suspension, there was no evidence of timely notification or proper follow-up.
Multiple residents reported abuse or neglect by a staff member, including physical and verbal mistreatment, but the facility failed to conduct complete investigations or document the allegations as required. Staff did not consistently obtain statements from all involved, and complaints were not always recorded in nurse's notes or the grievance log, resulting in unresolved and uninvestigated incidents.
A resident with dementia and severe cognitive impairment, requiring two staff for care due to behavioral issues, was forcefully pushed into a wheelchair by a staff member who was providing care alone. The resident sustained a bruise and skin tear, and the incident was not promptly reported or investigated according to facility policy, resulting in a failure to protect the resident from abuse.
A resident with dementia and behavioral disturbances, who was care planned for two staff to provide care during a specific shift due to aggression and sundowning, was instead cared for by a single nursing assistant. The staff member was unaware of the updated care plan and the requirement was not communicated, resulting in care being provided alone and an incident involving physical altercation and injury.
Immediate Jeopardy from Unsecured Food Cart Access by Wandering Residents with Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to the storage and handling of food carts and leftover food. A food cart used for collecting dirty meal trays was routinely left overnight in the hallway outside a locked kitchen door, without a cover on the cart or on the attached garbage container. This cart, sometimes containing leftover food on plates or in an open garbage, was accessible to cognitively impaired residents with wandering behaviors and prescribed modified diets. The facility did not have a policy addressing food cart storage or proper disposal of food, and the process for securing the cart inside the kitchen was not consistently followed, despite the expectation that the supervising nurse would lock the cart in the kitchen. Four residents with cognitive impairment, dysphagia, and/or wandering and elopement risk were identified as being affected by this unsafe practice. One resident had dementia, COPD, dysphagia, severe memory deficits, was dependent on staff for eating, and was on a regular pureed diet with thin liquids. This resident’s care plan and physician orders included a Wanderguard for wandering and elopement risk and interventions for wandering and nutrition, including a pureed diet and cues to eat slowly. Another resident had cerebral infarction, COPD, diabetes, severe memory deficits, and was on a low concentrated sweet, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering and elopement. A third resident had dementia, diabetes, dysphagia, severe memory deficits, required set-up assistance for meals, and was on a low concentrated sweet, no added salt, mechanical soft diet with thin liquids, with a Wanderguard and interventions for wandering. A fourth resident had schizophrenia, anxiety, dysphagia, moderate memory deficits, was independent with eating and mobility, and was on a regular mechanical soft diet with thin liquids, with a Wanderguard and identified risk for choking due to poor dental hygiene. The unsafe environment directly resulted in a choking episode for one resident. During an overnight shift, a nurse aide observed this resident, known to wander the halls at night looking for food and able to open unit double doors, at the food cart outside the locked kitchen door, choking after taking a piece of a peanut butter sandwich from the unattended cart. The LPN on duty performed the Heimlich maneuver, and the resident expelled the sandwich contents and returned to baseline. The nurse aide reported that the resident had previously attempted to take food from the dirty food cart on multiple occasions and had once taken a bite of a sandwich from the cart, but these incidents were not reported to licensed staff. The DON was aware the resident wandered and wore a Wanderguard but was not aware the resident was seeking food from the cart. The Director of Food Service and DON both acknowledged that the cart was not consistently locked in the kitchen, and the new RN supervisor on duty the night of the choking episode had not been trained on the meal tray collection process or the requirement to secure the cart, contributing to the failure to prevent access to the food cart and resulting in Immediate Jeopardy. Additional information from interviews further supports the pattern of unsafe practice. The Director of Food Service described the standard process of using the cart to collect trays, scrape food into the attached garbage, and return the cart to the kitchen, and stated that when dietary staff left at night, an empty cart was left outside the locked kitchen for staff to return remaining dishes, with the expectation that food would be scraped into the open garbage. He reported having previously informed Administration that the cart was not being stored inside the locked kitchen. A dietary aide on the morning shift confirmed that his first task was to empty plates from the cart left in the hallway overnight and that sometimes food remained on plates and sometimes it had been scraped into the open garbage. The Building Specific Orientation Tour for the RN supervisor did not include training on meal tray collection or food cart storage. The facility’s existing policies on providing a safe and homelike environment and on elopements and wandering residents required a safe physical layout and systematic monitoring and management of residents at risk for wandering and elopement, but there was no specific policy addressing food cart storage or food disposal, and the failure to secure the cart and to communicate and act on known wandering and food-seeking behaviors led to the identified deficiency and Immediate Jeopardy.
Failure to Follow Care Plan for Pureed Diet and Aspiration Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed a resident’s person-centered care plan and Resident Care Card (RCC) regarding a prescribed pureed diet and required monitoring for aspiration. The resident had dementia, COPD, dysphagia, severe short- and long-term memory deficits (BIMS score of 2), was dependent on staff for eating, and was identified as at risk for weight loss, wandering, and elopement. The care plan and RCC directed a regular, pureed texture diet with thin liquids, cues to eat slowly, maintaining an upright position after meals, offering snacks between meals and at bedtime as appropriate, monitoring during meals for aspiration, and removing food from the whole room due to the resident’s tendency to seek food from the roommate. Physician’s orders also specified a regular, pureed texture diet with thin liquids. Despite these directives, staff actions and inactions led to the resident accessing and consuming food inconsistent with the prescribed diet. During the night shift, the resident habitually wandered the hallway looking for food and had previously attempted to take food from the dirty food cart and had taken a bite of a sandwich from the cart, but the NA who observed these behaviors did not report them to a nurse, believing staff were already aware. The NA was not aware the resident was on a pureed diet and reported giving the resident snacks such as chocolate pudding during the night. On one occasion, the resident took a piece of a peanut butter sandwich from the food cart located outside the locked kitchen door and choked on it, requiring the LPN to perform the Heimlich maneuver to expel the sandwich. The DON later stated she was unaware of the prior incidents with the food cart and that the NA should have reported them, while facility policy directed that staff follow the plan of care and Care Card.
Failure to Ensure Staff Awareness of Prescribed Diet and Reporting of Unsafe Eating Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff were aware of a cognitively impaired resident’s prescribed pureed diet and to report and address unsafe eating behaviors. The resident had dementia, COPD, dysphagia, severe memory deficits (BIMS score of 2), was dependent on staff for eating, and had care plan interventions for a regular, pureed diet with thin liquids, cues to eat slowly, remaining upright after meals, and snacks between meals and at bedtime. The resident was also care planned and ordered for a Wanderguard due to wandering and elopement risk. Despite these orders and care plan interventions, the resident was able to access a food cart located outside the locked kitchen door and obtain a peanut butter sandwich that was inconsistent with the prescribed pureed diet. On the night of the incident, the resident wandered in the hallway and took a piece of a peanut butter sandwich from the food cart, then began choking. NA #1 observed the resident at the food cart choking and alerted LPN #1, who performed the Heimlich maneuver and the resident expelled the sandwich contents. NA #1 reported that the resident habitually wandered the hallway during the night looking for food, had previously attempted to take food from the dirty food cart, and had been seen taking a bite of a sandwich from the cart, but these prior incidents were not reported to licensed staff because NA #1 believed staff were already aware. NA #1 was not aware the resident was on a pureed diet and had been giving the resident snacks such as chocolate pudding at night. The DON stated she was unaware of the prior sandwich incident and confirmed that NA #1 had not reported the resident’s attempts to take or eat food from the food cart and that such incidents should have been reported to a licensed nurse.
Failure to Protect Resident from Verbal Mistreatment by Staff
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hemiplegia, anxiety, and major depression, who was dependent on staff for toileting and other activities of daily living, was subjected to verbal mistreatment by a nursing assistant (NA). The resident was frequently incontinent and required emotional support as part of their care plan. On the evening in question, two other nursing assistants witnessed and reported that the NA assigned to the resident spoke to them in a loud and derogatory manner, questioning why the resident needed to defecate and expressing frustration about having the resident on her assignment. The incident was reported to supervisory staff, and it was noted that the resident appeared stunned by the interaction. Facility documentation and interviews confirmed that the NA's communication style was inconsistent with facility expectations and policies regarding resident rights and abuse prevention. Although the facility's internal investigation did not substantiate abuse due to the resident's inability to recall the incident, multiple staff members corroborated the inappropriate language and tone used by the NA. The supervisor and DON were aware of previous concerns regarding the NA's communication style, but the incident was not immediately investigated in detail at the time it was reported.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
Staff failed to promptly report an allegation of verbal abuse involving a resident who was dependent for toileting, transfers, and bed mobility, and had a history of stroke, anxiety, and major depression. The incident occurred when a nursing assistant (NA) made disparaging and vulgar remarks to the resident regarding their incontinence and dietary intake. Two other staff members witnessed or overheard the incident and reported it to the charge nurse and supervisor. Despite being informed of the incident, the nursing supervisor did not initiate an incident report, notify the Director of Nursing (DON), or remove the accused staff member from duty to protect residents. The supervisor also did not gather specific details about the interaction or recognize the need for immediate escalation, even though she acknowledged that such behavior would be considered abusive. The DON was not notified of the allegation until the following day, resulting in a delay in the investigation and appropriate response. Facility policy required immediate reporting of suspected abuse to management, but this protocol was not followed, leading to a failure in timely reporting and response to the abuse allegation.
Failure to Prevent and Respond to Resident Burns from Hot Beverage Spill
Penalty
Summary
A resident with dementia, generalized muscle weakness, and polyneuropathy experienced multiple incidents resulting in injuries, including burns from a hot beverage spill. The resident was assessed as having moderately impaired cognition and was independent with eating and mobility. Despite this, the resident sustained a significant burn wound to the right inner thigh and genital area after spilling hot chocolate, as identified by occupational therapy and wound care staff. The clinical record did not initially identify the cause of the inner thigh wound, nor did it document wound treatment, monitoring, or preventative interventions after the wound was discovered. Following the burn incident, a physician's order was entered for the resident to use a sippy cup for all beverages to prevent further accidents. However, this intervention was not implemented effectively. Multiple staff members, including nursing assistants, therapy, and dietary staff, were unaware of the sippy cup order, and the intervention was not reflected on the resident's care card or adaptive equipment lists. Observations confirmed that the resident continued to receive hot beverages in open cups, and staff interviews revealed a lack of communication and process for ensuring adaptive equipment orders were followed. Additionally, the facility failed to conduct a full investigation into the injuries of unknown origin, as required by policy. There was no documentation of a completed accident and investigation report for the initial wound, and a full body skin assessment was not performed after the incident. The facility's policy required immediate assessment and investigation of unexplained injuries, but these steps were not documented or completed. The serving temperatures of hot beverages were also found to be high, with no policy provided regarding safe serving temperatures.
Failure to Timely Update Care Plan After New Wounds and Address Refusals of Care
Penalty
Summary
The facility failed to timely review and revise the care plan for a resident following the discovery of new wounds and did not address the resident's frequent refusals of care. Specifically, after a 16 cm by 7 cm skin tear was identified on the resident's right inner thigh, there was no documentation of an intervention being implemented immediately after the wound was discovered. Additionally, the resident's care plan was not updated to reflect the new wound until 10 days after the initial identification. The facility's own policy and the Director of Nursing Services (DNS) confirmed that interventions and care plan updates should have occurred within 24 hours of the incident, but this did not happen. Furthermore, documentation related to the investigation of the injury of unknown origin could not be located by the DNS. The resident, who had diagnoses including dementia, generalized muscle weakness, and polyneuropathy, also had a documented history of refusing care such as bathroom assistance, use of the call bell, personal care, and showering. Despite this, the care plan and care card did not include interventions or strategies to address these refusals, such as reapproaching the resident. Multiple nursing assistants and the DNS confirmed the resident's pattern of refusals, but the social worker responsible for updating behavior-related care plans was not aware of these refusals. The facility's policy required ongoing changes in resident status to be updated in the care plan, but this was not followed in this case.
Failure to Perform Timely Full Body Skin Assessment and Required Documentation After Injury
Penalty
Summary
The facility failed to ensure that a full body skin assessment was performed after the discovery of an injury of unknown origin for a resident with dementia, generalized muscle weakness, and polyneuropathy. After a significant skin tear was identified on the resident's right inner thigh, neither the charge nurse nor the wound nurse completed a full body skin assessment at the time of discovery. The first documented full body skin assessment occurred three days later, which did not reveal any new wounds. Interviews with nursing staff confirmed that the assessment was not performed immediately, as each nurse believed the other would complete it. Additionally, the facility did not comply with physician orders to document nursing notes every shift for 72 hours following the discovery of a wound to the resident's genitals. Review of the clinical record showed multiple shifts where required documentation was missing. The Director of Nursing Services (DNS) confirmed that notes should have been documented every shift per the physician's order, but this was not done. Facility policy required immediate assessment and documentation of unexplained injuries, as well as weekly and as-needed full body skin audits by licensed nurses. Despite these policies, the required assessments and documentation were not completed as directed after the discovery of the resident's injuries. The failure to follow these protocols was confirmed through staff interviews and review of facility documentation.
Failure to Address and Document Resident Grievances and Allegations of Abuse
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not follow its own grievance policy regarding prompt resolution and support after allegations of abuse or mistreatment. Multiple residents with varying degrees of cognitive and physical impairment reported incidents involving a nursing assistant who was described as rude, rough, and frightening. These residents expressed fear, anxiety, and reluctance to seek assistance due to the staff member's behavior. Despite these reports, there was no evidence in the grievance book or social service documentation that grievances were filed or that the required follow-up and support were provided to the residents. Interviews with staff revealed that although some staff members were made aware of the residents' complaints and concerns, they either did not document the incidents or failed to ensure that grievance forms were completed and submitted according to facility policy. Social service notes did not reflect any follow-up or support for the residents after the allegations, and the required daily meetings with residents for 72 hours following an abuse allegation were not documented. Additionally, administrative staff and the Director of Nursing were unaware of some of the reported incidents and could not locate any related grievance forms or investigations, despite being listed as participants in disciplinary records. The facility's own policy required that concerns and complaints be actively addressed, documented, and communicated to the resident or their representative. However, the review of records and interviews confirmed that these procedures were not followed for several residents who reported mistreatment. The lack of documentation and follow-up resulted in unresolved grievances and a failure to provide the necessary support to residents after allegations of abuse or mistreatment.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of allegations of abuse and mistreatment to the State Agency for four out of six residents reviewed. Multiple residents with varying degrees of cognitive impairment and physical dependency reported incidents involving a nursing assistant who was described as rude, rough, and verbally abusive. These allegations were communicated to various staff members, including occupational therapy, social work, and nursing supervisors. In several cases, residents expressed fear and distress related to the staff member's behavior, and some reported being afraid to request assistance due to concerns about being yelled at or mistreated. Despite these reports, there was a lack of documentation and follow-up regarding the allegations. Staff interviews revealed that while some immediate actions, such as suspending the accused staff member, were taken, there was confusion and inconsistency about whether the incidents met the criteria for abuse and should be reported to the State Agency. Statements and grievances were not consistently documented, and there was no evidence that the required notifications to the State Agency were made. The facility's own policy required immediate reporting of any abuse allegations, but this protocol was not followed. The review of the State Agency Reportable Events website confirmed that none of the incidents involving the four residents were reported as required. Interviews with current and former staff, including the DON and Administrator, indicated an inability to identify or locate documentation related to the incidents. The lack of timely reporting and investigation of these abuse allegations constitutes a deficiency in the facility's compliance with mandated abuse reporting requirements.
Failure to Investigate and Document Abuse Allegations
Penalty
Summary
The facility failed to appropriately investigate and document allegations of abuse or neglect for multiple residents. In one case, a resident with dementia and behavioral disturbances reported being physically assaulted by a staff member, resulting in visible bruising. Although an initial investigation was started, the facility did not obtain statements from all staff present during the incident, as acknowledged by the Director of Nursing Services (DNS) and Administrator. The investigation was therefore incomplete, and not all relevant staff were interviewed. Several other residents with varying cognitive and physical impairments reported concerns about a specific nursing assistant's (NA) behavior, including verbal abuse, rough care, and fear of retaliation. These complaints were reported to various staff members, including nursing supervisors and social workers, but were not consistently documented in nurse's notes or the grievance book. In some cases, staff members who received the complaints did not recall being notified, and there was a lack of follow-up or resolution communicated to the residents. Additionally, statements and documentation related to these allegations were either not completed or not retained, and the facility was unable to identify or locate records of certain complaints and investigations. The facility's abuse prevention policy requires prompt and thorough investigation of all abuse allegations, including interviewing all relevant staff and reporting to the appropriate authorities. However, the report shows that the facility did not follow these procedures for multiple allegations, resulting in incomplete investigations and a lack of documentation. The DNS and Administrator were unaware of some complaints and could not account for missing records or unresolved grievances, indicating systemic failures in responding to and investigating abuse allegations as required by policy.
Failure to Protect Resident from Abuse and Follow Care Plan
Penalty
Summary
A resident with dementia and severe cognitive impairment, who required supervision and two staff for care during certain shifts due to aggression and sundowning behaviors, was involved in an incident where a staff member was observed pushing the resident forcefully into a wheelchair. The resident had a history of combative behaviors and was care planned for specific interventions, including staff explanations and the presence of two staff during care. Despite these interventions, the staff member provided care alone and did not follow the care plan requirements. On the evening of the incident, another staff member witnessed the resident being pushed down into the wheelchair by the shoulders in a manner described as not gentle but a hard push. The resident repeatedly asked the staff member to leave, but the staff member remained, leading to the resident striking the staff member. The resident was later found with a bruise and skin tear on the right hand, which the resident attributed to being punched by the staff member. The incident was not immediately reported to supervisory staff, and initial reports to the nurse on duty were not acted upon or escalated as required by facility policy. The facility's documentation and interviews revealed that the required reporting and investigation procedures were not followed promptly. The nurse on duty did not report the incident to the appropriate supervisor, and the staff member involved continued to work with the resident despite the care plan indicating two staff were needed. The facility's abuse prevention policy required immediate reporting and protection of residents during investigations, but these procedures were not adhered to, resulting in a failure to ensure the resident was free from abuse.
Failure to Provide Two Staff for Care as Required by Resident Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to ensure that two staff members were present to provide care to a resident with dementia and behavioral disturbances during the 3:00 PM to 11:00 PM shift, as required by the resident's care plan. The resident, who had severely impaired cognition and a history of aggression and sundowning behaviors, was care planned to have two staff for all care during this shift. On the evening in question, only one nursing assistant provided care, contrary to the care plan and the resident's care card instructions. The nursing assistant was not aware of the recent update to the care plan and reported that the change had not been communicated to him, although he acknowledged that he should have followed the care card. The incident was reported after the resident alleged that a male staff member entered the room, was rough, and hit the resident multiple times, resulting in a bruise and a small scab on the resident's hand. Facility investigation found that the resident, who was known to be combative, had struck the nursing assistant, but there was no evidence to substantiate abuse by the staff member. Interviews with staff and facility leadership confirmed that the care plan requiring two staff was not followed, and the nursing assistant should have requested assistance when the resident became agitated. The facility was unable to provide a policy on Resident Care Cards when requested.
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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