Noble Horizons
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, Connecticut.
- Location
- 17 Cobble Rd, Salisbury, Connecticut 06068
- CMS Provider Number
- 075236
- Inspections on file
- 23
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 26 (1 serious)
Citation history
Health deficiencies cited at Noble Horizons during CMS and state inspections, most recent first.
Nurses were found to lack up-to-date competencies in IV therapy, with the last review conducted several months ago. The Staff Educator, who is responsible for annual IV competency assessments, was unaware of the outdated status until mid-year and had not received the necessary training. The DON acknowledged the issue.
The facility failed to discard expired food in the kitchen, including cans of beets, corn, and boxes of chickpea rotini. The Director of Dining Services, responsible for monthly checks, could not explain the oversight, despite facility policy requiring proper dating and rotation of food.
The facility failed to ensure that therapeutic and resident pets were up to date with vaccinations and veterinary visits as per facility policy. One of the facility cats had outdated vaccinations and wellness exams, and a resident's pet cat lacked evidence of a distemper vaccine. The facility's policies on pets and support animals were inconsistent with actual practices, leading to deficiencies in pet care and documentation.
The facility failed to ensure a dignified dining experience for eight residents by serving meals on dietary trays instead of placing food and drink items on the dining table. A nurse aide cited mess containment as the reason, while the ADNS confirmed this practice was against facility policy.
A facility failed to ensure an updated code status form was signed by both a resident and physician, reflecting a change from full code to DNR. The resident's consent was not documented, violating the facility's policy and the resident's rights.
A resident with type II diabetes mellitus and heart failure refused the prescribed dose of insulin, opting for a lower dose without notifying the physician. The incident was not reported to the evening/night shift supervisor or the physician, leading to delayed medical intervention and fluctuating blood sugar levels.
The facility failed to assess and obtain consent for the use of full siderails for a resident, which were considered a physical restraint. The resident, who had cognitive impairments and was readmitted after hip surgery, had siderails in place at night per family request. The facility did not conduct an assessment to determine if the siderails were a restraint and did not obtain the necessary consent for their use.
The facility failed to complete timely comprehensive assessments for two residents who experienced significant changes in condition, including the development of pressure ulcers and substantial weight loss. The MDS Coordinator did not perform the required significant change MDS assessments, leading to a deficiency in care.
The facility failed to complete quarterly MDS assessments for four residents in a timely manner. The MDS Coordinator, an LPN, cited being the sole staff member in the MDS office as the reason for the delays, which ranged from 28 to 57 days past due.
The facility failed to submit MDS assessments timely for four residents. An LPN responsible for the assessments was unable to meet the required timeframes due to being the only staff member in the MDS office.
The facility failed to ensure a comprehensive and individualized care plan for a resident with type II diabetes and heart failure. Despite the care plan indicating the use of alarms for fall risk, observations and staff interviews confirmed that no alarms were ever in place.
The facility failed to revise care plans for two residents after multiple falls and for another resident who frequently refused a daily treatment. Despite several incidents and refusals, the care plans were not updated with new interventions to prevent further falls or address treatment refusals. Interviews with staff confirmed that the care plans should have been updated but were not.
A resident with a history of falls experienced multiple unwitnessed falls, and the facility failed to complete the required neurological checks as per policy. The DNS confirmed that staff did not document any refusals for the missed checks, indicating a lapse in adherence to the neuro-check policy.
The facility failed to document the turning and repositioning of a resident at risk for pressure ulcers, leading to the development and progression of multiple pressure ulcers. The resident's care plan included interventions for pressure ulcer prevention, but the clinical record lacked documentation of these actions. Interviews confirmed the absence of documentation and identified issues with the facility's software.
The facility failed to ensure safety checks for a resident's alarm and did not complete fall assessments after multiple falls for another resident, contrary to their policies. This led to unaddressed safety risks and potential harm.
The facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. The resident, diagnosed with anxiety disorder and depression, was prescribed Trazadone 50 mg every 8 hours PRN for agitation without a discontinuation date. A pharmacy consult recommended a 'stop' date, but there was no documented provider response until after surveyor inquiry, contrary to facility policy.
A resident's medications were administered 30 minutes late, exceeding the facility's allowed time frame. The LPN responsible cited the difficulty of safely administering medications to 30 residents within the given time.
A resident with type II diabetes mellitus refused the prescribed dose of insulin and was administered a reduced dose by an LPN without notifying the supervisor or physician, leading to a significant medication error. Subsequent elevated blood sugar readings were recorded, and the facility's policy on reporting medication errors was not followed.
The facility failed to ensure clinical records were complete and accurate for a resident with dementia, anxiety, and depressive episodes. A pharmacy review recommendation was missing, and there was no evidence it had been addressed by the physician, contrary to the facility's policy.
The facility failed to ensure the Medical Director attended QAPI meetings quarterly. Despite being listed as a required member, there was no evidence of the Medical Director's attendance at any QAPI meetings from January 2023 through March 2024. The DNS acknowledged the requirement but noted the Medical Director might not have been able to attend. Attempts to contact the Medical Director were unsuccessful.
The facility failed to ensure infection control policies and procedures were reviewed annually. A review of the Infection Control Program revealed no documented evidence of an annual review, and the DON confirmed that such a review was never required. The facility was also unable to provide a policy for the review of policies and procedures when requested.
The facility failed to ensure the daily census was written on the 24-hour nurse staffing sheet posted in the lobby. Observations noted the missing census, and interviews revealed confusion between the receptionist and the scheduler regarding responsibility for filling in the census. The DNS and the scheduler were working on revising the procedure.
Outdated IV Competencies Identified Among Nursing Staff
Penalty
Summary
The facility failed to ensure nurses were competent in intravenous (IV) therapy, as evidenced by outdated IV competencies last reviewed on 12/23/22. The Staff Educator, responsible for annual IV competency assessments, only became aware of the outdated competencies after July 2023 and had not received the necessary training herself. The Director of Nursing Services acknowledged the need for addressing the issue.
Expired Food Not Discarded
Penalty
Summary
The facility failed to ensure that expired food was discarded, as identified during a tour of the kitchen. In the dry storage room and the overflow dry storage room, 12 cans of beets, several cans of corn, and 3 boxes of chickpea rotini were found to be expired. The Director of Dining Services, who is responsible for checking food storage monthly for expiration dates, could not explain why the expired foods were not discarded. The facility's Dietary Services policy mandates that all food must be dated when opened and stored, with the most recent dates utilized first to prevent expiration.
Deficiency in Pet Care and Documentation
Penalty
Summary
The facility failed to ensure that the facility assessment included therapeutic facility pets and individualized resident pets to meet the needs of the residents. Specifically, the facility did not ensure that therapy pets were up to date with vaccinations and veterinary visits as per facility policy. During an interview and document review with the Director of Recreation, it was found that one of the two facility cats had outdated vaccinations and wellness exams. Cat #2 was overdue for its rabies vaccine and had not had a wellness exam since 2019. Additionally, there was no evidence of a distemper vaccine for Cat #2. The Director of Recreation indicated that an appointment had been scheduled for Cat #2 with the veterinarian on the day of the interview. Furthermore, Resident #58 had a pet cat (Cat #3) whose veterinary care was managed by the resident's family. Upon request, documentation for Cat #3 was provided, showing up-to-date rabies vaccination and wellness exam but no evidence of a distemper vaccine. The facility's policies on pets and support animals were reviewed and found to be inconsistent with the actual practices observed during the survey. The facility's Pet Policy and Agreement required that pet cats have current veterinary health records, including distemper and rabies shots. However, the facility's Service and Support Animal Policy indicated that support animals are not subject to the Pet Policy and Agreement but must have an annual clean bill of health and be immunized against common diseases. The Recreation policy indicated that the Recreation Director was responsible for the wellbeing, shots, and licenses of resident cats. The facility assessment did not mention services and care offered based on resident needs concerning support animals, despite providing care for residents with psychiatric/mood disorders. This lack of documentation and adherence to policies led to the identified deficiencies in the care and management of therapeutic and resident pets.
Failure to Ensure Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for eight residents during the noon meal service. Observations on 3/13/24 at 12:15 PM revealed that these residents were served their meals on dietary trays, with food and drink items remaining on the trays rather than being placed on the dining table. An interview with a nurse aide indicated that the trays were used to contain messes caused by residents spilling their food and drinks. However, the Assistant Director of Nursing Services (ADNS) confirmed that the facility's policy required food and drink items to be removed from the trays and set in front of the residents. The ADNS was unsure why the policy was not followed and planned to investigate the issue. The Dietary Services Policy dated 7/28/21 emphasized the importance of resident rights, choice, and quality of life in meal service.
Failure to Update Code Status Form with Required Signatures
Penalty
Summary
The facility failed to ensure that an updated code status form was signed by both the resident and the physician to reflect the resident's wishes and the physician's orders. Resident #57, who was admitted with diagnoses including venous insufficiency, urinary tract infection, and anxiety, had a signed Advanced Directive form indicating full code status. However, a subsequent physician's order directed Do Not Resuscitate (DNR) without evidence of the resident's consent to this change. The clinical record did not provide documentation that the resident agreed to the DNR status, which is a violation of the resident's rights to participate in their care decisions. During an interview, both a Registered Nurse and a Licensed Practical Nurse confirmed that the updated code status form was not signed by the resident or the physician to reflect the change from full code to DNR. The facility's policy requires that such decisions be consensually reached between the resident and the attending physician, and the nurse managers are responsible for ensuring the accuracy of these forms. The deficiency was identified when the surveyor inquired about the documentation, leading to the discovery that the required signatures were missing.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to ensure the physician was notified of a medication refusal by Resident #52, who has diagnoses including type II diabetes mellitus and heart failure. The resident, who is cognitively intact and requires supervision for certain activities, refused the prescribed 6 units of Humalog insulin and insisted on receiving only 4 units. Despite patient teaching and encouragement to take the full dose, the resident's request was honored without notifying the physician or the evening/night shift supervisor. The incident was only reported to the day shift nurse manager the following morning, and no immediate action was taken to inform the physician or adjust the care plan accordingly. Interviews with the involved staff, including the LPN, RN, and APRN, revealed that the proper protocol for medication refusal was not followed. The Director of Nursing was unaware of the incident until the survey, and the facility's policy clearly states that changes in a resident's condition or medication should be reported timely to the physician or nurse practitioner. The failure to notify the physician of the medication refusal led to a delay in appropriate medical intervention, as evidenced by the resident's fluctuating blood sugar levels and the eventual administration of a higher insulin dose without prior notification to the on-call provider.
Failure to Assess and Obtain Consent for Use of Siderails as Restraints
Penalty
Summary
The facility failed to properly assess and obtain consent for the use of full siderails for a resident, which were considered a physical restraint. Resident #40, who was readmitted after hip surgery and had cognitive impairments, was found to have full siderails in place at night per family request. However, the facility did not conduct an assessment to determine if the siderails were a restraint and did not obtain the necessary consent for their use. The care plan indicated the use of siderails but did not classify them as a restraint, and there was no evidence of ongoing monitoring or evaluation of the siderails' use. Interviews with staff revealed that the resident was unable to remove or adjust the siderails independently, confirming their status as a restraint. The facility's policy required a specific consent form for the use of restraints, but this form was not provided. Additionally, the facility's Side Rail Policy was requested but not supplied. The lack of proper assessment, consent, and documentation led to the deficiency identified by the surveyors.
Failure to Complete Timely Comprehensive Assessments
Penalty
Summary
The facility failed to ensure a comprehensive resident assessment was completed timely after a significant change in condition was identified for two residents. Resident #47, who had a diagnosis including a fracture of the right femur and pressure ulcers, was found to have developed multiple new pressure ulcers and experienced a decline in the condition of an existing ulcer. Despite these significant changes, the MDS Coordinator did not complete a significant change MDS assessment as required by the Resident Assessment Instrument guidelines. The resident's condition, including the development of three pressure ulcers and likely weight loss, was not adequately monitored or reassessed in a timely manner. Similarly, Resident #38, who had diagnoses including dysphagia, dementia, and nutritional deficiency, experienced a significant weight loss over a short period. Despite a care plan that included monitoring weights and dietary interventions, the resident's weight continued to decline significantly. The MDS Coordinator acknowledged that a significant change MDS assessment should have been completed due to the resident's substantial weight loss, but it was not done. The facility's failure to complete these assessments in a timely manner represents a deficiency in their care processes.
Failure to Complete Quarterly Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly assessments for four residents were completed in a timely manner. Resident #12's quarterly MDS assessment was 33 days late, Resident #32's was 57 days late, Resident #53's was 28 days late, and Resident #56's was 33 days late. The MDS Coordinator, an LPN, acknowledged the delays and attributed them to being the only staff member in the MDS office, which hindered their ability to keep up with the workload. The facility's policy requires quarterly assessments to be completed every 92 days from admission to allow for necessary revisions to the care plan.
Failure to Submit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure timely submission of Minimum Data Set (MDS) assessments for four residents. Resident #12's quarterly MDS with an Assessment Reference Date (ARD) of 2/1/24 was due on 2/15/24 and required submission by 2/29/24, but it was not submitted as of 3/19/24, making it 19 days late. Similarly, Resident #32's quarterly MDS with an ARD of 1/8/24 was due on 1/22/24 and required submission by 2/5/24, but it was not submitted as of 3/19/24, making it 43 days late. Resident #53's quarterly MDS with an ARD of 2/6/24 was due on 2/20/24 and required submission by 3/5/24, but it was not submitted as of 3/19/24, making it 14 days late. Lastly, Resident #56's annual MDS with an ARD of 2/1/24 was due on 2/15/24 and required submission by 2/29/24, but it was not submitted as of 3/19/24, making it 19 days late. An interview with the LPN responsible for completing and submitting the MDS assessments revealed that she was the only one in the MDS office and was unable to keep up with the required timeframes. The LPN acknowledged the delays and attributed them to her being the sole person handling the MDS assessments. The Resident Assessment Instrument 3.0 user manual from October 2023 specifies that quarterly assessments must be completed within 14 days of the ARD and submitted within 14 days after completion, which was not adhered to in these cases.
Failure to Ensure Comprehensive and Individualized Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for Resident #52 was comprehensive and individualized. Resident #52, who has diagnoses including type II diabetes mellitus and heart failure, was identified as cognitively intact and requiring partial assistance with transfers and ambulation. The care plan dated 8/25/23 indicated that the resident was at risk for falls and included interventions such as the use of alarms to notify staff of the resident's needs. However, observations on 3/18/24 revealed that no safety devices were in use in the resident's room, and interviews with staff confirmed that the resident never had any alarms in place. LPN #7 acknowledged that nursing staff were responsible for initial care planning and that she should have removed the incorrect information regarding the use of alarms during her review. RN #1 admitted to placing interventions regarding alarms in the care plan as a precaution, even though the resident never had any motion detection alarms and would require an order and consent for their use. The Director of Nursing confirmed that the care plan should accurately reflect the individualized needs of the resident. The facility's policy mandates that the Resident Care Plan should ensure high-quality, individualized care and be developed within 21 days of admission.
Failure to Revise Care Plans After Falls and Treatment Refusals
Penalty
Summary
The facility failed to revise the care plan for Resident #11 after multiple falls. Despite several incidents where the resident was found on the floor, the care plan was not updated with new interventions to prevent further falls. The resident's care plan was last reviewed on 6/28/23, and subsequent falls on 8/13/23, 9/24/23, 9/26/23, 10/1/23, 10/16/23, 11/1/23, 12/8/23, 1/12/24, 1/18/24, 2/1/24, 2/26/24, 3/5/24, and 3/13/24 did not result in any new interventions being added to the care plan. Interviews with the DNS and MDS Coordinator revealed that the care plan should have been updated with each fall and personalized to the resident's needs, but this was not done. Resident #38 also experienced multiple falls without appropriate updates to the care plan. Despite being identified as at risk for falls due to moderate dementia, behaviors, and poor safety awareness, the care plan was not revised after falls on 2/11/24, 2/13/24, and 2/21/24. Although some revisions were made on 2/27/24, 3/6/24, and 3/8/24, these did not directly address the falls. The DNS indicated that the care plan is only updated if there is a change to be made, and interventions are not always added to the care plan. Resident #57 frequently refused a daily treatment of ACE wraps for bilateral lower extremities edema, but the care plan was not revised to reflect this. Observations on 3/13/24 and 3/18/24 showed the resident out of bed without the ACE wraps, and the MAR indicated refusals on 33 occasions. Interviews with LPN #2 and the DNS confirmed that the staff was aware of the refusals, but the care plan was not updated to include interventions to address this issue. The facility policy directed that the care plan should be reviewed and revised as needed, but this was not followed in the case of Resident #57.
Failure to Complete Neurological Checks Post-Fall
Penalty
Summary
The facility failed to ensure that neurological checks were completed to professional standards after Resident #11 experienced multiple unwitnessed falls. Resident #11, who was admitted with diagnoses including heart failure, generalized muscle weakness, and repeated falls, had a care plan identifying them as at risk for falls. Despite this, the facility did not consistently complete the required neurological checks following the resident's falls. Specifically, on five separate occasions, the neurological checks were either partially completed or not done at all, and there was no documentation of the resident refusing these checks as per facility policy. The DNS confirmed that staff should have attempted the checks and documented any refusals, but this was not done in the cases reviewed. The incidents occurred on 8/13/23, 9/24/23, 9/26/23, 1/18/24, and 2/26/24, with the resident found on the floor each time. The facility's policy required neurological assessments to be documented on a 24-hour flowsheet, with specific intervals for checks. However, the flowsheets for these dates showed missing entries, and in one instance, the flowsheet was not completed at all. The DNS could not provide an explanation for these lapses, indicating a failure to adhere to the facility's neuro-check policy designed to monitor residents following a head injury or suspected head injury.
Failure to Document Turning and Repositioning
Penalty
Summary
The facility failed to consistently document the turning and repositioning of Resident #47, who was at risk for pressure ulcers. The resident's diagnoses included a fracture of the right femur, pressure ulcer of the sacrum, and deep tissue damage of the left hip and right heel. The care plan dated 3/8/2024 indicated that the resident was at risk for pressure ulcers due to poor nutrition, immobility, and incontinence, and included interventions such as stage-appropriate wound care, pain management, and pressure reduction measures. However, a review of the clinical record from 2/27/24 through 3/7/24 showed no documentation of turning and repositioning per facility practice. Interviews with the DNS and MDS Coordinator confirmed the lack of documentation and identified that the facility software did not include a section for Nurse Aides to document these actions. The resident's condition deteriorated over time, with the development of new pressure ulcers and the progression of existing ones. On 3/1/2024, the resident was found to have a right heel deep tissue injury, and by 3/8/2024, new deep tissue injuries on the left hip and a stage 1 pressure ulcer on the coccyx were noted. By 3/15/2024, the coccyx wound had progressed to a stage 2 pressure ulcer. The MDS Coordinator indicated that the resident likely experienced weight loss, contributing to the development of the pressure ulcers. The facility's failure to document turning and repositioning as per their practice contributed to the resident's declining condition and the development of multiple pressure ulcers.
Failure to Conduct Safety Checks and Fall Assessments
Penalty
Summary
The facility failed to ensure that staff conducted safety checks as directed by the manufacturer to ensure the alarm was functional for Resident #10. The resident, who had diagnoses including dementia, abnormalities of gait, and rheumatoid arthritis, was found lying on the floor with a complaint of right hip pain. The Tab alarm, which was supposed to be used for safety, did not sound at the time of the fall. Interviews with staff revealed that safety checks were not logged, and there was uncertainty about whether the checks were completed the night of the fall. The facility's policy required safety checks every shift, but documentation of these checks was inconsistent or missing. For Resident #11, the facility failed to ensure fall assessments were completed after each fall as per facility policy. The resident, who had a history of multiple falls and was identified as at risk for falls, experienced several unwitnessed falls. Despite the facility's policy requiring a new fall risk assessment after each fall, reviews of clinical records and facility documentation showed that these assessments were not completed. Interviews with the DNS revealed a misunderstanding of the policy, with the DNS indicating that fall risk assessments were not necessary after every fall, contrary to the written policy. The facility's current Fall Prevention Policy, revised in 2019, indicated that a fall risk assessment should be completed quarterly, annually, and whenever a resident experiences a fall. However, this policy was not followed, leading to multiple instances where Resident #11 did not receive the required assessments after falls. This failure to adhere to the policy potentially compromised the resident's safety and well-being.
Failure to Respond to Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to respond to pharmacy recommendations for a resident receiving psychotropic medications. Resident #38, who had diagnoses including anxiety disorder and depression, was identified as moderately cognitively impaired and dependent with ADL assistance. The resident's care plan included the use of psychotropic drugs and directed attempts for gradual dose reductions and psychiatric consults. A physician's order prescribed Trazadone 50 mg every 8 hours PRN for agitation without a discontinuation date. A pharmacy consult recommended including a 'stop' date for the PRN use of Trazadone, but there was no documented provider response until after surveyor inquiry. The facility policy required monthly pharmacy consults to be reviewed by the practitioner, but this was not adhered to in this case.
Medication Administration Timeliness Deficiency
Penalty
Summary
The facility failed to ensure medications were administered timely and that medication errors did not exceed 5% for one of the residents reviewed. Resident #57, who had diagnoses including localized swelling and edema, vitamin deficiency, and left knee effusion, had specific physician orders for the administration of Vitamin C, Vitamin D3, and Hydrochlorothiazide at 8:00 AM daily. However, during an observation on 3/19/2024 at 9:30 AM, it was noted that these medications were administered 30 minutes late by an LPN. The facility policy allows for medications to be administered within one hour before or after the scheduled time, which was not adhered to in this instance. An interview with the Director of Nursing Services (DNS) and a review of the medication administration history confirmed the late administration. The DNS acknowledged that the medications were administered outside the allotted time frame and indicated that an interview with the LPN would be necessary to determine the reason. The LPN explained that the delay was due to the challenge of safely administering medications to 30 residents within the given time. The DNS mentioned the possibility of adjusting medication administration times to make them more manageable for the nursing staff.
Failure to Administer Prescribed Insulin Dose
Penalty
Summary
The facility failed to ensure that Resident #52 was free from significant medication errors following the administration of an unprescribed reduced dose of insulin. Resident #52, who had diagnoses including type II diabetes mellitus and heart failure, was cognitively intact and had specific physician orders for Humalog insulin to be administered based on a sliding scale. On 3/11/24, the resident's blood sugar was 300 mg/dl, requiring 6 units of insulin. However, the resident refused the prescribed dose and requested only 4 units, which was administered by LPN #4 without notifying the supervisor or the physician. This deviation from the prescribed dosage was not reported to the evening/night shift supervisor or the physician, contrary to the facility's policy on medication errors. The incident was only reported to the day shift nurse manager the following morning, who also did not notify the physician immediately. The Director of Nursing Services and the Advanced Practice Registered Nurse (APRN) were unaware of the medication error until later interviews. Subsequent blood sugar readings for Resident #52 showed elevated levels, including a reading of 432 mg/dl early the next morning, which required 12 units of insulin per APRN orders. The facility's policy mandates that all medication errors, including wrong doses, be reported to the supervisor, Director of Nursing, and the attending physician. However, this protocol was not followed, leading to a significant medication error. Interviews with the involved staff confirmed the failure to adhere to the policy and the lack of timely communication with the medical provider regarding the resident's refusal and the administration of a reduced insulin dose.
Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
The facility failed to ensure clinical records were complete and accurate for a resident diagnosed with dementia with psychotic disturbance, anxiety, and depressive episodes. The quarterly Minimum Data Set (MDS) indicated the resident was cognitively impaired and received antipsychotic and antidepressant medications. The care plan included interventions such as monitoring mood and response to medications, consulting with the psychiatric APRN, conducting an Abnormal Involuntary Movement Scale (AIMS) assessment every six months, and assessing and recording the effectiveness and side effects of the medication. However, during an interview and record review with the Director of Nursing Services (DNS), it was revealed that a monthly pharmacy review recommendation made on 12/4/2024 could not be found, nor was there evidence that the recommendation had been addressed by the physician. The facility's policy on Medication Regimen, dated 1/2024, required that within 24 hours of the medication regimen review, the consultant pharmacist provides a written report to the physicians for each resident reviewed, including the resident's name, the name of the medication, the identified irregularity, and the pharmacist's recommendation. The policy further indicated that copies of medication regimen review reports, including the physicians' responses, are to be maintained as part of the permanent medical record. The failure to adhere to this policy resulted in incomplete and inaccurate clinical records for the resident in question.
Medical Director's Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director attended Quality Assurance Performance Improvement (QAPI) meetings quarterly. A review of facility documentation and interviews revealed that although the Medical Director was listed as a required member of the QAPI committee, there was no evidence of their attendance at any QAPI meetings from January 2023 through March 2024. The Director of Nursing Services (DNS) acknowledged that the Medical Director was aware of the requirement but may not have been able to attend the meetings. The Medical Director was reportedly updated during medical staff meetings, but no evidence of these meetings was provided. Attempts to contact the Medical Director for further clarification were unsuccessful.
Failure to Review Infection Control Policies Annually
Penalty
Summary
The facility failed to ensure infection control policies and procedures were reviewed annually. During the survey, a review of the facility's Infection Control Program and policies revealed no documented evidence of an annual review. An interview with the Director of Nursing Services confirmed that the facility had never required a documented review of current policies and procedures. Additionally, the facility was unable to provide a policy for the review of policies and procedures when requested.
Failure to Post Daily Census on Nurse Staffing Sheet
Penalty
Summary
The facility failed to ensure the daily census was written on the 24-hour nurse staffing sheet posted in the lobby for the view of the residents and the public. Observations on two separate occasions noted that the resident census was missing from the designated space on the form. Interviews with the receptionist and the scheduler revealed confusion and miscommunication regarding the responsibility for filling in the census. The receptionist believed it was the scheduler's responsibility, while the scheduler initially indicated it was the receptionist's duty before acknowledging it was their own responsibility. The Director of Nursing Services (DNS) and the scheduler were working on revising the procedure for completion and posting of the 24-hour nurse staffing sheet.
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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