Saint John Paul Ii Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Danbury, Connecticut.
- Location
- 33 Lincoln Avenue, Danbury, Connecticut 06810
- CMS Provider Number
- 075354
- Inspections on file
- 28
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Saint John Paul Ii Center during CMS and state inspections, most recent first.
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 The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for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 severe cognitive impairment and high fall risk was found on the floor by a nurse aide, who moved the resident back to bed without notifying the charge nurse or RN supervisor and without an RN assessment. The resident later reported pain and was diagnosed with a displaced humerus fracture. Facility policy required immediate reporting and RN assessment after a fall, which was not followed.
A resident with severe cognitive impairment and dependent transfer status was found on the floor and was manually lifted back into bed by a nurse aide, contrary to the care plan requiring two staff and a mechanical lift. The aide did not check the transfer status or report the fall, and the resident was later diagnosed with a displaced humerus fracture.
A resident who required two-person assistance for mechanical lift transfers was moved by a single nurse aide, contrary to facility policy. During the transfer, the sling shifted and struck the resident's nose, causing a minor nosebleed. The aide did not request help from another aide present in the room, despite being trained on the two-person transfer requirement. The resident's care plan and facility policy both specified the need for two staff during such transfers.
A resident with multiple medical conditions was subjected to inappropriate physical contact when a nurse aide, following a verbal altercation with an LPN, grabbed the resident's wrist in the hallway after the resident intervened. The incident was witnessed by staff and reported, and the facility's zero-tolerance abuse policy was not followed.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
The facility did not ensure that a licensed pharmacist consistently performed required monthly drug regimen reviews for several residents with complex medical conditions, resulting in missing documentation for multiple months. Interviews indicated that changes in pharmacy providers and facility ownership contributed to the lack of pharmacy consultant services and incomplete medication reviews, contrary to facility policy.
Surveyors identified that medication refrigerators were found unlocked, expired medications were not discarded, and refrigerator temperature logs were incomplete in two medication rooms. Staff interviews confirmed lapses in daily checks and documentation, as well as a broken lock on a refrigerator used for medication storage, contrary to facility policy.
Staff failed to serve meals at appropriate temperatures, with food items significantly cooling between leaving the kitchen and being served to a resident. Despite food leaving the kitchen at high temperatures, by the time the last resident was served, items were well below the acceptable minimum for hot foods, contrary to facility policy and staff expectations.
A resident with a history of mental health disorders received a new diagnosis of schizoaffective disorder, but the facility did not refer this new diagnosis to the state mental health authority for a required Level II evaluation. The social worker was unaware that a new referral was needed for a long-term care resident with a previous Level II, resulting in the omission.
A resident with neuromuscular disease and limited mobility, requiring assistance with ADLs, did not consistently receive scheduled showers as documented in their care plan. Staff interviews and medical record review confirmed missed showers, with staff citing insufficient availability and lack of follow-up on the resident's complaints. Facility policy required real-time documentation of ADL care, but records did not reflect that showers were provided as scheduled.
Two residents experienced deficiencies: one did not have a written physician order entered for a diagnostic x-ray after a fall, leading to confusion about the intended imaging, and another had a cervical collar that was repeatedly positioned incorrectly by staff who were not fully trained on proper application, despite a physician's order and facility policy requiring correct placement.
A resident with severe cognitive impairment and a stage 3 pressure ulcer was found using a specialty air mattress without a physician's order or documented instructions for mattress settings, contrary to facility policy. Licensed staff could not locate the required order or evidence of regular monitoring, resulting in a deficiency related to pressure ulcer care.
A resident with obesity, dysphagia, and aphasia experienced significant unplanned weight loss, but staff failed to obtain timely reweights and did not document or notify the physician as required by facility policy. The resident's weight was not checked within the required timeframe after hospital readmission, and the responsible RN was unaware of the missed weights and did not update the care plan or notify the physician.
Licensed staff, including an LPN hired in 2023, did not have required clinical competency validations completed for 2024. Review of employee files and facility documentation showed these validations were missing for all licensed staff, and the DON confirmed that none had been completed due to the departure of the responsible staff member. The facility could not provide a policy for clinical competency validations.
Two residents with severe cognitive impairment and court-appointed conservators did not have proper consent or refusal obtained from their responsible parties for influenza vaccination for the current season. Although the facility attempted to contact conservators and power of attorneys, the process was incomplete, and immunization records did not indicate whether the vaccine was offered or administered.
A resident with diabetes was discharged without receiving necessary education on insulin administration, diabetes management, or use of a glucometer, and was also sent home without prescribed medications and supplies due to a lack of medication reconciliation and communication among staff.
A resident with multiple diagnoses, including seizure disorder and anxiety, repeatedly refused prescribed morning doses of Primidone and Hydroxyzine over a month. Despite facility policy requiring physician notification for medication refusals, nursing staff did not inform the physician or document the refusals beyond the MAR. The unit manager, APRN, and DON were unaware of the refusals, resulting in a deficiency due to lack of required communication.
A resident with multiple diagnoses, including seizures and anxiety, repeatedly refused prescribed medications, but the facility did not develop or implement a comprehensive care plan to address these refusals. Despite documentation of frequent medication refusals and facility policy requiring individualized care planning for such situations, staff interviews confirmed that no specific interventions or care plan were in place.
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 Notify RN and Assess Resident After Fall
Penalty
Summary
A resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility, who required maximum assistance for bed mobility and was dependent for transfers, experienced an unwitnessed fall during the night. The resident, who had severely impaired cognition, was found on the floor by a nurse aide who, without notifying the charge nurse or RN supervisor, picked the resident up and placed them back in bed. The resident later complained of pain and was found to have a displaced fracture of the left humerus. The nurse aide admitted to not reporting the fall to nursing staff and to moving the resident without an RN assessment, despite knowing facility policy required notification and assessment before moving a resident after a fall. The RN supervisor on duty was unaware of the fall until informed later by management, and confirmed that the nurse aide should have reported the incident so an RN assessment could be completed. Facility documentation and interviews confirmed that the resident required two staff and a mechanical lift for transfers, and that the nurse aide acted alone and failed to follow protocol. The facility's falls management policy defined a fall as any instance of a patient found on the floor and required immediate reporting and assessment, which was not followed in this case.
Failure to Follow Care Plan for Dependent Transfer After Fall
Penalty
Summary
A deficiency occurred when a resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility was not transferred in accordance with their care plan. The resident, who had severely impaired cognition and was dependent for transfers, was found on the floor by a nurse aide during the night. The care plan required two staff and a mechanical lift for all transfers due to the resident's high fall risk and physical limitations. However, the nurse aide, without checking the resident's transfer status, lifted the resident alone and placed them back in bed without using the required mechanical lift or seeking assistance. The nurse aide did not report the fall to the charge nurse as required. The resident subsequently complained of pain and was found to have a displaced fracture of the left humerus, confirmed by hospital evaluation. Interviews with facility staff, including the Director of Rehabilitation and the Director of Nursing, confirmed that the resident's care plan specified the use of a mechanical lift with two staff for all transfers, and that the nurse aide's actions were not in accordance with facility policy or the resident's care plan.
Failure to Follow Two-Person Mechanical Lift Transfer Policy Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to morbid obesity, osteoarthritis, gait abnormalities, and generalized muscle weakness, was transferred using a mechanical lift by only one nurse aide, contrary to the facility's policy requiring two staff members for such transfers. The resident's care plan and care card both specified the need for two-person assistance during mechanical lift transfers. On the day of the incident, the assigned nurse aide performed the transfer alone because other aides were occupied, and did not request assistance from another aide who was present in the room but separated by a curtain. During the solo transfer, the sling of the mechanical lift shifted and the resident's nose was struck by the end of the sling straps, resulting in a minor nosebleed. The resident was alert and oriented, reported the incident, and denied hitting any metal part of the lift, attributing the injury to the sling straps. A subsequent assessment found no other injuries, and x-rays were normal. The resident later expressed reluctance to get out of bed, which was noted as potentially related to the incident. Interviews with staff confirmed that the nurse aide was aware of the policy requiring two staff for mechanical lift transfers and had received training on this procedure. The facility's policy explicitly stated that two trained staff are required for all mechanical lift transfers, regardless of manufacturer instructions. The nurse aide admitted to not following this policy and did not seek help from the other aide present in the room.
Failure to Protect Resident from Inappropriate Physical Contact by Staff
Penalty
Summary
A deficiency occurred when a resident, who had multiple medical diagnoses including surgical aftercare, dysthymic disorder, and hypertensive heart disease, was subjected to inappropriate physical contact by a nurse aide. The resident, who was alert and oriented, reported that the nurse aide grabbed their wrist too hard during an altercation that began with a verbal argument between the nurse aide and an LPN in the hallway. The resident intervened by asking the nurse aide to calm down, at which point the nurse aide approached and grabbed the resident's wrist. The resident immediately objected to being touched and pulled away, stating, 'don't touch me.' Multiple staff statements corroborated that the nurse aide engaged in a loud verbal altercation and then physically grabbed the resident's wrist in the hallway. The incident was witnessed by other staff and reported to the nursing supervisor. The facility's policy mandates zero tolerance for abuse and requires staff to prevent any form of abuse or neglect. The nurse aide's actions were in direct violation of this policy, as the physical contact was not warranted and occurred in the context of a heated exchange.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the residents or staff involved, were not provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Consistently Complete Monthly Pharmacy Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist consistently performed monthly drug regimen reviews, including review of the medical chart, for several residents as required by policy. For four of five residents reviewed for unnecessary medication use, documentation showed that monthly pharmacy reviews were missing for specific months. In some cases, such as with residents diagnosed with end stage renal failure, anxiety, major depression, dementia, schizophrenia, diabetes, and other serious conditions, the required monthly reviews were not completed or could not be located in the clinical records. Care plans for these residents indicated they were at risk for complications related to psychotropic and other high-risk medications, and interventions included monitoring for side effects and consulting with a pharmacist as needed. Interviews with the Director of Nursing Services (DNS) revealed that a change in pharmacy providers and a change in facility ownership led to lapses in pharmacy consultant services, resulting in missed monthly medication regimen reviews. The DNS was unable to provide documentation for the missing months and could not explain the absence of pharmacy consultations for other periods. Facility policy required monthly review and documentation of medication administration records, but these were not consistently completed or available for review for the affected residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication storage and labeling in two medication rooms. In one instance, a medication refrigerator containing medications was found unlocked, and a registered nurse acknowledged forgetting to secure it. In another medication room, an expired ear wax removal medication, which should have been discarded after the resident's departure, was found stored. Nursing staff are responsible for weekly checks for expired medications, but the expired item had been missed. Additionally, temperature logs for medication refrigerators were incomplete, with numerous days across several months lacking documentation of temperature checks and signatures. Staff interviewed confirmed that temperature logs are required to be completed daily during the overnight shift but could not explain the lapses. Furthermore, a refrigerator storing medications was found unlocked due to a broken lock, and staff were unsure how long the lock had been inoperable. Facility policy requires daily temperature checks and removal of expired medications from storage areas.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at appropriate temperatures, as required by policy. Observations showed that food trucks left the kitchen with hot food items at high temperatures (pureed eggs at 200°F, pureed hash browns at 198°F, and pureed bread at 182°F). However, by the time the last resident on Unit 2 North was served, the temperatures of these items had dropped significantly (pureed hash browns at 110.1°F, pureed bread at 106°F, and pureed eggs at 106.3°F). The time between the food leaving the kitchen and being served to the last resident was approximately 46 minutes. Staff from various departments were observed passing out dietary trays, and the last resident served was dining in their room. Interviews with the Food Service Director and the DNS confirmed that the expectation is for meals to be served warm, with 135°F identified as the acceptable minimum temperature for hot foods. Both acknowledged that the temperatures measured at the time of service were not warm enough for consumption. The DNS also noted that food trays should be distributed immediately upon arrival to the unit and suggested that better organization of trays and delivery could improve efficiency. The facility's policy requires that each resident receive food and drink that is palatable and at a safe and appetizing temperature, which was not met in this instance.
Failure to Refer New Mental Health Diagnosis for Level II Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to refer a newly identified mental health diagnosis to the appropriate state-designated mental health authority for a Level II evaluation, as required by policy. The clinical record review for one resident revealed that although a previous Level II evaluation had been completed for a diagnosis of delusional disorder, a new diagnosis of schizoaffective disorder was identified several months later without evidence of a subsequent referral for reassessment. The facility's policy mandates prompt notification to the state mental health authority after a significant change in mental or physical condition for residents with mental disorders. The resident involved had a history of schizoaffective disorder, mild cognitive impairment, and delusional disorder, and was assessed as severely cognitively impaired but independent in certain activities of daily living. The care plan noted ongoing psychosocial distress and the use of antipsychotic medication, with interventions including evaluation for psychiatric or behavioral health consults. During interviews, the social worker indicated she was unaware that a new referral was required for a new mental health diagnosis in a long-term care resident with a prior Level II evaluation, leading to the failure to initiate the necessary referral process.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
A deficiency occurred when a resident with Guillain-Barre Syndrome and muscle weakness, who required assistance with activities of daily living (ADLs) such as bathing and grooming, did not consistently receive scheduled showers. The resident's care plan specified the need for assistance with bathing, and the Minimum Data Set (MDS) assessment confirmed the resident required partial to moderate assistance for bathing and transfers. Despite being cognitively intact, the resident reported missing two scheduled showers and stated that staff told them the day staff were too busy to provide the shower. Documentation in the medical record confirmed the absence of showers on the scheduled dates, and only one shower was documented during the review period, with bed baths provided on other dates. Multiple staff interviews corroborated the resident's complaint, with nurse aides and the unit manager acknowledging the missed showers and the resident's requests. Staff indicated that the resident sometimes requested showers at times when adequate staff were not available to assist, and there was confusion or lack of follow-up regarding the resident's complaints. Review of nursing progress notes and behavior monitoring did not identify any care refusal or behaviors that would have prevented the resident from receiving showers. Facility policy required real-time documentation of ADL care, but the medical record did not reflect that showers were provided as scheduled.
Failure to Obtain Written Physician Order and Improper Cervical Collar Positioning
Penalty
Summary
A deficiency occurred when a resident with dementia and a history of repeated falls experienced a fall after dinner and complained of right thigh pain. The Advanced Practice Registered Nurse (APRN) was notified and verbally ordered an x-ray, and the responsible party was informed that an x-ray would be completed. However, there was inconsistency in the documentation regarding whether a hip or femur x-ray was ordered, and no written physician order was entered into the electronic order management system as required by facility policy. The radiology report later indicated a femur x-ray was performed, but the lack of a written order created confusion about the intended diagnostic procedure. Another deficiency was identified involving a resident admitted with a cervical spine fracture and a physician's order to maintain a cervical collar at all times, except for care. Observations revealed that the resident's cervical collar was not appropriately positioned, with the chin piece on the resident's chin and the front piece floating above the chest. Nursing staff believed this was the correct placement, and one LPN stated she had not received the in-service training provided by physical therapy. The Director of Physical Therapy later confirmed the collar was not properly positioned and adjusted it accordingly. Documentation showed that staff education on collar alignment had been provided only to those present at the initial in-service. Review of the resident's care plan and nursing notes did not indicate prior issues with the resident moving the collar or behaviors affecting its alignment. Only after surveyor inquiry was the care plan updated to address resistance to care related to the cervical collar. Facility policy specified correct collar placement, but this was not consistently followed, resulting in improper positioning of the cervical collar for the resident.
Failure to Obtain Physician Order and Monitor Specialty Mattress Settings for Pressure Ulcer Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a stage 3 pressure ulcer, not present on admission, was found to be using a specialty air mattress without a physician's order specifying the mattress settings. The resident's care plan included interventions such as the use of a pressure redistribution surface and regular repositioning, but there was no documentation of a physician's order for the mattress or instructions regarding its settings and monitoring. During observations and staff interviews, it was revealed that licensed staff were unable to locate any physician order or guidance for the air mattress settings, despite facility policy requiring such an order and regular monitoring by nursing staff. The facility's policy also stipulated that the mattress settings should be adjusted according to manufacturer recommendations and checked by a licensed nurse, which was not documented as being done for this resident.
Failure to Obtain and Document Weights per Policy for Resident with Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to obtain and document resident weights according to its own policy for a resident with a history of weight loss and multiple risk factors, including obesity, dysphagia, and aphasia. The resident experienced significant weight loss over a period of weeks, with electronic records showing a drop from 155.0 pounds to 147.6 pounds, and later to 140.0 pounds. Despite these changes, no reweight was obtained within 24 hours to verify the weight loss, as required by facility policy. Additionally, a readmission weight was not obtained within 48 hours after the resident returned from the hospital, and the first weight post-readmission was documented six days later, two days after the dietician requested it. The facility's policy required prompt reweighing and documentation in cases of unplanned weight loss or gain of 5 pounds or more, as well as timely notification to the physician and updates to the care plan. However, interviews and record reviews revealed that the responsible RN was unaware of the missed weights and did not monitor weights after hospital readmissions. There was also no documentation that the physician was notified of the significant weight loss, nor evidence that the care plan was adjusted in response to these changes.
Failure to Complete Clinical Competency Validations for Licensed Staff
Penalty
Summary
Licensed staff, including an LPN hired in May 2023, did not have documented clinical competency validations completed for the year 2024. Review of employee files and facility documentation revealed that these required validations were missing for all licensed staff. The facility assessment emphasized the importance of employee competency assessment and education as essential for proper resident care, and staff are expected to understand their scope of practice and daily responsibilities. During an interview, the Director of Nursing Services confirmed that no licensed staff had received clinical competency validations for 2024, attributing this lapse to the departure of the staff member responsible for conducting the validations. Additionally, the facility was unable to provide a policy for clinical competency validations for licensed staff.
Failure to Obtain Proper Consent for Influenza Vaccination
Penalty
Summary
The facility failed to obtain proper consent or refusal for influenza vaccination from the responsible parties of two residents with severe cognitive impairment and court-appointed conservators. In the first case, a resident with severe cognitive impairment and a conservator had previously received consent for the influenza vaccine from the conservator, but the conservator changed, and no new consent or refusal was obtained from the new conservator for the current vaccination season. The immunization record did not indicate whether the resident had received or been offered the influenza vaccine for the current season. In the second case, another resident with severe cognitive impairment was initially self-responsible and gave consent for the influenza vaccine, but later had a conservator appointed. For the current vaccination season, neither consent nor refusal was obtained from the new conservator. Although the facility attempted to contact conservators and power of attorneys via email to obtain consent, the process was incomplete, and the immunization record did not reflect whether the vaccine was offered or administered for the current season.
Failure to Provide Discharge Education and Medication Reconciliation for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus, among other diagnoses, was discharged from the facility without receiving necessary education on diabetes management, specifically regarding the use of newly prescribed Insulin Lispro, insulin sliding scale, and self-injection techniques. The clinical record and facility documentation showed that the resident did not receive teaching or training on diabetes care, use of a glucometer, or insulin administration during their stay, despite care plans and physician orders indicating these needs. Nursing notes failed to document any education provided on these critical aspects of diabetes self-management prior to discharge. Additionally, the facility failed to perform proper medication reconciliation before the resident's discharge. The discharge summary and medication list indicated that the resident was to continue with Insulin Lispro and gabapentin, but these medications and necessary supplies were not provided to the resident upon discharge. Communication breakdowns between nursing staff and the prescribing provider led to the assumption that the resident had all required medications, resulting in the omission of new prescriptions and supplies needed for safe transition home. Interviews with facility staff confirmed that the resident was discharged without the prescribed medications and without the required education on their use. The facility's own discharge planning policy required reconciliation of all pre- and post-discharge medications and provision of education, but these steps were not completed. The deficiency was identified after the home care nurse reported the missing medications and lack of discharge teaching, prompting an internal investigation that confirmed the failures in discharge planning and education.
Failure to Notify Physician of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the physician when a resident repeatedly refused prescribed medications, as required by facility policy. The resident, who had diagnoses including seizures, anxiety, depression, ADHD, and gender identity disorder, was care planned for medication administration and monitoring for side effects and effectiveness. Despite physician orders for Primidone and Hydroxyzine, the resident refused the morning doses of Primidone on 18 out of 30 days and Hydroxyzine on 10 out of 30 days during a one-month period. Documentation review confirmed these refusals were recorded in the Medication Administration Record (MAR). Interviews with nursing staff revealed that the charge nurse was aware of the refusals but could not recall notifying the physician or documenting the refusals in a nurse's note. The unit manager and APRN were not aware of the medication refusals and stated that their expectation was to be notified in such cases. The Director of Nursing confirmed there was no documentation of physician notification regarding the refusals, and facility policy required such notification. This lack of communication and documentation led to the deficiency.
Failure to Develop and Implement Care Plan for Medication Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address a resident's repeated refusals of prescribed medications. The resident, who had diagnoses including seizures, anxiety, depression, ADHD, and gender identity disorder, was prescribed Primidone for seizures and Hydroxyzine for anxiety. Despite a care plan that addressed behavioral concerns and medication monitoring, there was no specific care plan or interventions in place to address the resident's frequent medication refusals. The Medication Administration Record showed that the resident refused Primidone on 18 out of 30 days and Hydroxyzine on 10 out of 30 days during the review period, with only one nurse's note documenting a refusal. Interviews with facility staff, including the unit manager and Director of Nursing Services (DNS), confirmed that a care plan should have been implemented for medication refusals, but none was found in the clinical record. The facility's own policy required a person-centered care plan that addresses services not provided due to a resident's exercise of rights, such as refusing treatment. The DNS was unable to provide documentation or an explanation for the lack of a comprehensive care plan addressing the resident's medication refusals.
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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