Springs At East Hill, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Southbury, Connecticut.
- Location
- 611 East Hill Road, Southbury, Connecticut 06488
- CMS Provider Number
- 075441
- Inspections on file
- 18
- Latest survey
- April 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Springs At East Hill, The during CMS and state inspections, most recent first.
A resident admitted with malnutrition and dysphagia did not receive ordered J-tube feeding for over 11 hours because nursing staff could not locate the formula and supplies, and failed to notify the provider as required by facility policy. Interviews and documentation confirmed that the formula and supplies were present in the facility but not used, and no timely notification to the APRN or physician occurred.
A resident with a J-tube and orders for continuous enteral feeding did not receive the prescribed tube feeding for over 11 hours after admission because nursing staff could not locate the formula and supplies, despite these items being present in the facility. Staff did not contact the APRN or physician to establish an alternate plan, resulting in a significant delay in providing ordered nutrition.
The facility failed to ensure that all licensed staff had valid CPR certification, with 13 LPNs lacking certification. Miscommunication between the DNS and HR led to a lack of tracking, resulting in RN #2 working 79 shifts without a valid CPR card. The facility's policy requires CPR certification, but it was not enforced.
The facility failed to ensure that all licensed nursing and supportive nursing personnel had the appropriate IV training, certification, and competencies. An RN and an LPN provided IV care to a resident without having the necessary certifications on file. Additionally, the facility did not complete IV competency validation for nurse aides in 2024, as required by their policies.
The facility failed to conduct 90-day and annual performance evaluations for nurse aides in 2023 and 2024, and did not provide mandatory education for 2024. The Director of HR and DNS acknowledged the lapses, with personnel files showing missing evaluations and education records. Critical topics like infection control and resident rights were not covered.
A facility failed to verify the Infection Preventionist's certification upon hire, leading to a deficiency identified during a survey. The RN, responsible for infection control, had completed a certification course in 2019 but lacked documentation. Miscommunication between the DNS and Human Resources led to the oversight, which was only addressed after the survey.
A facility failed to create a baseline care plan for a resident with significant cardiac and respiratory issues, including recent coronary artery bypass surgery and a pneumothorax. The resident required a Lifevest device, but the care plan did not document these needs. An LPN cited workload as a reason for the oversight, acknowledging that the care plan should have included these critical health needs as per facility policy.
The facility failed to create comprehensive care plans for two residents, one with depression, anxiety, and aortic dissection, and another with MRSA bacteremia and a PICC line for antibiotic treatment. The care plans lacked necessary interventions for medications and specialized treatments due to the MDS coordinator's workload and lack of support, leading to deficiencies in addressing the residents' medical needs.
The facility failed to obtain weights for a resident as per physician's orders, leading to delayed identification of fluid overload. Another resident was not provided with a physician's order or staff training for a Lifevest device, and respiratory assessments were inconsistently documented. Additionally, a third resident did not receive the second step of a PPD test for TB as ordered, indicating lapses in admission procedures and monitoring.
A resident with severe protein-calorie malnutrition was not weighed as per physician's orders, leading to a 12.5% weight loss over 16 days. Despite the resident's awareness and collaboration with staff, there was no documentation of weight refusals. Interviews revealed a lack of communication and documentation regarding weight monitoring, contributing to the oversight in addressing the resident's nutritional needs.
A resident with chronic respiratory conditions did not have their oxygen and nebulizer tubing changed weekly as ordered by a physician. The tubing was last changed 12 days prior to observation, contrary to the facility's policy and physician's directive. Interviews with staff revealed a lack of adherence to the protocol and possible gaps in documentation practices.
A facility failed to train staff on the use of a Lifevest device for a resident admitted after cardiac surgery. The resident, who required the device for cardiac monitoring, managed the device independently due to staff's lack of training. Interviews revealed that staff, including the DNS, LPNs, NAs, and therapy staff, were not educated on the device, and the care plan lacked interventions for the resident's cardiac needs. The facility's assessment claimed adequate resources for staff education, yet no policies or procedures for the Lifevest were available.
The facility failed to consistently complete shift-to-shift controlled drug counts, as observed during a survey. On multiple dates, the change of shift inventory record for controlled drugs was missing nurse signatures across all shifts on a specific unit. Interviews revealed that staff were unaware of the missing signatures, despite the facility's policy requiring accurate counts and signatures at each shift change.
The facility failed to notify the Ombudsman of hospital transfers for two residents. One resident had two hospital leaves in May and June, and another was transferred in October, without notifications being sent. The social worker responsible was unaware of the requirement, and the facility's policy for monthly reporting was not followed.
A resident with multiple sclerosis and mobility impairments, who required assistance with toileting, was told by a nurse aide to go to the bathroom independently. The resident attempted to do so and soiled themselves, as the aide failed to provide the necessary help, violating the resident's right to dignity and respect.
A resident with cognitive impairment and significant care needs was subjected to repeated sexually inappropriate comments by a nursing assistant during a scheduled shower, in the presence of the resident's spouse and other staff. Despite being instructed not to provide care to the resident after the incident was reported, the nursing assistant proceeded to shower the resident. Facility investigation confirmed the occurrence of verbal sexual abuse.
A resident with cognitive impairment and significant care needs was subjected to sexually inappropriate comments by a nursing assistant. Despite a directive from the DNS to remove the staff member from the resident's care, the nursing assistant continued to provide care to the resident after the allegation was reported, in violation of facility policy requiring immediate removal of accused staff from resident contact.
A resident with dementia and mobility issues was mistreated by an LPN, who was observed being rough and verbally inappropriate during a transfer. The incident was witnessed by another LPN and an RN, leading to the LPN's termination. The facility's failure to protect the resident from mistreatment constitutes a deficiency.
Failure to Notify Provider of Inability to Administer Ordered Tube Feeding
Penalty
Summary
The facility failed to ensure timely notification of the medical provider when a resident was unable to receive ordered tube feeding upon admission. The resident, admitted with diagnoses including protein-calorie malnutrition and dysphagia, had orders for J-tube feeding with a specific formula and rate. Upon admission, nursing staff were unable to locate the required tube feeding formula and administration supplies, resulting in the resident not receiving the prescribed feeding for approximately 11 and a half hours. Documentation shows that the formula and supplies were present in the facility but not found or used by the staff on duty. Nursing staff did not notify the APRN or physician about the inability to provide the ordered feeding, as confirmed by interviews and review of the medical record. Both the evening and night shift nurses acknowledged awareness of the issue but did not contact the medical provider or document any notification. Facility policy required immediate consultation with the physician when treatment could not be provided as ordered, but this was not followed. The deficiency was identified through clinical record review, staff interviews, and policy review.
Delay in Initiation of Ordered Tube Feeding Due to Supply and Communication Failures
Penalty
Summary
A deficiency occurred when a resident admitted with protein-calorie malnutrition and dysphagia, and with a J-tube for enteral feeding, did not receive tube feeding as ordered by the physician. Upon admission, the resident had physician orders for Vital AF 1.2 at 55 ml per hour for 22 hours daily via J-tube, with hourly water flushes. Nursing staff documented that the prescribed tube feeding formula and necessary administration supplies were not available upon the resident's arrival, resulting in a delay in initiating the tube feeding. Although the resident arrived with some containers of the formula, staff were unable to locate the appropriate supplies and did not start the feeding as ordered. The resident went approximately 11 and a half hours without the ordered tube feeding, missing about 660 ml of nutrition. During this period, staff were able to administer medications and flush the J-tube as ordered, but the enteral nutrition was not provided. Interviews revealed that the on-call APRN or physician was not contacted to establish an alternate plan when the feeding could not be started, despite facility policy requiring appropriate treatment for residents with feeding tubes. The feeding and supplies were later found to have been present in the facility, but not located or used by the nursing staff at the time of need.
Failure to Ensure CPR Certification for Licensed Staff
Penalty
Summary
The facility failed to ensure that all licensed staff had valid, current CPR certification, as required by their policy. A review of CPR certification records revealed that only 2 RNs and 2 LPNs had valid CPR certification, while 13 LPNs did not. Interviews with the Director of Nursing Services (DNS) and Human Resources (HR) personnel indicated a lack of clarity regarding responsibility for tracking CPR certifications. The DNS believed it was the nurses' responsibility to update their CPR cards and provide copies to DNS and HR, while HR personnel indicated that the DNS was responsible for tracking certifications. The Administrator was under the impression that HR was responsible for ensuring all licensed nursing staff were CPR certified. Further investigation revealed that RN #2, who was hired without a valid CPR certification, worked the 11:00 PM to 7:00 AM shift as the only nurse on duty for 79 out of 112 days. RN #2 indicated that he was CPR certified at a hospital in 2021, but his certification expired in 2023, and he had lost the expired card. Despite the facility's policy requiring CPR certification to be obtained and tracked, RN #2 was not asked to provide his CPR card since his hire. The facility's failure to track and ensure current CPR certification for all licensed staff represents a significant deficiency in compliance with their own policies and state regulations.
Lack of IV Certification and Competency in Nursing Staff
Penalty
Summary
The facility failed to ensure that all licensed nursing and supportive nursing personnel had the appropriate IV training, certification, and competencies. Specifically, 7 out of 17 licensed nurses, including an RN and an LPN, did not have an IV therapy certification on file. The RN provided care for a resident with a PICC line, performing tasks such as flushing the line on multiple occasions, while the LPN administered IV Daptomycin via a PICC to the same resident. The RN had previous IV training in an emergency department setting but lacked certification for long-term care and could not recall completing any competencies or skill demonstrations at the facility. The Human Resources Director was unaware of her responsibility to obtain and track IV certifications, and the DNS acknowledged that it was ultimately her responsibility to ensure the certifications and competencies were completed. Additionally, the facility failed to provide IV competency validation for nurse aides in 2024. The DNS admitted that due to a lack of residents requiring IV therapy recently, annual IV therapy education and competency evaluations for nurse aides were overlooked. The facility's policies require that nurse aides receive IV education initially, yearly, and as needed, with competency determined by the facility. The DNS recognized her oversight in not completing the necessary education and competencies for the nurse aides.
Failure to Conduct Performance Evaluations and Mandatory Education
Penalty
Summary
The facility failed to conduct 90-day and annual performance evaluations for nurse aides in 2023 and 2024, as well as the mandatory annual education for 2024. The Director of HR acknowledged that the 90-day evaluations were not completed due to department heads being busy, and the annual evaluations were also not conducted. The Director of HR was responsible for tracking and notifying department heads of upcoming evaluations, but the process was not followed through. The DNS confirmed that she was behind on annual evaluations for the nursing department and was unsure about the 90-day evaluations for new hires. Personnel files for five nurse aides revealed missing evaluations for the specified periods. Additionally, the facility did not provide the mandatory education for nursing staff in 2024. The DNS was unable to present documentation of completed mandatory education for the year. Personnel files for the nurse aides showed no record of the required education, which included various critical topics such as infection control, resident rights, and emergency procedures. Despite requests, the facility could not provide a policy for mandatory annual education for nurses and nurse aides.
Infection Preventionist Certification Oversight
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a registered nurse (RN), had completed specialized training in infection prevention and control. The RN was hired on October 23, 2024, and during a survey conducted on January 6, 2025, the facility could not provide documentation that the RN had completed the necessary training or certification. The RN had previously completed an Infection Preventionist certification course in 2019 but was unable to provide documentation of this due to the certificate being located five hours away. The RN had been working at the facility for approximately 90 days, dedicating over 40 hours per week to infection control responsibilities, yet had not been asked for her credentials upon hire. Interviews with the Director of Nursing Services (DNS) and the Human Resources Director revealed a lack of communication and responsibility regarding the verification of the RN's credentials. The DNS assumed that the Human Resources department was responsible for obtaining the certification documentation, while the Human Resources Director believed it was the responsibility of the DNS or the Administrator. This oversight was only identified during the survey, and the RN subsequently provided a certification dated January 9, 2025. The facility's policy requires the Infection Preventionist to be qualified by education, training, experience, or certification, which was not initially verified in this case.
Failure to Develop Baseline Care Plan for Resident with Cardiac and Respiratory Issues
Penalty
Summary
The facility failed to develop a baseline care plan for a newly admitted resident with significant cardiac and respiratory issues. Resident #226 was admitted following a hospital stay for coronary artery bypass surgery and experienced a spontaneous pneumothorax requiring chest tube placement. The resident was also discharged with a Lifevest device, a wearable defibrillator for continuous heart monitoring. Despite these critical conditions, the baseline care plan did not document the resident's cardiac or respiratory diagnoses, recent surgery, pneumothorax, or the need for the Lifevest device. An interview with the LPN responsible for MDS assessments and care plan updates revealed that due to workload, there was a delay in reviewing and individualizing care plans. The LPN acknowledged that the baseline care plan should have included the resident's specific needs, such as respiratory and cardiac monitoring and the use of the Lifevest device, as indicated in the hospital discharge documentation. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, including necessary healthcare information to provide effective, person-centered care, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical needs. Resident #9 was admitted with diagnoses including depression, anxiety, and aortic dissection, and was on medications such as Lexapro, Alprazolam, and Heparin. Despite these conditions and a history of falls, the care plan did not include interventions for the use of antidepressant, antianxiety, and anticoagulant medications, nor did it address the resident's fall risk. The MDS coordinator, responsible for creating the care plan within 21 days of admission, acknowledged the oversight, citing workload and lack of coverage as reasons for the delay. Resident #224 was admitted with MRSA bacteremia, chronic kidney disease, and diabetes, and was receiving Daptomycin via a PICC line. The care plan failed to include interventions related to the intravenous medication or the PICC line, which was crucial for the resident's long-term antibiotic treatment. The MDS coordinator admitted to falling behind on updating care plans due to her dual role as a medical records clerk, which impacted her ability to ensure care plans were individualized to residents' needs. The facility's policy mandates the development of a comprehensive care plan within seven days of the comprehensive assessment, including measurable objectives and timetables to meet residents' needs. However, the care plans for both residents did not meet these requirements, as they lacked specific interventions for their medical conditions and treatments. This deficiency was attributed to the MDS coordinator's workload and the absence of adequate support, resulting in incomplete care plans that did not address the residents' specialized needs.
Deficiencies in Weight Monitoring, Device Management, and TB Testing
Penalty
Summary
The facility failed to obtain weights for Resident #224 as per the physician's order upon admission. The resident was admitted with a diagnosis of MRSA bacteremia and required specific weight monitoring for Daptomycin dosing. However, the initial weight was not documented until two days after admission, showing a significant weight loss from the hospital's recorded weight. This oversight led to a delay in identifying the resident's fluid overload condition, which was only addressed after a notable weight gain was observed. For Resident #226, the facility did not secure a physician's order for the use of a Lifevest device, a critical cardiac monitoring tool, nor did they provide staff training on its operation. The resident, who had undergone major cardiac surgery, was left to manage the device largely independently, including battery changes, despite having physical limitations. Additionally, the facility failed to consistently document respiratory assessments as ordered, with gaps in the clinical record for several days. Resident #9 did not receive the second step of a two-step PPD test for tuberculosis as ordered upon admission. The facility's policy required this test to be completed to ensure the resident was free from active TB, but the second test was not administered or documented. This lapse in following physician orders and facility policy highlights a deficiency in the facility's admission procedures and monitoring of new residents.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to a physician's order for weight monitoring for a resident diagnosed with severe protein-calorie malnutrition. Resident #7, who was admitted with conditions including dysphagia, hyponatremia, Myelodysplastic Syndrome, and severe malnutrition, was to be weighed on admission, daily for three days, weekly for four weeks, and then monthly. However, the facility did not complete the required weekly weights from 12/14/24 through 12/30/24, resulting in a significant weight loss of 12.5% during this period. The care plan for Resident #7 identified nutritional problems but failed to address refusals of care. Despite the resident's awareness of their weight loss and collaboration with facility staff, there was no documentation of weight refusals. Interviews with the dietitian and nursing staff revealed that the resident had not refused care or weights, and the dietitian adjusted nutritional supplements only after the weight loss was identified. The facility's weight policy mandates that weights be documented and appropriate follow-up initiated if weight changes occur, but this was not adhered to in Resident #7's case. Interviews with facility staff, including LPNs and the DNS, indicated a lack of communication and documentation regarding the resident's weight monitoring. The DNS expected weights to be completed per physician orders, and the APRN anticipated weight loss due to the resident's medical conditions but expected adherence to the weight monitoring order. The failure to obtain and document the resident's weights as ordered contributed to the oversight in addressing the resident's nutritional needs in a timely manner.
Failure to Change Respiratory Tubing Weekly
Penalty
Summary
The facility failed to adhere to physician orders regarding the timely change of oxygen and nebulizer tubing for Resident #174, who was diagnosed with chronic obstructive pulmonary disease, chronic respiratory failure, Covid-19, and dementia. The resident was admitted to the facility with these conditions and required oxygen therapy and nebulizer treatments. A physician's order specified that the oxygen and nebulizer tubing should be changed weekly on Wednesday night shifts. However, observations on January 6th revealed that the tubing had not been changed since December 25th, indicating a lapse of 12 days without the required change. Interviews with facility staff, including an LPN and the DNS, confirmed that the tubing should have been changed on January 1st, as per the physician's order. The DNS acknowledged that the nurse responsible for changing the tubing should not have signed off on the task if it was not completed. Additionally, an RN indicated a lack of clarity on where to document the tubing change, suggesting a possible gap in training or communication. The facility's policy on respiratory equipment changes emphasizes the importance of changing equipment weekly to prevent infections, yet this protocol was not followed in this instance.
Lack of Staff Training on Lifevest Device for Resident
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and educated on the use of a specialized device, the Lifevest, for a newly admitted resident, Resident #226. This resident was admitted following major cardiac surgery, which included coronary artery bypass surgery and the removal of pacemaker/defibrillator wires. During the hospital stay, the resident experienced a pneumothorax requiring a chest tube, and upon discharge, was required to use a Lifevest device, a wearable defibrillator. However, the facility's care plan did not include interventions related to the resident's cardiac or respiratory issues, nor did it mention the Lifevest device. Interviews with various staff members, including the Director of Nursing Services (DNS), Licensed Practical Nurses (LPNs), Nurse Aides (NAs), and Physical and Occupational Therapy staff, revealed a lack of training and education on the Lifevest device. The DNS confirmed that no training had been provided to the staff regarding the Lifevest prior to or after the resident's admission. The resident had been managing the device independently, including monitoring and changing the battery, despite having mild arthritis and overall weakness from surgery, which made these tasks challenging. Staff members were aware of the device but had not received formal training or instructions on its use. The facility's failure to provide training and education on the Lifevest device was further highlighted by the absence of physician's orders related to the device's monitoring and battery changes. The facility's assessment claimed the ability to provide person-centered care and sufficient resources for staff education, yet no policies or procedures regarding the Lifevest were available. The lack of documentation and training posed a risk to the resident's well-being, as the Lifevest is critical for monitoring and treating potential cardiac events.
Failure to Complete Shift-to-Shift Controlled Drug Counts
Penalty
Summary
The facility failed to ensure that shift-to-shift controlled drug counts were consistently completed, as observed during a survey. On multiple dates in January 2025, the change of shift inventory record for controlled drugs was missing nurse signatures across all shifts on the Short End unit. This deficiency was identified during an observation of the medication carts with an RN, who was unaware of the missing signatures until the surveyor pointed them out. Interviews with an LPN, the RN, the Director of Nursing Services (DNS), and the Administrator revealed that none were aware of the missing signatures, although they all acknowledged the expectation that nurses should count narcotics at each shift change and sign the narcotic count sheet. The facility's policy requires that all Scheduled II-IV medications be accounted for at the end of each shift, with any discrepancies promptly investigated. The policy specifies that both the oncoming and off-going medication-distributing associates are responsible for counting the controlled medications and signing the controlled medication count/key sign-out sheet after verifying the count's accuracy. Despite this policy, the facility did not adhere to these procedures, resulting in the observed deficiency.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman regarding hospital transfers for two residents. Resident #2 was admitted to the facility and experienced hospital leaves on two occasions, in May and June 2024, without the Ombudsman being notified. The facility's documentation, including the Emergency Transfers document and the Long-Term Care Ombudsman Program Notification Details, did not reflect these notifications. Interviews with the social worker (SW #1) revealed a lack of awareness about the requirement to report unplanned discharges to the hospital to the Ombudsman, which she only learned about a month prior to the interview. The Administrator confirmed the expectation for monthly reporting of all resident transfers to the Ombudsman. Similarly, Resident #23 was transferred to the hospital in October 2024, but the facility failed to notify the Ombudsman. The emergency transfers form did not include notifications for any resident hospital transfers from June 2024 through November 2024. Interviews with SW #1, the Director of Nursing Services (DNS), and the Administrator confirmed that SW #1 was responsible for these notifications, but they were not being done monthly. The facility's policy requires that emergency transfer notices be sent to the Ombudsman, either individually or in a list format on a monthly basis, but this was not adhered to.
Failure to Assist Resident with Toileting Results in Loss of Dignity
Penalty
Summary
A resident with multiple sclerosis, generalized muscle weakness, and mobility impairments required moderate assistance with transfers and toileting, as documented in the care plan and MDS assessment. The resident was identified as needing the assistance of one staff member for activities of daily living and ambulation, and was frequently incontinent of bowel and occasionally incontinent of bladder. Despite these documented needs, a nurse aide failed to provide the required assistance when the resident requested help to use the bathroom. Instead, the aide instructed the resident to go to the bathroom independently. As a result of not receiving the necessary assistance, the resident attempted to ambulate to the bathroom alone and soiled themselves in the process. Facility documentation, including a grievance form and an accident and incident report, substantiated that the aide did not honor the resident's request in a timely manner and failed to assist as required. The facility's policy on resident rights directs that all staff must treat residents with respect and dignity at all times, which was not upheld in this instance.
Failure to Protect Resident from Verbal Sexual Abuse by Staff
Penalty
Summary
A resident with moderately impaired cognition, metabolic encephalopathy, retroperitoneal hematoma, generalized muscle weakness, and requiring assistance with personal care was subjected to verbal sexual abuse by a nursing assistant (NA). The resident's care plan and physician's orders specified scheduled showers and encouraged participation in care. During an interaction in the resident's room, the NA made sexually inappropriate comments about how the resident would be showered, including explicit references to the resident's body and sexual arousal, in the presence of the resident's spouse and other staff. Multiple staff members, including another NA, an LPN, and the RN supervisor, either overheard or were informed of the inappropriate comments. The resident's spouse expressed discomfort with the NA's behavior and reported the incident to facility leadership. Despite being directed by the RN supervisor not to provide care to the resident following the incident, the NA proceeded to shower the resident that evening. Facility documentation and interviews confirmed that the NA repeated the inappropriate comments multiple times and that the incident was witnessed by staff and the resident's spouse. The facility's investigation substantiated the allegation of verbal sexual abuse, confirming that the resident was not protected from abuse as required by policy and regulation.
Failure to Suspend Staff After Alleged Verbal Sexual Abuse
Penalty
Summary
A deficiency occurred when the facility failed to suspend an employee after an allegation of verbal sexual abuse toward a resident. The resident, who had diagnoses including metabolic encephalopathy, retroperitoneal hematoma, generalized muscle weakness, and required assistance with personal care, was the subject of a complaint made by the resident's spouse. The complaint detailed that a nursing assistant made sexually inappropriate comments to the resident in the presence of others. Despite the direction from the Director of Nursing Services (DNS) to remove the nursing assistant from the resident's care assignment for the remainder of the shift, the nursing assistant proceeded to provide a shower to the resident that evening. Facility policy required that any staff member accused of abuse be removed from contact with all residents until the investigation was concluded. However, interviews and documentation confirmed that the nursing assistant continued to have contact with the resident after the allegation was reported, contrary to policy. The investigation substantiated the allegation of verbal sexual abuse, and the failure to immediately suspend the staff member after the allegation constituted the deficiency.
Resident Mistreatment by LPN
Penalty
Summary
The facility failed to protect a resident from mistreatment, as evidenced by an incident involving a Licensed Practical Nurse (LPN) and a resident with dementia and mobility issues. The resident required moderate assistance from two staff members for transfers and could ambulate up to 200 feet with assistance. During an incident, an LPN was observed being rough with the resident, including placing her hand on the resident's face in a cupping motion and roughly placing the resident into a wheelchair. This behavior was witnessed by another LPN and a Registered Nurse (RN), who intervened during the transfer. The incident was reported and investigated by the facility, which substantiated the allegation of abuse. The facility's policy on abuse and neglect defines physical abuse to include actions such as hitting, slapping, and pinching, and verbal abuse as the use of disparaging and derogatory terms. The LPN involved in the incident did not respond to the facility's attempts to contact her and was subsequently terminated from employment. The facility's failure to ensure the resident was free from mistreatment constitutes a deficiency in providing a safe environment for residents.
Latest citations in Connecticut
The facility failed to follow CDC guidance for Legionella environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. Despite being advised that water cultures should be collected every two weeks for three months using 1 L (1000 ml) samples, the facility initially collected only 100 ml per site and later tested only monthly instead of bi-weekly. State infectious disease officials determined that these tests were inadequate in both volume and frequency and could not be counted toward the required monitoring sequence. Additionally, Nephros S100 sink filters installed as point-of-use controls were not replaced within the 90-day operational period specified by the manufacturer, as staff relied on the distant "use by" date on the box rather than the three-month use limit. The facility’s water management policy and IPCP lacked specific guidance on Legionella testing volume and frequency after a confirmed case.
A resident with dementia, a right femur fracture, and very high Braden risk had a right leg brace ordered to remain on with non-weight bearing, and staff were directed to remove the brace every shift for skin checks and to maintain ABD padding at the ankle and thigh. Over several days, multiple LPNs documented or observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor, and some documented no abnormalities beyond baseline discoloration. A NA later removed the brace after noticing odor and moisture and discovered a large open ankle wound with exposed tendon at the brace site. Subsequent assessment by the wound physician identified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration of more than three days, and the physician noted he had not been informed earlier of the bruising or soft skin or of the existing padding order.
A resident with dementia, a right femur fracture, and very high risk for pressure injuries had a right leg brace ordered to remain on at all times, with removal each shift for skin checks and placement of ABD padding at the ankle and thigh. Over several shifts, LPNs observed bruising and soft skin under the brace, with no barrier between the brace and the skin, but did not notify a provider or supervisor because the skin was not yet open or was believed to be an existing impairment. A NA later removed the brace during care, noted odor and moisture, and discovered a large open ankle wound with exposed tendon and no padding in place. Subsequent assessments documented a broad area of denuded skin with exposed tendon, and a wound physician classified it as a medical device–associated Stage IV pressure injury, confirming that earlier notification of bruising or soft skin could have led to protective padding between the brace and the skin.
Two residents experienced accidents related to inadequate supervision and failure to follow facility policies for safe ambulation and transfers. One resident with weakness and mobility limitations, care planned for assisted ambulation with a rolling walker and gait belt, was assisted in the hallway by a NA without a gait belt, lost balance, and fell, sustaining a left forearm skin tear and a nondisplaced left olecranon fracture confirmed by X-ray. Another resident with severe cognitive impairment and multiple comorbidities, documented as requiring assistance for transfers, was transferred from wheelchair to bed by two NAs while agitated and was subsequently found to have a new skin tear on the left lower leg. Staff interviews and facility policies confirmed that gait belts were required for assisted ambulation and that residents were to receive adequate supervision and appropriate assistive devices to prevent accidents.
A resident with severe cognitive impairment, nonverbal status, and total dependence for ADLs and incontinence care was not provided timely peri/incontinent care despite care plans and CNA assignments directing frequent checks and assistance. Morning staff provided care and transferred the resident out of bed early, then failed to return the resident to bed after breakfast, relied only on smell to assess incontinence, did not re-offer care after a family member declined, and did not notify an RN that no further care had been given for many hours. Evening staff were not informed that care had been missed, were occupied in the dining room, and did not provide incontinence care until after the evening meal, at which time the brief was heavily wet and soiled with a bowel movement, demonstrating prolonged lack of required incontinence care and monitoring.
Surveyors found that a CNA providing ADL, incontinent, and meal care had gel artificial fingernails with raised rhinestone and metal decorations, contrary to infection control expectations. Leadership acknowledged that staff were allowed to wear gel nails, though the DNS stated attached jewels or sharp areas were not permitted. The facility’s appearance policy required clean, well-manicured nails that do not compromise resident safety, while WHO and CDC guidance reviewed by surveyors generally prohibit artificial nails, including gel nails, for direct care staff due to infection control concerns.
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with rheumatoid arthritis and other comorbidities was discharged from a hospital with an order for methotrexate to be given as divided doses once weekly, but an RN transcribed the order in the EMR as a daily medication. Despite an EMR dose warning and required checks by a supervising RN, an APRN, a physician, the pharmacy, and the pharmacy consultant, the incorrect daily order was not corrected, and the drug was administered daily for nine days. The resident, who was cognitively intact and required moderate assistance with ADLs, subsequently developed thrush, painful oral mucositis, poor intake, nausea, vomiting, diarrhea, severe leukopenia/neutropenia, and hypoxia, and was transferred to the hospital where methotrexate toxicity, neutropenic fever, and sepsis were diagnosed. The error was recognized as a significant medication error that placed the resident in Immediate Jeopardy and was associated with the resident’s ICU admission and death.
A resident with multiple cardiac conditions, COPD, and Alzheimer’s disease experienced repeated respiratory changes over several days, leading nursing staff to request multiple evaluations by an APRN, who ordered a chest x-ray, IV Lasix, STAT labs, and oxygen therapy. Although the resident was cognitively intact and had a COP, documentation showed that the COP was not notified of the earlier changes in condition or new treatments, and notification only occurred later when the resident became acutely hypoxic. The resident subsequently died, and record review and staff interviews confirmed that the facility did not follow its own notification-of-change policy requiring prompt notification of the resident’s representative for acute conditions and new treatments.
A resident with heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s was evaluated by an APRN for respiratory symptoms, including increased wheezing, and a chest x-ray was ordered and discussed with nursing. The care plan called for monitoring abnormal breath sounds, breathing difficulty, and signs of heart failure, but the medical record contained no entered order for the chest x-ray and no documentation explaining why it was not performed. Subsequent reassessment documented no acute cardiopulmonary process and did not reference the earlier x-ray order. Days later, the resident developed increased respiratory distress and hypoxia, received IV Lasix, oxygen, and STAT orders for labs and a chest x-ray, and was later pronounced dead the same day. Staff interviews showed no nurse recalled receiving or entering the original chest x-ray order, and there was no documentation of follow-through on that order.
Failure to Follow CDC Legionella Water Testing Protocols and Filter Replacement Guidelines
Penalty
Summary
The facility failed to follow CDC guidance for environmental water testing and manufacturer instructions for point-of-use sink filters after a resident was reported positive for Legionella while hospitalized. After notification of the positive Legionella case, the DON communicated with a state epidemiologist and was informed that water cultures should be collected every two weeks for three months, followed by monthly testing for three additional months if no Legionella was detected. CDC guidance also specified that each water sample from sinks, showers, and other sites should be 1 liter (1000 ml). However, the facility initially collected water samples using only 100 ml per site, which was 900 ml less than the recommended volume, and this occurred on multiple testing dates. In addition to using insufficient sample volumes, the facility did not adhere to the required testing frequency. Although the facility believed it was testing every two weeks in December and January, it was doing so with the wrong sample volume. From January through March, the facility tested only monthly instead of every two weeks as directed by CDC guidance. Communication from the state infectious disease assistant director later confirmed that the early tests with 100 ml volumes and the later tests performed almost a month apart were inadequate and would not count toward the required monitoring sequence. The facility’s Water Management Policy did not specify the required volume and frequency of surveillance testing after a confirmed positive Legionella case. The facility also failed to replace point-of-use Nephros S100 sink filters within the 90-day operational period specified by the manufacturer. Observations showed that the filters were installed when the facility was first notified of the positive Legionella case and had not been changed by the time of survey, despite the manufacturer’s instructions that the filters should operate for up to three months of normal use. The Director of Maintenance confirmed that the filters had remained in place since installation and had expired based on the 90-day use guidance. The DON further explained that the facility relied on the “use by” date on the filter box (2028) rather than the 90-day operational limit, and the facility’s Infection Prevention and Control Program, although generally outlining surveillance and outbreak response expectations, did not provide specific direction on Legionella testing volume and frequency after a confirmed case.
Failure to Monitor and Report Skin Changes Under Leg Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered interventions, conduct ongoing skin monitoring, and timely identify and report changes in skin condition for a resident at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Physician orders and the resident care plan required the right leg brace to remain on at all times with non-weight bearing to the right lower extremity, and directed staff to remove the brace every shift for skin checks and circulation, motion, and sensation assessments, as well as to ensure ABD padding at the ankle and thigh every shift. Subsequent skin assessments documented resolution of the initial right Achilles bruising and, on multiple dates in February, described the resident’s skin as warm, dry, with normal color and no issues, except for moisture-associated skin damage to the coccyx. Despite these orders and the resident’s very high Braden risk score, staff did not consistently identify, document, or report significant skin changes under the right leg brace. On 2/24, an LPN observed bruising from mid-calf to ankle under the brace but did not notify the provider. On 2/26, the same LPN again noted persistent bruising and soft skin and still did not report these findings to a supervisor or provider because the area was not open. Another LPN later reported that on 2/27, during a skin check, the brace was removed, the skin was visualized, there was no barrier between the brace and the skin, and bruising was present; this LPN also did not report the bruising, believing it to be an existing impairment. Other LPN statements for shifts on 2/25, 2/26, and 2/27 indicated that when they removed the brace, they either did not observe abnormalities or only noted baseline discoloration and applied skin prep to the heels and toes. On 2/28, a nursing assistant providing care to the resident for the first time detected an odor and moisture on her gloves while checking the heels, removed the right leg brace, and found a large open wound on the right ankle with a white wound bed and exposed tendon, and no barrier between the brace and the skin. A subsequent nursing note that evening documented a wound at the right lateral ankle at the brace site, with specific measurements and a non-blanchable, edematous, red peri-wound and an open wound bed. The wound physician later classified this as a medical device-related Stage IV pressure injury of the right ankle, with exposed tendon and a duration greater than three days. The contracted wound physician stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin, and he was unaware of the existing orthopedic order for padding that the facility was expected to follow.
Failure to Report Skin Changes Under Brace Leading to Stage IV Device-Related Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and appropriate nursing staff regarding a significant change in a resident’s skin condition under a right leg brace, despite the resident being at very high risk for pressure injury development. The resident was admitted with a right femur fracture, dementia, a sacral pressure injury, and right Achilles bruising noted on admission. Care plan interventions and physician orders required the right leg brace to remain on at all times, be removed every shift for skin checks and circulation, motion, and sensation assessments, and for ABD padding to be placed at the ankle and thigh every shift. A subsequent skin assessment documented that the right Achilles bruising present on admission had resolved. On multiple occasions, nursing staff observed concerning skin changes under the brace but did not notify a provider or supervisor. An LPN performing a skin assessment identified bruising from the right mid‑calf to ankle under the brace and did not notify the provider. During a later shift, the same LPN again observed persistent bruising and soft skin in the same area and still did not report these findings because the skin was not open. Another LPN, assigned on a different shift, removed the brace, observed bruising and no barrier between the brace and the resident’s skin, and did not report the bruising to the supervisor, believing it to be an existing skin impairment. These observations occurred in the context of existing orders to remove the brace each shift, inspect the skin, and ensure padding was in place. The change in the resident’s condition was ultimately identified by a nursing assistant who, while providing care, noted an odor, moisture on her gloves, and upon removing the brace, found a large open wound on the right ankle with a white wound bed and exposed tendon and no barrier between the brace and the skin. Subsequent nursing and physician documentation described a wound at the right lateral ankle where the brace had been, with an open wound bed, non‑blanchable, edematous, red peri‑wound tissue, and later a broad area of denuded skin with exposed tendon extending from mid‑lower leg to ankle. A contracted wound physician later classified the injury as a medical device‑associated Stage IV pressure injury of the right ankle and stated that if he had been notified earlier of soft skin, redness, or bruising, he would have recommended padding between the brace and the skin. The facility’s own change in condition policy required physician notification when there was a significant change in the resident’s condition, but the observed bruising and soft tissue changes under the brace were not reported in a timely manner, resulting in delayed medical evaluation and intervention and the subsequent development of the Stage IV pressure injury.
Failure to Use Gait Belt and Safely Manage Transfers Resulting in Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe ambulation and transfers in accordance with its own policies, resulting in accidents for two residents. One resident with anemia, osteoarthritis, weakness, and difficulty walking had a care plan and aide care card directing staff to provide assistance of one for transfers and ambulation using a rolling walker and a gait belt. The admission MDS documented that this resident required extensive assistance for transfers and ambulation and used both a rolling walker and wheelchair, with no prior history of falls. Despite these documented needs and the facility’s policy requiring gait belt use for residents who cannot ambulate or transfer independently, a nursing assistant assisted the resident with ambulation in the hallway without applying a gait belt. During this assisted ambulation without a gait belt, the resident lost balance and fell to the floor while using a rolling walker. Nursing documentation identified that the resident sustained a skin tear to the left forearm and reported left elbow pain rated 7 out of 10. The resident was transferred to the hospital, where imaging showed posterior elbow soft-tissue swelling and a nondisplaced fracture of the left olecranon. Interviews with an LPN, an occupational therapy assistant, and the DNS confirmed that the nursing assistant had not used a gait belt, that the resident required assistance of one for ambulation, and that facility policy required gait belt use for such residents. Staff also stated that the purpose of the gait belt was to allow staff to maintain a secure grasp if a resident lost balance. The deficiency also includes an incident involving another resident with type 2 diabetes mellitus, dementia, venous insufficiency, anxiety, and peripheral vascular disease, who had severe cognitive impairment and required extensive assistance for transfers. The MDS and aide care card documented that this resident was non-ambulatory and required the assistance of one staff member with a rolling walker for transfers. During a transfer from wheelchair to bed performed by two nursing assistants, the resident was noted afterward to have a new skin tear on the left lateral lower leg, measuring 2.5 cm by 1.5 cm. Facility documentation and staff statements indicated that the resident did not have a skin tear prior to the transfer and that the resident had been agitated and “giving them a hard time” during the transfer, with one aide acknowledging they could have waited for the resident to calm down. The DNS confirmed that the skin tear was identified after the transfer and that the resident had been agitated during the transfer, while also stating that the resident should have been free from any type of accident while care was being provided. The facility’s accidents and supervision policy stated that the environment would be maintained free of accident hazards and that each resident would receive adequate supervision and appropriate assistive devices to prevent accidents.
Failure to Provide Timely Incontinence Care to a Dependent, Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a severely cognitively impaired, nonverbal resident dependent on staff for all ADLs and incontinent care was provided timely personal and incontinence care, resulting in neglect. The resident had diagnoses including Alzheimer’s disease, dementia, and diabetes with chronic kidney disease, and the care plan and CNA care card directed extensive assistance with personal hygiene, toileting, and incontinence care as needed. The resident’s MDS showed a BIMS score of 0/15, frequent bowel and bladder incontinence, and total dependence for ADLs, confirming the need for staff to perform regular checks and care. On the morning in question, the assigned NA on the 7 AM–3 PM shift reported providing peri/incontinent care and transferring the resident out of bed around 7–7:30 AM. The NA stated her usual routine was to return the resident to bed after breakfast but did not do so that day. Around 10 AM, she only repositioned the resident in a tilt-in-space wheelchair and checked for incontinence by smell alone, without touching the brief or checking the brief’s indicator line. Later, when a family member was visiting and wanted the resident to remain up, the NA stated she informed the visitor around 1 PM that the resident needed to return to bed for care; the visitor declined, and the NA did not re-offer care, did not notify the nurse, and did not inform the nurse that the only care provided had been before breakfast approximately seven hours earlier. During the 3 PM–11 PM shift, the next NA reported that the resident remained up in the tilt-in-space wheelchair and that she was unable to provide incontinent care from 3 PM until after the evening meal because she was occupied in the dining room. She stated she was not informed by the off-going NA or the nurse that the resident had not received peri/incontinent care since early that morning. The LPN on the evening shift also reported not being notified that care had been refused earlier or that care had not been provided since before breakfast. When the evening NA finally returned the resident to bed and provided incontinent care around 7 PM, she found the brief heavily wet and the resident incontinent of a bowel movement. Facility leadership and nursing staff confirmed that residents were to be checked and changed every two to three hours, that relying on smell alone to assess incontinence was inappropriate, and that the CNA job description required rounds at the beginning of each shift and every two hours thereafter, which did not occur for this resident.
Noncompliance with Infection Control Policy Due to Staff Artificial and Decorated Nails
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to staff fingernail practices during direct resident care. On observation, a nursing assistant who worked on a resident unit and provided ADL care, incontinent care, and meal service was noted to have gel-like artificial fingernails approximately 1/4 to 1/2 inch long. These nails had multiple round silver/white glitter rhinestone-like raised items and silver-colored metal-like decorative designs attached to several fingernails on each hand. The decorative items were described as raised, firm to the touch, and glued onto the nails. A subsequent observation on the following day confirmed that the same gel-like nails with the raised decorative items and metal-like designs remained in place. During interviews, the nursing assistant confirmed that the glitter-like rhinestone items and silver metal-like designs were glued onto the nails. The DNS stated that while staff were allowed to have gel fake nails, they should be at a comfortable length and that no attached jewels or sharp areas were allowed due to concern for infection. The DNS, Administrator, and a regional RN later acknowledged that the facility allowed staff to wear gel fingernails, and the regional RN stated she believed the attached items were securely in place and thought the gel covered the top of the gems. Review of the facility’s Personal Appearance and Dress Policy showed it required fingernails to be clean, well-manicured, and not so long as to compromise resident safety for employees involved in direct resident care or where infection control may be an issue. Review of WHO guidelines and CDC hand hygiene guidance indicated that artificial nails, including gel nails, are generally prohibited for healthcare workers in direct patient care because they can harbor bacteria and are difficult to sanitize, and that artificial fingernails or extensions should not be worn when having direct contact with high-risk patients.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Detect Methotrexate Transcription Error Leading to Toxicity and Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and verification of a methotrexate order for a resident admitted with diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure. The hospital discharge orders specified methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given one time per week. When the orders were transcribed at the facility, the methotrexate frequency was incorrectly entered as one time per day instead of one time per week. The Medication Administration Record (MAR) generated a dose warning indicating that the entered dose and daily frequency exceeded the usual dosing regimen of one to ten tablets every seven days, but the warning was not acted upon. Multiple required reconciliation and review processes failed to detect the error. An APRN reviewed the discharge paperwork and medication list and approved all medications as written, believing the methotrexate was ordered weekly per the original hospital discharge summary. RN staff responsible for the second check of admission orders did not identify the incorrect daily frequency when reconciling the orders against the hospital discharge paperwork. The physician later reviewed the discharge medications but was not aware that the methotrexate order had been transcribed incorrectly. The pharmacy filled the medication according to the incorrect daily order, and the pharmacy consultant, who was responsible for reviewing medication orders for new admissions, also did not identify the incorrect dosing despite the EMR dose warning. Following the initiation of daily methotrexate, the resident developed progressive clinical signs consistent with methotrexate toxicity. The resident, who was cognitively intact and required moderate assistance with activities of daily living, developed thrush and mouth sores, reported mouth pain and inability to eat, and experienced poor oral intake, nausea, vomiting, and large loose stool. Bloodwork later showed a critically low white blood cell count (0.8), and the resident was identified as neutropenic. The care plan was revised to address neutropenia and altered respiratory status, and the resident was placed on leukopenia precautions. The resident subsequently became hypoxic, required oxygen, and was transferred to the hospital, where diagnoses included neutropenic fever, methotrexate toxicity, and sepsis. The methotrexate medication error—daily administration for nine consecutive days instead of weekly—was discovered at the hospital and was identified by facility staff and providers as a significant medication error that placed the resident in Immediate Jeopardy and resulted in the resident’s death. Interviews with involved staff confirmed the sequence of actions and inactions that led to the deficiency. RN staff acknowledged incorrectly transcribing the methotrexate frequency and failing to detect the error during the supervisory second check. The APRN and physician confirmed they reviewed and approved the medications but did not recognize that the methotrexate had been entered as a daily rather than weekly dose. The pharmacy and pharmacy consultant also did not identify the incorrect dosing despite the EMR dose warning. Facility leadership, including the President of Clinical Services, characterized the incorrect methotrexate administration as a significant medication error and confirmed that the error was not detected by any of the required reconciliation and review processes prior to the resident’s hospitalization and subsequent death.
Removal Plan
- Educated all licensed nursing staff, pharmacy personnel, pharmacy consultants, and medical providers on medication administration, including professional responsibilities for administering medications, second checks on medications for newly admitted residents, reviewing medication orders prior to signing off, Methotrexate weekly dosing, medication reconciliation, and drug alert icons in the EMR.
- Provided one-to-one education to RN #1, RN #2, and pharmacy staff.
- Conducted random audits of residents receiving Methotrexate, other high-risk medications, and all newly admitted residents.
- Reviewed audit results through QAPI and monitored.
- Assigned the Director of Nursing responsibility for implementation and monitoring, with the Administrator maintaining overall regulatory oversight.
Failure to Notify Resident Representative of Repeated Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s Conservator of Person (COP) of significant changes in the resident’s condition over an eight-day period, as required by facility policy. The resident had multiple serious diagnoses, including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring of cardiac status, abnormal breath sounds, difficulty breathing, and signs of heart failure. The resident was cognitively intact per a quarterly MDS, with a BIMS score of 14, and required extensive assistance with ADLs. On one date, APRN #1 was asked to evaluate the resident due to respiratory symptoms and increased wheezing, continued cardiac medications, and ordered a chest x-ray, documenting that the plan was discussed with nursing. On another date, APRN #1 was again asked to evaluate the resident’s respiratory status, but the clinical record from that period did not show that the COP was notified of these changes in condition. Subsequently, nursing documentation showed that the resident became short of breath, with initially normal vital signs, then became hypoxic with an oxygen saturation of 72% on room air, which improved to 93% with 2L oxygen. APRN #1 was notified, administered IV Lasix 40 mg, and ordered STAT labs and a STAT chest x-ray, with continuation of oxygen. The nurse’s note for that event documented that the COP was notified of the change in condition. Later that same day, the resident’s death was pronounced, and the death certificate listed heart failure due to sick sinus syndrome and COPD as the primary cause of death. Review of the clinical record from the earlier dates through the date of death showed no documentation that the COP had been notified of the earlier changes in respiratory condition or the provider evaluations, despite facility policy requiring prompt notification of the resident’s representative for new treatment, acute conditions, deterioration in health, or exacerbation of chronic conditions. Interviews with the President of Clinical Services, APRN #1, and the ADON confirmed that nursing staff should have notified the COP and that the facility failed to follow its Notification of Change Policy during that period.
Failure to Complete Provider-Ordered Chest X-Ray for Resident with Respiratory Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a provider-ordered diagnostic test was obtained and documented for a resident experiencing respiratory symptoms and multiple cardiac and pulmonary comorbidities. The resident had diagnoses including heart failure, atrial fibrillation, sick sinus syndrome, atherosclerotic heart disease, COPD, and Alzheimer’s disease, and was care planned for monitoring abnormal breath sounds, difficulty breathing, and signs of heart failure. On 12/15/25, an APRN evaluated the resident for respiratory symptoms, noted increased wheezing, and ordered a chest x-ray, with the plan discussed with nursing. However, the clinical record from 12/15/25 to 12/23/25 contained no chest x-ray order and no documentation explaining why the chest x-ray was not performed, despite facility policy requiring licensed staff receiving verbal orders to enter them into the medical record and follow through with appropriate notifications. Subsequent provider notes on 12/18/25 documented reassessment of the resident’s respiratory status, with no acute cardiopulmonary process noted and no mention of the previously ordered chest x-ray. On 12/23/25, the APRN again evaluated the resident for increased respiratory distress, administered IV Lasix, and ordered a STAT chest x-ray and STAT labs. Nursing documentation that day showed the resident became hypoxic with an oxygen saturation of 72% on room air, was placed on 2L oxygen with improvement to 93%, and that the APRN was notified and provided additional orders. Later that evening, the resident’s death was pronounced. Interviews with the APRN and multiple nurses who worked on the relevant shifts revealed no one could recall receiving or entering the original chest x-ray order, and there was no documentation to indicate why the chest x-ray ordered on 12/15/25 was not completed, constituting a failure to provide necessary care and services according to provider orders.
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