Twin Maples Healthcare, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Durham, Connecticut.
- Location
- 809 New Haven Road #r, Durham, Connecticut 06422
- CMS Provider Number
- 075431
- Inspections on file
- 22
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Twin Maples Healthcare, Inc during CMS and state inspections, most recent first.
A resident with TBI, dementia, and behavioral disturbances, who required extensive ADL assistance, made generalized complaints about a CNA, stating the CNA was mean and should not be near them. The DON informed the CNA that allegations had been made and removed the CNA from the assignment but did not treat the complaint as a formal grievance, did not obtain detailed information from the resident, did not collect staff statements, and did not document an investigation or findings. The Social Services Director, designated as the grievance official per facility policy, was not notified of the complaint and therefore did not complete a written investigative report or follow-up, resulting in the resident’s grievance not being processed according to the facility’s grievance policy.
A resident with significant mobility impairments and a high fall risk was transferred to the bathroom by only one staff member, contrary to physician orders and facility protocols requiring two-person assistance and the use of a gait belt. The staff member was unaware of the required assistance level and did not use a gait belt, resulting in the resident's foot catching on a bathroom floor lip and causing a fall with multiple fractures. Facility documentation and interviews revealed confusion among staff regarding transfer requirements and inconsistent adherence to safety policies.
A resident with dementia and a history of wandering was not accounted for, and staff delayed notifying police for approximately 45 minutes after discovering the resident was missing, despite facility policy requiring notification within ten minutes. The resident was later found with injuries and required hospital evaluation.
A resident with dysphagia and a history of stroke was served a meal that did not comply with the physician-ordered Level 5 minced and moist diet, resulting in a choking incident that required the Heimlich maneuver. Despite clear dietary orders and care plan interventions, the meal was not prepared as specified, and staff could not explain the deviation.
Annual performance evaluations for nurse aides were not completed as required by facility policy. Personnel file reviews and staff interviews confirmed that no evaluations had been conducted for several years, and the DNS acknowledged not performing these reviews during her tenure. The Administrator was unaware of this lapse, despite the facility's policy mandating annual performance improvement reviews.
Two residents with significant fall and behavioral risks did not have their care plans properly implemented or developed. One resident was left unattended despite a care plan directive, resulting in a fall, while another resident's arm-flailing behavior was not addressed in the care plan, even after staff observed the behavior and the resident sustained a fracture. Lack of communication, documentation, and adherence to care plans contributed to these deficiencies.
A resident with moderate cognitive impairment and a history of falls was left unattended and experienced a fall after attempting to walk to the bathroom alone. Despite this incident, the care plan was not updated to address the new fall, contrary to facility policy requiring ongoing evaluation and intervention for fall prevention.
A nurse without current CPR certification initiated chest compressions for a resident with full code status who became unresponsive after episodes of vomiting and bowel movements. The facility's policy required CPR to be performed by a certified nurse, but documentation of the nurse's certification was not available, and the DON acknowledged the oversight.
Six licensed nurses did not have current IV therapy certifications or documented annual competencies, despite facility requirements for annual education and competency testing in IV-line care and medication administration. The DNS confirmed the lack of documentation and that IV therapy was not part of nursing orientation, with no formal policy provided for IV therapy education.
Multiple vials of Insulin, including Novolog, Lantus, and Aspart, were found in use beyond the 28-day period after opening, contrary to professional standards and facility policy. An LPN admitted to not checking expiration dates before administering Insulin, and staff interviews confirmed that vials should be dated and discarded after 28 days. The facility was unable to provide a specific policy on Insulin use duration after opening.
Two residents with dementia and psychiatric diagnoses did not have pharmacy recommendations regarding their medication regimens addressed within required timeframes. For one resident, pharmacy recommendations about antipsychotic use and blood pressure monitoring were delayed for over six weeks due to communication lapses, and monthly medication review documentation was missing. For another resident, recommendations about PRN psychotropic medication were not discussed with hospice or acted upon, and there was no recordkeeping of pharmacy recommendations. Staff interviews revealed inconsistent practices and expectations for handling pharmacy recommendations, and the facility could not provide relevant policies.
Multiple MDS assessments, including quarterly, annual, and admission types, were not completed within the required 14-day timeframe for several residents. Facility staff confirmed that there was no specific policy for timely MDS completion and that the responsible RN, who worked part-time, had fallen behind, resulting in overdue assessments.
A staff member did not immediately report concerns of possible mistreatment and inappropriate medication administration involving a resident with dementia and significant care needs. The charge nurse also delayed reporting the allegation, resulting in the alleged staff member continuing to work for several days before being removed pending investigation.
A facility failed to ensure complete and accurate documentation for a resident with a scheduled skin inspection who subsequently developed a pressure ulcer. The resident, at risk for pressure ulcers, did not have a documented weekly skin assessment as required. Subsequent evaluations confirmed the presence of an unstageable pressure ulcer and moisture-associated skin damage.
A resident with multiple diagnoses, including multiple sclerosis and dementia, received improper wound care when a nurse failed to change gloves and perform hand hygiene between tasks. The Director of Nursing confirmed the expected procedure, but the facility did not provide a hand hygiene policy.
Failure to Investigate and Document Resident Grievance Against Staff Member
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and ensure a resident’s complaint about a staff member was referred to the designated grievance official, investigated, and documented with findings and resolution. Resident #1 had diagnoses including traumatic brain injury, dementia with behavioral disturbances, conduct disorder, anxiety disorder, and psychosis, and was assessed as having severely impaired cognition, requiring substantial assistance with mobility and total assistance for personal hygiene, toileting, and transfers. The resident’s care plan identified impaired decision-making, a history of making allegations and inappropriate comments toward staff, angry outbursts, and poor social boundaries, with interventions focused on calm, firm approaches, redirection, and support. A behavior note by the Director of Social Services documented that on 2/13/26 the resident was heard making inappropriate comments toward a staff member assisting other residents, which disturbed other residents; the Director of Social Services met with the resident, discussed the behavior, and provided emotional support and reassurance. On a later interview, Resident #1 stated that NA #5 was mean and that they did not want NA #5 near them, though the resident could not provide specific examples or recall the earlier incident. NA #5 reported being the resident’s primary NA on the day shift until being informed by the DON on 2/13/25 that the resident had made generalized allegations against him and that he would no longer be assigned to the resident; NA #5 stated he had never had issues with the resident, the resident had never complained directly to him, and he was not asked to provide a written statement. The Director of Social Services stated she was not aware that the resident had made a complaint about NA #5 beyond the initial behavior incident and acknowledged that a grievance should have been initiated and investigated. The DON reported that after the 2/13/26 incident, the resident told her he was upset because NA #5 was a “chump,” but she did not obtain further details, did not document the complaint as a grievance, did not obtain statements, did not conduct or document an investigation or rationale for determining the complaint unsubstantiated, and did not notify the Director of Social Services. This was inconsistent with the facility’s grievance policy, which designated the Social Worker as the grievance official responsible for preparing a written investigative report and documenting findings and resolution.
Failure to Follow Transfer Protocols and Use Safety Equipment Results in Resident Fall and Multiple Fractures
Penalty
Summary
A deficiency occurred when a resident with significant mobility impairments, including Erb's paralysis, hemiplegia, and a high risk for falls, was not transferred according to the physician's order, rehabilitation screen, and nurse aide assignment card. The resident was assessed to require the assistance of two staff members for stand-pivot transfers, as documented in the care plan, therapy screens, and assignment sheets. However, on the day of the incident, only one staff member, an LPN, assisted the resident during a transfer to the bathroom. The LPN was unaware of the required level of assistance and did not use a gait belt, despite facility policy mandating its use for all transfers requiring physical assistance. During the transfer, the resident's foot became caught on the lip of the bathroom floor, resulting in a fall that caused multiple fractures, including to the right tibia, malleolus, and humerus. The incident was witnessed, but the LPN was unable to prevent the fall. Interviews and documentation revealed inconsistencies and confusion among staff regarding the resident's required level of assistance, with some staff believing only one person was needed, despite clear orders and assignment sheets specifying two. The care assignment was not posted in the resident's room, and gait belts were not consistently available or used by staff. Further review showed that the facility lacked a specific transfer and ambulation policy, and staff did not consistently refer to or follow physician's orders or rehabilitation recommendations. The facility's fall prevention and gait belt policies required identification of fall risks and the use of gait belts for all assisted transfers, but these were not adhered to in this case. The failure to provide adequate supervision, follow prescribed transfer protocols, and use required safety equipment directly led to the resident's fall and subsequent injuries.
Failure to Timely Implement Missing Person Policy for Wandering Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement its Missing Person Policy for a resident with a history of wandering and an identified elopement risk. The resident, who had diagnoses including vascular dementia, hemiplegia, and insomnia, was noted to have memory deficits and was independent with ambulation using a walker. The care plan indicated the use of a wander guard placed in a tennis ball on the walker, as the resident would remove the device if placed on their body. On the date of the incident, the resident was last seen at 4:30 AM, and by 5:15 AM, staff realized the resident was missing. Staff initiated a search of the building's interior and exterior, and the DON was notified at 6:00 AM. Despite the facility's policy requiring police notification within ten minutes of discovering a missing resident, the police were not contacted until 6:03 AM, approximately 45 minutes after the resident was found to be missing. The resident was eventually located at 6:40 AM and was transferred to the hospital for evaluation, where injuries including a skin tear and contusions were identified. Interviews confirmed that staff did not follow the policy's timeline for police notification, and the DON acknowledged the delay in contacting authorities.
Failure to Follow Physician-Ordered Therapeutic Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when the facility failed to follow the physician's recommended therapeutic diet for a resident with a history of cerebral vascular accident and dysphagia. The resident had been assessed by speech therapy and a barium swallow study, both of which recommended a Level 5 minced and moist diet with specific restrictions, including no regular dry bread or mixed consistencies, and required supervised feeding. The care plan and physician's order reflected these recommendations. Despite these clear directives, the resident was served a meal that was not properly prepared according to the prescribed diet, specifically a minced chicken nugget with the sauce not applied as required. As a result of this failure, the resident choked on the food and required the Heimlich maneuver to clear the airway. The incident was documented in the nurse's progress notes, and subsequent evaluation showed no ill effects such as pneumonia or heart failure. Interviews with dietary staff and the DON confirmed that the meal was not prepared as ordered, and the dietary aide could not explain the deviation from the prescribed diet. The facility's policy required consistency with IDDSI guidelines, but this was not followed in this instance.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for its nurse aides as required by its own policy. Review of personnel files for three nurse aides revealed that annual performance evaluations had not been conducted. The Director of Nursing Services (DNS), who has been employed for seven years, confirmed in an interview that she had not completed any nurse aide performance evaluations during her tenure, including the years 2021 through 2025. The facility employs a total of 25 nurse aides across all shifts, and the Administrator was unaware that these evaluations had not been performed. The facility's employee handbook states that performance improvement reviews are to be conducted annually or as needed, but documentation and interviews confirmed this process was not followed.
Failure to Implement and Develop Comprehensive Care Plans for Residents at Risk
Penalty
Summary
The facility failed to implement and develop comprehensive care plans for two residents with significant risks, resulting in deficiencies related to accident prevention and behavioral management. For one resident with schizophrenia, bipolar disorder, and moderate cognitive impairment, the care plan specified that the resident should not be left unattended when out of bed during the day due to a history of unsteady gait and noncompliance with seeking assistance. Despite this, the assigned nurse aide left the resident unattended in their room after providing toileting assistance, which led to the resident falling while attempting to walk to the bathroom. The nurse aide was unaware of the care plan directive and admitted to routinely leaving the resident unattended, indicating a lack of communication and training regarding the resident's specific needs. Another resident, admitted with dementia, multiple fractures, and a history of repeated falls, exhibited behaviors such as flailing arms and fidgeting in bed. Although staff observed and reported these behaviors, there was no documentation or care plan intervention addressing the flailing of arms, despite the potential for self-injury. The care plan focused on the resident's dependence for activities of daily living and transfer needs but did not include strategies to manage or mitigate the behavioral risks. Staff interviews revealed that the director of nursing was not informed of the flailing behavior, and nursing staff did not document these incidents in the resident's record. The facility's failure to identify, document, and address specific behavioral and safety risks in the care plans for both residents resulted in unaddressed hazards and injuries. The lack of communication among staff, absence of thorough documentation, and non-adherence to established care plan interventions contributed directly to the deficiencies cited in the report.
Failure to Revise Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise the care plan for a resident with a history of repeated falls following a new fall incident. The resident, who had diagnoses including schizophrenia, bipolar disorder, and overactive bladder, was identified as having moderate cognitive impairment and required one-person assistance with ambulation and toileting. The care plan in place noted the resident's risk for falls due to an unsteady gait and noncompliance with seeking assistance, with interventions such as ambulation with a walker and not leaving the resident unattended. Despite a physician's order specifying the use of a two-wheeled rolling walker for transfers and ambulation, the resident experienced a fall after being left unattended in their room. Following the fall, documentation showed that the resident was last assisted with toileting and later found on the floor after attempting to walk to the bathroom alone. The post-accident report and care plan review revealed that the care plan was not updated after the incident to address the new fall and prevent future occurrences. The Director of Nursing Services (DNS) acknowledged that the care plan had not been revised, citing a lack of additional interventions to implement. This failure to update the care plan was not in accordance with the facility's fall prevention policy, which requires evaluation and implementation of measures to prevent falls for at-risk residents.
Failure to Ensure Staff Maintained Current CPR Certification
Penalty
Summary
A deficiency occurred when a nurse failed to maintain current CPR (cardiopulmonary resuscitation) certification while being responsible for providing emergency care to a resident. The resident, who had diagnoses including Parkinson's disease and hypertension, was identified as having moderate cognitive impairment and required two-person assistance for mobility and toileting. The resident's care plan and physician's orders specified full code status, indicating that all life-saving measures, including CPR, were to be implemented in the event of a medical emergency. On the evening in question, the resident experienced multiple episodes of vomiting and bowel movements, after which the nurse assessed the resident and found them unresponsive with no pulse. The nurse initiated chest compressions and emergency medical services were called. However, upon review, the nurse was unable to provide documentation of current CPR certification, and the Director of Nursing Services acknowledged that maintaining the nurse's certification had been overlooked. Facility policy required that CPR be performed by a CPR-certified licensed nurse, but no evidence of the nurse's prior certification was provided.
Failure to Maintain IV Therapy Competencies for Licensed Nursing Staff
Penalty
Summary
The facility failed to ensure that six out of eleven licensed nursing staff had current intravenous (IV) therapy certifications or completed annual competencies as required. Review of the IV Therapy Certifications and Infusion Medications Administration Competencies binder revealed that several registered nurses and one LPN did not have documentation of IV therapy certification or recent competency assessments. Some staff had outdated competencies, and others had no record of certification or competency completion at all. The Director of Nursing Services (DNS) confirmed that she was responsible for overseeing the IV therapy program and staff education but acknowledged that the facility did not have up-to-date documentation for these staff members. The DNS stated that IV therapy was not included in the nursing orientation and that, although she had observed and validated the nurses administering IV medications or fluids, there was no formal documentation of these competencies. The facility assessment required all staff to receive education and competency testing in specialized care areas, including IV-line care, and mandated annual competency evaluations for licensed nursing staff in medication administration, including intravenous routes. Despite these requirements, the facility did not provide a policy for IV therapy education or documentation of completed competencies when requested.
Failure to Discard Insulin Vials After 28 Days
Penalty
Summary
The facility failed to discard multiple vials of Insulin 28 days after opening, as required by professional standards and facility policy. During an observation of a medication cart, several vials of Novolog, Lantus, and Aspart Insulin were found to be in use beyond the 28-day period indicated on their labels and stickers. The vials were partially full and had open dates that exceeded the allowed timeframe for use. The charge nurse responsible for administering medications admitted to not checking the dates on the Insulin vials prior to use and confirmed that she had administered Insulin from these expired vials recently. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the protocol required nurses to date Insulin vials upon opening and to discard them after 28 days. The DNS also stated that nurses should check expiration dates before each use. Despite these policies, the facility did not provide a specific policy on the length of time Insulin can be used after opening when requested. The failure to follow established procedures resulted in the use of expired Insulin for resident care.
Failure to Address Pharmacy Recommendations in a Timely Manner
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding residents' medication regimens were addressed in a timely manner, as required by policy and regulatory guidelines. For one resident with dementia and mood disturbances, there was no documentation of a monthly medication review by a pharmacist for a specific month, and pharmacy recommendations regarding the use of Seroquel and monitoring for orthostatic blood pressure changes were not communicated to the psychiatric APRN for over six weeks. The Director of Nursing acknowledged that the pharmacy recommendation was not placed in the APRN communication book, resulting in a significant delay in provider review and response. Additionally, the recommended orthostatic blood pressure monitoring was not implemented as directed by the pharmacy. For another resident with anxiety disorder and dementia, pharmacy recommendations regarding the continued use and justification of PRN Ativan were not addressed. The Director of Nursing did not discuss the recommendations with hospice, who was involved in the resident's care, and there was no recordkeeping of pharmacy recommendations after they were received by the facility. The psychiatric APRN was not made aware of the need to re-evaluate the PRN Ativan until prompted by surveyor inquiry, and the facility's process for ensuring timely review and response to pharmacy recommendations was not followed. Interviews with facility staff, including the Director of Nursing, medical director, and APRNs, revealed inconsistent expectations and practices regarding the handling and documentation of pharmacy recommendations. The facility was unable to provide a policy for pharmacy recommendations and monthly reviews when requested. These failures resulted in pharmacy recommendations not being addressed within the expected timeframes and a lack of documentation and follow-through on medication regimen reviews for the residents involved.
Failure to Complete MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete Minimum Data Set (MDS) assessments within the required 14-day timeframe for eight out of ten sampled residents. Clinical record reviews and facility documentation showed that several types of MDS assessments, including quarterly, annual, and admission assessments, remained in process past their due dates. The residents affected included those requiring both routine and admission assessments, and the deficiency was identified through direct review of records and interviews with facility staff. Interviews with the MDS Coordinator, a registered nurse, and the Director of Nursing (DON) confirmed that the facility did not have a specific policy for timely MDS completion but relied on the guidance from the Long-Term Care Facility RAI 3.0 User's Manual. Both staff members acknowledged that the assessments were overdue and attributed the delay to the MDS Coordinator working part-time and falling behind. The manual requires that admission MDS assessments be completed within 13 days of entry and other comprehensive assessments within 14 days of the Assessment Reference Date, which was not met for the sampled residents.
Failure to Timely Report Alleged Mistreatment and Suspected Abuse
Penalty
Summary
A staff member failed to immediately report an allegation of mistreatment involving a resident with vascular dementia, hallucinations, visual impairment, depression, and incontinence, who required maximum assistance with activities of daily living. The incident occurred when a nurse aide overheard another aide state an intention to give the resident liquid Melatonin and observed the resident yelling 'stop' during a shower, though she did not witness rough handling. Despite these concerns, the aide did not report the incident right away, instead contacting the charge nurse at home the following day. The charge nurse, upon receiving the report, did not immediately escalate the allegation, citing uncertainty about the required procedure. As a result, the alleged perpetrator continued to work for three days before the concern was reported to the nursing supervisor and the staff member was removed pending investigation. Documentation shows that the resident's family was notified and a body check was performed, but the delay in reporting meant the alleged staff member remained in contact with residents during the interim.
Failure to Document Weekly Skin Assessment Leading to Pressure Ulcer
Penalty
Summary
The facility failed to ensure complete and accurate documentation for a resident with a scheduled skin inspection who subsequently developed a pressure ulcer. Resident #1, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and dementia, was identified as being at risk for pressure ulcers. The resident's care plan included interventions such as using an alternating pressure mattress and limiting time seated in a wheelchair. A physician's order directed a weekly skin assessment on Fridays during the 3:00 PM - 11:00 PM shift. However, the clinical record lacked a documented weekly skin assessment for 10/27/23. On 11/1/23, a nurse's note identified that Resident #1 had developed an open area to the coccyx, which appeared necrotic, and a second macerated area. Subsequent evaluations confirmed the presence of an unstageable pressure ulcer and moisture-associated skin damage. During an interview, RN #1, who was responsible for the weekly skin inspection on 10/27/23, stated that she completed the assessment but may not have documented it. The Director of Nursing confirmed the expectation for weekly skin assessments. Despite requests, a policy for complete and accurate documentation was not provided.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure appropriate infection control practices were followed for a resident receiving wound treatment. Resident #1, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and dementia, was identified as having an unstageable pressure ulcer. A physician's order directed specific wound care procedures, including irrigating the wound with normal saline and packing it with moistened gauze. During an observation of the wound treatment, a registered nurse did not change gloves or perform hand hygiene between tasks, which is a breach of infection control protocols. The nurse admitted to being nervous and skipping the necessary steps. The Director of Nursing confirmed that the expected procedure is to change gloves and perform hand hygiene between dirty and clean tasks. Despite a request, the facility did not provide a policy for hand hygiene during wound care. This incident highlights a failure in adhering to infection control practices, specifically during the wound care process for Resident #1.
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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