Villa Maria Nursing And Rehabilitation Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Plainfield, Connecticut.
- Location
- 20 Babcock Avenue, Plainfield, Connecticut 06374
- CMS Provider Number
- 075084
- Inspections on file
- 25
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Villa Maria Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
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.
The facility did not consistently update or review resident care plans within the required timeframe following care conferences for three residents with complex medical and cognitive needs. Staff interviews confirmed that care plans were not revised as required and that care conferences were not always held quarterly, with no clear explanation for these lapses.
Multiple residents reported receiving cold food and insufficient portions, with direct temperature checks confirming that both hot and cold foods were served outside of safe and palatable temperature ranges. The Dietary Director acknowledged the issue, and observations showed that food not meeting temperature standards was still served to residents.
Two residents experienced deficiencies related to lack of timely physician notification: one resident with multiple comorbidities developed hypotension and respiratory symptoms after nitroglycerin administration, but staff did not notify the physician or reassess vital signs promptly; another resident did not receive prescribed Prozac for two days due to pharmacy delivery issues, and the LPN failed to notify the supervisor or physician about the missed doses.
Staff failed to promptly report allegations of sexual abuse and missing personal property involving three residents to the State Agency as required. In one case, a cognitively intact resident reported inappropriate behavior by a nurse aide, but the administrator did not notify authorities, dismissing the claim. In two other cases, residents' missing cell phones were reported to staff, but the incidents were not escalated or documented according to policy, resulting in delayed investigation and reporting.
A resident with multiple medical conditions and no cognitive impairment reported that a nurse aide exposed her breasts and acted inappropriately. The allegation was reported to supervisory staff and the Administrator, but no investigation was initiated, and the accused staff member remained on the facility schedule, contrary to policy. The incident was not addressed until brought to attention by surveyors.
Two residents experienced deficiencies in care when staff failed to follow professional standards and facility policy. In one case, a resident with obvious injuries from a fall was physically lifted by staff before EMS arrival, despite policy prohibiting movement prior to assessment. In another case, a resident with a significant change in condition, including hypotension and chest pain, did not receive an RN assessment or timely physician notification, and was sent for hemolytic treatment without appropriate evaluation.
A resident with end stage renal disease and multiple comorbidities experienced a significant change in condition, including chest pain and low blood pressure, but staff failed to communicate this to the dialysis center prior to the resident's scheduled treatment. Documentation and required information exchange between the facility and the dialysis center were not completed as required, resulting in the resident being sent to dialysis in an unstable condition and subsequently requiring emergency care.
A resident with lower limb wounds received wound care from an LPN who failed to perform hand hygiene between glove changes after removing soiled dressings and before cleansing and dressing the wounds. Interviews with facility leadership and review of policy confirmed that hand hygiene was required at these points, but the protocol was not followed, resulting in a deficiency.
Three residents with significant medical conditions did not have their COVID-19 vaccination status identified, were not offered the vaccine, and did not receive documented education about the vaccine. Care plans and health records lacked required information, and the Infection Preventionist confirmed that vaccination status and education were not tracked or provided, contrary to facility policy.
A resident with dementia and a history of right leg fractures, who required a hinged knee brace and assistive device for transfers, was assisted by two nurse aides after a shower without the knee brace being reapplied and without use of the designated device. The resident's knees buckled during the transfer, resulting in a fall and an acute proximal tibia fracture. Staff interviews revealed the aides did not review the care plan or Kardex and were unaware of the specific transfer requirements.
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 Timely Update and Review Resident Care Plans
Penalty
Summary
The facility failed to review and revise resident care plans (RCPs) and did not conduct care plan conferences as required for three sampled residents. For one resident with diagnoses including malignant neoplasm, chronic heart failure, and PTSD, the care plan was not updated within 5-7 days following several resident care conferences, despite the resident having no cognitive impairment and requiring significant assistance with daily activities. Interviews with facility staff confirmed that care plans were not updated in a timely manner after multiple care conferences, and staff could not provide reasons for these delays. Another resident, diagnosed with dementia, diabetes, and anxiety, had severe cognitive impairment and required moderate assistance with personal care. The care plan for this resident was also not updated within the required timeframe after several care conferences. Additionally, there was a significant gap between care conferences, exceeding the required quarterly schedule, which staff attributed to a change in staffing but could not otherwise explain. A third resident with hemiplegia, diabetes, and moderate cognitive impairment also experienced delays in care plan updates following care conferences. Facility policy requires care plans to be developed within 7 days of the comprehensive MDS and updated at least quarterly, but this was not consistently followed. Staff interviews confirmed the lapses in timely care plan updates and the inability to account for the missed deadlines.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported receiving cold food, including cold toast, coffee, eggs, and meat that was sometimes raw. One resident stated that he remained hungry after meals due to insufficient food portions. Direct temperature checks conducted by surveyors and the Dietary Director revealed that hot foods such as chicken nuggets and French fries were served below the recommended palatable temperature of 140°F, with recorded temperatures as low as 116.0°F and 96.2°F, respectively. Cold food items, such as coleslaw, were found to be served at 57.1°F, exceeding the safe maximum of 45°F for cold foods. Observations indicated that the coleslaw was not promptly removed from plates after it was found to be above the safe temperature, and it continued to be delivered to residents. The Dietary Director acknowledged the temperature issues, attributing the heat loss to inadequate plate lids. The Administrator confirmed awareness of resident complaints regarding cold food. Review of the facility's food preparation and serving policy showed a requirement to maintain proper hot and cold temperatures during food service, which was not met during the survey period.
Failure to Notify Physician of Change in Condition and Medication Omission
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident, who was alert and oriented, experienced chest pain and was administered nitroglycerin as ordered. Following this, the resident developed hypotension, with blood pressure readings dropping to 80/40 and remaining low for several hours. Despite these abnormal findings and the resident presenting with increased lethargy, mild shortness of breath, and diminished lung sounds, there was no documentation that the physician or hemolytic center was notified of these changes. Nursing staff did not reassess vital signs in a timely manner, and the resident was sent to hemolytic treatment without physician notification. Upon return, the resident was found to be unstable and was sent to the emergency room, where they were admitted for hypoxic respiratory failure and exhibited stroke-like symptoms. In a separate incident, the facility failed to notify the physician when a prescribed medication was not available for administration to another resident. The resident, who was cognitively intact and required psychotropic medication for depression, did not receive Prozac as ordered on two consecutive days due to the medication not being delivered by the pharmacy. The responsible LPN did not notify the nursing supervisor, contact the pharmacy, or inform the physician about the missed doses. The MAR and nursing notes did not provide an explanation for the missed medication administration, and the issue was only addressed after the RN supervisor was informed by the LPN on the following day. Facility policy required immediate reporting of changes in condition to the unit manager or shift supervisor, assessment and documentation of the resident's status, and prompt notification of the physician for non-emergent changes. Additionally, policy required that discrepancies or omissions in medication delivery be reported to the pharmacy and charge nurse. In both cases, staff failed to follow these policies, resulting in a lack of timely physician notification for significant changes in condition and medication administration issues.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse and misappropriation of property to the State Agency as required by policy and regulation. In one instance, a resident with a history of malignant neoplasm, chronic heart failure, and post-traumatic stress disorder, who was cognitively intact, reported that a nurse aide had exposed herself and engaged in inappropriate behavior. The resident communicated this to another nurse aide, who then reported it to a registered nurse and the facility administrator. Despite these reports, the administrator did not notify the State Agency, dismissing the incident as a hallucination, and the nurse aide in question continued to work, only being removed from the resident's care assignment. Multiple staff interviews confirmed knowledge of the allegation, but no timely report was made to authorities as required by the facility's abuse policy. In another case, two residents with chronic medical and psychiatric conditions reported missing cell phones. One resident reported the missing phone to the Therapeutic Recreation Director, who searched for the phone but did not escalate the issue to the administrator or complete a grievance. The Director of Environmental Services was also informed but did not file a report, assuming the issue had already been addressed. The second resident reported the missing phone to a nurse aide, who searched for the phone but did not report the incident, believing others were already aware. In both cases, the missing property was not reported to the appropriate supervisory staff or the State Agency in a timely manner, as required by facility policy. Interviews with facility leadership, including the Director of Nursing and the administrator, revealed that staff were expected to report such incidents immediately, but this did not occur. The facility's abuse prohibition policy clearly directed staff to report any knowledge of abuse, neglect, or misappropriation of property to supervisors and the State Agency within specified timeframes. Despite this, staff failed to follow reporting protocols, resulting in delayed notification and investigation of the allegations.
Failure to Investigate and Remove Staff Following Sexual Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident with diagnoses including malignant neoplasm of the head, face, and neck, congestive heart failure, and post-traumatic stress disorder. The resident, who was cognitively intact and dependent on staff for personal hygiene and transfers, reported that a nurse aide had exposed her breasts and behaved inappropriately. The resident informed another nurse aide, who reported the incident to a registered nurse and the Administrator. Despite this, the Administrator dismissed the allegation as a hallucination and did not initiate an investigation. The nurse aide accused of abuse continued to work in the facility and was only removed from the resident's care assignment, not from the facility schedule. Multiple staff interviews confirmed that the allegation was reported up the chain of command, but neither the Director of Nursing Services nor the State Agency was notified at the time. The facility's abuse reporting policy required immediate notification of the Administrator, a thorough investigation, and removal of the alleged perpetrator from resident contact pending investigation. These steps were not followed, as the staff member remained on the schedule and the incident was not investigated until prompted by surveyor inquiry. The failure to act according to policy resulted in a lack of protection for the resident and a delay in addressing the abuse allegation.
Failure to Follow Professional Standards in Resident Assessment and Post-Fall Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two separate incidents involving two residents. In the first incident, a resident with a history of dementia, depression, heart failure, and hypertension, who was at risk for falls, experienced a fall in the dining room. The resident was found on the floor with a head injury, visible deformity of the left wrist, and hip pain. Despite the presence of obvious injuries, including a shortened leg indicative of a hip fracture and a visible wrist deformity, three staff members physically lifted the resident from the floor to a chair before emergency medical services arrived. This action was contrary to the facility's policy, which directs staff not to move a resident with suspected injury until evaluated by a physician or EMS. Interviews with staff and review of facility policy confirmed that the resident should not have been moved, and the Director of Nursing was unable to explain why this occurred. In the second incident, another resident with end stage renal disease, diabetes, hypertension, and a history of stroke-like events, experienced a change in condition characterized by chest pain, hypotension, increased lethargy, mild shortness of breath, and diminished lung sounds. The resident was administered nitroglycerin for chest pain, but subsequent blood pressure readings revealed abnormally low values. Despite these findings, there was no documentation that a Registered Nurse assessed the resident or that the physician was notified of the change in condition. The resident was sent for hemolytic treatment without further assessment or notification to the treatment center regarding the change in condition. Interviews with LPNs and review of the clinical record confirmed that no RN assessment or provider notification occurred during this period. Both incidents demonstrate failures to follow established standards of practice and facility policies regarding the assessment and management of residents with injuries or changes in condition. The deficiencies were identified through observations, record reviews, staff interviews, and review of facility policies, which clearly outlined the required procedures that were not followed in these cases.
Failure to Communicate Resident Status to Dialysis Center
Penalty
Summary
The facility failed to ensure appropriate communication and documentation with the dialysis (hemolytic) treatment center for a resident with end stage renal disease, diabetes, hypertension, and a history of cerebral infarction. The resident required regular dialysis treatments and had a care plan in place that specified the need for communication with the dialysis center regarding medications, treatments, and coordination of care. However, a review of records from November 2024 through June 2025 revealed a lack of documentation from the dialysis center and no evidence that facility staff had communicated essential information such as diagnoses, current medications, dietary needs, assistance required for activities of daily living, fluid needs, or changes in condition. On one occasion, the resident experienced a significant change in condition, including chest pain, administration of nitroglycerin, and a drop in blood pressure. Despite these changes, the nurse on the following shift did not recheck vital signs or inform the dialysis center of the resident's unstable condition before sending the resident for treatment. Upon arrival at the dialysis center, the resident was noted to be lethargic, short of breath, and hypotensive, prompting the dialysis center to administer treatment at a minimal level and monitor the resident closely. After returning from dialysis, the resident remained unstable and was sent to the emergency department. Interviews with facility staff and the dialysis center nurse confirmed that there was no communication from the facility regarding the resident's change in condition. The facility's own communication tool and policy required that information about recent medications, signs of infection, and changes in condition be shared with the dialysis center, but this was not done. The Director of Nursing acknowledged that required documentation and communication had not been completed since the resident's admission.
Failure to Ensure Proper Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified in the facility's infection prevention and control program related to improper hand hygiene during wound care for a resident with multiple lower limb wounds, including cellulitis, chronic ulcers, and deep tissue injuries to both heels. The resident required significant assistance with mobility and had physician orders for daily wound care on both heels. During an observed wound care procedure, an LPN failed to perform hand hygiene between glove changes after removing soiled dressings and before cleansing and dressing the wounds. Specifically, the LPN removed gloves and donned new gloves multiple times without performing hand hygiene, despite being interrupted and acknowledging the correct procedure. Further interviews with facility leadership, including the Director of Nursing Services and the Infection Preventionist, confirmed that hand hygiene should be performed before care, with each glove change, and after care is complete. Review of the facility's policy also indicated that staff are required to wash or sanitize hands after removing soiled dressings and before applying clean dressings. The observed failure to follow these protocols during wound care led to the identified deficiency.
Failure to Identify, Offer, and Document COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to identify, offer, and document COVID-19 vaccination status and education for three residents with various medical conditions, including cellulitis, lymphedema, diabetes, end stage renal disease, protein calorie malnutrition, Alzheimer's disease, rheumatic tricuspid insufficiency, and chronic kidney disease. For each resident, the care plans and electronic health records did not reflect COVID-19 vaccination status, documentation of vaccine education, or evidence that the vaccine was offered. Additionally, there were no physician orders related to COVID-19 vaccination for these residents. During an interview and review of records with the Infection Preventionist, it was confirmed that the vaccination status and education for these residents had not been obtained or provided, and none of the residents appeared on the vaccination log. The Infection Preventionist indicated that staff were no longer required to offer or track COVID-19 vaccination for residents. This was inconsistent with the facility's own policy, which required education, offering the vaccine, and documentation of these actions.
Failure to Apply Required Knee Brace and Use Assistive Device Results in Resident Fall and Fracture
Penalty
Summary
A deficiency occurred when staff failed to apply a required hinged knee brace to a resident's right leg prior to assisting the resident to stand, which resulted in the resident's leg buckling and a subsequent fall. The resident, who had a history of dementia, a lower end right femur fracture, osteoarthritis of the right knee, and generalized weakness, was dependent on staff for transfers and had physician orders and care plan interventions specifying the use of a hinged knee brace during weight-bearing activities and transfers. The care plan also required the use of a specific assistive device and assistance from two staff members for transfers. On the day of the incident, two nurse aides assisted the resident with a shower and removed the knee brace for the shower. After the shower, they attempted to help the resident stand to dry off without reapplying the knee brace and without using the designated assistive device. As the resident was assisted to stand, the knees buckled twice, and the aides lowered the resident to the floor. The resident was subsequently found to have sustained an acute fracture of the proximal tibia and required transfer to the hospital for evaluation and treatment. Interviews and facility documentation confirmed that the nurse aides did not review the resident's care requirements in the Kardex and were unaware of the orders for the knee brace and assistive device. The Director of Nursing confirmed that the aides failed to follow the plan of care, which led to the resident's fall and injury. Facility policies required staff to provide care in accordance with the resident's care plan and to prevent decline in functional status.
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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