Water's Edge Center For Health & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Middletown, Connecticut.
- Location
- 111 Church Street, Middletown, Connecticut 06457
- CMS Provider Number
- 075381
- Inspections on file
- 27
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Water's Edge Center For Health & Rehab during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and pain was ordered a Fentanyl 12 mcg transdermal patch every 72 hours. After an LPN removed a patch early, an RN supervisor obtained a verbal order to replace it but mistakenly entered Fentanyl 75 mcg into the eMAR and co‑signed the order alone. Nursing staff continued to administer 12 mcg patches while documenting 75 mcg on the MAR, without fully verifying the order against the medication packaging. Later, an APRN, not recognizing the erroneous increase in the record, refilled the prescription at 75 mcg, the pharmacy dispensed that strength, and a 75 mcg patch was applied. The resident subsequently developed decreased respirations and low oxygen saturation, and the discrepancy between the intended 12 mcg dose and the administered 75 mcg patch was identified as a clinically significant medication error.
A resident with osteoarthritis, anxiety, Alzheimer’s dementia, impaired cognition, incontinence, and unsteady gait was identified as a fall risk and care planned for supervise/touching assist with toileting and personal hygiene, use of a cane, and non-skid socks, but had no documented scheduled toileting or prompted voiding program. During one bathroom assist, a NA partially closed the door and turned away to provide privacy, after which the resident sustained an unwitnessed fall with head strike and a right distal humerus fracture. Documentation later described the resident as noncompliant with transfers and frequently ambulating without assistance or using the call light. The resident was subsequently found on the bathroom floor again after attempting to use the toilet, this time with severe left upper extremity pain and a left displaced comminuted distal humerus fracture, demonstrating that supervision and fall-prevention interventions were not effectively implemented for this high-risk, cognitively impaired resident.
A cognitively impaired resident with osteoarthritis, anxiety, and Alzheimer’s dementia, who was frequently incontinent and not on a toileting program, did not have a comprehensive, person-centered care plan that included scheduled toileting or prompted voiding despite documented fall risk and self-care deficits. The care plan called for supervised/touching assist with toileting and personal hygiene and general fall-prevention measures, but lacked a structured toileting program. The resident was assisted to the bathroom by a NA, who partially closed the door and turned away, then found the resident on the floor after an unwitnessed fall that resulted in a distal humerus fracture. Later documentation noted ongoing issues with transfers, unassisted ambulation without using the call light, and another bathroom fall causing a second distal humerus fracture, while facility policies required ADL assistance and fall-prevention interventions to be based on a person-centered evaluation and incorporated into the care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with atrial fibrillation was given Aspirin 81 mg daily instead of the prescribed twice-weekly dose due to a transcription error by a nurse, which was not caught by the orienting nurse or through the facility's required second-check process. The error resulted in the resident receiving the medication more frequently than ordered until the mistake was discovered after discharge.
A resident with severe cognitive impairment sustained a facial injury during care, and a nursing assistant later alleged that another staff member may have struck the resident. The allegation was not reported to a supervisor or the state agency until five days after the incident, contrary to facility policy requiring immediate reporting of abuse allegations.
A resident with severe cognitive impairment and total dependence for ADLs did not receive care according to their plan, which required two staff for assistance. Instead, a nurse aide provided care alone while the resident was agitated, resulting in the resident sustaining a left eye bruise and cut from a Hoyer lift sling attachment. Documentation and interviews confirmed the aide was aware of the two-person requirement but proceeded alone due to delays in obtaining help.
A resident with dementia experienced an unwitnessed fall, resulting in a minor head contusion. Despite facility policy requiring neurological monitoring, the medical record lacked documentation of completed assessments. The DNS confirmed monitoring was done but could not provide the records, indicating a failure to maintain accurate documentation.
A resident with dementia and traumatic brain injury, at high risk for elopement, was able to exit a secured unit unsupervised due to an expired wander guard. Despite weekly checks, the device was not replaced, allowing the resident to access the elevator and leave the facility. Staff failed to document elopement behaviors or conduct required monitoring, and the facility's policies on wander guard usage and elopement prevention were not followed.
The facility failed to maintain a clean, sanitary, and homelike environment across all units, with issues such as damaged and stained floors, walls, and ceilings observed. The Director of Maintenance was aware of some issues but did not document findings, while the ADNS and DNS were unaware of the extent of the problems. The facility's infection prevention program requires monthly rounds, but documentation was lacking.
A resident with dementia and other medical conditions experienced a significant delay in receiving dentures due to poor communication and follow-up by the facility. Despite initial steps taken in 2021 and 2022, the resident did not receive dentures for over two years, even though dental services were available. The facility failed to adhere to its policy of providing necessary dental care and documenting delays.
The facility failed to serve food at a safe temperature, as observed during a test tray evaluation. The main entree and peas were found to be below the required temperature of 140 degrees Fahrenheit. The FSD could not explain the temperature drop, despite meals being plated on a warming tray and delivered quickly. Facility policy requires action if food temperatures fall below 135 degrees Fahrenheit.
The facility failed to maintain sanitary conditions in the kitchen, with surveyors observing unsanitary conditions such as empty trash bags and boxes on countertops, opened and undated food items, and improperly stored non-resident items. The FSD cited short staffing as a challenge in adhering to cleaning schedules and storage expectations. The facility's policies on food storage and sanitation were not met, as confirmed by the DNS and Administrator.
The facility failed to notify resident representatives and physicians of significant changes in condition for two residents. One resident, at high risk for elopement, left a secured unit twice without proper notification or documentation. Another resident experienced eye discomfort and a rash, but the physician and representative were not promptly informed. Interviews revealed lapses in communication and adherence to facility policies.
The facility failed to monitor and document care for two residents, one with itchy skin and another with edema. The first resident did not receive prescribed anti-itch medication, and there was no behavior monitoring. The second resident was not assessed by an RN for eye discomfort and did not consistently receive compression stockings as ordered. Lack of policies and adherence to physician orders contributed to these deficiencies.
A resident with multiple diagnoses, including a fractured kneecap and gout, experienced inadequate pain management over a weekend due to a lack of prn medication orders and failure of staff to contact the physician for additional pain relief. Despite expressing significant pain, the resident was not provided further Acetaminophen, resulting in a sleepless night. The facility's Pain Management Policy, which requires prompt evaluation and treatment, was not adhered to, leading to unmanaged pain.
A facility failed to provide a bed hold notice to a resident with intact cognition during four hospital transfers, despite policy requirements. The resident, admitted with bowel obstruction and anemia, only signed the notice at admission. Interviews revealed that the RN Supervisor did not follow the procedure to send the notice with the resident, contrary to facility policy.
Significant Fentanyl Patch Dosing Error and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error related to Fentanyl transdermal patches. The resident had diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, chronic respiratory failure, and congestive heart failure, and had severely impaired cognition. Physician orders from early November through late February directed application of a Fentanyl 12 mcg patch every 72 hours for pain, and controlled substance disposition records showed that 12 mcg patches were dispensed and applied on that schedule. The resident’s care plan identified actual pain related to disease process and altered respiratory status related to chronic respiratory failure, with interventions to administer medications as ordered and monitor for effectiveness and side effects. On one shift, an agency LPN removed the resident’s Fentanyl patch a day earlier than scheduled and then realized there was no order to replace it. The LPN notified the RN supervisor, who contacted the APRN and obtained a verbal order to replace the patch and continue the 72‑hour cycle. When entering the new order into the electronic MAR, the RN supervisor inadvertently selected Fentanyl 75 mcg instead of 12 mcg and co‑signed the order herself rather than obtaining a second nurse verification. Subsequent review of controlled substance disposition records showed that no 75 mcg patches were dispensed at that time and that 12 mcg patches continued to be applied on multiple dates, while the February MAR reflected that staff were documenting administration of a 75 mcg patch on those same dates. Nursing staff continued to sign for Fentanyl 75 mcg on the MAR even though only 12 mcg patches were being dispensed and applied, and they did not fully read and verify the physician’s order against the medication packaging. Later, the APRN refilled the Fentanyl prescription and, not recognizing that the dose in the record had been erroneously increased, accidentally refilled the prescription for Fentanyl 75 mcg instead of 12 mcg. The pharmacy then dispensed 75 mcg patches, and the first 75 mcg patch was applied to the resident. After application of the 75 mcg patch, the resident experienced a change in condition characterized by a decreased respiratory rate and low oxygen saturation on room air, which improved with repositioning and supplemental oxygen. The event was identified as a clinically significant medication dose discrepancy, with the patch in place being Fentanyl 75 mcg while the intended dose was 12 mcg. Interviews with the DNS, APRN, RN supervisor, and pharmacist confirmed that the incorrect 75 mcg order had been entered into the eMAR, that the APRN later refilled the higher dose in error, and that nursing staff failed to follow the facility’s medication administration policy and the six rights of medication administration, resulting in the resident receiving a Fentanyl 75 mcg patch instead of the ordered 12 mcg dose.
Failure to Adequately Supervise High-Risk Resident During Toileting Leading to Recurrent Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention interventions for a cognitively impaired resident with incontinence and a known fall risk, resulting in two unwitnessed falls with major injuries. The resident had osteoarthritis of the knee, anxiety, and Alzheimer’s dementia, with a BIMS score of 5, was frequently incontinent of bowel and bladder, and was not on a toileting program. The resident’s care plan identified a self-care deficit related to weakness and deconditioning, with interventions including toileting and personal hygiene using a straight point cane with supervise/touching assist of one staff, and dementia-related interventions to anticipate and meet needs. The care plan also identified potential for falls due to unsteady gait, with interventions such as non-skid socks, monitoring for gait changes, and offering diversional activities including toileting and ambulating. However, the clinical record did not show a scheduled toileting or prompted voiding program to address incontinence and toileting needs. On one occasion, the resident was assisted to the bathroom by a nursing assistant, who opened the bathroom door and observed the resident place the cane in the sink. The nursing assistant, aware that the resident liked privacy, partially closed the door and turned away, after which a sound was heard and the resident was found on the floor with a head strike and painful right forearm, later diagnosed as a bicondylar intra-articular fracture of the distal humerus. The DNS stated that at the time of this first fall, the resident was care planned as a supervised assist of one for toileting and personal hygiene, meaning staff were to supervise the ADL to allow for cueing and assistance, and acknowledged that the nursing assistant did not provide constant supervision because his back was turned. Subsequent documentation noted the resident was noncompliant with transfers and was observed multiple times ambulating without assistance and not using the call light. Later, the resident was found lying on the bathroom floor on the left side after using the bathroom, complaining of severe left upper extremity pain and inability to move the arm, and was diagnosed with a left displaced comminuted fracture of the distal humerus. These events occurred despite the resident’s known cognitive impairment, incontinence, unsteady gait, and identified fall risk.
Failure to Develop Comprehensive Toileting and Fall-Risk Care Plan for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a cognitively impaired resident’s toileting needs and fall risk, including the absence of a scheduled toileting or prompted voiding program. The resident had osteoarthritis of the knee, anxiety, and Alzheimer’s dementia, with a BIMS score of 5 indicating impaired cognition, and was frequently incontinent of bowel and bladder without being on a toileting program. The Resident Care Plan identified self-care deficits related to weakness and deconditioning, dementia with an intervention to anticipate and meet needs, and potential for falls due to unsteady gait, with interventions such as supervised/touching assist for toileting and personal hygiene, use of non-skid socks, monitoring gait changes, and offering diversional activities including toileting and ambulating. However, the care plan did not include a structured toileting schedule or prompted voiding program despite the resident’s incontinence and cognitive impairment. The resident experienced an unwitnessed fall in the bathroom with a head strike, resulting in a frontal head hematoma and a painful right forearm, and was later diagnosed in the ED with a bicondylar intra-articular fracture of the distal humerus. At the time of this fall, the resident was assisted to the bathroom by a NA, who opened the bathroom door, observed the resident place a cane in the sink, then partially closed the door to provide privacy and turned away, subsequently hearing a sound and finding the resident on the floor. The DNS stated that the resident was care planned as a supervised assist of one for toileting and personal hygiene, meaning staff were to supervise the ADL to allow for cueing and assistance, and acknowledged that the NA did not have constant supervision because his back was turned. Subsequent nursing notes documented the resident being noncompliant with transfers, being found in the bathroom after asking to lie down, ambulating multiple times without assistance and not using the call light, and later being found lying on the bathroom floor again after using the bathroom, with severe pain and inability to move the left upper arm, and an ED diagnosis of a left displaced comminuted fracture of the distal humerus. The facility’s ADL policy and Fall Prevention Program required assistance per the person-centered care plan and incorporation of risk-based interventions into the care plan, which were not fully implemented regarding scheduled toileting and fall prevention for this resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Medication Order Transcription Error Leads to Incorrect Aspirin Administration
Penalty
Summary
A deficiency occurred when a physician's order for Aspirin 81 mg to be administered twice a week was incorrectly transcribed as a daily order for a resident with atrial fibrillation. The hospital discharge summary specified the correct dosing frequency, but during the admission process, a registered nurse transcribed the order into the electronic medical record as a daily dose. The medication was then administered daily for five consecutive days, rather than the intended twice-weekly schedule. The error was not identified until after the resident was discharged, when a medication incident report was completed. Interviews revealed that the nurse responsible for transcribing the order did not re-check the order before confirming it in the EMR and assumed her preceptor would review her work. The preceptor, who was orienting the nurse, did not verify the accuracy of the transcribed order. The Director of Nursing Services confirmed that the facility's process requires a second nurse to review and confirm new orders in the EMR, but this second check was not completed, resulting in the medication error.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Staff failed to report an allegation of abuse in a timely manner for a resident with dementia and severe cognitive impairment. The resident, who was dependent for activities of daily living and required assistance with mobility and transfers, sustained a left eye bruise and cut during care involving a mechanical lift. A nursing note documented the injury and indicated the resident was agitated and had banged their head, but later, a nursing assistant alleged that another staff member could have struck the resident during care. The allegation was not reported to a supervisor until five days after the incident, despite facility policy requiring immediate reporting of abuse allegations. Documentation and interviews confirmed that the delay in reporting occurred because the nursing assistant who heard the resident's accusation did not notify a supervisor until several days later. The incident was subsequently reported to the state agency five days after it occurred. The director of nursing acknowledged that the incident should have been reported immediately, in accordance with facility policy. The failure to promptly report the suspected abuse resulted in a deficiency finding during the survey.
Failure to Follow Two-Person Assist Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependent for activities of daily living (ADLs), and frequently incontinent, did not receive care in accordance with their plan of care. The resident's care plan and aide care card both directed that two staff members were required to assist with care, including bed mobility, repositioning, and transfers using a mechanical lift. Despite these directives, a nurse aide provided care alone while the resident was agitated, and only called for assistance when it was time to use the Hoyer lift for transfer. During this episode, the resident sustained a left eye bruise and cut, reportedly from the Hoyer lift sling attachment, after expressing pain and agitation. Interviews and documentation confirmed that the nurse aide was aware of the requirement for two-person assistance but proceeded alone due to delays in obtaining help. The Director of Nursing confirmed that the resident was care planned for two-person assistance and that care should not have been provided while the resident was agitated. The incident was identified through clinical record review, staff interviews, and facility documentation, which showed that care was not provided according to the resident's plan of care.
Incomplete Neurological Monitoring Documentation After Resident Fall
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate, specifically regarding documentation of neurological monitoring following an unwitnessed fall. The resident, who had a diagnosis of dementia and was severely cognitively impaired, experienced a fall resulting in a minor contusion to the head. Despite the facility's policy requiring neurological evaluations and monitoring after such incidents, the record review did not identify completed neurological assessments. The Director of Nursing Services (DNS) confirmed that neurological monitoring was conducted but was unable to provide documentation of the assessments, indicating a lapse in maintaining accurate medical records. The facility's Neurological Assessment/Evaluation Policy mandates that licensed nurses perform neurological evaluations and monitoring for residents who have experienced unwitnessed falls, especially those on anticoagulant therapy. The policy outlines a specific schedule for neurological checks, which was not documented in the resident's medical record. Additionally, the facility's Documentation Guidelines policy requires that services provided to residents be documented in the electronic medical record, with provisions for adding late notes if documentation is omitted. The absence of documented neurological assessments suggests non-compliance with these policies, leading to the identified deficiency.
Resident Elopement Due to Expired Wander Guard and Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident with dementia and traumatic brain injury, who was at high risk for elopement and falls. The resident, who was on a secured locked unit and wore a wander guard, was able to exit the unit unsupervised on two occasions. The wander guard had expired eight months prior, and despite being checked weekly, it was not replaced. The resident was able to access the elevator and leave the secured unit without the alarm system locking the elevator doors, allowing the resident to reach the first floor and exit the building. The facility's documentation and staff interviews revealed a lack of adequate supervision and failure to implement necessary interventions after the resident's initial elopement. The resident's care plan included the use of a wander guard and behavior monitoring for elopement, but these measures were not effectively executed. Staff failed to document the resident's elopement behaviors and did not conduct the required 15-minute checks or 1:1 monitoring after the incidents. Additionally, there was a lack of communication among staff regarding the malfunctioning wander guard and the resident's elopement risk. The facility's policies on wander guard usage and elopement prevention were not followed, contributing to the resident's ability to leave the secured unit and the facility. The wander guard system was supposed to lock doors when a monitored resident approached, but it failed to do so due to the expired device. The facility's failure to adhere to its own policies and procedures resulted in the resident being unsupervised and at risk in unsecured areas of the facility and outside the building.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment across all five units, as observed during a survey. The maintenance repair log from April to June 2024 did not document the condition of resident rooms, and environmental rounds conducted by RN #1 also lacked documentation regarding room conditions. Observations on July 2, 2024, revealed numerous issues, including damaged and stained floor tiles, walls, and ceilings, as well as dirty and debris-laden floors in various rooms and common areas across multiple floors. The Director of Maintenance, who has been employed since November 2023, acknowledged awareness of some issues and mentioned ongoing efforts to repair damaged walls, but did not document his rounds or findings. The Assistant Director of Nursing Services (ADNS) was unaware of the stained and dirty conditions of the floors and curtains and planned to discuss these issues with relevant staff. The Director of Nursing Services (DNS) was also unaware of the issues and intended to hold a meeting with key personnel to address the expectations for a homelike environment. Interviews with RN #1 and the Director of Housekeeping were not obtained. The facility's Infection Preventionist position description outlines responsibilities for maintaining a safe environment, and the facility's infection prevention rounds program requires monthly rounds by the Infection Prevention Committee and department heads. The janitor, housekeeper, and maintenance worker position descriptions emphasize routine tasks to ensure cleanliness and maintenance of the facility.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services to a resident, identified as Resident #57, who was admitted with diagnoses including dementia, stroke, hemiplegia, and diabetes. A physician's order was made in July 2021 to obtain a dental consult for dentures, and consent was given by the resident later that month. However, despite the initial steps taken, including dental evaluations and impressions made in early 2022, the process was delayed significantly. The resident was informed of the need for removal of dental roots before denture fabrication, but due to various reasons, including the resident's medical appointments and surgeries, the dentures were not provided. Throughout 2023 and into 2024, the resident expressed a desire to proceed with the denture process after completing hip surgeries. Despite being seen by dental services multiple times, the resident did not receive the dentures. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental needs. The resident repeatedly requested to be seen by dental services, but there was no effective system in place to ensure these requests were addressed promptly. The facility's policy required them to provide necessary dental services and document any delays, but this was not adhered to. The dental services were available in the facility on numerous occasions, yet the resident's needs were not prioritized. Interviews with the dental hygienist and dentist indicated that they were waiting for the resident to request further action, but the facility staff did not facilitate this communication effectively. As a result, the resident remained without dentures for over two years, impacting their ability to chew food.
Failure to Serve Food at Safe Temperature
Penalty
Summary
The facility failed to serve food at a safe and palatable temperature, as observed during a test tray evaluation. On the specified date, the Surveyor and Food Service Director (FSD) followed a meal cart to the 4th floor dining room and measured the temperature of the last meal on the cart. The main entree, turkey, was found to be at 124 degrees Fahrenheit, and the peas were at 127 degrees Fahrenheit. These temperatures were below the facility's guidelines, which require hot foods to be held at 140 degrees Fahrenheit or higher. The FSD was unable to explain the temperature drop, despite indicating that meals were plated on a warming tray and delivered relatively quickly by nurse aides. The facility policy states that foods are in the danger zone when below 135 degrees Fahrenheit and requires action to be taken if temperatures are not within the acceptable range.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure meals were distributed at a palatable temperature. During an initial walkthrough, surveyors observed several unsanitary conditions, including empty trash bags and boxes on countertops near food, opened and undated food items, and a discarded latex glove near a food mixer. Additionally, a rack with unused disposable lids was found near unused garbage bags, and a soiled orange safety cone was partially underneath the rack. The freezer contained opened, undated, and uncovered food items with signs of freezer burn, and non-resident items such as ice cream and a bottle of spring water were improperly stored. The refrigerator had undated sandwiches and a sleeve of turkey meat with a tear in the plastic wrapping. The Food Service Director (FSD) acknowledged the kitchen was short-staffed, making it difficult to adhere to the cleaning schedule and storage expectations. The facility's policy requires food from non-approved sources to be stored separately and mandates proper labeling and storage of refrigerated foods. Damaged food products should be kept away from usable stock, and the storeroom should be clean and rodent-proof. The policy also emphasizes the importance of cleaning and sanitizing food service equipment and surfaces to minimize contamination risks. Despite these policies, the facility did not meet the expected standards, as confirmed by interviews with the Director of Nursing Services (DNS) and the Administrator.
Failure to Notify Resident Representatives and Physicians of Changes in Condition
Penalty
Summary
The facility failed to notify the resident representative and physician in two separate incidents involving residents with significant changes in their conditions. Resident #78, who was admitted with dementia and a traumatic brain injury, was at high risk for elopement and had a wander guard device in place. Despite these precautions, the resident managed to leave a secured locked unit on two occasions, on 6/25/24 and 6/28/24, without the knowledge of the resident's representative or physician. The facility's documentation and interviews revealed discrepancies in the timing and handling of these incidents, including a lack of immediate notification to the appropriate parties and failure to document the elopement behaviors adequately. In the case of Resident #101, who was admitted with dementia, hypertension, and a stroke, the facility did not promptly notify the resident's representative or physician of a change in condition involving eye discomfort and a rash on the hands. The resident complained of eye discomfort on 6/22/24, but the physician was not notified until 6/25/24, and the resident's representative was only left a message without further follow-up. The facility's policy required immediate notification and documentation of such changes, which was not adhered to in this case. Interviews with facility staff, including the DNS and various nurses, highlighted lapses in communication and documentation. The DNS acknowledged that the facility's policies on change of condition and elopement were not followed, as the responsible parties were not notified in a timely manner, and documentation of attempts to reach the resident's representative was insufficient. These deficiencies indicate a failure to adhere to established protocols for resident safety and communication.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility failed to adequately monitor and document the care of Resident #91, who had a history of dry, itchy skin and was prescribed Triamcinolone Acetonide lotion for itchiness. Despite the physician's order to apply the lotion as needed, the treatment administration records did not show any documentation of its application throughout June 2024. Observations revealed that Resident #91 had multiple areas of skin at various stages of healing, indicating ongoing scratching behavior. Interviews with staff indicated a lack of behavior monitoring and documentation, and the facility did not provide a policy for behavior monitoring or nursing documentation. Resident #101, who had diagnoses including dementia and edema, was not assessed by a registered nurse when complaints of eye discomfort were noted. The resident was also not consistently provided with compression stockings as per the physician's order. Observations showed that the resident was often without the prescribed stockings, leading to visible edema. Interviews with staff revealed confusion and lack of adherence to the physician's orders regarding the application of compression stockings, and there was no facility policy provided for the use of compression stockings. The facility's failure to monitor and document the care of these residents, as well as the lack of adherence to physician orders, highlights deficiencies in the facility's care processes. The absence of policies for behavior monitoring, nursing documentation, and compression stocking application contributed to these deficiencies, impacting the residents' care and treatment.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to meet the pain management needs of a resident, identified as Resident #289, who was admitted with multiple diagnoses including a fractured kneecap, polymyalgia rheumatica, fibromyalgia, and gout. The baseline care plan highlighted the need for pain management related to arthritis, with interventions such as administering medications per physician orders and responding immediately to complaints of pain. However, the facility did not adhere to these interventions, as evidenced by the resident's experience over a weekend when pain management was inadequate. On 6/29/24, Resident #289 received a one-time dose of Acetaminophen 650 mg for pain, as per a physician's order. Despite this, the resident reported a pain level of 6 out of 10 later that day and was unable to receive additional pain relief due to the absence of a prn pain medication order. The resident expressed frustration at not receiving further Acetaminophen, which resulted in a sleepless night due to pain. LPN #10, who was on duty, acknowledged the resident's pain but did not contact the physician for additional orders, instead placing a note in the APRN communication book without documenting the resident's pain or need for medication. Interviews with the APRN and MD revealed that the physician was not contacted over the weekend for additional pain management orders, although he was available and willing to provide them. The DNS confirmed that the charge nurse should have informed the supervisor and APRN of the resident's need for pain medication immediately. The facility's Pain Management Policy emphasizes prompt evaluation and treatment of pain, which was not followed in this instance, leading to the resident experiencing unmanaged pain over the weekend.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative prior to the resident's transfer to the hospital on four separate occasions. The resident, who had intact cognition, was admitted with diagnoses including bowel obstruction and anemia. Despite the facility's policy requiring a written bed hold notice to be given at the time of transfer, the resident only signed the notice at admission, and it was not provided during subsequent hospitalizations. Interviews with facility staff revealed that the RN Supervisor was responsible for sending the bed hold notice with residents during hospital transfers. However, this procedure was not followed for the resident's hospitalizations. The facility's policy mandates that a copy of the bed hold notice be given to the resident, maintained in their medical record, and provided to the business office, but these steps were not completed for the resident's transfers.
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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