Failure to Obtain Physician Orders for Adaptive Device
Summary
The facility failed to ensure that a resident had physician orders for immediate care upon admission, specifically for the use of a magnet device intended to manage seizure activity. The resident, a male with a history of sepsis, UTI, Marfan syndrome, and epilepsy, was admitted without an order for the magnet device, which was crucial for his care. The absence of this order was identified during a review of the resident's records, which showed no documentation of the device despite its mention in hospital admission paperwork. On the day of the incident, the resident was found in respiratory distress by a CNA, who then alerted a nurse. The nurse attempted to use the magnet device, which was provided by the resident's family, but there was no response from the resident. The nurse initiated CPR after the resident showed no pulse, but the resident was pronounced deceased shortly after EMS arrived. Interviews with staff revealed that the device was not known to the attending physician, and there was no formal order for its use, which was a critical oversight given the resident's condition. Further interviews with the facility's staff, including the DON and other nurses, confirmed that there was a lack of awareness and formal documentation regarding the magnet device. The family had brought the device to the facility, but it was not integrated into the resident's care plan or communicated to the physician. This lack of communication and documentation led to the facility's failure to provide appropriate care, contributing to the resident's death.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Administer Ordered IV Antibiotic: A resident admitted with bacterial meningitis had an order for Ampicillin 2 g IV q4h, but the facility did not have the medication available and the ordered doses were not given as scheduled. The MAR and progress notes showed the IV antibiotic remained on order after admission, and the DON and ID physician confirmed the resident did not receive the scheduled IV medication.
A resident admitted with neurogenic bladder and an indwelling urinary catheter did not have a physician order for catheter care at admission, even though the care plan called for catheter care every shift and as needed. The DON said the order should have been entered on admission but was missed, and the MDS C nurse said the daily interdisciplinary review should have caught it. Staff reported they had been providing catheter care, but no active order was in place.
A resident was admitted with an ileostomy and implanted port, but the chart lacked physician orders for care and monitoring of either device at admission. The record showed care plans for the port and ostomy, and the DON stated that admission orders are supposed to be entered by the admitting nurse and followed up by the IDT, but only IV fluids were ordered.
A resident admitted with a suprapubic catheter did not have physician orders in place for catheter care at admission. The chart showed diagnoses including CKD, overactive bladder, and catheter-related infection, but the care plan did not identify the catheter and the orders on file did not include catheter care. The LVN, NP, and DON all acknowledged the missing order, and the resident’s family reported the urologist had recommended routine catheter changes.
Admission seizure medication orders were not timely processed for a resident with tracheostomy status, epilepsy, and convulsions. The hospital discharge paperwork listed lacosamide, Keppra, and Depakene, but the facility initially had only the AVS and did not enter orders for Keppra or Depakene; lacosamide was entered later. The MAR showed no evidence the resident received Keppra or Depakene, and staff interviews confirmed the missing orders were not fully communicated or processed at admission.
Missed Anticoagulant Orders on Admission: A resident admitted after a suspected CVA with emphysema and cardiomyopathy had hospital discharge orders for apixaban starter pack therapy, but the facility did not ensure the medication was ordered correctly on admission. Review of the MAR showed 4 missed 10 mg doses, and the DON stated the admission nurse transcribed orders while the ADON reviewed them as a second set of eyes.
Failure to Administer Ordered IV Antibiotic
Penalty
Summary
The facility failed to follow its Physician Orders policy and did not ensure that resident medications were administered in accordance with the licensed physician’s order and the physician order summary. This deficiency involved one resident, R8, who was admitted from the hospital with bacterial meningitis and an order for Ampicillin 2 g IV every 4 hours for 31 doses through 6/13/2026. The hospital After Visit Summary documented the last hospital dose was given at 4:58 PM on 6/8/2026, and the facility census showed R8 was admitted at 7:00 PM that same day. The facility’s Physician Order Summary listed Ampicillin Sodium 2 g IV every 4 hours with a start date of 6/9/2026, and the MAR showed the first scheduled administration at 2:00 AM on 6/9/2026. However, progress notes and medication administration notes documented the medication was “new admission” and “on order” at 2:38 AM, 6:34 AM, 9:03 AM, and 1:01 PM on 6/9/2026, indicating the ordered IV antibiotic was not available or administered as scheduled. The DON stated R8 did not receive the scheduled IV antibiotic on 6/8/2026 and 6/9/2026 because the facility did not have the medication, and the Infectious Disease physician stated R8 should have received the scheduled IV medication at the nursing facility but did not.
Missing Physician Order for Catheter Care
Penalty
Summary
The facility failed to ensure that Resident #29 had physician orders in place for immediate care at the time of admission. Resident #29 was a male admitted with a diagnosis of reflex neuropathic bladder, and the MDS assessment documented that he had an indwelling catheter. The physician orders included an order for a 16Fr catheter connected to a closed urinary drainage system for neurogenic bladder, but no order was present for catheter care. The resident’s baseline care plan identified that he had an indwelling catheter related to neurogenic bladder and included an intervention to provide catheter care every shift and as needed. During interview, the resident stated staff had been providing care for the catheter, and observation confirmed he had an indwelling urinary catheter. The DON stated catheter care should have been ordered upon admission and that the order was missed for unknown reasons. The MDS C nurse stated the interdisciplinary team reviews orders daily and should have caught the missing order, while an LVN and CNA stated they had been providing catheter care and were not aware there was no active order for it.
Missing Admission Orders for Ostomy and Implanted Port Care
Penalty
Summary
The facility failed to ensure that a newly admitted resident had physician orders in place for ostomy care and implanted port care at the time of admission. Resident B was admitted with diagnoses including other complications of enterostomy, dehydration, and encounter for surgical aftercare following surgery on the digestive system, and was later discharged to the hospital. The clinical record showed care plans for an implanted port and an ileostomy, with interventions such as changing dressings as ordered, flushing as ordered, keeping the site clean and dry, assisting with stoma changes, and monitoring for abnormal findings, all initiated on 6/30/26. A progress note documented that the resident arrived by wheelchair and had a port in the left upper chest without signs or symptoms of infection and an ileostomy in place. Physician orders reviewed for June and July 2026 included IV sodium chloride 0.9% for dehydration, but there were no orders for care or monitoring of the implanted port or the ileostomy. The DON stated that on admission, orders are supposed to be put in place for care and monitoring if a resident has an ostomy or implanted port, and that the admitting floor nurse should enter the orders into the record while the IDT follows up on them.
Missing Admission Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that at the time of admission, Resident #1 had physician orders in place for immediate catheter care. Resident #1 was admitted with a suprapubic catheter and a midline, and the record showed diagnoses including chronic kidney disease, overactive bladder, and infection and inflammatory reaction due to catheter. The baseline care plan did not indicate the resident’s use of a suprapubic catheter, and the physician orders available in the chart included gentamicin but did not include an order for catheter care. A progress note documented that the resident arrived alert and oriented, was receiving gentamicin through the midline, and had a suprapubic catheter in place. During observation, the resident was seen with the catheter hanging below bladder level with a privacy cover on the bag. The resident stated he had only been at the facility for about a week and was concerned about catheter care. The resident’s family stated he had been admitted after treatment in the hospital for a urinary infection with the catheter in place, and that the urologist had recommended the catheter be changed every three weeks, with a change scheduled for the prior day. During interview, the LVN stated that when a resident is admitted with a catheter, nurses must confirm with the MD that an order is in place for standard catheter care, but he could not recall seeing such an order in the chart. The NP stated residents usually arrive with catheter orders from the urologist or discharging hospital, and if not, staff should notify her or the MD so the urologist can be contacted immediately; she had not received a call about the missing order. The DON stated he was unaware there were no catheter care orders and said he was about to call the urologist for an order. The facility policy on Physician Orders stated that admission orders are to be verified with the physician or physician extender for all residents admitting or readmitting.
Admission seizure medication orders were not timely processed
Penalty
Summary
Admission medication orders for Resident #80 were not processed in a timely manner after the resident was admitted to the facility with diagnoses including tracheostomy status, unspecified epilepsy, and unspecified convulsions. The resident’s hospital discharge summary dated 06/04/26 listed lacosamide 200 mg twice daily, levetiracetam (Keppra) 2000 mg twice daily, and valproic acid (Depakene) 750 mg three times daily, but the hospital after visit summary did not list those medications on the resident’s medication list. The resident was admitted to the facility at approximately 2:15 P.M., and the physician orders upon admission did not include lacosamide, Keppra, or Depakene on 06/04/26. The resident’s orders later included lacosamide 10 mg/mL, 20 mL via g-tube twice daily on 06/05/26 at 8:12 A.M., but no orders were initiated for Keppra or Depakene. The June 2026 MAR showed no evidence that Keppra or Depakene were administered. Staff interviews confirmed the facility had only the after visit summary at admission, that additional paperwork containing the missing information was later found by an LPN, and that the NP was notified only about the lacosamide order. The DON confirmed the facility was aware of the resident’s seizure diagnoses before admission and stated staff should have notified the NP about the need for orders for Keppra and Depakene.
Missed Anticoagulant Orders on Admission
Penalty
Summary
The facility failed to ensure that physician orders for immediate care were in place at the time of admission for Resident #30, who was admitted from the hospital with diagnoses including emphysema, cerebral infarction, and cardiomyopathy. The resident’s admission record showed a hospitalization for a suspected cardiovascular accident, and the care plan documented that the resident was on anticoagulant therapy and medications were to be administered per the medical doctor’s orders. The hospital discharge orders prescribed apixaban starter pack therapy upon admission, and the manufacturer’s dosing instructions indicated 10 mg twice daily for 7 days followed by 5 mg twice daily. Review of the medication orders and MAR from 6/2/2026 through 6/23/2026 showed the resident was not prescribed apixaban as ordered and missed 4 doses of apixaban 10 mg: the morning dose on 6/3/2026, the morning and evening doses on 6/4/2026, and the morning dose on 6/5/2026. During interview, the DON stated the admission nurse was responsible for transcribing physician admission orders and the ADON reviewed them as a second set of eyes, but the DON was not aware the apixaban had been missed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.