Failure to Arrange Timely Psychiatric Consultation for Resident
Summary
The facility failed to ensure timely arrangements for outside psychiatric services for a resident with dementia who exhibited physical aggression. The resident, who had no prior history of physical aggression, punched another resident and was ordered for a psychiatric evaluation. However, there was no documented evidence that the psychiatric consult was completed until several months later, after the resident was involved in another incident of aggression. The facility did not have policies and procedures in place for arranging outside consultations, and there was a lack of documentation and follow-up to ensure the psychiatric evaluation was conducted as ordered. Interviews with facility staff revealed that the responsibility for arranging outside consultations was not clearly defined, and there was a failure in communication and documentation. The unit clerk, who was responsible for scheduling psychiatric appointments, did not have evidence that the resident was on the list to be seen by the psychiatrist. The psychiatrist, who visited the facility regularly, was not informed of the consultation order. The medical director and other staff acknowledged that the resident should have been seen by the psychiatrist following the initial incident, but the lack of a formal policy and procedure contributed to the oversight.
Penalty
Resources
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A resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic/proximal tracheal stenosis had a provider order for an ENT referral and a subsequent NP note calling for ENT f/u. The Transportation Driver sent the referral to an ENT office, which refused to schedule due to the resident’s lack of active insurance and self-pay status, and the driver documented unsuccessful attempts to reach the family to confirm payment. The Business Office Manager later stated the resident was Medicaid pending and that the facility would have been responsible for payment if an outside provider would not accept that status, but she was never informed that the ENT would not see the resident for this reason. Consequently, the ordered ENT evaluation for the resident’s tracheostomy and tracheal stenosis was not obtained.
A resident with COPD and obstructive sleep apnea was ordered to have a follow-up sleep study at a sleep disorder center. Facility documentation showed that after the resident reported ear pain, the sleep study was put on hold pending pulmonology input. The facility contacted the sleep center and learned the center could not provide needed ADL and transfer assistance, but there was no evidence that the facility arranged nursing support or other outside resources to assist the resident during the study, and the appointment was cancelled without being rescheduled.
Two residents did not receive necessary outside professional services when staff failed to coordinate and follow through on podiatry and dermatology consults. One resident, who could not trim her own long, uncomfortable toenails, had a nursing note indicating need for a podiatry referral, but her name was never added to the podiatry visit list and no further action was documented. Another resident with morbid obesity, diabetes, and kidney failure had ongoing severe dry, itchy, scaly skin, with physician orders for dermatology consultation, follow-up, and ammonium lactate lotion, yet the MAR/TAR showed no treatment provided during the review period and there was no documentation of dermatology visits. The SSD reported relying on nursing to notify her of needed referrals, while nursing and leadership interviews revealed lack of awareness and verification of consult orders, resulting in missed or unconfirmed specialty services.
Surveyors found that the facility did not have a written contract with an outside dental provider, despite facility policy requiring a contract with a licensed dentist and outlining how routine and 24-hour emergency dental services should be provided. The Administrator and regional leaders were responsible for obtaining such contracts, but the Administrator could not explain why no agreement was in place, even though a local dentist had recently visited and provided care and physicians might select community dentists. The DON stated that residents could receive dental services through community providers but acknowledged that the absence of a formal contract created a potential risk that residents might not receive needed dental care.
Facility administration permitted a nephrology NP to conduct consultations, including on new admissions, without an executed contract and without required physician orders, in violation of facility policy. One resident’s consult documented a medication error that the NP did not report to staff, and the issue was only identified later by surveyors. Additional residents were also seen by this NP over several months with consult notes uploaded days after visits and no corresponding nephrology orders. The medical director reported that nephrology consults should be based on diagnosed need and attending physician orders, was not overseeing these consults, and confirmed there was no nephrologist signing off on the NP’s work.
A resident did not receive a needed gynecology appointment after the attending MD requested an evaluation for symptoms and possible infection. The request was routed to a staff member responsible for arranging outside appointments and transportation, who was unable to schedule with the usual gynecologists because they would not accept the resident due to the large stretcher required. The staff member stated the resident’s daughter makes all appointments, but the daughter reported she was unaware of the need for a gynecology visit and said she could have obtained an appointment. The DON acknowledged she would look into the situation, but the MD was never informed that the appointment had not been made, and no alternative outside professional resource was secured.
Failure to Secure ENT Evaluation for Resident With Tracheostomy and Tracheal Stenosis
Penalty
Summary
The facility failed to obtain outside professional ENT services for a resident when it did not employ a qualified professional to provide the required service. The resident was admitted with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Hospital records documented that the resident previously had a tracheostomy exchange by ENT due to hemoptysis, experienced a respiratory arrest with a dislodged trach, and had significant subglottic and proximal tracheal stenosis. ENT had recommended against trialing a Passy Muir Valve and advised changing the trach every three months. A physician order for an ENT referral related to stenosis and tracheostomy status was initiated, and a later nurse practitioner note documented the need for follow-up with ENT for subglottic and tracheal stenosis. The Transportation Driver documented that an order for the ENT visit was received and sent to the ENT office, but the office reported the resident did not have insurance and would require self-pay, and therefore would not schedule the appointment without confirmation from the family. The Transportation Driver reported multiple unsuccessful attempts to contact the family and did not secure an appointment. The Business Office Manager stated the resident was Medicaid pending, that she had been in contact with Medicaid since admission, and that if an outside provider would not accept a Medicaid pending resident, the facility would be responsible for payment. The Business Office Manager also stated she was not informed that the ENT provider would not see the resident due to Medicaid pending status and that, had she known, she would have discussed payment with the Administrator so the resident could be seen by ENT. As a result, the resident did not receive the ordered ENT evaluation for tracheostomy and tracheal stenosis.
Failure to Coordinate Outside Services for Resident Sleep Study
Penalty
Summary
The facility failed to employ or obtain outside professional resources to provide required services for a resident with obstructive sleep apnea. The resident’s comprehensive MDS showed they were cognitively intact and had a diagnosis of obstructive sleep apnea, and the care plan documented altered respiratory status/difficulty breathing related to COPD. An After Visit Summary from a Sleep Disorder Center indicated the resident was to have a follow-up sleep study. A progress note documented that the DON and nursing supervisor met with the resident, who reported right ear pain, and the resident was informed that the sleep study would be put on hold pending an update from pulmonology. The same progress note showed that the facility contacted the sleep center and informed them the resident required assistance with ADLs, but the sleep center stated they could not provide transfer or care assistance. The resident later reported in interview that the sleep study appointment was cancelled and that the facility did not further coordinate to reschedule the appointment. Review of the clinical record revealed no documentation that the facility coordinated nursing services to assist the resident during the sleep study and no evidence that the sleep study was rescheduled with the center, resulting in a failure to ensure use of outside resources when the facility could not provide the needed service.
Failure to Coordinate Podiatry and Dermatology Consults for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure outside professional resources were obtained and coordinated for required services, specifically podiatry for one resident and dermatology for another. One resident reported to nursing staff that her toenails were very long, that she could not cut them herself, and that they were uncomfortable. A nursing progress note documented on 2/16/2026 that this resident’s nails were very long and that she needed a referral to a podiatrist. However, there was no further follow-up in the medical record regarding a podiatry referral, and the resident’s name did not appear on the podiatry visit list for the provider’s 2/18/2026 visit. Another resident, who was cognitively intact and had diagnoses including morbid obesity, Type 2 diabetes, and unspecified kidney failure, was observed in bed scratching and itching her arms and upper body, with scaly, dry, rough skin and small fishlike flakes. The resident stated she was supposed to see a dermatologist, that her family had discussed this with the facility the previous Friday, and that she was only using regular store lotion, which was not helping, while her itching was getting worse. Physician orders included a dermatology consultation for body itching, a follow-up with dermatology, and an order for ammonium lactate lotion to be applied twice daily for dry skin. Review of the MAR and TAR showed the resident was not receiving any treatment for the ongoing itching condition during the reviewed period. The facility’s own consult policy stated that Social Services would coordinate most resident referrals (such as podiatry and vision), that referrals should be based on physician evaluation and orders, and that Social Services would document referrals and maintain a listing of referral agencies. In practice, the Social Services Director reported that nursing staff were expected to notify her of residents needing podiatry so they could be added to the list, but there was no evidence this occurred for the resident with long nails. For the resident with dermatologic issues, the Social Services Director stated dermatology appointments were scheduled by nursing and that she had not been informed of any concerns, family complaints, or need for dermatology, and no grievance had been initiated. Nursing staff and the ADON were not aware of or did not verify dermatology orders or visits, and record review showed no documented dermatology visits or physician notes beyond a single prior encounter, indicating a lack of coordination and follow-through with outside dermatology services despite existing orders and ongoing symptoms.
Lack of Written Contract for Dental Services with Outside Provider
Penalty
Summary
The facility failed to ensure that agreements with outside professional resources for dental services were in place and specified in writing that the facility assumed responsibility for obtaining services that meet professional standards. Record review of the facility’s contract binder on 01/30/2026 showed there was no contract with the dental service provider. The Administrator reported that a new company purchased the facility in November 2025 and should have contracted with a local dental facility to provide dental services to residents who needed dental care, but she did not know why a contract had not been established. She stated that a local dentist had visited the facility and provided dental care to residents on 01/27/2026, and that residents’ doctors might choose the dental provider. The Administrator and regional company leaders were identified as responsible for obtaining contracts with outside resources, and the Administrator acknowledged that without a contract, residents might not have dental care. The DON stated that residents received dental services if needed because their doctors might choose community dentists, but also acknowledged that without a contract with a dental facility there was a potential risk of residents not receiving dental care. Review of the facility’s policy titled “Dental Services,” revised 12/2016, indicated that routine and 24-hour emergency dental services were to be provided through a contract agreement with a licensed dentist who comes to the facility monthly, or by referral to the resident’s personal dentist, community dentists, or other health care organizations that provide dental services. Despite this policy, the facility did not have the required written agreement with a dental service provider at the time of the survey.
Unauthorized Nephrology Consultations Without Orders or Contract Oversight
Penalty
Summary
Facility administration allowed a nephrology nurse practitioner (NP #13) to provide consultation services to residents without an established contract in place and without physician orders authorizing these consultations, contrary to facility policy. For Resident #16, a nephrology consult was completed on 1/13/26 and not uploaded until 1/15/26, and there was no physician order for this resident to be seen by a nephrologist or consultant. Within that consult, NP #13 documented a medication error on the resident’s medication administration record but did not notify facility staff; the error was instead brought to the DON’s attention by the survey team on 1/21/26, eight days after NP #13 identified it. The facility’s policy on Provision of Physician Ordered Services, revised 2/18/25, states that no diagnostic tests or consultation requests will be performed without specific orders from a physician, PA, NP, or CNS in accordance with state law. Further record review of four additional randomly selected residents showed that all had been seen by the same nephrology NP consultant beginning around 11/9/25, with consultation notes uploaded days after the visits and no corresponding physician orders for nephrology consultations. NP #13 was reportedly seeing every new admission based on lists provided by unit managers when she arrived. The facility medical director stated that the process for nephrology consultation should involve residents with a diagnosed need and an order from their attending physician, and acknowledged that the contract for this consultant was not signed until 1/27/26, despite her seeing residents since at least November 2025. He also stated that he was not the resource following up on NP #13’s consultations and that this should be an actual nephrologist, and there was no nephrologist signing off on NP #13’s consultations.
Failure to Arrange Required Gynecology Appointment for Dependent Resident
Penalty
Summary
The facility failed to obtain an outside professional gynecological service for Resident #6 after the attending physician requested a gynecology appointment on 11/23/25 for symptoms and possible infection. The physician’s request was sent to Staff #5, who is responsible for arranging outside appointments and transportation. Staff #5 was unable to schedule the appointment because the gynecologists typically used by the facility would not accept the resident due to the large stretcher required, which they stated would not fit through their office doors. Staff #5 reported that the resident’s daughter makes all appointments, but the daughter stated she was unaware that an appointment with a gynecologist was needed and indicated she would have been able to obtain one. The DON stated she would look into the matter, but the physician was never notified that the resident had not yet received the gynecology appointment. This resulted in Resident #6 not receiving the requested evaluation by a gynecologist, and the facility did not employ or obtain an outside qualified professional resource to provide the required service when its usual providers could not accommodate the resident’s needs.
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