Unauthorized Administration of Topical Medication by Unlicensed Staff
Summary
The facility failed to adhere to its policy and procedure for administering medications, specifically for a resident who received topical medication without a physician's order by unlicensed staff. The resident reported that Certified Nursing Assistants (CNAs) applied ointments under his belly to help heal wounds, despite there being no documentation or physician's order for such treatment in the resident's medical record. The Minimum Data Set Nurse confirmed the absence of documentation and stated that CNAs are not permitted to apply ointments, which are kept locked in the medication cart. Further interviews revealed that CNAs had been applying a barrier cream to the resident's abdominal folds, sometimes at the resident's request, without proper authorization or documentation. The Treatment Nurse confirmed that there were no treatment orders for the application of Thera Calazinc Body Shield, a skin protection ointment, and reiterated that CNAs are not allowed to administer medications. The Director of Nursing also stated that Calazinc is considered a medication and should not be applied by CNAs. The facility's policy on administering medications clearly states that only licensed individuals may administer medications, and all treatments must be recorded on the resident's treatment record.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure LPNs practiced within their professional standards and defined scope when one LPN independently assessed, measured, and staged pressure ulcers for two residents with significant cognitive and physical impairments, including heel and sacral pressure injuries. This LPN regularly performed wound assessments and staging when the wound NP was unavailable, yet facility job descriptions for treatment and unit nurse roles did not include pressure ulcer assessment or staging responsibilities, and no LPN job description was available to support this practice.
The facility did not ensure that employees received and completed required annual training, as staff were provided with in-service packets to sign in advance of the actual due date, and some only briefly reviewed the materials or were unsure of their location. The Human Resource Director lacked a system to track training completion after discontinuing the online program, and the Administrator confirmed that other education provided was insufficient. This affected all employees reviewed and had the potential to impact all residents.
An LPN failed to follow professional standards by preparing and administering medications for two residents at the same time, instead of handling each resident's medications separately as required. Both residents had complex medical conditions and multiple medications ordered, and the facility's policy and CDC guidelines specify that medications should be prepared and administered for one resident at a time to prevent contamination or infection.
LPNs Performed Pressure Ulcer Staging Outside Defined Scope and Job Descriptions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that LPNs practiced within their professional standards and scope of training regarding pressure ulcer assessment and staging, as required by applicable laws and accepted professional standards. For Resident #20, who had Alzheimer’s disease, depression, spinal stenosis, osteoarthritis, severe cognitive impairment, dependence for most ADLs, incontinence, and was at risk for pressure ulcers, multiple skin issue assessments were completed by LPN #1500. These assessments documented an in-house acquired right heel unstageable pressure ulcer with specific measurements and tissue composition, followed by subsequent documentation of the same right heel wound as a stage 3 pressure ulcer on later dates, with changing measurements and wound bed composition. On observation and interview, LPN #1500 confirmed that she personally measured and staged the right heel pressure ulcer and would document the assessment in the chart. The DON verified that LPN #1500 was the one who staged and measured this resident’s right heel pressure ulcer on three specific dates. For Resident #30, who was admitted with diagnoses including severe protein calorie malnutrition, hemiplegia and hemiparesis after cerebral infarction, muscle weakness, and a stage 4 sacral pressure ulcer, LPN #1500 also completed skin issue assessments. These assessments documented a sacral stage 4 pressure ulcer with detailed measurements and wound bed composition on two separate dates. The DON confirmed that LPN #1500 assessed, staged, and measured this resident’s sacral stage 4 pressure ulcer on those dates. Review of the facility job descriptions for the Treatment Nurse and Unit Manager positions showed no inclusion of pressure ulcer wound assessments, including measuring, staging, and assessments, in their essential functions. The facility was unable to provide any job description for LPNs, and thus there was no documented authorization or role definition for LPNs to perform pressure ulcer wound assessments and staging, despite LPN #1500 performing these functions for at least two residents.
Failure to Ensure Required Annual Staff Training
Penalty
Summary
The facility failed to ensure that employees received the required annual training as mandated by applicable laws and regulations. Review of personnel files for 13 employees revealed that staff were provided with two types of in-service packets, which they signed to acknowledge receipt and review. However, some employees signed these packets upon hire or in advance of the actual annual due date, indicating that the training may not have been completed at the appropriate time. Additionally, the packets were distributed for the upcoming year, and signatures were obtained before the information was reviewed. Interviews with staff confirmed that some employees only briefly reviewed the materials or were unsure of the location of their packets, suggesting that the training was not effectively delivered or tracked. The Human Resource Director stated that the facility had discontinued its online training program and replaced it with the packet system, but did not have a method to track completion of education otherwise. The Administrator acknowledged that other training provided by the DON throughout the year was insufficient, as it was not conducted monthly. This deficiency affected all 13 employees reviewed and had the potential to impact all 111 residents in the facility.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered to two residents according to professional standards of practice. During an observation, an LPN dispensed medications for two residents into two medication cups at the same time and proceeded to administer the medications, rather than preparing and administering medications for one resident at a time as required by accepted standards. The LPN confirmed during interview that medications should have been dispensed and administered separately for each resident. Both residents involved had complex medical histories, including conditions such as atrial fibrillation, hypertension, heart disease, and Alzheimer's disease, and had physician orders specifying multiple medications to be administered upon rising. Review of CDC nursing standards and facility policy confirmed that medications should be prepared for one resident at a time and administered in accordance with professional standards to prevent contamination or infection.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
