Failure to Complete Neurological Assessments After Falls
Summary
The facility failed to ensure that neurological assessments were completed for two residents after unwitnessed falls and a head strike. Resident #12, who had a history of falls and was admitted with vascular dementia and other conditions, experienced an unwitnessed fall on 5/28/24. Although an initial neurological check was documented, no further assessments were recorded as required by the facility's policy. The DNS, who was not in position at the time of the incident, confirmed that neurological checks should have been completed and documented on the flowsheet, but no such documentation was found. Resident #48, admitted with Parkinson's Disease and a history of falls, experienced multiple unwitnessed falls and a head strike incident. On several occasions, neurological assessments were either incomplete or not conducted at all. For instance, on 8/11/24, 13 out of 24 assessments were not completed following an unwitnessed fall. Similarly, on 11/29/24 and 12/2/24, neurological assessments were not completed as required. On 1/7/25, after a head strike incident, 10 out of 24 assessments were not completed, and the resident's refusal to undergo assessments was not properly managed or documented. Interviews with the DNS and nursing staff revealed a lack of adherence to the facility's neurological assessment policy. The DNS expected that all sections of the neurological assessments would be completed after unwitnessed falls or head injuries. However, staff failed to follow the protocol, and there was a lack of communication and documentation regarding the residents' refusals and the inability of staff to perform the assessments due to other duties. The facility's policy required that any changes in neurological status be reported to a physician, but this was not consistently done.
Penalty
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Two residents did not receive care in accordance with professional standards. One resident on warfarin for a valve replacement had invalid initial PT/INR labs, an order to hold warfarin pending results, and later dose changes, yet MAR entries showed warfarin was administered on days it should have been held, including when INRs were elevated and critically high, with no evidence the physician was contacted or that ordered follow-up INRs were drawn as prescribed. Another resident’s medication pass was observed where an LPN correctly administered six oral medications and held insulin for a blood sugar of 109, but later documented on the MAR that a polyethylene glycol 3350 dose had been given when it had not; after being questioned, the LPN retrieved the medication from the supply room and administered it after signing for it.
Surveyors found that staff did not follow multiple physician orders for several residents, including not obtaining ordered occult blood stool tests for a resident with ESRD, failing to notify a physician when a diabetic resident’s blood glucose repeatedly exceeded 300 mg/dL, administering carvedilol to a resident with dementia and HTN despite heart rates below the ordered parameter, and not applying ordered Prevalon boots for a resident at risk for skin breakdown while in bed. The DON confirmed these lapses in implementing the prescribed treatment and monitoring.
A resident with Type 2 DM, recent hospitalization for sepsis and CKD, and documented low POC glucose was admitted on Insulin Glargine 10 units HS without any physician orders for blood glucose monitoring or a documented baseline blood sugar. The MAR reflected the insulin order only, and the diabetes care plan referenced maintaining blood sugars within the physician’s acceptable range and monitoring for side effects and effectiveness, but the clinical record contained no evidence of routine blood sugar checks. After a CNA observed abnormal oral secretions, staff obtained a blood sugar of 54 mg/dl, administered glucagon, and transferred the resident to the hospital, where the resident was admitted with hypoglycemia, sepsis, and for wound evaluation; the DON and facility physician acknowledged that fingerstick monitoring should have been ordered and that its absence was an oversight.
A resident with quadriplegia and muscle wasting had a physician order for a house diet with restrictions and an additional order allowing double portions for all meals, six times a day, and the care plan and nutrition evaluation documented the resident’s request for large entrée portions. Surveyors observed a lunch meal where the tray ticket did not indicate large or double portions, and the Food Service Manager confirmed that only breakfast trays reflected large portions, while lunch and dinner tickets did not. The FSM stated that diet orders flow from the EMR to the meal tracker system and that he could not change them, and he did not see the double-portion order because it had been entered under an “other” category instead of dietary. The DON confirmed that diet orders should be entered correctly under dietary, documented on a dietary slip, and handed off to dietary staff, and acknowledged that the double-portion order had been miscategorized and not properly communicated.
The deficiency involves two residents for whom the facility did not follow established care expectations. A resident with multiple risk factors for impaired skin integrity reported a blister on the back of the thigh that later tore during a mechanical lift transfer; despite the resident’s report and a staff-taken photo days earlier, the skin alteration was not formally identified or assessed until it was observed by surveyors, revealing a MASD area on the posterior thigh. In a separate case, a resident receiving prn Oxycodone and care-planned as at risk for constipation went multiple times more than three days without a documented BM, including one eight-day interval, with no documented nursing interventions, no laxatives given, and no evidence of physician notification, even as prn opioid doses continued.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Failure to Follow Anticoagulation Orders and Accurate Medication Documentation
Penalty
Summary
The deficiency involves failures in anticoagulation management and medication administration/documentation for two residents. For one resident with a history of valve replacement, the physician ordered warfarin (5 mg every other day) and associated PT/INR and CMP labs. Initial PT/INR labs were reported as invalid, and the physician subsequently ordered warfarin to be held pending INR results. When INR results were later received, the physician adjusted the warfarin dose to 2.5 mg on one day and 5 mg daily on subsequent days. The MAR showed nurses initialed administration of 5 mg doses on multiple days, even though the order to hold warfarin remained in effect until a later date. Nursing documentation reflected elevated INRs of 3.38 on two days and a critically elevated INR of 9.12 on another day, yet warfarin was still administered and there was no evidence the physician was contacted for guidance when these elevated INRs were obtained. When the INR was critically elevated at 17.63, the physician ordered vitamin K 10 mg injection and daily INR labs for two days, but there was no evidence the ordered labs were drawn or that staff followed up with the lab; labs were not completed until several days later, by which time the resident’s condition had deteriorated, including becoming nonresponsive and not eating, and the resident was transferred to the hospital. Pharmacy records showed 21 warfarin 5 mg tablets were dispensed and 20 were returned at discharge, despite MAR entries indicating four doses (one 2.5 mg and three 5 mg) had been administered, and the DON confirmed there were no warfarin tablets taken from the emergency kit and no other residents on warfarin. For a second resident, a medication pass was observed with a licensed nurse who prepared and administered six oral medications, which the surveyor verified by name and dose. The nurse confirmed that no additional medications were to be given at that time other than insulin, which was held due to a blood sugar of 109. However, on the MAR, the nurse documented that she had also administered polyethylene glycol 3350 powder, 17 g twice daily, even though this medication was not given during the observed pass. When questioned, the nurse acknowledged she had signed for administering the polyethylene glycol despite not having given it. She then searched the medication cart, found no polyethylene glycol, went to the supply room to retrieve a bottle, and administered the medication after the fact. The nurse stated she must have obtained the medication from another cart when she administered the morning dose, since none was available on the current cart at the time of the evening pass.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies; this plan of correction is prepared and/or executed solely because it is required (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. On [R] Physician was notified of prior events and current conditions for resident discharged to Lawnwood Regional Medical Center on [R] . No additional residents were affected at this time. C. On [R] , comprehensive medication and lab review for resident #1 was completed to ensure all physician orders and current and being followed; resident transferred to hospital prior to additional interventions being implemented. D. As of [R] , the licensed nursing staff identified in the deficient practice are no longer employed by the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A. On [R], the Director of Nursing/Designee identified and reviewed current residents receiving [R]. The review included verification of current physician orders, review of [R] INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of the review, there were no residents in the facility receiving [R] [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification orders. (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R], the facility implemented system changes, including the establishment of an [R] Management Protocol outlining INR critical value parameters, required interventions for elevated INR levels, and mandatory physician notification guidelines. A Lab Tracking Log was also implemented to ensure all ordered laboratory tests are completed as scheduled, reviewed in a timely manner, and escalated appropriately when not obtained. In addition, High-Risk Medication Audits [R] tool for [R] monitor compliance and medication safety practices. Education was completed with licensed nursing staff regarding the administration, monitoring, [R] management of [R] including therapeutic INR ranges, timely physician notification, documentation requirements, and appropriate interventions for abnormal lab values. B. By [R], Licensed Nursing Staff will have been educated by Director of Nursing/Designee on the components of F684 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. C. Newly hired licensed nursing staff will receive education by the Director of Clinical/Designee on the components of F684 with an emphasis on medication administration safety, documentation accuracy, and appropriate clinical decision-making and escalation protocols. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: A. The Director of Nursing/Designee will conduct audits on 5 residents on weekly x 4 weeks, then biweekly x 4 weeks, then monthly x 1 month. Audits will include medication administration accuracy, lab completion and follow up, physician notification compliance. The findings of these quality monitoring's to be reported to the quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Follow Physician Orders for Diagnostics, Monitoring, Medications, and Pressure Injury Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physician orders for multiple residents. One resident with end stage renal disease and on dialysis had a physician order dated March 27, 2026, for an occult blood stool test to be obtained for three days; review of the clinical record showed no documentation that this test was ever obtained. Another resident with type 2 diabetes mellitus with diabetic kidney complications and acute respiratory failure had an order dated August 29, 2025, for blood sugar checks before meals and at bedtime, with instructions to notify the physician if blood sugar was below 70 mg/dL or above 300 mg/dL. The Medication Administration Records showed that this resident’s blood sugar exceeded 300 mg/dL once in January 2026, seven times in February 2026, and seven times in March 2026, with no documented evidence that the physician was notified of these elevated readings. A third resident with hypertension and dementia had a physician order dated March 24, 2026, for carvedilol to be administered twice daily, with a specific parameter not to administer the medication if the resident’s heart rate was less than 60 beats per minute. Review of the MAR revealed that carvedilol was administered twice in March 2026 and six times in April 2026 when the resident’s heart rate was below 60 beats per minute. A fourth resident with cerebral infarction, vascular dementia, and muscle weakness had a physician order dated June 24, 2025, for Prevalon boots to be applied while in bed, and the care plan identified the resident as being at risk for skin breakdown. Multiple observations on April 28 and 29, 2026, showed this resident in bed without the ordered Prevalon boots applied. In interviews on April 30, 2026, the DON confirmed that the occult blood test was not done, the physician was not notified of the high blood sugars, and the medication was administered outside ordered parameters.
Plan Of Correction
Infection Control Nurse will educate providers on how to enter hemoccult order into treatment instead of into lab orders by 5/16/26. Infection Control Nurse will educate charge nurses to move hemoccult order from lab order into treatment order if it has been mistakenly entered into lab order by 5/16/26. Charge nurses will run order listing report daily and check for incorrect lab orders. Staff Development will educate nurses re: physician notifications by . ADONs will audit random events that required notification weekly x 4 weeks, biweekly for 4 weeks, then monthly. ADON completed audit on 5/7/26 regarding all Prevalon boot orders - all care plans and tasks updated. Charge nurses will audit that boots are in place for all residents with order for boots- weekly x 4 weeks, then randomly monthly. Root cause analysis revealed that nurse did not understand greater than and less than symbols. ADON completed audit of all meds with parameters utilizing greater than or less than symbols. Wording was corrected / symbols were removed to ensure clarity. Order template was update to include words, not symbols. Charge nurses will audit medication parameters weekly x 4 weeks, biweekly for 4 weeks, then monthly. Staff development will educate charge nurses will on the importance of running their order listing report and reviewing all new/updated orders for follow up. All audits will be reviewed monthly at QAPI.
Failure to Monitor Blood Glucose for Resident on Insulin Glargine
Penalty
Summary
The deficiency involves the facility’s failure to monitor blood glucose levels for a resident receiving Insulin Glargine (Lantus), contrary to professional standards of practice and the resident’s care plan. The manufacturer’s prescribing information for Insulin Glargine specifies that dosing should be individualized and adjusted based on metabolic needs, blood glucose monitoring results, and glycemic control goals, and notes that the medication is contraindicated during episodes of hypoglycemia. Despite these requirements, the resident was started on Insulin Glargine 10 units subcutaneously at bedtime for regulation of blood glucose, without any corresponding physician’s orders for blood sugar monitoring or accu-checks. The resident had a medical history that included Type 2 Diabetes Mellitus and had recently been hospitalized with diagnoses including Type 2 Diabetes, sepsis, and chronic kidney disease. Hospital records from the prior admission documented point-of-care glucose readings, including a low value of 60 mg/dl, followed by readings of 90 mg/dl and 109 mg/dl on the day of discharge. Upon admission to the facility, the resident’s physician orders and MAR reflected the initiation of Insulin Glargine therapy, but there was no documented baseline blood sugar at admission and no orders for ongoing blood glucose monitoring, despite the resident’s diabetic status and recent low blood sugar reading in the hospital. The resident’s care plan for diabetes stated that the resident was on a carbohydrate-controlled diet and included a goal of maintaining blood sugars within the physician’s acceptable range, with interventions to administer diabetes medications as ordered and to monitor for side effects and effectiveness. However, the clinical record contained no documented evidence that blood sugar levels were being monitored. On one occasion, a CNA reported that the resident had a pool of saliva at the corner of the mouth, prompting staff to check vital signs and blood sugar, which was found to be 54 mg/dl. Glucagon was administered, EMS was called, and the resident was transferred to the hospital, where the resident was admitted with hypoglycemia, sepsis, and for wound evaluation. The DON and facility physician later confirmed that there had been no orders for fingerstick blood sugar monitoring, that such monitoring should have been in place, and that the lack of monitoring was an oversight.
Failure to Implement Diet-Related Physician Order for Double Portions
Penalty
Summary
The facility failed to implement a physician’s diet-related order for double portions at all meals for one resident. Surveyors observed the resident’s lunch meal and noted the tray ticket did not indicate large or double portions. Record review showed the resident was admitted with diagnoses including unspecified quadriplegia, muscle wasting and atrophy of multiple sites, and other lack of coordination. Physician orders included a house diet with regular texture and thin liquids, no pork, and lactose intolerance restrictions starting in January, and an additional order starting in March that the resident may have double portions for all meals six times a day. The resident’s care plan and nutrition evaluation documented that the resident requested large entrée portions at meals and that large portions were to be provided per the resident’s request. Interviews and further record review revealed that the Food Service Manager (FSM) confirmed the resident received large portions at breakfast only, and that the lunch and dinner meal tickets did not show large portions. The FSM explained that dietary orders entered into the electronic medical record are automatically transferred to the meal tracker system, which prints the meal tickets, and that he could not adjust orders himself. He stated he did not see the double-portion order because it was categorized as “other” rather than under dietary. The DON reported that diet orders are to be entered by nursing leadership or the RD, documented on a dietary slip, and provided to dietary personnel, and confirmed that the double-portion order had been incorrectly entered under the “other” category and not communicated properly to dietary. The facility did not provide a policy related to physician or dietary orders.
Plan Of Correction
Formatted text (without <text> tags or quotes): Corrective Action for Resident Affected:Resident #4 was evaluated by nursing staff and theDietician to ensure the physician-ordered diet wasimplemented accurately. The order was changed inthe electronic health record and on the meal ticket toadd large portions to breakfast, lunch, and dinner. Identification of Other Residents at Risk:The Dietician and Clinical Reimbursement Directorcompleted an audit of current residents with physician-ordered dietary interventions to ensure dietary orders were accurately transcribed both in the electronic health record and displayed accurately on the meal ticket. Any discrepancies identified were corrected as indicated. Systemic Changes implemented: The Director of Nursing/designee re-educated Licensed nurses on the importance of implementing physician-ordered diets as written in the electronic health record. Education included the process for verifying diet orders following admissions, readmissions, and physician changes. Monitoring to Ensure Compliance: The Director of Nursing and/or Dietary Manager/designee will conduct audits of physician-ordered diets and meal tray accuracy weekly for four weeks, then monthly for two months to ensure compliance with ordered dietary interventions. Audit findings will be reviewed during the facility's Quality Assurance Committee meetings until substantial compliance is met.
Failure to Address New Skin Breakdown and Constipation in Residents at Risk
Penalty
Summary
The deficiency involves the facility’s failure to identify and treat a new skin condition for a resident at high risk for impaired skin integrity. The resident had diagnoses including spinal stenosis, radiculopathy, type II diabetes, hypertension, a current surgical wound, a history of MASD, anemia, and morbid obesity, and a care plan requiring weekly head-to-toe skin assessments and prompt reporting of abnormal findings. A weekly skin assessment documented on 03/30/25 indicated no skin issues. However, the resident later reported having what she believed to be a blister on the back of her left thigh that tore during a mechanical lift transfer, resulting in a wound that she stated was not addressed by staff despite her request for a nurse assessment. A nurse recalled the resident mentioning a blister weeks earlier but reported not seeing any area at that time. On 04/08/26, observation revealed an area on the back of the resident’s left thigh that appeared dry, peeling, and healing, approximately two by three inches, which an LPN confirmed. Subsequent documentation that same day described a new MASD area on the left posterior thigh measuring eight by 12 centimeters. The resident reported that a CNA had taken a picture of the back of her thigh on 04/03/26 using the resident’s phone, showing the area existed several days before the facility formally identified and documented it. A supervising RN confirmed that if a wound had been found and photographed on 04/03/26, it should have been identified and treated before 04/08/26, when the facility became aware of the skin alteration through the surveyor. This sequence shows a gap between the resident’s report of a skin issue, staff awareness via a photograph, and the formal recognition and assessment of the skin impairment. A second deficiency concerns the facility’s failure to implement interventions when a resident went more than three days without a bowel movement despite being at risk for constipation related to opioid use. The resident had diagnoses including adult-onset diabetes mellitus, generalized osteoarthritis, hypokalemia, depression, and anxiety disorder, and had an order for prn Oxycodone 5 mg by mouth every four hours for pain since admission. Her care plan identified her as at risk for constipation due to opioid use, with a goal of having a bowel movement at least every three days and interventions to observe for signs and symptoms of constipation. Bowel records over a 30-day period showed three episodes where no bowel movement was documented for more than three days: one four-day interval, one eight-day interval, and another four-day interval. During these periods, there was no documentation of any nursing interventions to promote a bowel movement, no laxatives administered, and no evidence of physician contact for constipation management, even though the resident continued to receive prn Oxycodone. The DON acknowledged the extended intervals without recorded bowel movements and the lack of documented interventions, and stated there was no bowel protocol in place, although it was an expectation that nurses contact the physician if no bowel movement occurred within three to four days.
Plan Of Correction
Formatted text (without <text> tags or quotes): 1. Resident #8 had their skin alteration evaluated by the wound nurse and appropriate treatment orders implemented on 4/8/26. Resident #99 had a medium bowel movement documented on 4/17/26 by the STNA and was assessed by the RN Unit Manager on 5/7/26 with no ill effects of going greater than 3 days without a bowel movement. Licensed Nurse obtained physician's order on 5/7/26 for stool softener. 2. Like Residents are identified as residents who have a skin alteration. A full-house skin sweep was completed by the Wound Nurse on 4/23/26 to identify any unreported skin alterations. Utilizing the Skin Alteration Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that skin alterations are evaluated and have appropriate treatment orders in place. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who have greater than 3 days with no bowel movement documented as indicated on the clinical alerts via PCC. Utilizing the Change in Condition Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that residents who do not have a bowel movement documented within three days have documentation in place for appropriate intervention/follow up. This audit will look back to 5/2/26. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNAs, including CNA #373 and RN #330 on the Skin Management and Notification of Change Policy to include reporting of skin alterations and notifying the physician of a resident change in status. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses utilize PCC to identify and address clinical alerts related to no bowel movements greater than three days and to follow the Notification of Change Policy regarding physician notification. This education will be completed on or before 5/13/26. 4. Utilizing the Skin Alteration Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that skin alterations are evaluated and have appropriate treatment orders in place. Noncompliance noted during the audits will be corrected with appropriate treatment orders in place. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Change in Condition Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that residents who do not have a bowel movement documented within three days have documentation in place for appropriate intervention/follow up. Noncompliance noted during the audits will be corrected with documentation in place for appropriate intervention/follow up. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
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