Deficiencies in Resident Care and Documentation
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for all ten residents reviewed for quality of care. Specifically, the facility did not administer and read the purified protein derivative test for tuberculosis for two residents, and failed to notify a provider when a resident's blood sugar was critically low. Additionally, the facility did not monitor the vital signs of a newly admitted resident as required. One resident was administered an excessive amount of Acetaminophen, exceeding the prescribed limit, and was left in distress without adequate pain management, leading to a call to 911 for hospital transport. The facility also documented vital signs for this resident after they had already been discharged. Furthermore, the facility failed to obtain and document monthly vital signs according to provider orders for several residents, with instances of duplicate vital signs being recorded, indicating a lack of proper monitoring and documentation. The deficiencies highlight a pattern of inadequate care and documentation practices across multiple units within the facility, affecting residents with various medical conditions, including diabetes, hypertension, and mental health disorders. These failures demonstrate a significant lapse in adhering to established care protocols and ensuring the well-being of the residents.
Plan Of Correction
Plan of Correction: Approved February 1, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Immediate corrective action: Resident #365 no longer resides in facility. Resident #368 has reached compliance upon return from hospital with two-step Purified protein derivative plant and read per facility policy and completed on 1/9/2025. Provider notified on 1/9/2025 of incident with no new orders recommended. The Medical provider was notified on 1/9/2025 of residents #638, 29, 89, 73 that facility failed to monitor vital signs per provider order with no new order recommended. Licensed staff responsible for failure to notify medical provider of resident blood sugar outside parameters was counseled and reeducation completed on 1/10/2025 by the Assistant Director of Nursing. 2. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence: Nurse management conducted a 90-day look back from 10/9/24 through 1/9/25 for residents with active orders for blood sugar monitoring. As a result of the audit, no issues noted. All residents have the potential to be affected by the deficient practice. The facility's plan to prevent reoccurrence, the previous 30 days of admissions were reviewed for compliance with purified protein derivative placement and results documented per policy. Audit completed on 1/10/2025. A total of 30 residents were reviewed. Out of the 30, 8 residents were discharged, 2 were compliant, and 20 were identified to be out of compliance. A [MEDICATION NAME] screen was completed for those residents per policy. The results of the [MEDICATION NAME] screen were reported to the medical provider for further review. No further directives given. Nursing management conducted a full house review on 1/17/2025 on residents with active orders containing Tylenol to determine the potential for the resident to exceed the recommended limit. Results of the review concluded one resident was identified at risk to potentially exceed the daily recommended limit. Those residents identified were submitted to the medical provider for review with one resident with new orders. A full house review was conducted on 1/16/2025 on residents’ vital signs per the provider order. The results of those residents with orders for monthly vital signs concluded all residents to be out of compliance. Results submitted to the medical provider with new order for one resident. Results of resident review for new admission vital sign orders concluded 23 residents reviewed. Review of audit concluded 14/23 residents were identified to be out of compliance. Any residents identified as having vital sign omissions received updated vitals and results reviewed with the medical provider. 3. The systemic changes: The facility reviewed the policies titled Vital Signs, Diabetes Mellitus Guidelines, and [MEDICAL CONDITION]. They were reviewed by medical with no revisions necessary. The facility educator re-educated licensed staff on vital signs, diabetes mellitus guidelines, and [MEDICAL CONDITION] policies with emphasis on notifying the provider with results of blood sugar outside parameters, administration and timely result documentation per MD order of Purified protein derivative, daily recommended Tylenol consumption not to exceed recommended limit, and obtaining and monitoring of resident-specific vital sign order for frequency. This education was accompanied by a post-test to ensure retention. All results of blood sugar, results of the [MEDICATION NAME] skin test, and results of vital signs will be documented in the medication administration record. The facility supervisor will complete a 24-hour look back of all new Tylenol orders to ensure there is no potential to exceed the recommended daily limit. The facility supervisor will complete a 24-hour look back on residents' blood sugars to ensure residents identified with blood sugars outside parameters were reviewed and submitted to the medical provider. The facility supervisor will complete a 48-hour look back on residents who received a [MEDICATION NAME] skin test to follow up and document [MEDICATION NAME] skin test read. The facility supervisor will complete a 24-hour look back of those residents with active vital sign orders to determine vital signs obtained per provider order. Any result out of compliance, the supervisor will notify the medical provider for further directives and will document the outcome in the medical record. 4. Quality assurance: The Unit managers will audit all new admissions' Purified protein derivative status to ensure compliance is met. This will be audited weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Assistant Director of Nursing will submit weekly immunization documentation tracker form weekly. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit residents' blood sugars. This audit will look for any documented value outside parameters to ensure the medical provider was notified. This will be conducted weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Unit managers will audit compliance with vital signs completion weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. Unit managers will audit all active Tylenol orders to ensure residents do not exceed the daily limit. This audit will be done weekly x 4 weeks, then monthly x 3 months. Results of the completed reviews will be brought to monthly Quality Assurance Performance Improvement for review and determine recommendations of frequency of reviews required. The Director of Nursing will oversee all audits. Responsible Party: Director of Nursing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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