Failure to Provide Timely Wound Care and Skin Assessments
Summary
The facility failed to provide appropriate treatment and care according to professional standards and the resident's care plan for a resident with a skin tear. The resident, a 47-year-old male with a history of cerebral infarction, type II diabetes, and muscle wasting, developed a skin tear on his left lower extremity. The facility did not conduct a complete skin assessment when the skin tear was first noted, and several wound care treatments were missed, leading to an infection that required antibiotic treatment. The resident's care plan included interventions for diabetes management, such as checking the body for skin breaks and treating them promptly. However, the facility did not adhere to this plan, as evidenced by missed treatments on specific dates. The resident's wound care orders were not consistently followed, and the necessary skin assessments were not conducted weekly as required by the facility's policy. Interviews with staff revealed a lack of communication and documentation regarding the resident's wound care needs. The facility's failure to perform timely skin assessments and adhere to wound care protocols resulted in the resident developing an infection. The resident's nurse practitioner was not informed of the wound until it had already worsened, and antibiotics were only started after the infection was identified. The facility's policies on skin assessments and wound care were not followed, contributing to the resident's compromised skin integrity and subsequent infection.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic kidney disease, mild vascular dementia, and limited mobility was started on polyethylene glycol (MiraLAX) for constipation, with the provider’s order specifying use "until BM." Bowel records showed the resident had a bowel movement the day after the medication was initiated, but MAR review revealed staff continued to administer the laxative for several additional days instead of discontinuing it as ordered. The care plan identified constipation risk and directed staff to administer medications as ordered, and the DON later acknowledged the medication should have been stopped after the bowel movement.
A resident admitted after a lumbar laminectomy arrived with a surgical dressing in place and emergency room documentation noting the recent back surgery, but the admission nursing assessment recorded no skin impairment. A later skin assessment described a lower back surgical incision with granulation tissue, scab, and moderate serous drainage, confirming the wound was present on admission. No wound treatment orders or instructions to leave the dressing intact were in place until days after admission, and the eTAR showed no wound treatments documented for that period. In interviews, nursing staff and the DON reported that their usual process is to perform a head-to-toe skin assessment on admission, identify wounds, and obtain treatment orders or orders not to remove dressings, as required by the facility’s skin assessment policy.
Staff failed to follow physician-ordered blood pressure parameters for Midodrine administration for a resident with hypotension related to ESRD and dialysis dependence. The order required Midodrine 10 mg via PEG tube every 8 hours only when SBP was under 100 mmHg, but the MAR showed the medication was given multiple times when SBP readings were above 100 mmHg. An LPN confirmed that the medication should have been held based on the documented blood pressures, despite the care plan and facility policy requiring adherence to ordered parameters and monitoring of vital signs.
Staff failed to administer several ordered medications and did not consistently notify the provider when medications were unavailable for a resident. Record review showed missed doses of Hydralazine, diltiazem (Cardizem), and pantoprazole (Protonix) without appropriate documentation or evidence of provider notification, despite active orders. Omnicell records indicated at least one of the medications was available on-site, contradicting a note that it was awaiting pharmacy refill. Interviews with an LPN, the ADON, and others revealed inconsistent practices regarding checking the Omnicell, contacting the pharmacy, and notifying the provider when medications were not available, which did not fully align with the facility’s written medication administration policy.
Staff failed to administer and/or accurately document multiple medications as ordered for three residents. One resident did not have two scheduled morning doses of Calcium Carbonate documented on the MAR. Another resident with a new order for Ciprofloxacin for a UTI had two scheduled doses on the start date left blank on the MAR, despite the drug being available in the emergency backup supply. A third resident on scheduled Lorazepam for anxiety had conflicting records between the MAR and the narcotic sign-out sheet, with several doses charted as given on the MAR but not recorded on the narcotic log, and one scheduled dose missing entirely from the narcotic record. An LPN confirmed that if a medication is not documented, it is considered not administered, and described the expected process for narcotic handling and documentation.
Staff failed to monitor and document blood sugar checks as ordered for a resident with diabetes, and did not initiate or document required neurological checks after falls resulting in head injuries for two other residents, despite facility policy and physician orders. Interviews and record reviews confirmed these omissions, with administrative staff acknowledging the lack of evidence for the required care.
Failure to Discontinue Laxative as Ordered After Bowel Movement
Penalty
Summary
Facility staff failed to provide treatment and care according to medical provider orders and professional standards of practice for one resident. The resident had multiple diagnoses including chronic kidney disease, mild vascular dementia with agitation, left femur fracture, and difficulty walking, and had a BIMS score of 12/15 indicating moderately impaired cognition. On 2/16/26, a medical provider progress note documented that the resident was flagged for constipation greater than three days and that polyethylene glycol (MiraLAX) 1 capful every evening had been added until the resident had a bowel movement. A corresponding MD Communication Form dated 2/16/26 specified the order as polyethylene glycol 1 capful “until BM.” The facility’s policy on non-controlled medication orders required that medication orders specify the quantity or duration of therapy. Review of the resident’s bowel elimination record for February 2026 showed the resident had a bowel movement on 2/17/26. Despite this, the February 2026 MAR showed that staff continued to administer polyethylene glycol at bedtime from 2/16/26 through 2/24/26, rather than discontinuing it after the bowel movement as ordered. The comprehensive person-centered care plan identified the resident as at risk for constipation related to reduced physical mobility and included an intervention to administer medications as ordered. During the survey, the DON acknowledged that the MiraLAX should have been discontinued after the resident’s bowel movement on 2/17/26, confirming that staff did not follow the provider’s order regarding the duration of the medication.
Failure to Timely Assess and Treat Surgical Wound on Admission
Penalty
Summary
Facility staff failed to provide timely assessment and treatment of a surgical wound for one resident following admission. The resident had recently undergone a lumbar laminectomy and was admitted to the facility from the emergency room with a dressing over the laminectomy site that appeared normal and had been placed several days earlier. Emergency room discharge notes documented the recent surgery and the presence of the dressing, and the resident’s admission MDS later identified a surgical wound and surgical wound care. However, the nursing admission assessment dated 3/29/2024 documented no skin impairment, despite a subsequent skin assessment describing a surgical incision to the lower back with specific measurements, granulation tissue, scab, and moderate serous drainage, indicating the wound was present on admission. Physician orders dated 4/1/2024 directed staff to cleanse the lower back surgical wound with wound cleanser, pat dry, and apply calcium alginate and silicone foam dressing daily and as needed until healed, and the comprehensive care plan for impaired skin related to the laminectomy was also initiated on that date. There was no evidence of any wound treatment orders prior to 4/1/2024 or any order to leave the dressing intact and not remove it. Review of the eTAR for March showed no treatments completed for the surgical wound. In interviews, nursing staff and the DON stated that standard practice was to complete a full head-to-toe skin assessment on admission, identify any wounds, and obtain or confirm treatment orders from hospital discharge information or the physician, including orders to leave dressings in place if applicable. The facility’s skin assessment policy required a full body skin assessment by a licensed or registered nurse upon admission, but the resident’s surgical wound was not assessed and treated until several days after admission.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
Facility staff failed to administer Midodrine according to physician orders for one resident with hypotension related to end stage renal disease and dependence on dialysis. The physician’s order, dated 11/4/2025, specified Midodrine 10 mg via PEG tube every 8 hours to be given only when the resident’s systolic blood pressure (SBP) was under 100 mmHg. The comprehensive care plan documented the resident’s hypotension and directed staff to give medications as ordered and monitor vital signs as ordered and as clinically indicated. The facility’s medication administration policy required staff to validate physician-ordered parameters prior to medication administration. Despite these orders and policies, the January 2026 MAR showed that Midodrine was administered on multiple occasions when the resident’s SBP was above 100 mmHg. Specifically, the drug was given when blood pressures were recorded as 126/80, 122/76, 126/86, 148/80, 125/78, and 117/83. During an interview, an LPN stated that when a medication has blood pressure parameters, the nurse should take the blood pressure and then administer or hold the medication based on the physician’s order, and acknowledged that the Midodrine should not have been administered under the documented blood pressure readings. Administrative staff were informed of these findings, and no additional information was provided prior to survey exit.
Failure to Administer Ordered Medications and Notify Provider of Unavailable Drugs
Penalty
Summary
Facility staff failed to administer medications in accordance with active physician orders and did not consistently notify the provider when medications were not available for a resident in the survey sample. Review of the clinical record and MAR for this resident showed that on one occasion Hydralazine HCL, ordered for blood pressure management, was not administered, with a nursing progress note stating the medication was unavailable and awaiting refill from the pharmacy. However, review of the facility’s Omnicell content listing indicated that this medication should have been available on-site for staff to administer. On another date, the resident did not receive the ordered dose of diltiazem HCl ER beads (Cardizem), used to treat hypertension and other cardiac conditions, and there was no nursing documentation indicating why the dose was missed or that the provider had been notified. Further review of the resident’s June MAR revealed no documentation of administration of pantoprazole sodium (Protonix), a proton pump inhibitor, on a specified date, and there were no progress notes explaining the omission or showing that the physician was informed. Interviews with LPNs and nursing leadership showed variation in how staff responded when medications were not available, including differing practices regarding when to contact the provider and how to document missed doses. The facility’s written policy on medication administration required staff to search for ordered medications in multiple locations and contact the pharmacy or use the emergency kit if the medication could not be located, but the documented omissions and lack of provider notification for this resident demonstrated that these steps were not consistently followed.
Medication Administration and Documentation Errors for Multiple Residents
Penalty
Summary
Facility staff failed to administer medications according to physician orders and to accurately document administration for three residents. For one resident, a standing order for Calcium Carbonate 500 mg by mouth each morning, in place since 3/22/2025, was listed on the December 2025 MAR, but there was no documentation of administration on 12/5/2025 and 12/26/2025; the MAR boxes for those dates were left blank. During interview, an LPN confirmed that nurses evidence medication administration by checking off the MAR and acknowledged that if it is not documented, it is considered not done. For another resident with an order dated 12/18/2025 for Ciprofloxacin HCL 500 mg by mouth every 12 hours for 7 days for a UTI, the December MAR showed the order starting 12/19/2025, but the 9:00 a.m. and 9:00 p.m. doses on that date were left blank, despite Ciprofloxacin being available in the emergency backup box. For a third resident admitted for respite care, staff failed to administer and/or accurately document Lorazepam Oral Concentrate per a physician order dated 12/4/2025 for 2 mg/mL, 0.25 mL by mouth every 2 hours for anxiety. The December MAR showed the medication as given at 4:00 p.m., 6:00 p.m., 8:00 p.m., and 10:00 p.m. on 12/4/2025, and at 4:00 a.m. and 6:00 a.m. on 12/5/2025. However, the narcotic sign-out sheet documented only two doses on 12/4/2025 at 5:30 p.m. and 7:00 p.m., with no entries for the other scheduled times. On 12/5/2025, the narcotic sheet showed doses at 12:00 a.m., 2:00 a.m., and what appears to be 6:00 a.m., with no documented 4:00 a.m. dose. The resident’s comprehensive care plan noted the resident was at risk for adverse reactions and side effects from antianxiety medications and included an intervention to administer antianxiety medications per orders. The LPN described the process for narcotic administration as removing the drug from the narcotic box, signing it out in the narcotic book, and then documenting the dose on the MAR, highlighting the discrepancy between the two records.
Failure to Monitor Blood Sugar and Perform Post-Fall Neuro Checks
Penalty
Summary
Facility staff failed to provide care and services to promote the highest level of wellbeing for three residents by not following physician orders and facility policies. For one resident with diabetes, acute/chronic respiratory failure, and a tracheostomy, staff did not perform or document blood sugar checks as ordered before meals and at bedtime on multiple occasions. The resident was cognitively intact and dependent for most activities of daily living. Staff interviews confirmed that if blood sugar checks are not documented, there is no evidence they were performed, and review of the facility's policy indicated that a physician's order must be verified for such procedures. Two other residents, both with significant medical histories including cerebrovascular accident, atrial fibrillation, NSTEMI, diabetes, CHF, subdural hemorrhage, and tracheostomy, experienced falls resulting in head injuries and bleeding. In both cases, the facility failed to initiate and document neurological checks post-fall as required by facility policy and standard clinical practice. Staff interviews revealed that neuro checks should be started immediately after a fall, especially when the resident is on anticoagulants or has sustained a head injury, and should be documented on a paper flowsheet. However, administrative staff confirmed that there was no evidence of neuro checks being performed for either resident after their respective falls. Facility documentation and staff interviews consistently indicated that the required monitoring and documentation were not completed for these residents. The facility's own policies on obtaining fingerstick glucose levels and managing falls and fall risks were not followed, and there was no evidence provided to show that the necessary assessments and interventions were carried out as ordered or per policy.
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.
