Failure to Obtain Written Hospice Orders
Summary
The facility failed to ensure that Hospice providers supplied written physician orders for a resident receiving Hospice services. The Hospice's agreement allowed nurses to receive and transcribe physician orders, which were to be countersigned by the facility's Director of Nursing or another nurse. However, for the resident in question, the facility did not have written documentation of medication order changes, aspiration risk orders, or instructions for administering medications. The resident's care plan indicated they were admitted to Hospice services with a terminal prognosis related to Alzheimer's Disease and Severe Protein Malnutrition, and they expired without the facility having complete Hospice documentation. Interviews with facility staff revealed that Hospice orders were often given verbally, and it was the responsibility of the facility nurses to enter these orders into the Electronic Health Record. The facility's Director of Nursing and Registered Nurses acknowledged that verbal orders were taken without written documentation, and the Hospice nurses did not leave progress notes or plans of care at the facility. This lack of written documentation led to confusion among the nursing staff, as one nurse admitted to not knowing the correct method of administering Ativan to the resident. The absence of written orders and clear communication between the Hospice and facility staff contributed to the deficiency in care provided to the resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure physician oversight of wound care, resulting in two residents with significant wounds not receiving timely medical assessment or treatment. In both cases, wounds were documented by staff but not reported to a physician, and no wound treatments were initiated. The nurse practitioner involved was not wound certified, and the medical director was not informed of the residents' conditions. Both residents required hospital transfers for severe wound-related complications.
The facility failed to obtain written physician approval for the admission of three residents, each with complex medical histories and varying levels of cognitive and physical assistance needs. This deficiency was confirmed by the Regional Clinical Nurse during an interview.
The facility failed to provide wound physician follow-up for a resident with a complicated abdominal wall wound as ordered on admission. Despite the resident's history of severe medical conditions and the need for wound care, the facility did not arrange for necessary follow-up appointments, and an order for wound care assessment was canceled without explanation.
Failure to Ensure Physician Oversight of Wound Care
Penalty
Summary
The facility failed to ensure that wound care for residents was overseen by a physician, resulting in a lack of appropriate medical oversight and treatment for residents with significant wounds. In one case, a resident with multiple comorbidities, including diabetes and cognitive impairment, developed a worsening wound on the left foot. Despite weekly wound reports documenting the decline of the wound, there was no evidence that a physician was notified or that wound treatments were initiated. The wound nurse only measured the wound and did not assess it or communicate with the physician, and the nurse practitioner involved was not wound certified. The resident was eventually transferred to the hospital with severe sepsis due to the untreated wound, and the hospital expressed concerns about the extent of the wounds. Another resident with end stage renal disease, diabetes, and a history of amputation developed an ulcer on the right heel, which was identified by the dialysis center but not documented or reported by facility staff in weekly skin assessments. The dialysis center attempted to notify the facility about the ulcer, but there was no evidence of follow-up or physician notification. The resident's condition deteriorated, and upon eventual hospital transfer, was found to have a necrotizing soft tissue infection requiring emergency above-the-knee amputation. The physician confirmed he was not made aware of the wound until after the resident was hospitalized. Interviews with facility staff and review of facility policy revealed that there was no physician oversight of wound care, and the nurse practitioner providing wound care was not wound certified nor supervised by a wound certified provider. The medical director was not informed of the residents' wounds and did not oversee wound care. Facility leadership confirmed they were unaware that wound care was not being overseen by a physician, contrary to facility policy requiring the medical director to oversee the medical care of all residents.
Failure to Obtain Physician Approval for Resident Admissions
Penalty
Summary
The facility failed to ensure that a physician approved the admission of residents in writing, affecting three residents out of five reviewed for physician services. Resident #58, who was admitted with multiple diagnoses including schizophrenia, severe intellectual disabilities, and type two diabetes mellitus, had no documentation of physician approval for admission. The resident required assistance with various activities of daily living and had severely impaired cognition, as noted in the admission Minimum Data Set (MDS) assessment. Similarly, Resident #85, admitted with diagnoses such as schizoaffective disorder and a history of traumatic brain injury, also lacked written physician approval for admission. This resident was cognitively intact and required minimal assistance with daily activities. Resident #92, with a complex medical history including schizophreniform disorder and major depressive disorder, was also admitted without documented physician approval. This resident was cognitively intact and required assistance with several daily activities. The Regional Clinical Nurse confirmed the absence of written physician approval for these admissions during an interview.
Failure to Provide Wound Physician Follow-Up
Penalty
Summary
The facility failed to provide wound physician follow-up for a complicated abdominal wall wound for Resident #97 as ordered on admission. Resident #97 had a history of an unspecified open wound of the abdominal wall, chronic obstructive pulmonary disorder, type two diabetes mellitus, and hypertensive chronic kidney disease in stage five end stage renal disease. The resident was admitted to the facility with a wound vac to his abdominal wall surgical site, which was later found to be infected and treated with antibiotics. Despite the discharge orders including oral antibiotics and no incision care orders, the facility did not arrange for follow-up appointments with a wound care physician as required. The admission assessment initially indicated no wound issues, but a subsequent skin assessment revealed an abdominal surgical incision that required evaluation by the wound care team. An order was placed for the wound care physician to assess the resident on 01/15/24, but this order was canceled on 01/16/24 without explanation. The facility's policy on wound care was not followed, as the resident did not receive the necessary wound care interventions or referrals to a wound care specialist. The deficiency was confirmed through interviews with the Administrator and Corporate RN, who acknowledged the lack of follow-up and the cancellation of the wound care order prior to the resident's discharge on 01/16/24.
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.
