Failure to Notify CHF Clinic of Significant Weight Gain in Resident
Summary
The facility failed to ensure that a resident with a diagnosis of congestive heart failure (CHF) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not notify the CHF clinic of the resident's significant weight gain as required by provider orders. The resident experienced a weight increase of more than 10 pounds within a week, as documented in daily weight records, and exhibited symptoms such as shortness of breath and low oxygen saturation levels. Despite clear physician orders to notify the CHF clinic for weight gains of 2 or more pounds overnight or 3-5 pounds in one week, there was no documentation in the nursing progress notes that such notifications were made during the period of weight gain. Interviews with nursing staff confirmed that although weights were taken and abnormal findings were reported during shift handovers, no direct notification was made to the CHF clinic. The resident's care plan also included interventions to monitor for respiratory distress and to contact the medical provider if noted, but these interventions were not fully implemented as required. The lack of timely notification resulted in the resident requiring IV Lasix administration at the CHF clinic after the significant weight gain and onset of shortness of breath. Family members and clinical staff from the CHF clinic confirmed that they were not informed of the resident's weight changes by the facility, which led to a delay in care. The facility's own policy required prompt notification and documentation of changes in condition, but this was not followed in this case, as confirmed by interviews with the DON, nursing staff, and the resident's physician.
Removal Plan
- The facility activity report and the 24-hour report will be audited by the Director of Nursing/Designee to identify any documentation that indicates changes in resident's condition and notification to provider as ordered.
- The Director of Nursing will be reeducated by the Clinical Consultant on following providers orders to prevent a delay in treatment and change in condition including: prompt notifications documented in residents medical record to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; nursing leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor; shortness of breath; weight gain in residents with Congestive Heart Failure causing shortness of breath.
- Licensed nurses, including PRN nurses, will be reeducated by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; shortness of breath; weight gain in Congestive Heart Failure residents causing shortness of breath. Licensed Nurses, including PRN nurses not receiving this education will receive prior to their next scheduled shift and this will be completed in New Hire orientation.
- Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months.
- The Administrator will oversee the continuation of this plan.
- Ad Hoc QAPI will be held.
- The Medical Director was notified of the Immediate Jeopardy and contents of this plan.
- Monitoring included the following: Record review completed of the facility 24-hour report. Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up.
- Record review of an in-service titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes.
- Record review of an additional in-service on prompt notifications to providers, documentation, and validation in clinical morning meetings.
- Record review of in-service titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
- Record review of a staff in-service revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
- Record review of a staff in-service revealed staff were educated on prompt notifications to providers, documentation, notifications to required medical staff of weight changes as ordered, shortness of breath, and weight gain in Congestive Heart Failure residents causing shortness of breath.
- Record Review of training titled: Change of Condition revealed staff were trained on licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered.
- Record review of the Adhoc QAPI for F684 revealed the meeting included the ADM, DON, CC, and MD.
- Record Review of a signed statement by the DON revealed notification to the MD regarding Immediate Jeopardy.
- Record review of the new hire orientation packet which included an added section revealed the following: respiratory care all nurses validate resident is receiving oxygen per MD orders; change of condition recognition and notification to providers; prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record; notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB; policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities.
- Record review of education provided to the only 2 agency nurse staff working revealed education included change of condition and CHF education.
- Record review of an email from the DON to RN C revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- Record review of an email from the DON to LVN B revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure.
- Record review of text messages from the DON to LVN A revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- Record review of text messages from DON to LVN D revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- In-service training and verbal assessment for LVN E prior to her shift on changes of condition and the need to notify providers, including a PowerPoint on CHF management.
- In-service training and verbal quiz for LVN F prior to her shift on changes of condition, who to notify, weight gain, CHF management including s/s and concerns to look for.
- Ongoing training to any oncoming agency, PRN, or new staff.
- Review completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.