Failure to Follow Resident Transfer Plan of Care
Summary
Facility staff failed to follow the written plan of care for a resident who was documented as requiring transfer with a mechanical lift and two-person assistance due to confusion, left side weakness, and impaired mobility following a stroke. The resident's care plan and comprehensive assessment indicated substantial to maximal assistance was needed for transfers, and the use of a mechanical lift was specified in the closet care plan. Despite these documented requirements, staff transferred the resident manually without the mechanical lift. The incident occurred when a CNA and an LPN entered the resident's room to transfer the resident from a wheelchair to a bed. The LPN instructed the resident to place their hands around the nurse's neck and attempted to lift the resident out of the wheelchair, but was unable to clear the wheelchair armrest. Multiple attempts were made, during which the resident's feet became caught in the wheelchair foot pedals, and the resident was ultimately lifted over the armrest and onto the bed without proper support. The family member present reported the transfer was performed in a rough manner, resulting in the resident's head and legs being left dangling off the bed before being quickly repositioned by the nurse. Following the transfer, the resident complained of left knee pain and was unable to participate in physical therapy at their previous level for several days. An x-ray showed no acute fracture or dislocation, but moderate osteoarthritic changes were noted. The therapist confirmed the resident's knee pain limited therapy participation temporarily, though the resident returned to baseline function within a week. The facility's investigation, including review of camera footage, substantiated that the staff did not follow the resident's plan of care, as the mechanical lift was not used during the transfer.
Penalty
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A CNA administered PRN liquid cough medication to a resident instead of the nurse, despite the resident’s care plan and physician order for the medication to be given by licensed staff. The resident said the CNA brought the cough medicine when the nurse was supposed to, and the CNA acknowledged she was not authorized to give meds and that it was her error; the RN said he poured the medication and handed it to the CNA while standing at the doorway.
Facility nursing personnel failed to maintain current CPR certification for Healthcare Providers for three of 42 licensed nurses. Review of policy showed online-only CPR was not acceptable, and the CPR cards for three LPNs showed non-healthcare provider online-only classes without a hands-on session. The NHA and DON confirmed the deficiency.
A CNA independently performed wound care and dressing changes for four residents without supervision, despite facility policy and staff job descriptions limiting wound care to licensed nursing staff. The CNA said she relied on memory because she could not access orders, while the TAR showed the treatments were signed off as completed by an LPN. Interviews with LPNs and other CNAs confirmed wound care was normally done by licensed nurses and that CNAs were not permitted to perform it.
Uncertified LPNs performed CPR on a full-code resident after the resident was found unresponsive on the floor, not breathing, and without a pulse with a cord wrapped around the neck. LPNs #5, #11, and #12 all participated in compressions and related resuscitative efforts, but the facility had no documentation that they held current CPR certification; one LPN said hands-on training was not complete, another said they did not have current certification, and the DON stated noncertified staff could perform CPR under the good Samaritan law.
A resident with a G-tube, dysphagia, anorexia, GERD, and gastroparesis had orders for bolus enteral feedings with residual checks before feeding. A family member observed a student nurse start a bolus feeding without the instructor or an RN/LVN present and without checking residuals, with the instructor arriving only near the end. Staff gave conflicting accounts about whether checked-off students could perform the task independently, and the DON and Administrator stated the facility had no protocol or policy for student nurses providing care on their own.
A resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II DM had a physician order for nursing staff to apply bilateral elastic compression bandages from the dorsum of the feet to below the knees each morning and remove them at bedtime. Review of the Treatment Administration Record for the month showed multiple missed leg wrap treatments, with no corresponding documentation of refusals or physician notification. The DON confirmed that nurses are required to document treatments on the TAR, notify the physician of refusals, and that the resident’s legs were to be wrapped daily per the physician’s order.
CNA Administered PRN Cough Medication
Penalty
Summary
The facility failed to provide care by qualified persons in accordance with the resident’s written plan of care when CNA D administered liquid cough medication to a resident with dysphagia, paraplegia, fibromyalgia, and intact cognition. The resident’s care plan noted that he had complaints of cough at times and had PRN medication in place to treat it, and the physician order was for guaifenesin oral liquid 200 mg/10 mL, 10 mL by mouth every 4 hours as needed for cough. During interview, the resident stated that CNA D gave him cough medicine and that the nurse was supposed to bring it to him. CNA D stated that the resident asked for cough medicine, that she told RN E, and that she gave the medication while RN E stood by the resident’s door. CNA D acknowledged that CNAs were not authorized to give medication and said it was her error to give it. RN E stated he poured the medication into a cup and handed it to CNA D while he stood at the doorway to ensure safety, and the DON later confirmed she was informed of the grievance regarding the CNA giving the medication.
LPNs Lacked Acceptable CPR Certification
Penalty
Summary
Facility nursing personnel did not maintain current CPR certification for Healthcare Providers through a CPR provider whose training included a hands-on session in a physical or virtual instructor-led setting, as required by facility policy and accepted national standards. Review of the facility policy showed that licensed nursing staff must have current CPR certification for healthcare providers with hands-on practice and in-person skills assessment, and that online-only certification is not acceptable. Review of the facility’s list of 42 licensed nurses and the CPR certification cards for LPN Employees E1, E3, and E4 showed that their certifications were for online-only CPR classes for non-healthcare providers and did not include a hands-on session. During interview, the NHA and DON confirmed that the facility failed to ensure current CPR certification for these three licensed nurses.
Unlicensed CNA Performed Wound Care and Dressing Changes
Penalty
Summary
The facility failed to ensure dressing changes were completed by a licensed nurse for four residents, identified in the report as R3, R4, R5, and R12. Facility policy stated dressing changes were to be completed per physician order and documented on the treatment record and weekly wound progress report. The RN supervisor job description described oversight and coordination of nursing services, while the LPN job description stated treatments were to be provided in accordance with physician orders and nursing policies and procedures. The CNA job description described direct resident care duties under the supervision of licensed nursing personnel, not independent wound care. An anonymous complaint alleged that CNA Employee E1 was doing wound care and that nurses were being told to sign off on treatments completed by the CNA. During interview, CNA Employee E1 confirmed she independently performed wound care for R3, R4, R5, and R12 without oversight or another staff member present. She stated she was assigned to assist the wound care nurse and wound care provider, but on the day the wound care nurse was off and staff were busy, she changed the dressings herself. She also stated she could not access the orders and relied on memory from prior rounding with the wound care nurse and wound care provider. The TAR showed dressing changes were signed off as completed by a licensed nurse for the four residents. Interviews with multiple LPNs confirmed that they performed their own wound care when the wound care nurse was unavailable and that CNAs were not permitted to do wound care. One LPN stated she did not remember asking CNA Employee E1 to do treatments. Other CNAs stated they did not do wound care and were not trained or permitted to do so. The NHA and DON confirmed the facility failed to ensure residents received necessary treatment and services provided by a qualified person.
Uncertified LPNs Performed CPR on Full-Code Resident
Penalty
Summary
The facility failed to ensure that services provided or arranged were delivered by qualified persons when three LPNs performed CPR on Resident #1 without valid CPR certification. Resident #1 had diagnoses including Huntington's disease, suicidal ideations, and post-traumatic stress disorder, and had a physician order for full code status with no limitation on medical interventions. On the morning of the event, the resident was found lying on the floor next to the bed, unresponsive, not breathing, and without a pulse, with a cord wrapped around the neck. A code blue was called and staff began CPR before the resident was transferred to a hospital. Staff statements documented that LPN #5 found the resident on the floor during a medication pass, saw the red full-code wristband, called the code blue, and participated in CPR with other nurses and an AED until paramedics arrived. LPN #11 stated they responded to the code blue, found the resident without pulse or respirations, and performed multiple rounds of compressions, with LPN #12 taking over compressions while suctioning was performed. LPN #12 stated they entered the room and saw LPN #11 performing compressions and assisted until EMS took over. The facility provided a list of staff with current CPR certification, but there was no documented evidence that LPN #5, LPN #11, or LPN #12 were certified. LPN #5 stated they had completed online CPR modules but had not finished hands-on training and were not currently certified, LPN #11 stated they did not possess a current CPR certification, and the DON stated staff without CPR certification could perform CPR under the good Samaritan law.
Student Nurse Performed G-Tube Feeding Without Required Supervision
Penalty
Summary
The facility failed to ensure care and services were provided by qualified persons in accordance with the written plan of care for a resident with a G-tube. The resident’s record showed diagnoses including dysphagia, anorexia, encounter for attention to gastronomy, GERD, and gastroparesis, and the care plan identified that the resident required use of a feeding tube. The order summary included enteral feeding orders for bolus feedings four times a day and instructions to check residuals before feeding, return gastric contents if over 100 mL, withhold medication, and notify the physician. A family member stated they observed a student nurse enter the resident’s room with feeding supplies and begin a bolus feeding without the instructor or a nurse present. The family member stated the student nurse did not check for residuals before starting the feeding, and that the instructor arrived only near the end of the feeding and assisted with the last portion of formula and water. The family member stated the resident was not in distress during the event. Staff interviews showed differing understandings of whether student nurses could perform bolus feedings independently once checked off. LVN staff stated students were allowed to do the task alone after competency validation and that they would later check on the resident. The clinical instructor stated students were checked off in skills lab and again at the facility and were competent to perform the skill without supervision. The DON and Administrator stated the facility did not have a protocol or policy regarding student nurses performing tasks independently, and the facility record review confirmed there was no policy in place regarding student nurses providing care to residents.
Failure to Follow Physician Orders for Daily Leg Wrap Treatments
Penalty
Summary
Failure to provide care by qualified persons according to a resident’s written plan of care occurred when nursing staff did not consistently implement a physician’s order for daily bilateral leg wraps. A cognitively intact resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II diabetes mellitus had a physician order directing nursing to wrap both legs with elastic compression bandages from the dorsum of the feet to below the knee every morning and remove them at bedtime. Review of the Treatment Administration Record for April 2026 showed seven missed treatments for the ordered leg wraps between 4/1/26 and 4/23/26. The Director of Nurses confirmed that nurses are required to document treatments on the TAR, to notify the physician if residents refuse treatments, to document refusals in the medical record, and that this resident’s legs were to be wrapped daily per the physician’s order. These findings demonstrate that the ordered leg wrap treatments were not provided and/or not documented as required, and that there was no documented physician notification or refusal documentation corresponding to the missed treatments, resulting in a failure to follow the resident’s plan of care and physician orders.
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