Out on Pass Order Was Not Properly Evaluated or Clarified
Summary
The facility failed to follow its Out on Pass policy and its Physician Orders and Telephone Orders policy for Resident 1, who was admitted with end stage heart failure, dilated cardiomyopathy, chronic kidney disease stage 2, acute pulmonary edema, cocaine abuse, non-compliance with medical treatment, and hospice services. The record showed Resident 1 was identified as a risk for elopement and falls, and the care plan directed staff to monitor the resident’s whereabouts frequently, document wandering behavior, and attempt diversional activity. The resident’s H&P documented that he had capacity to understand and make decisions, and the MDS showed he could make himself understood and understand others, but also required assistance or supervision with multiple activities of daily living. The record showed an order for Resident 1 to go out on pass starting 10/1/2025, and a progress note on 10/6/2025 documented that he went out on pass on 10/7/2025 at 12:50 PM. Facility documentation then showed the resident had not returned and staff attempted to contact him multiple times on 10/7/2025, 10/8/2025, and 10/9/2025 without success. The notes also stated the Social Services Director had been trying to reach the resident since 10/7/2025 at 3:07 PM. During interviews, facility staff stated they could not find an IDT assessment for the resident’s out on pass, and RN 1 stated the facility did not perform an IDT meeting to assess the resident’s safety and ability to go out on pass. RN 1 also stated the order to go out on pass was not clear and did not include an agreed upon return time. The DON and ADM stated the facility did not follow its out on pass policy, did not create a care plan for the pass, did not provide medications when the resident left, and did not have an agreed upon return time. The hospice doctor stated he was not aware of the out on pass order, would not have allowed the resident to go out independently, did not know the resident had a car or could drive himself, was not invited to participate in an IDT meeting, and stated the resident should have been accompanied by a responsible party and should not have been out for longer than four hours.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure that Psychiatry Group progress notes were available for continuity of care for a resident with schizophrenia who received outpatient mental health services. The resident said he attended therapy every three months for medication and care, but the clinical record contained no progress notes or other documentation from the outside provider. The DON contacted the clinic, which said a signed release was needed before records could be sent, and the ADON later confirmed no documentation had been received.
Delayed and inaccurate physician documentation affected two residents. An NP and attending physician did not enter progress notes, H&Ps, and orders into the chart in a timely manner after seeing a resident, and some notes were not available for staff review until days later. The record for one resident also showed conflicting documentation about a Seroquel GDR, with the NP and attending continuing to chart the admission dose despite the GDR being completed.
Physician Block Orders Not Signed During Required Visits: A resident’s provider completed progress notes during multiple required regulatory visits, but the physician block orders for meds and tx were not signed on the visit dates. The orders were signed days later after each visit, and the DON confirmed the finding during interview.
A provider failed to review and revise a resident’s care after a urology consult for urinary retention. The consult noted the resident could not communicate voids, had dry diapers on assessment, and raised concern for silent retention, with a plan for bladder scans and continued straight catheterization per policy. A later provider note mentioned monitoring for UTI or retention symptoms and using bladder scans for discomfort or poor voiding, but did not address the straight catheterization recommendation. The DON stated the facility did not have a bladder scan machine and used bladder ultrasounds instead.
A resident with AFib, DM, and HF was receiving Warfarin and had orders for PT/INR monitoring plus multiple additional labs. The record showed the ordered labs were not completed, there was no documented notification to the MD or RN supervisor, and there was no documented follow-up by the MD on the missing lab work.
A physician telephone order for Tylenol suppository 240 mg was given for an infant resident but was not written, signed, or dated by the MD. The dose was administered after the parent requested medication for irritability, and the next morning the resident had vomiting and increased sleepiness; the NP noted the dose exceeded the loading dose for age and weight, Poison Control was contacted, and the resident was sent to the ER for evaluation.
Missing Psychiatry Progress Notes for Resident Mental Health Care
Penalty
Summary
The facility failed to ensure that the Psychiatry Group provided progress notes for continuity of care with each visit for one resident with schizophrenia. Review of the resident’s MDS dated 6/3/26 showed a diagnosis of schizophrenia, and the clinical record indicated the resident used an outside mental health provider for psychiatric care. During an interview on 7/21/26, the resident stated he went to outpatient therapy every three months for care and medication and had no issues obtaining his mental health medication. Review of the resident’s clinical record did not identify any progress notes or other documentation from the outpatient therapy providers related to continuity of care. The DON stated on 7/21/26 that she called the clinic and left a message with Medical Records, and the clinic later stated the facility needed the resident to sign a release form before records could be sent, even though he was a resident of the facility. The DON then had the form faxed and planned to have it signed by the resident, and the ADON later stated the clinic did not send any documentation.
Delayed and Inaccurate Physician Documentation
Penalty
Summary
Physicians and the nurse practitioner failed to have progress notes, history and physicals, and orders entered into the medical record in a timely manner after seeing residents, and the documentation did not always reflect the most accurate resident information. For Resident #9, NP #27 visited on 4/14/26 and discussed with the power of attorney the plan for a below-the-knee amputation, but the note was not available in the record until 4/18/26. For Resident #1, multiple hospitalizations required new history and physicals on each readmission, but several notes were initiated and posted more than 24 hours after the resident was seen and orders were reviewed. An admission note initiated on 5/14/26 with an effective date of 5/15/26 was not available until 5/17/26, and another admission note from 6/23/26 was not signed or available until 6/25/26. Additional attending physician notes dated 7/2/26 and 7/5/26 were not available until 7/10/26. The record also showed a gradual dose reduction for Seroquel completed on admission in fall 2025, while both NP #27 and Attending #28 continued to document that Resident #1 remained on the admission dose from August 2025 through January 2026.
Physician Block Orders Not Signed During Required Regulatory Visits
Penalty
Summary
The facility failed to ensure that the resident’s doctor reviewed the resident’s total program of care during required regulatory visits and signed the physician block orders for medications and treatments at the time of those visits. Record review showed that a required regulatory visit was completed on 12/9/25, with a provider progress note documented that day, but there was no evidence that the physician block order was signed on the day of the visit. The facility was unable to provide evidence that the order was signed on that date, and the physician block orders were not signed until 1/12/26, 34 days later. The same issue occurred during subsequent required regulatory visits on 2/12/26, 4/14/26, and 6/4/26. Each visit had a provider progress note completed on the visit date, but there was no evidence that the physician block order was signed on the day of the visit. The facility could not provide evidence of same-day signing, and the physician block orders were signed later on 3/8/26, 5/4/26, and 6/29/26, respectively. On 7/21/26 at 12:05 p.m., the DON confirmed the finding during interview.
Provider Did Not Address Urology Recommendations for Urinary Retention
Penalty
Summary
The primary medical provider failed to review and revise Resident #28’s total program of care after a urology consult addressed urinary retention. The resident was observed near the nurses’ station on multiple days, with staff using a communication board to communicate with the resident. On 7/15/26, the medical record was reviewed and showed that the resident had been seen by a urology consultant on 6/29/26 for urinary retention. The consult note stated urinary retention had been noted at the hospital, the resident was unable to communicate voids, diapers were dry on assessment, and silent retention was a concern. The plan included checking bladder scans for post void residual at reasonable intervals to establish a trend and continuing straight catheterization for urinary retention per facility policy. A provider progress note dated 7/13/26 documented that urology had noted no acute concern for retention and recommended monitoring UTI or retention symptoms, and it stated to use bladder scan for discomfort or poor voiding and trend volumes. However, the note did not acknowledge the consult recommendation for straight catheterization for retention. During interview, the DON stated the facility did not have a bladder scan machine and would not be able to provide the recommendation, and that the facility used bladder ultrasounds if retention needed to be evaluated. When asked whether the provider should have contacted urology for an alternative plan if resources were not available, the DON confirmed that would be her expectation.
Physician Did Not Follow Up on Ordered Labs for Resident on Warfarin
Penalty
Summary
The facility did not ensure that the physician reviewed the resident’s total program of care, including medications and treatments, at the required visits. This was identified for one resident who had diagnoses including atrial fibrillation, diabetes mellitus, and heart failure, and whose MDS documented intact cognition and anticoagulant use. The resident was discharged from the hospital on Warfarin, and the physician ordered Warfarin therapy along with monitoring for signs and symptoms of bleeding and laboratory follow-up for Prothrombin Time/International Normalized Ratio testing. The physician also ordered multiple laboratory tests on 03/18/2026, including PT/INR, PTT, CD4 and CD8 counts, renal and liver function tests, Hemoglobin A1c, thyroid studies, lipid panel, CBC with differential, platelet count, urinalysis, hepatitis testing, and other labs. The record showed no documented evidence that these laboratory tests were performed, and there was no documented evidence that the physician or the RN supervisor were notified that the tests were not done. A nursing note later documented the PT/INR-related order, but the medical notes reviewed from 03/18/2026 through 04/24/2026 contained no documented evidence that the physician followed up on the ordered laboratory tests. Facility policies stated that residents receiving anticoagulation therapy should have labs drawn as ordered to determine effectiveness of therapy, that nurses should assess and document recent labs and therapeutic dose monitoring, and that abnormal lab results should be reported to the HCP and documented. During interview, the Medical Director stated that monitoring depends on the clinician, that nursing should have notified the physician that the labs were not done, and that the physician should have followed up. The Medical Director also stated they were not aware the resident’s labs were not performed.
Unsigned Telephone Order for Tylenol Given to Infant Resident
Penalty
Summary
The facility failed to ensure that the physician wrote, signed, and dated a telephone order for Tylenol suppository 240 mg that was given to an infant resident. The resident was a 7-month-old premature infant admitted with diagnoses including pulmonary hypertension of newborn, feeding difficulties, interstitial pulmonary disease, congenital hypotonia, and other neonatal conditions. A nursing note documented that the resident’s parent requested Tylenol for irritability after a vaccine, and the attending physician was called and gave a telephone order for Tylenol suppository 240 mg rectally, which was administered at 9:30 PM. The record showed no evidence that the attending physician wrote, signed, or dated the telephone order. The facility policy required telephone orders to be documented, read back for verification, and authenticated by the ordering practitioner. The physician later stated they gave the order by telephone, were thinking of another resident’s dosage, did not recall the nurse reading back the dosage, and did not enter or sign the order because they did not have access to a computer. The next morning, the resident’s parent reported vomiting and increased sleepiness, and the nurse practitioner was notified that the resident had received 240 mg rectally. The nurse practitioner documented that the dose exceeded the Tylenol loading dose for the resident’s age and weight, contacted Poison Control, and the resident was transferred to the emergency room for evaluation. The hospital discharge summary documented no abnormal findings, and the emergency department noted low concern for acute Tylenol toxicity given the amount and route administered.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 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.