Failure to Ensure Competent Tracheostomy Care by Qualified Staff
Summary
The facility failed to ensure that staff were educated and competent in providing necessary care and services for residents with tracheostomies, as required by each resident's written plan of care. Multiple residents with tracheostomies experienced repeated episodes where staff were unable to perform routine tracheostomy care, such as suctioning, cleaning, and tube changes. In several cases, residents were sent to the hospital for issues that should have been managed within the facility, including removal of mucus plugs, tracheostomy replacement, and management of secretions. Documentation revealed that staff did not perform suctioning when residents exhibited symptoms such as secretions or emesis from the tracheostomy, and there was a lack of documentation of interventions to prevent repeated tracheostomy dislodgement in one resident. One resident was found unresponsive, and staff performed CPR incorrectly by bagging the resident's mouth instead of the tracheostomy, as they were unaware of the correct procedure. Staff interviews confirmed that neither the LPNs nor CNAs had received training on tracheostomy care or emergency response for residents with tracheostomies. The local fire department and paramedics reported frequent calls to the facility for non-emergent tracheostomy issues, such as suctioning and cleaning, which they considered routine care that should be managed by facility staff. In several instances, emergency responders found that the facility lacked necessary equipment, such as suction tips, and that staff were not using available equipment properly. The deficiency was further evidenced by staff statements indicating a lack of formal or routine training on tracheostomy care, with some staff expressing discomfort and lack of knowledge in providing such care. The facility's own documentation and job descriptions required staff to remain current in facility policies and procedures, including specialized care needs such as tracheostomy care. Despite this, the facility assessment indicated that tracheostomy care was a service provided, yet staff were not adequately prepared to deliver this care, resulting in repeated hospital transfers and, in one case, a resident death.
Removal Plan
- Tracheostomy in-service was completed
- All nurses, including agency nurses, were educated
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
Unlicensed CNA applied a prescribed Lidocaine patch to a resident with cerebral palsy and back pain after a bed bath, even though facility policy allowed only licensed nurses or certified medication technicians to administer medications. The surveyor observed the patch application without a licensed nurse present, and the DON confirmed the CNA was not authorized to administer meds and that the patch was a physician-ordered medication.
Unqualified staff assisted with resident transfers and repositioning involving mechanical lifts. An Activity Aide with no CNA training helped operate a sit-to-stand lift for a resident who required lift assistance, and a BOM with no CNA training helped reposition another resident with severe contractures using a fireman method after staff could not safely position the Hoyer sling. During that repositioning, staff heard a popping sound in the resident’s arm, and an x-ray later showed a humerus fracture.
QMAs failed to practice within their scope when administering PRN narcotic pain medications and performing advanced wound care. A resident with chronic pain and another with diabetes and depression received PRN narcotic analgesics from a QMA without documented RN/LPN assessment, nurse authorization, or nurse initials on the controlled substance records, despite facility policy requiring nurse assessment and co-signature for PRN administration. In addition, a resident with a stage 4 sacral pressure ulcer had complex wound treatments and wound monitoring signed off by QMAs, even though the facility’s QMA scope of practice prohibits QMAs from providing treatments for stage II–IV pressure ulcers or independently assessing residents’ conditions.
A resident with a history of major CVA and g-tube dependence was hospitalized after the DON, lacking documented certification or competency and without consulting the physician, replaced a 16 Fr g-tube with a 20 Fr urinary catheter at the request of the family. The DON stated this procedure was not normally done at the facility, there was no facility policy for changing g-tubes, and her experience came only from prior hands-on training without documentation. Following the change, the resident experienced g-tube leakage, fever, and vomiting; hospital evaluation found the urinary catheter had migrated into the proximal jejunum, causing partial bowel obstruction and substantial leakage, with imaging and labs confirming malposition and pancreatitis. The facility’s feeding tube policy required use of tubes intended for enteral feeding and specified conditions, settings, and personnel for tube replacement.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer with 100% eschar, which was initially assessed by an RN and care planned with interventions including ordered treatment and referral to a wound specialist. Facility policy required weekly wound rounds and assessment by qualified staff, but a subsequent weekly wound evaluation was performed and documented solely by an LPN acting in a leadership role, without an RN or wound provider present. The LPN recorded wound measurements and characteristics and noted treatment response, yet there was no documentation that a wound provider or RN assessed the ulcer at that time. Interviews and state scope-of-practice guidance confirmed that LPNs may collect wound data but may not perform nursing assessments, and leadership and the wound provider acknowledged that the weekly assessment should have been completed by an RN, demonstrating that the resident’s pressure ulcer was not assessed by a qualified person as required by the care plan and regulations.
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.
Unlicensed CNA Applied Prescribed Lidocaine Patch
Penalty
Summary
The facility did not ensure that only qualified persons administered medications according to residents’ plans of care when an unlicensed CNA applied a Lidocaine external patch 4% to R27’s lower back. The facility policy titled "Administering Medication," revised 01/22/2024, states that only licensed staff may administer or record the administration of medications, and certified medication technicians may administer specific medications only if competency has been determined. R27 was admitted with diagnoses of cerebral palsy and back pain and had a physician’s order for Lidocaine external patch 4% to be applied to the lower back twice daily for pain. On 04/21/2026 at 9:05 AM, the surveyor observed CNA D apply the Lidocaine patch to R27’s lower back after a bed bath. CNA D stated that nurses give the patch to her to put on. The patch had been observed at R27’s bedside before application, and no licensed nurse was observed in the room during the application. The MAR showed RN D’s initials for administration of the Lidocaine patch that morning. Facility staffing records showed CNA D was not a medication administration technician. RN C and DON B both stated that only licensed nurses and certified medication technicians could administer medications, and DON B confirmed CNA D was not allowed to administer medications and that the Lidocaine patch was considered a medication ordered by a physician.
Unqualified staff assisted with mechanical lift transfers and repositioning
Penalty
Summary
The facility did not ensure residents received services by qualified persons according to their written plans of care for two residents who required mechanical lift-related assistance. For one resident with dementia, Parkinson’s disease, and degenerative back and neck disorders, an Activity Aide who was not a CNA and had no documented competency for transfer assistance assisted a CNA with a sit-to-stand mechanical transfer. The aide pushed the button on the lift while transferring the resident on and off the toilet, and both the aide and the DON stated the aide was not trained to use the lift but could assist by pressing the button. For another resident with spastic quadriplegic cerebral palsy, contractures of the left wrist and hand, and cervical disc degeneration, the care plan directed a Hoyer total assist. During an incident, the resident was sliding down in a wheelchair and staff attempted to reposition the resident using a Hoyer sling, but the sling was too far down to safely move the resident. A CNA and the Business Office Manager, who had no CNA training, then used a fireman method to boost the resident by lifting under the arms and pulling on the resident’s pants/briefs. As they lifted the resident, they heard a popping sound in the resident’s right arm, and an x-ray the next day showed a fracture of the surgical neck of the right humerus. Interviews confirmed that non-nursing staff were involved in resident repositioning and lift-related tasks. The NHA stated non-nursing staff were allowed to assist with repositioning because it was not considered direct patient care, and the BOM stated she had no CNA training and had only been shown how to reposition residents by the NHA. The BOM also stated that non-nursing staff are allowed to help with boosts, and the DON stated that for sit-to-stand lifts, one staff member needs to be qualified while the other does not.
QMAs Functioning Outside Scope for PRN Narcotics and Stage 4 Wound Care
Penalty
Summary
The deficiency involves failure to ensure qualified medication aides (QMAs) practiced within their defined scope and that care was provided by qualified persons according to each resident’s written plan of care. For one resident with rheumatoid arthritis, chronic pain, and osteoarthritis, a physician’s order directed PRN oxycodone 5 mg every 4 hours for pain. Documentation showed that a QMA administered the PRN narcotic, but the clinical record lacked evidence of a licensed nurse’s initials on the controlled substance record, a documented nursing assessment prior to administration, and documented permission from a licensed nurse, contrary to facility practice as described by an LPN. For another resident with a stage 4 sacral pressure ulcer, the physician’s order required cleansing with normal saline, packing with Dakin’s-soaked gauze, and covering with an ABD pad twice daily, and a separate order required monitoring the sacral wound for signs of infection or decline. The treatment administration record showed QMAs signed off as having completed the stage 4 wound treatment and the monitoring of the stage 4 sacral wound, despite the QMA scope of practice prohibiting them from performing treatments involving stage II–IV pressure ulcers. A third resident with diabetes and major depression had a physician’s order for PRN hydrocodone-acetaminophen 5-325 mg every 8 hours for pain. Records indicated a QMA administered the PRN narcotic, but the clinical record again lacked documentation of a licensed nurse’s initials on the controlled substance record, a nursing assessment prior to administration, and documented permission from a licensed nurse. The facility’s QMA Parameters and Scope of Practice, provided by the DON, specified that QMAs may not assess a resident’s condition and may administer previously ordered PRN medications only after contacting a licensed nurse, documenting the contact, symptoms, permission, and time, and ensuring the record is co-signed by the nurse by the end of the shift or next tour of duty. The same scope document also stated that QMAs may not administer treatments involving advanced skin conditions, including stage II, III, and IV pressure ulcers. These documented practices and omissions show that QMAs performed tasks outside their authorized scope and without required licensed nurse assessment and documentation.
Unqualified G-tube Replacement with Urinary Catheter Leading to Complications
Penalty
Summary
The facility failed to ensure that care was provided by qualified staff according to a resident's written plan of care when the DON replaced a gastrostomy tube (g-tube) without documented training, competency, or adherence to facility policy. The DON reported that a nurse approached her stating the family wanted the g-tube changed, and she proceeded with the change as a "routine procedure" under what she described as a standing order, without contacting the resident's physician. She replaced the resident's existing 16 French g-tube with a 20 French urinary catheter, stating the stoma had stretched and that the larger size would make feeding easier. The DON acknowledged that changing g-tubes was not normally done at this facility, that there was no facility policy or procedure for changing g-tubes, and that she had no certification for this procedure, only hands-on training from a previous employer, which could not provide any documentation of competencies. The resident had a history of a major cerebrovascular accident with right-sided hemiparesis and aphasia and was admitted to the hospital from the facility for a leaking g-tube, fever, and an episode of vomiting. The resident’s son, who is the power of attorney, reported that the facility had changed the g-tube and placed a 20 French urinary catheter, and that it had been leaking since that time. Hospital evaluation found the g-tube displaced into the proximal jejunum, with labs showing an elevated lipase consistent with pancreatitis and a CT scan confirming the tube’s position. A procedure note documented that the balloon of the old g-tube (a urinary catheter placed through the gastrostomy stoma) was deflated and that the catheter had migrated into the jejunum, with only the tip visible at the skin site, causing partial bowel obstruction and substantial leakage from the stoma. The facility’s written policy on feeding tubes specified that only tubes designed for enteral feeding would be used except under extenuating circumstances and for the shortest time possible, and that directions would be provided regarding when and by whom tubes could be replaced, including when replacement must occur in another setting.
Unqualified Wound Assessment for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s pressure ulcer was assessed by a qualified person in accordance with the written plan of care and facility policy. The resident was admitted with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency, and had an unstageable pressure ulcer with 100% black/brown eschar on the right heel identified on admission by a registered nurse. The care plan for alteration in skin integrity documented an actual pressure injury to the right heel with eschar and included interventions such as applying treatment per order and referring to a wound care specialist as needed. Facility policy on Wound Identification and Wound Rounds required that residents with pressure injuries be identified, assessed, and managed in accordance with current standards of practice, with the Wound Nurse/Designee, wound care provider, and registered dietitian notified and the resident scheduled for weekly wound rounds. On 9/19/2025, an interdisciplinary high-risk meeting was held for the resident, during which it was documented that the resident had a right heel pressure ulcer and would be referred to the in-house wound provider. The initial wound evaluation on 9/18/2025 was completed by a registered nurse, who documented the unstageable right heel ulcer with 100% eschar and no visible wound bed. However, the weekly wound evaluation dated 9/25/2025 was documented by an LPN, who recorded the same measurements, 100% black/brown eschar, no exudate or odor, and noted that treatment was in place with an improved response, adding a comment to refer to the wound care provider. There was no documented evidence that the in-house wound care provider or any other qualified person, such as a registered nurse, assessed the resident’s right heel pressure ulcer on that date. Interviews confirmed that the LPN who completed the 9/25/2025 weekly wound evaluation was functioning as a travel resource nurse and acting Assistant Director of Nursing, and that a registered nurse was not present with them during the wound assessment for this resident. The LPN stated they evaluated the wound alone, documented what they observed, and did not refer the resident to the wound care provider on that date because there was no change in the wound, although they indicated the nurse practitioner should have been notified and should have assessed the resident. The DON acknowledged that LPNs could measure but could not assess wounds and were supposed to document observations in a nursing progress note, and the wound care provider stated it was unacceptable for there to be no weekly assessment by a registered nurse when the wound care provider did not see the resident. Information from the New York State Education Department clarified that LPNs may collect and report clinical data but may not perform nursing assessments or determine nursing diagnoses, and that RNs are responsible for assessing wounds and determining the plan of care, underscoring that the 9/25/2025 wound assessment was not performed by a qualified person as required.
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