Failure to Competently Assess and Report New Pressure Ulcers and Manage Support Surfaces
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses had the competencies and skills to adequately assess, describe, and report a new pressure ulcer for a resident with multiple existing pressure injuries and significant comorbidities. The resident had Parkinson’s disease, encephalopathy, a cognitive communication deficit, and multiple stage 4 pressure ulcers to the sacrum and both hips, and was mostly dependent on staff for ADLs. Care plans initiated for impaired skin integrity included generic interventions such as “treatment as ordered” and did not specify the actual wound treatments, staging details, or individualized interventions beyond broad statements. The resident’s MDS documented three stage 4 pressure ulcers and risk for additional PUs, and physician orders included specific wound care treatments and turning/repositioning every two hours, but these details were not clearly integrated into individualized care plans. Surveyors’ review of CNA documentation for turning and repositioning showed numerous time slots over multiple days with no documented evidence that the resident was repositioned as ordered. A CNA reported that she tried to reposition the resident but sometimes found the resident in the same position four hours later. The resident was observed with adhesive dressings on the right upper arm and left shin; the CNA stated the resident had pressure ulcers to the buttocks, right upper arm, and a more recent one to the left lower leg. The treatment nurse later stated the resident was being treated for four pressure ulcers (sacrum, left posterior trochanter, right buttocks, and right shoulder DTPI) but was initially unable to state what was under the dressings to the right upper arm and left shin, incorrectly believing those areas had healed PUs. The treatment nurse also acknowledged that head-to-toe skin assessments are supposed to be done and that SBARs and care plans must be updated for new or reclassified wounds, but admitted that treatments on care plans were documented only as “treatment as ordered” and that this same generic wording was used for multiple residents. An SBAR note dated 1/23/2026 documented a pressure injury to the left shin and right shoulder, with concern for an unstageable pressure injury on the shin and a DTPI/UTI-type injury on the shoulder, and indicated the development of pressure injury due to pillow placement. During wound care observation, the room had a foul odor, and the right upper arm ulcer was covered in black-brown jelly-like eschar, while the left shin ulcer measured approximately 7 cm by 3 cm with hard yellow-grey slough and a red halo, with no drainage. The family member reported they only learned of the left shin pressure ulcer a few days earlier during a visit and that the facility had not informed them of this new wound. The treatment nurse admitted that no SBAR had been completed when the right shoulder DTPI was discovered and that the left shin DTI had just been discovered that morning, acknowledging that a head-to-toe assessment could have identified it earlier and prompted SBAR completion and physician and representative notification. The treatment nurse initially stated he had not done the resident’s wound care on 1/21/2026, later recalled that he had, and was still unable to accurately describe the shin wound or what a DTPI looked like. Additional findings showed that the resident’s low air loss (LAL) mattress was not set according to the resident’s weight. The resident weighed 139 lbs, but the mattress was set over the maximum of 400 lbs. The DON stated that mattresses were usually set at 400 lbs to ensure tubes were inflated and should not be set lower than 152 lbs, but could not explain why, while the wound care specialist and an LVN stated that LAL mattresses are weight-based and must be set as close to the resident’s weight as possible, and that incorrect settings could lead to more or worsening pressure injuries. The facility’s pressure ulcer/skin breakdown policy required nurses to perform and document a full assessment of pressure sores, including location, stage, measurements, exudate or necrotic tissue, pain, mobility status, current treatments including support surfaces, and all active diagnoses. The survey findings showed that licensed nursing staff did not consistently perform or document comprehensive assessments, did not accurately describe and stage new wounds, did not promptly complete SBARs or notify the physician and resident representative of new pressure injuries, and did not ensure that support surfaces such as the LAL mattress were properly set, all contributing to a delay in treatment for the resident’s new unstageable pressure injury to the left shin, which the report states could have resulted in further deterioration, infection, sepsis, organ failure, and/or death.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insulin Pen Priming Competency Not Verified: An LPN administered Humalog insulin to a resident without priming the Kwik Pen first and stated she was unaware that priming was required. The facility could not produce the nurse's skills check sheet, and the competency form reviewed did not include priming an insulin pen, despite the insulin instructions stating the pen must be primed before each injection.
A facility failed to ensure a QMA had a current license while distributing meds to residents. Record review showed the QMA was scheduled and worked on multiple days across 3 resident units, but the licensure binder and Indiana License Registry showed the QMA's license had expired. The ED stated staff should not distribute meds with an expired QMA license and that the facility had no written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
CNA Competency Review Completed After Annual Evaluation: The facility failed to ensure that a CNA received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. Record review showed the CNA's annual performance review was completed before the competency review, and the DSD stated she was unaware of the requirement that the skills competency evaluation be completed prior to the annual evaluation.
Incompetent PEG Tube Medication Administration: An LPN was observed administering crushed medication via a resident’s PEG tube but poured the diluted medication directly into the tube without a syringe, causing it to spill. The LPN then did not know how to connect the syringe to the PEG tube and had to call for help, while the DON provided instruction. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction, and the DON stated the resident did not receive the full dose of medication.
A resident with urinary retention and BPH required a coude catheter, but when the catheter became obstructed, an LPN told the resident to wait until day shift for a change and did not notify the RN supervisor or seek help. Facility records showed no competency training, return demonstration, or skills validation for Foley or coude catheter care, and multiple nurses said they had not received facility-specific education or competency checks for coude catheter management.
Insulin Pen Priming Competency Not Verified
Penalty
Summary
The facility failed to ensure staff possessed the skills and competencies required when a Licensed Nurse administered Humalog insulin to R19 without priming the Kwik Pen first. On 06/02/2026 at 10:13 AM, R19 walked in the hall with a walker, then went to her room with the nurse to receive insulin. The nurse clicked up seven units in the pen and administered the insulin in R19's left arm without priming the pen, and then verified that she had not primed it and stated she was unaware she was supposed to. When the facility was asked for the nurse's skills check sheet, it could not provide it. Review of a blank medication pass competency check sheet showed no competency assessment for priming an insulin Kwik Pen. The insulin pen instructions in the pamphlet directed staff to prime the pen before each injection, and Administrative Nurse D stated she expected staff to prime the insulin pen with two units before administration. She also stated that nurses were required to complete an insulin competency check-off upon hire, and later verified that the nursing skills check lacked a competency item for priming an insulin Kwik Pen.
Expired QMA License During Medication Distribution
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant had a current license while distributing medications to residents. A record review showed that QMA 3 was scheduled to distribute medications and had worked as a QMA on multiple days across three resident units from April through the review period. The facility's Employee Certification and Licensure binder showed that QMA 3's license had expired, and the Indiana License Registry website also indicated the license was expired. In interviews, the Executive Director stated that staff should not distribute medications with an expired QMA license and that the facility did not have a written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA
Penalty
Summary
Certified Nurse Aide #1 was assigned resident care duties on 05/11/2026 as agency staff, but the facility could not provide documentation showing completion of required orientation and mandatory training before the aide worked independently. The missing documentation included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, Trauma Informed Care, Communication Training, and other required orientation and in-service training elements. During the survey, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff and that training modules, sign-off documentation, and post-tests are maintained in employee files. However, the facility was unable to locate records verifying that Certified Nurse Aide #1 completed the required training. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or any of the listed training topics before being assigned to provide resident care on Units 2 and 3. The Administrator also stated that all staff are required to complete mandatory orientation and in-service training prior to working independently and that documentation should have been maintained in the employee file.
CNA Competency Review Completed After Annual Evaluation
Penalty
Summary
The facility failed to implement its policy regarding nursing staff competency by not ensuring that CNA 3 received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., the Director of Staff Development reviewed CNA 3's personnel file, the C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form, and the Annual Performance Review form. The review showed that CNA 3's clinical competency review was completed on 1/22/2026, while the annual performance evaluation was completed earlier, on 12/24/2025. During a concurrent interview and record review on 5/29/2026 at 12:26 p.m., the Director of Staff Development reviewed the facility's policy titled Nursing Staffing Competency and stated she was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. The policy stated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations, and that successfully completed orientation and skills check are required prior to the employee's annual evaluation.
Incompetent PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.
Lack of competency validation for coude catheter care
Penalty
Summary
The facility failed to ensure licensed nursing staff possessed and demonstrated the competencies needed to safely assess, manage, and provide care for residents requiring a coude catheter. Resident 9 was admitted with urinary retention and benign prostatic hyperplasia with lower urinary tract symptoms, and a care plan dated March 30, 2026, identified the need for a coude catheter. On May 7, 2026, nurse documentation and interview with the DON showed the resident’s coude catheter became obstructed during the night shift, and the LPN on duty told the resident he would need to wait until day shift staff arrived for the catheter to be changed. The DON stated the LPN reported she was not comfortable changing the coude catheter because of a lack of familiarity and experience with that type of catheter, and she did not notify the RN supervisor or seek assistance to ensure timely catheter intervention. Review of facility documentation titled Skilled Nursing Competency Training showed competencies listed for licensed practical nurses, including nephrostomy tubes and suprapubic catheters, but the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management, or coude catheter care and replacement. During interviews, four licensed nurses stated they had general catheter education in nursing school and prior experience with coude catheters at previous employers, but all reported the facility had not provided facility-specific education, training, competency evaluation, or skills validation related to coude catheter care, evaluation, insertion, replacement, or management. The DON was unable to provide documented evidence that licensed nursing staff had completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management.
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