Dietary services failed to follow resident diet orders and tray tickets were inaccurate
Summary
The facility failed to ensure that outside contracted food and nutrition resources followed professional standards in providing dietary services. Surveyor review of correspondence between the contracted dietitian and dietary manager showed repeated concerns about diet audits, incorrect diets, missing fluid restrictions, and lack of access to the electronic clinical system used to verify resident diet orders. The documentation also showed communication about Resident #14’s report of not receiving double portions as ordered and going to bed hungry at night. During observation of meal service, Resident #172 was found eating breakfast from a tray ticket that listed a diabetic diet with thin liquids, hot cereal, waffles, syrup, sausage links, orange juice, milk, and coffee, but the tray actually contained cold cereal instead of hot cereal, regular table syrup instead of the listed diet syrup, and no coffee. Staff confirmed the ticket and stated the resident should not have been receiving regular syrup or sugary cold cereal, but that was what the kitchen sent. Resident #172’s record showed a diabetic diet order with double protein and a diagnosis of Type 2 DM with diabetic neuropathy. Resident #52 stated that the correct diet was not being provided and that fluids were not being served correctly. Review of meal tickets for that resident showed a regular diet with thin liquids and no documentation of a substitute for a listed pork dislike, even though the medical record showed a renal diabetic diet with thin liquids, a 1500 ml/day fluid restriction, double protein, Type 2 DM with diabetic neuropathy, and ESRD with dialysis. Additional tray ticket observations showed mismatches between the posted menu and what was served, including cheese ravioli and meat sauce being served when the ticket listed beef ravioli in sauce, and another tray ticket listing beef ravioli in sauce while cheese ravioli in meat sauce was observed on the tray.
Penalty
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Failure to obtain ordered infectious disease and urology consults: A resident with dementia, stroke-related weakness, immunodeficiency, chronic pain, and genital HSV had severe cognitive impairment and complained of groin pain while moaning with movement. An ID appt was cancelled by facility staff because no CNA was available to accompany the resident, and a urology order for penile cellulitis and chronic HSV/condyloma remained without consult documentation or explanation for why it had not been discontinued.
A resident with vertigo and multiple comorbidities, including Type 2 DM with neuropathy, heart failure, and CKD stage 3A, missed a scheduled ENT appointment when transportation arrived but the resident had not been informed of the appointment and was not prepared to go. The resident reported being told the appointment would be rescheduled, but this did not occur. An RN confirmed the appointment had to be rescheduled and that Medical Records staff handle such scheduling, while the CNA/Medical Records staff stated she was not aware the appointment needed rescheduling and later did not complete the task due to lack of time. The DON stated that appointments are expected to be followed up on timely, and the facility’s Transportation Services policy requires coordination with the Medical Records designee and timely rescheduling, which did not occur in this instance.
A resident with RA, spinal stenosis, respiratory failure, dry eye syndrome, and DM had multiple referrals to neurology, rheumatology, pulmonology, and ophthalmology that were not followed up in a timely manner. Several specialty offices reported missed appointments, some were rescheduled without the resident attending, and the chart lacked nursing progress notes documenting the missed visits. Staff said medical records handled scheduling and transportation, but they could not locate documentation for several of the missed appointments, and the DON noted staffing gaps and weather-related transportation cancellations.
A resident with a suprapubic catheter missed outside ophthalmology and urology appointments. The resident said he needed eye care for his vision and monthly urology follow-up, but the transportation log and appointment binder had no entries for him, and records noted a missed urology visit due to transport issues. Staff interviews showed the facility relied on nursing, medical records, and MAR-based coordination, but the process did not result in the resident’s appointments being arranged and completed as expected.
A resident receiving HD had a physician order for treatment at an outside dialysis company, but the facility did not have a written agreement with the dialysis clinic. The ADM confirmed no agreement existed and stated the agreement was important to ensure the resident received dialysis care. The facility policy called for ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.
A resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic/proximal tracheal stenosis had a provider order for an ENT referral and a subsequent NP note calling for ENT f/u. The Transportation Driver sent the referral to an ENT office, which refused to schedule due to the resident’s lack of active insurance and self-pay status, and the driver documented unsuccessful attempts to reach the family to confirm payment. The Business Office Manager later stated the resident was Medicaid pending and that the facility would have been responsible for payment if an outside provider would not accept that status, but she was never informed that the ENT would not see the resident for this reason. Consequently, the ordered ENT evaluation for the resident’s tracheostomy and tracheal stenosis was not obtained.
Failure to Obtain Ordered Infectious Disease and Urology Consults
Penalty
Summary
The facility failed to follow a physician’s order to obtain timely infectious disease and urology consults for a resident with multiple complex diagnoses, including dementia with behavioral disturbance, stroke with right-sided weakness, immunodeficiency disease, chronic pain syndrome, papillomavirus, expressive aphasia, and genital herpes. During an interview, the resident complained of groin pain and moaned with movement while seated, and a family member stated that the resident was in constant pain and that the medications being provided were not working. The resident’s BIMS score was 3/15, indicating severe cognitive impairment. A physician ordered an infectious disease evaluation, and an appointment was scheduled, but the facility cancelled it the morning of the visit because staff said there was no available nursing aide to accompany the resident. The outside office reported that the facility cancelled the appointment because it could not send a CNA and stated the resident could not go without one. The record also contained a physician order to schedule a urology consult for penile cellulitis and chronic HSV infection with condyloma acuminata, but the scheduler could not produce urology consult notes and could not explain why the order had not been discontinued by the attending physician.
Failure to Coordinate and Reschedule ENT Appointment for Resident with Vertigo
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and follow through with an outside Ear, Nose and Throat (ENT) medical appointment for one resident. On 04/08/2026, the resident was observed in bed in a nightgown and reported having vertigo and being scheduled to see an ENT specialist. He stated that on the day transportation arrived for the appointment, he was not ready because no one at the facility had informed him of the appointment, and that this occurred about a month prior. He further stated the facility told him the appointment would be rescheduled, but it never occurred. Record review showed the resident was originally admitted on 10/10/2023 and readmitted on 02/26/2026 with diagnoses including Type 2 DM with diabetic neuropathy, heart failure (unspecified), and CKD stage 3A. An order summary dated 04/08/2026 showed an ENT appointment scheduled for 02/11/2026 at 11:00. In an interview, an RN confirmed the resident had an ENT appointment on 02/11/2026 for vertigo that had to be rescheduled and stated that Medical Records staff are responsible for scheduling appointments, but she did not know if the appointment was ever rescheduled. The CNA/Medical Records staff member reported that the NP had informed her that the resident wanted to see the ENT, but she was not made aware that the appointment needed to be rescheduled after it was missed. She stated that on a Monday shortly before the survey, the NP asked if she had rescheduled the ENT appointment, and she told the NP she would get to it but did not reschedule it because she did not have time. The DON stated his expectation that appointments should be followed up on timely. The facility’s Transportation Services policy, dated 02/2025, states that the facility will arrange transportation services as needed to ensure each resident receives a complete continuum of service consistent with the plan of care and outlines procedures for notifying the Medical Records designee and rescheduling appointments when necessary, which were not followed in this case.
Missed Specialist Appointments Not Timely Followed Up
Penalty
Summary
The facility failed to ensure timely follow-up on outside specialist referrals for one resident who had rheumatoid arthritis, spinal stenosis, respiratory failure, chronic dry eye syndrome, diabetes, and intact cognition. The resident had referrals to neurology, rheumatology, pulmonology, and ophthalmology, but the record showed missed appointments and no documented nursing progress notes addressing several of those missed visits. The facility policy stated outside appointments and consultations were to be coordinated, documented, and followed up on, including when appointments were missed or refused. The resident was scheduled for neurology, pulmonology, rheumatology, and retina vitreous surgery appointments, but multiple offices reported the resident did not show up for appointments and some were rescheduled without the resident attending the later visits. The neurology office reported missed appointments and no current scheduled visits; the pulmonology office reported missed appointments and rescheduling; the retina vitreous surgery office reported a missed appointment with no reschedule; and rheumatology could not confirm the resident was seen or provide current appointment information. The record did not contain nursing progress notes documenting these missed appointments. The resident stated that multiple specialist appointments were often cancelled by the facility because staff were unavailable to accompany the resident or transportation was not coordinated, and that this had been occurring for several months since the scheduler left. Facility staff stated medical records was responsible for scheduling appointments and transportation, and that staff were assigned to accompany residents, but they could not locate documentation for several of the resident’s missed specialty appointments. The DON stated the facility had been without medical records staff for three months, which contributed to missed appointments, and also noted transportation cancellations in bad weather.
Missed Outside Appointments Due to Scheduling and Transportation Failures
Penalty
Summary
The facility did not ensure outside physician appointments were arranged and scheduled in a timely manner for one resident who had a suprapubic catheter and reported needing monthly urology follow-up, as well as an ophthalmology appointment for vision concerns. During interview, the resident stated he had missed an outpatient ophthalmology appointment and also missed his monthly urologist appointment for March. An appointment card showed an ophthalmology visit scheduled for 01/16/2026, and the resident stated he needed to be seen by his eye doctor for his vision. Record review showed the resident declined the scheduled ophthalmology appointment on 01/16/2026, after which a new appointment was arranged for 02/02/2026. Progress notes also showed the resident returned from a urology appointment on 01/12/2026 with a follow-up scheduled for 02/02/2026, and later a nurse practitioner note stated the resident missed a recent urology appointment due to transport issues. Interviews with the RN/UM, ADON, and DON showed the facility used a transportation binder, nursing staff, medical records staff, and MAR entries to coordinate appointments and transportation, but the transportation log for January, February, and March had no entries for the resident and the March binder had no appointment entry for him.
Missing Written Agreement for Dialysis Services
Penalty
Summary
The facility failed to obtain a written agreement for services furnished by an outside dialysis resource for one of 24 sampled residents, Resident 10, who was receiving hemodialysis. Resident 10 was admitted in October 2025 with diagnoses including atherosclerotic heart disease and end stage renal disease. A physician order dated 3/6/26 directed hemodialysis at a named dialysis company and address on Monday, Wednesday, and Friday. During interviews on 3/19/26 and 3/20/26, the Administrator stated he would look for the agreement with the dialysis clinic, then stated the facility had no agreement with the dialysis clinic and that the importance of the agreement was to make sure Resident 10 receives dialysis care. The facility policy titled Hemodialysis Care and Coordination stated the facility would provide necessary care and treatment and maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services.
Failure to Secure ENT Evaluation for Resident With Tracheostomy and Tracheal Stenosis
Penalty
Summary
The facility failed to obtain outside professional ENT services for a resident when it did not employ a qualified professional to provide the required service. The resident was admitted with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Hospital records documented that the resident previously had a tracheostomy exchange by ENT due to hemoptysis, experienced a respiratory arrest with a dislodged trach, and had significant subglottic and proximal tracheal stenosis. ENT had recommended against trialing a Passy Muir Valve and advised changing the trach every three months. A physician order for an ENT referral related to stenosis and tracheostomy status was initiated, and a later nurse practitioner note documented the need for follow-up with ENT for subglottic and tracheal stenosis. The Transportation Driver documented that an order for the ENT visit was received and sent to the ENT office, but the office reported the resident did not have insurance and would require self-pay, and therefore would not schedule the appointment without confirmation from the family. The Transportation Driver reported multiple unsuccessful attempts to contact the family and did not secure an appointment. The Business Office Manager stated the resident was Medicaid pending, that she had been in contact with Medicaid since admission, and that if an outside provider would not accept a Medicaid pending resident, the facility would be responsible for payment. The Business Office Manager also stated she was not informed that the ENT provider would not see the resident due to Medicaid pending status and that, had she known, she would have discussed payment with the Administrator so the resident could be seen by ENT. As a result, the resident did not receive the ordered ENT evaluation for tracheostomy and tracheal stenosis.
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