Failure to Provide and Document Ordered Wound Care and Weekly Skin Assessments
Summary
The deficiency involves the facility’s failure to provide and document wound care and weekly skin assessments according to physician orders, facility policy, and standards of practice for multiple residents with skin conditions and wounds. Facility policies required evidence-based wound treatments per physician orders, weekly and as-needed wound assessments, and complete documentation of wound characteristics and treatments on the TAR or in the electronic health record. Policies also required weekly skin assessments by licensed nurses, use of a weekly schedule for skin checks, and documentation of wound status each shift when no treatment was due. Interviews with nursing leadership and staff confirmed that if care was not documented, it was considered not done, and that there should not be blank spaces on the TAR. For one resident with diffuse traumatic brain injury, peripheral vascular disease, and dermatitis, the MDS showed severe cognitive impairment and risk for pressure injuries, and the care plan identified fragile skin and potential for skin impairment. This resident had physician orders for a light two-layer compression wrap to the left lower extremity, later revised to include cleansing with wound cleanser and continued compression wraps. The TAR for February showed multiple dates where these ordered treatments were not documented as completed, and there were no nursing notes indicating that wound care was not provided or was refused. The ADON’s wound measurement list contained no measurements for this resident, and no weekly skin assessment was documented, despite observations of undated wraps on both lower legs and subsequent wound physician notes describing bilateral stasis dermatitis and recommendations for doppler testing and continued wrapping. For another resident with CHF, an infected right lower extremity amputation stump, and an open wound on the right lower leg, the weekly skin observation documented multiple existing skin issues, including a wound vac to the right stump and ulcers and scabs on the left lower extremity and foot. The care plan required weekly skin assessments, wound treatments as ordered, and weekly skin audits by a licensed nurse. The wound care provider documented a skin tear on the left lateral calf present on admission, and the admission MDS showed the resident was cognitively intact, at risk for pressure injuries, and had open lesions and a surgical wound. Physician orders directed daily dressing changes to the left lower extremity and daily dressing changes to the right stump incision. The February TAR showed several days where these treatments were not documented as completed. The ADON’s wound measurement list showed an improved left calf wound, and observation with the wound physician and DON revealed undated bandages on the right stump and left lower leg, with the left leg wound improved and new orders initiated. A third resident with acute and chronic respiratory failure with hypoxia, COPD, and end stage renal disease had a quarterly MDS indicating cognitive intactness, risk for pressure injuries, and no open wounds at that time, with substantial to moderate assistance needed for ADLs. Later physician orders directed cleansing and dressing of venous wounds on both lower extremities three times per week and as needed, and then daily cleansing and skin prep to the right lower leg. The February TAR showed multiple dates where these ordered treatments were not documented as completed. Nursing progress notes contained no documentation of wound care not being provided or refused, and no weekly skin assessments were noted. Wound physician notes documented full-thickness venous wounds on both legs with specific measurements and no signs of infection, and later measurements showed changes in wound size. Observations showed the resident’s bilateral lower legs wrapped with undated gauze, and during wound rounds the DON removed undated dressings, revealing a scabbed right leg and a draining left leg wound. Another resident with COPD, CHF, cardiac arrhythmias, chronic kidney disease, and mitral insufficiency had a care plan identifying risk for impaired skin integrity and requiring weekly skin assessments and reporting of issues to the physician. Physician orders directed daily cleansing of facial sutures from a skin cancer excision with antibacterial soap and water, removal of crusts, and application of Bacitracin with a nonadherent dressing for two weeks on the evening shift. The February TAR showed that this treatment was documented on only two dates, with several ordered days lacking documentation. During an observation and interview, the resident reported recent skin cancer removal from the face and concern that staff were not treating and bandaging the area daily; at that time, the resident had no bandage on the face. The quarterly MDS indicated moderate cognitive impairment, open lesions requiring non-surgical dressings and ointments, and dependence on staff for transfers, bed mobility, and showers. Interviews with nursing staff and leadership confirmed systemic issues with completing and documenting wound care and weekly skin assessments. An LPN reported that residents had complained that wound care was not completed at times and that some days it was difficult to complete all resident care. An RN stated that nurses were responsible for weekly wound assessments using a binder schedule, that the TAR showed when wound care was due, and that if care was not charted it was considered not done; the RN would not expect to see gaps on the TAR without notes or handoff in report. The ADON acknowledged monitoring wound tracking, stated that dressings should be dated and documented on the TAR, and admitted that some days wound care was not charted even though he/she believed it was done, and that he/she had been doing most wound care until floor nurses took over. The DON stated that floor nurses complete weekly skin assessments, that TARs should always be completed including refusals, and that she had not been able to audit TARs weekly due to staffing issues. The Medical Director, primary care physician, wound physician, and Administrator all stated that staff were expected to follow physician orders and document care, and that if it was not documented, it was considered not done.
Penalty
Resources
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An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
A resident with a stage 4 pressure injury and sepsis had ongoing loose stools, but the MAR showed no documented PRN loperamide use and the record showed no provider notification despite repeated large loose stools. The same resident was also receiving daily anticoagulant injections and was observed with dark red urine in an indwelling catheter, yet there was no documented bleeding/bruising monitoring, no progress note about the blood in the urine, and no alert charting.
A resident with chronic GI symptoms, malnutrition, diabetes, depression, and PTSD had persistent watery diarrhea, abdominal pain, and nausea, but the facility did not adequately track stool testing, confirm lab results, or complete the ordered GI referral. The resident reported frequent diarrhea, fatigue, reduced intake, and soreness, while staff documentation showed conflicting entries about specimen refusal versus sleeping, and the lab later had no record of the specimen that was charted as sent. The record also lacked evidence that the GI specialist appointment was scheduled or completed, and a separate resident’s ordered ECHO for pericardial effusion was not documented as scheduled or completed.
A resident with a growing facial lesion had a dermatology consult delayed for about 3 months. The resident’s chart included provider orders for dermatology follow-up, but the appointment remained pending while the lesion increased in size. Notes from the NP and unit manager documented ongoing waiting for the consult, and the DON stated the health plan should have scheduled it and that consults need to be scheduled in a timely manner.
A resident with HTN and HF had an order for metoprolol succinate to be held if the pulse was below 55 bpm, but MAR and pulse record review showed missing pulse documentation on multiple occasions, pulse checks done after the med was given, and doses administered when the pulse was less than 55 bpm. Staff stated the pulse should have been checked before administration, and the DNS confirmed the expectation was to follow the order and hold the med when indicated.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Failure to Monitor Loose Stools and Bleeding During Anticoagulant Therapy
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for Resident 81, who was admitted with a stage 4 pressure injury to the bottom and sepsis and was able to make needs known. For bowel management, the resident reported loose stools for a couple of weeks and later stated they had been having diarrhea with abdominal discomfort for 3 days, so loperamide was started as needed. The bowel monitor documented repeated loose stools over several days, including two loose stools on 06/04/2026, three large loose stools on 06/05/2026, and two large loose stools on 06/06/2026 through 06/08/2026. The resident stated staff had not given any medication for the loose stools, the June 2026 MAR showed no documented doses of loperamide, and the record showed no documentation that the provider was notified of the three large loose stools. Staff interviews indicated that frequent loose stools should have been reported to the provider, PRN medication given, and the resident placed on alert charting, but this did not occur. For anticoagulant therapy, Resident 81 was receiving daily anticoagulant injections starting 05/21/2026. During observation, the resident was lying in bed with an indwelling urinary catheter and dark red urine was noted in the tube and bag; the resident stated, "It's never been like that. It's scary." The EHR showed no monitoring for bleeding and bruising related to anticoagulant therapy, and the progress notes contained no documentation about the blood in the urine or alert charting. Staff interviews confirmed the resident had blood in the catheter for a couple of days and that monitoring for bleeding should have been in place, but it was not.
Failure to Follow Up on GI Symptoms, Stool Testing, Specialty Referral, and Diagnostic Order
Penalty
Summary
The facility failed to assess, monitor, follow up, and implement physician-ordered care for a resident with ongoing gastrointestinal symptoms, and failed to develop a care plan addressing persistent diarrhea. The resident was cognitively intact, had diagnoses including diabetes mellitus, protein-calorie malnutrition, depression, and PTSD, and was documented as continent, independent with toileting and transfers, and using a wheelchair. The resident’s care plan addressed GI issues such as peptic ulcer disease, pancreatitis, and chronic nausea, but it did not include a problem, goals, or interventions for ongoing diarrhea, abdominal pain, stool testing, infectious GI illness, or management of frequent stools. The resident’s provider documented worsening diarrhea, abdominal pain, and nausea, and ordered stool testing for enteric pathogens and C. difficile, along with a GI specialist follow-up. Facility records showed repeated documentation of stool collection attempts, including entries that the resident refused or was sleeping, while the resident stated she never refused and that staff often asked when she could not provide a sample or was asleep. A stool specimen was documented as collected and faxed to the lab as STAT, but the medical record lacked laboratory results for that specimen, and later review with the lab found no record that the specimen had been received. The resident continued to report frequent watery diarrhea, abdominal pain, nausea, fatigue, reduced intake, and soreness from repeated bowel movements and wiping. The record also showed that the ordered GI specialist appointment was not documented as scheduled or completed. Staff interviews identified that the HUC was responsible for scheduling follow-up appointments, while nursing staff were expected to enter orders and follow up on pending testing. The DON stated staff should have followed up on pending stool testing, maintained infection control precautions while awaiting results, and notified the provider if the resident refused specimen collection. The resident was later found to have C. difficile detected on stool testing, and the record showed delayed identification and treatment after weeks of unresolved symptoms. In a separate deficiency, the facility failed to ensure a physician’s order was implemented for another resident with end stage renal disease, pericardial effusion, atrial flutter, chronic heart failure, and dialysis dependence. The physician ordered that an echocardiogram be scheduled for the resident by a specified timeframe, but the electronic record lacked documentation that the ECHO had been scheduled, implemented, or completed. The DON and Administrator stated that physician orders were to be entered and verified, and that medical records staff scheduled appointments and nurse managers oversaw implementation, but the order was not completed.
Delayed Dermatology Appointment for Facial Lesion
Penalty
Summary
The facility failed to ensure a dermatology appointment was scheduled for a resident with a facial skin growth, resulting in a 3-month delay in evaluation. Resident #97 had a raised red growth on the left side of the chin/jaw area, with part of the growth hanging from the chin and tangled with the resident’s long hair. During an interview, the resident stated that the nurse practitioner wanted it removed and that it was benign, and later stated that it was growing and needed to be seen by a dermatologist. Record review showed provider orders dated 2/16/2026 and 3/6/2026 for follow-up with dermatology for the lesion on the left jaw/facial lesion, with the health plan to schedule the appointment. Notes from the nurse practitioner and unit manager documented that the resident had been waiting on dermatology, that the lesion had increased in size over the past month, and that the appointment was still pending. The DON stated the health care plan should have scheduled the dermatology consult and that consults need to be scheduled in a timely manner, and also stated there was no policy for scheduling appointments.
Failure to Follow Hold Parameters for Metoprolol
Penalty
Summary
The facility failed to follow physician orders for a resident admitted with hypertension and heart failure who had an order for metoprolol succinate to be held if the pulse was less than 55 bpm. Review of the MAR and pulse records showed no pulse documentation on multiple dates in May and June 2026, and on several dates the resident’s pulse was taken after the medication had already been administered. The records also showed that metoprolol succinate was administered on several dates when the resident’s pulse was less than 55 bpm. During interviews, staff stated the pulse should have been checked before giving the medication, and the DNS stated the MAR was not triggering for the pulse to be taken prior to administration, while also confirming the expectation was to follow the physician order and hold the medication if the pulse was below 55 bpm.
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