Unattended Unit Leads to Missed Early‑Morning Medications, Treatments, and Documentation Failures
Summary
The deficiency involves the facility’s failure to ensure continuity of care and timely administration of medications and treatments for all 41 residents on the 4th floor when the only licensed nurse assigned to that unit left the building for over two hours without relief. According to the facility incident report and interviews, the RN assigned to the 4th floor clocked out and left at approximately 4:19 AM, leaving 41 residents with only two CNAs and no licensed nurse to assess, administer medications, or respond to medical needs and emergencies between 4:19 AM and about 6:30 AM. The nurse left the medication keys with the front receptionist instead of a licensed nurse, and the receptionist then attempted to give the keys to the 3rd floor nurse, who refused to assume responsibility for an additional 41 residents. The DON, who was the on‑call manager, did not respond to calls or texts at the time because she was asleep, and no other nurse manager or on‑call nurse responded, leaving the 4th floor without licensed nursing coverage during that period. Record review showed that during this time frame, multiple scheduled medications, PRN medications, and treatments due during the night and early morning were not administered or documented as given for numerous residents with significant medical conditions. One resident with pain, vascular angioplasty, malignant neoplasm of bone, and a pressure ulcer did not receive scheduled 6:00 AM medications including Lasix and omeprazole, and PRN hydrocodone for pain was not assessed or administered. Another resident with type 2 DM, COPD, and chronic pain did not receive scheduled famotidine and hydralazine doses, and PRN pain medication was not assessed. A resident with COPD, heart failure, and acute kidney failure did not receive scheduled ipratropium‑albuterol breathing treatments at midnight and 6:00 AM, and pain assessments and PRN pain medications were not documented. A resident with malignant neoplasm of the mandible, PEG tube, and need for routine suctioning did not receive scheduled suctioning, levothyroxine, gabapentin, ondansetron, or scheduled PEG‑tube pain medications during the night and early morning. Additional residents with acute respiratory failure, quadriplegia with tracheostomy and gastrostomy, chronic pain, diabetes, CKD stage 5, hypertension, heart failure, and other serious diagnoses also missed ordered treatments and medications. One resident missed albuterol nebulizer treatments at midnight and 6:00 AM and was later sent to the hospital for a change in condition on that date. Another resident did not receive scheduled lidocaine patches for knee pain. A quadriplegic resident with trach and PEG did not receive scheduled baclofen, nutritional supplement (Med Pass), tizanidine, or documented turning and repositioning every two hours. A resident with diabetes and CKD stage 5 did not receive scheduled insulin glargine at 6:00 AM. Other residents did not receive scheduled furosemide, omeprazole, sertraline, Ventolin inhaler doses, ipratropium‑albuterol breathing treatments, or ordered blood pressure checks and antihypertensive medication at 6:00 AM. Late entries by the DON were made approximately two weeks later, documenting generic assessments such as “no signs and symptoms of pain or discomfort noted,” without contemporaneous documentation from the date of the incident. The investigation also identified failures in narcotic control documentation and shift‑to‑shift reconciliation. Review of the controlled substance shift inventory for the 4th floor medication carts showed missing entries and lack of required two‑nurse signatures for narcotic counts on the relevant date and surrounding dates. The Unit Manager confirmed that policy requires two nurse signatures each shift to balance narcotics and that if it is not written, it did not happen. The facility’s charting and documentation policy requires that all services provided, progress toward care plan goals, and any changes in condition be documented in the EMR to facilitate communication among the interdisciplinary team, yet multiple services, assessments, and medication administrations during the period without a licensed nurse were not documented as provided. The administrator did not provide requested policies related to medication administration, scheduling, narcotic counts, change‑of‑shift duties, and missed medications at the time of surveyor request, and the list of residents sent to the hospital did not include the resident who was documented as having been sent out for a change in condition on the date in question.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
An LPN failed to follow the manufacturer’s instructions when preparing and administering NovoLog insulin from a FlexPen for a resident with DM and cognitive impairment. The LPN dialed and depressed the pen before attaching the needle, then attached the needle, dialed the ordered dose, and gave the insulin without priming the pen after needle attachment or confirming insulin flow; the DON stated the expected process was to attach the needle, prime with 2 units until a drop appeared, then dial the correct dose.
Medication administration was not performed according to standards for two residents. One resident with dementia, anxiety, and adult failure to thrive had redness under the breasts and in the abdominal folds, and staff applied cleansing and Gold Bond powder without an active order. Another resident with glaucoma received eye drops from an LPN, but the resident rubbed his eyes afterward and the LPN did not provide the full post-administration instructions required by policy.
Expired Vitamin B12 was administered to a resident after an MA gave a daily dose from a medication cart bottle that had an expiration date of 1/2026 and still contained 92 pills. During the med storage observation, the MA stated she had already given the expired dose that morning and admitted she did not check the expiration date before administration. The MAR confirmed the resident received the Vitamin B12, and the DON and Administrator stated their expectation was that residents receive non-expired medications.
A cognitively intact resident with seizure disorder/epilepsy and chronic pain was not informed when medication changes occurred, despite staff stating residents should be educated about such changes and the care plan emphasizing resident-centered care. The resident said he felt frustrated and out of control when not told about his medications. Staff also failed to give ordered Norco for over 12 hours after it ran out, even though the nurse acknowledged it could have been given from the emergency supply; the resident reported pain at 8/10 and said the medication usually reduced it to about 4/10.
Insulin orders were not clarified or followed for a resident with DM, dementia, and other chronic conditions. The MAR showed scheduled and sliding-scale insulin instructions, but multiple elevated blood glucose readings were documented without evidence that the MD or NP was notified as ordered. An LPN stated she did not call anyone, and the DON said the orders should have been clarified.
A resident with encephalitis, encephalomyelitis, and hepatic encephalopathy did not receive ordered itraconazole via G-tube on time. The MAR showed three missed doses, and notes documented that the antifungal had not been received from the pharmacy, then could not be located in the med carts after it reportedly arrived. The resident was later transferred to the ER because anti-fungal medication was needed.
Improper NovoLog FlexPen Preparation During Insulin Administration
Penalty
Summary
The facility failed to ensure licensed nursing staff followed the manufacturer’s instructions when preparing and administering NovoLog insulin from a FlexPen for one resident. The manufacturer’s directions required cleaning the end where the needle attaches, installing the needle, removing the cap, and priming the pen by dialing to two units until a drop of insulin appeared before dialing the correct dose. The resident had moderate cognitive impairment and a diagnosis of diabetes mellitus, and the provider’s orders directed NovoLog insulin 100 units/1 ml on a sliding scale three times a day. During the insulin administration, an LPN reviewed the resident’s blood sugar of 183 and determined the resident required 4 units of insulin. The LPN obtained the NovoLog FlexPen, dialed it to two units and depressed the injection button before attaching the needle, then cleansed the rubber stopper, attached the needle, dialed four units, and administered the insulin without priming the pen after the needle was attached or verifying that insulin flowed from the needle. The LPN stated that was the way she always primed the pen. The DON stated the expected procedure was to remove the cap, sanitize the top, attach the needle, prime the needle by dialing up two units and watching for a drop of insulin, then dial the correct dosage and administer it. The facility’s Medication and Treatment Orders policy and Medication Pass Checklist Tool did not identify preparing and administering insulin using a NovoLog FlexPen.
Medication Administration Not Performed According to Standards
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of practice for Resident #30 and Resident #9. Resident #30, who was admitted with diagnoses including dementia, anxiety, and adult failure to thrive, was observed with redness to the lower abdomen and under the breasts. CNA #2 stated she assisted with keeping the areas clean twice daily, and later stated she cleansed the affected areas with warm soapy water and patted them dry before the nurse applied powder. However, the resident’s skin evaluation documented redness to the abdominal folds and under the breasts with treatment in place, while the physician orders and MAR/TAR contained no orders for skin treatment to those areas. LPN #2 later stated Gold Bond powder was being applied and acknowledged there was no active order for it. Resident #9, who had diagnoses including unspecified glaucoma, hypertension, and prostate cancer, had physician orders for Brimonidine Tartrate ophthalmic solution one drop in both eyes three times daily and Dorzolamide HCL ophthalmic solution one drop in both eyes two times daily. During observation, an LPN handed the resident a tissue, administered the eye drops, and the resident rubbed both eyes with the tissue after each administration. The LPN told the resident not to rub his eyes, but was not heard instructing him to close his eye gently, encourage gentle eye movement, blot excess medication, or press a finger between the eye and the top of the nose after administration. The LPN later stated she told the resident to dab his eyes and not rub them, but did not educate him on the importance of not rubbing his eyes after the eye drops were given.
Expired Vitamin B12 Administered to Resident
Penalty
Summary
The facility failed to prevent the administration of an expired medication for Resident #71, who had been admitted to the facility and had a physician's order dated 4/30/26 for Vitamin B12 oral tablet 500 micrograms by mouth daily as a supplement. During a medication storage observation on 7/8/26 at 8:45 AM, a bottle of Vitamin B12 500 MCG with an expiration date of 1/2026 was found on the A Hall Medication Cart with 92 pills remaining. The Director of Nursing Services and Medication Aide #1 were present during the observation. Medication Aide #1 stated that the expired Vitamin B12 had already been administered to one resident that morning and reported that Resident #71 had received one pill of the expired Vitamin B12 500 MCG. She stated she became aware the medication was expired when it was discovered during the observation and said she should have checked the expiration date before giving it, explaining she did not think to look before administering the dose. Review of the MAR at 8:55 AM confirmed Resident #71 received Vitamin B12 oral tablet 500 MCG that morning. The DON stated he expected the Nurse or MA to check expiration dates before administering any medication, and the Administrator stated her expectation was for residents to receive medications that were not expired.
Failure to Inform Resident of Medication Changes and Delay in Pain Medication
Penalty
Summary
Nursing staff failed to provide resident-centered care for a cognitively intact 78-year-old male resident with seizure disorder/epilepsy, DM, and parkinsonism by not informing him when changes were made to his medication regimen. The resident stated he wanted to be informed about his care and medication changes because, without that information, he had no control and no way of knowing whether a nurse had made a mistake. He also stated he felt frustrated and horrible when he was not informed, and he reported that no nurse had explained that some of his medications had been changed. The record showed the resident had physician-ordered levetiracetam (Keppra) for seizure control and hydrocodone-acetaminophen (Norco) for moderate to severe pain. The MARs documented that Keppra was last given on 6/28/26 and then was not administered on 6/29/26 or 6/30/26, with the medication later reordered on 7/1/26. Facility staff stated that medication changes were discussed in stand-up meetings and then communicated to the resident by the charge nurse or unit manager, but the DON confirmed the nursing progress notes did not document that the resident had been educated about medication changes. Nursing staff also failed to medicate the resident for pain per physician orders. The resident’s care plan identified acute/chronic pain and directed staff to administer the opioid as prescribed, with a goal that he would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The MAR showed Norco was administered regularly in June, but on 7/2/26 the resident reported he had not received Norco since the previous day, had requested it at 9 a.m. and again at 2 p.m., and his pain was 8/10. The nurse stated the Norco had run out the previous day and had been reordered, but none was given during the day shift while awaiting pharmacy delivery, even though she acknowledged it could have been administered from the emergency supply. The DON confirmed the medication had been on order since the previous day and that the resident had not received Norco since approximately 1:52 a.m. when it was administered from the emergency kit.
Insulin Orders Were Not Clarified or Followed for Blood Sugar Notifications
Penalty
Summary
The facility failed to clarify two insulin orders for a resident with insulin dependent diabetes, stroke, underweight, depression, anorexia, dementia, and high blood pressure. The resident’s most recent MDS showed the resident was unable to complete the interview and had short- and long-term memory difficulties. The clinical record included an order for Insulin Lispro 4 units subcutaneously three times a day with instructions to hold if blood sugar was less than 120 and to call the MD if blood glucose was less than 60 or greater than 250. The May 2026 MAR documented this order, and blood sugars were recorded at 318, 347, 319, 308, 256, 308, 278, and 312 on multiple dates and times, but the record did not show that the physician or NP was notified as ordered. The record also included a sliding scale insulin order for Insulin Lispro before meals, with directions to give 0 units for 140-199, 2 units for 200-259, 4 units for 300-349, and to call MD for 350-400. On 5/1/2026 at 11:30 a.m., the resident’s blood sugar was documented as 500, and the NP was notified. During interview, an LPN stated she did not call anyone for the blood sugars and acknowledged she should have called. The DON reviewed the orders and stated they should have been clarified. The Administrator and DON were informed of the findings, and no further information was provided before exit.
Delayed Administration of Ordered Antifungal Medication
Penalty
Summary
The facility failed to meet professional standards of care when Resident 1 did not receive the physician-ordered itraconazole oral solution in a timely manner. Resident 1 was admitted in June 2026 with diagnoses including encephalitis, encephalomyelitis, and hepatic encephalopathy, and the physician determined the resident did not have the mental capacity to make healthcare decisions. The order summary showed itraconazole oral solution 10 mg/mL, 30 mL via G-tube every 12 hours for systemic fungal infection, and the after visit summary identified itraconazole as the resident’s most important medication. The medication administration record showed the itraconazole was not administered on 6/17 at 9:00 p.m. or on 6/18 at 9:00 a.m. and 9:00 p.m. Progress notes documented that the medication had not been received from the pharmacy, that the nurse called the pharmacy and was told the medication had arrived at the facility at 6:04 p.m., and that the nurse could not find it in the med carts. The resident was transferred to the hospital emergency room on 6/19/26 at 12:22 a.m. for the reason that anti-fungal medication was needed. During interview, LN 1 confirmed the missed doses, and the DON stated there had been a delay in the medication and it was not administered on time.
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