Untimely Medication Administration and Poor Wound/Dressing Management
Summary
Surveyors identified that medications were not administered according to physician orders, resident preferences, and facility policy for multiple residents. During a confidential resident council interview with eight residents, five reported concerns about delayed medication administration, including the absence of a nurse on their wing until midnight and not receiving scheduled morning medications such as a pain patch due between 9:00 AM and 10:00 AM. At the time of the interview, three additional residents also reported they had not yet received their 9:00 AM medications. Review of Medication Administration Records (MARs) on 3/24/26 at 12:40 PM showed that several residents had no documentation of their scheduled 9:00 AM medications or treatments being administered, and there were no progress notes or physician notifications regarding missed or late doses. Record review for one resident with diagnoses including atrial fibrillation, congestive heart failure, diabetes, and chronic kidney disease showed multiple daily medications such as Eliquis, furosemide, lisinopril, and potassium chloride ordered, but the 9:00 AM MAR entries for that day were blank. Another resident with acute and chronic respiratory failure, COPD, heart failure, atrial fibrillation, and multiple cardiac and anticoagulant medications had orders for time-specific doses at 9:00 AM and 9:00 PM, including apixaban, hydralazine, sacubitril-valsartan, and isosorbide dinitrate, yet the 9:00 AM medications were not documented as given by 12:40 PM. A third resident with heart failure, COPD, diabetes, hepatitis C, and neuropathy had multiple scheduled medications and sliding scale insulin ordered before meals and at bedtime; documentation showed the last blood sugar check and insulin administration at 7:00 AM, with no documentation of a blood sugar check before the noon meal despite the resident already being in the dining room and a history of frequent sliding scale insulin coverage before meals. A fourth resident with dementia, hypertension, diabetes, hyperlipidemia, and anemia had several daily medications and nutritional supplements ordered at 9:00 AM and 5:00 PM, but the 9:00 AM medications were not documented as administered. When interviewed, the nurse assigned to the unit stated the morning medication pass was not completed due to a heavy med pass and acknowledged not notifying administration or the physician about the delays. The facility’s Medication Administration policy required medications to be given within 60 minutes of the scheduled time, but the policy did not address late or missed medications, and the DON could not explain the lack of documentation or notifications. Surveyors also found failures in wound and dressing management for two residents. One resident with intact cognition and diagnoses including heart failure, peripheral vascular disease, and diabetes had a right knee abrasion care plan and a physician order to cleanse the abrasion and apply triple antibiotic ointment with a border gauze dressing on Monday, Wednesday, Friday, and as needed. On observation, the resident’s right leg dressing was visibly soiled, saturated, and dated 3/17, and the resident reported no one had offered to change it since that date. The Treatment Administration Record (TAR) showed the treatment documented as completed on 3/18 and 3/20 by the nurse manager, but the observed condition of the dressing and the resident’s report conflicted with that documentation. In another case, a cognitively intact resident admitted with pleural effusion, sepsis, and malnutrition was observed with an undated, worn bandage on the right hand that the resident stated had been applied at an outside appointment on 3/17/26 and had not been assessed or changed by facility staff. The same resident also had an undated foam border dressing on the left outer arm, which the resident reported had not been changed for a couple of days, despite a care plan requiring weekly head-to-toe skin assessments and a physician order for right arm abrasion care every Monday, Wednesday, Friday, and as needed. The TAR showed the right arm treatment marked as completed on 3/20 and left blank on 3/23, and a skin check dated 3/21 documented no skin issues. When the DON later removed the hand dressing, an old, soiled dressing was revealed over a scabbed area, and the DON confirmed that dressings should be dated and that nurses were expected to assess any dressing without an order and obtain appropriate treatment orders. The facility’s Skin Management policy required licensed nurses to monitor, evaluate, and document changes in skin condition, including dressings and surrounding skin, and to notify the resident, responsible party, practitioner, DON/designee, and treatment team when a new area of skin impairment was identified. Despite these requirements, the observations and record reviews showed that dressings were left in place for extended periods without being changed, were not dated, and were not consistently assessed or documented. In addition, there were discrepancies between TAR documentation and the actual condition of residents’ dressings, with one nurse manager having documented treatments as completed on dates when the dressing remained unchanged and soiled. These actions and inactions led to deficiencies in ensuring medications and treatments were provided according to physician orders, resident needs, and facility policies.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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