Failure to Consistently Assess, Document, and Follow Up on Wounds and Skin Conditions
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, and to accurately and consistently assess and document skin conditions and wounds for multiple residents. For one resident with acute osteomyelitis, DM, PVD, CHF, and anemia, the medical record showed inconsistent documentation of a left heel wound, alternately described as a DM ulcer, a pressure ulcer, and a surgical site. The quarterly MDS did not document a surgical wound, despite other records indicating the presence of a left heel wound that had been debrided in the hospital and categorized as a surgical wound with serosanguinous drainage. A wound clinic note documented a left heel pressure ulcer with surgical site and sutures, but a later wound physician note contained no documentation that the facility addressed the left heel wound. For this same resident, the facility had a physician order to cleanse the left heel and apply petroleum gauze and a silicone bordered dressing three times per week and as needed, and the wound nurse confirmed that these treatments were being performed. However, the wound nurse also stated that the facility had not measured the left heel wound from the time the resident was last seen at the wound clinic until the survey date, because they relied on the wound clinic to monitor the wound. The outpatient wound RN reported that the resident was last seen at the wound clinic in mid-January for evaluation of a left heel pressure ulcer with surgical site, and that the clinic had called the facility in early March to schedule a follow-up appointment but did not receive a return call. This resulted in a lack of ongoing wound measurements and a missed follow-up wound clinic appointment for the resident’s left heel wound. Another resident, admitted with cerebral infarction with left hemiplegia, mood disorder, HTN, and epilepsy, had repeated documentation on shower sheets over multiple dates indicating redness under both breasts and in the groin area, with notes that the redness had worsened and that powder had not worked and had been present for months. Despite this, weekly skin assessments during the same period documented no skin issues. A weekly wound observation later identified fungal areas under both breasts and the belly button, but without measurements. Physician orders existed for miconazole cream under the breasts, later changed to antifungal powder, and additional orders were written for antifungal cream to the buttocks, oral Diflucan, and later Benadryl for itching. A wound NP note documented extensive fungal dermatitis under the breasts, in the groin, umbilicus, and buttocks, with erythema and odor, and provided specific measurements for several areas. The DON confirmed that weekly skin assessments in January and February did not document the rash and that no treatment was initiated for the groin or umbilical rash until late February, and also confirmed that Keflex ordered by Urgent Care for fungal infection of the skin and candidal intertrigo was not administered. A third resident with DM, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity had a non-pressure wound to the left sacrum documented by a wound NP as a trauma/injury with specific measurements and moderate serous exudate and slough, later described as a full-thickness trauma wound that underwent surgical debridement. A physician order directed daily cleansing of the sacral wound and application of calcium alginate with bordered gauze, and records showed treatments were completed as ordered. However, the medical record did not contain documentation of what caused the trauma or what type of trauma occurred to the sacrum. The MDS nurse confirmed that there was no documentation in the record to identify the cause or type of trauma to the sacral area. These combined findings for three residents demonstrate failures in ongoing assessment, timely and accurate documentation, and follow-through with ordered or recommended wound-related care and evaluations.
Plan Of Correction
F684 Quality of Care The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 wound is healed per wound nurse 4-31-26.No further follow-up wound clinic appointment was needed or scheduled. Resident #10 has a treatment for rash which was ordered by the wound CNP and written by the wound nurse this order was written 3/18/26 which is demonstrating improvement and resident #51 is no longer in the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents in the facility have the potential for an identified practice census of 47. A sweep of residents to include any skin and wound conditions was done by 3-25-2026 by the wound nurse and certified wound nurse practitioner. The wound nurses look for any skin issues, and the wound nurse practitioner sees all residents with any skin concerns. (treatment order was in place, follow-up appointments with wound clinic had been scheduled), accurate assessments were in place, and the cause of wound injury/trauma had been The facility has no residents requiring treatment from an outside wound clinic; all current skin/ wound conditions have been described and measured. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-service all nurses in proper management of skin and wound issues. The resident's wounds must be reported, documented, and the MD notified. The areas F 0684 must be assessed completely and described in progress notes with origin. Treatment order in place. Residents going to the wound clinic are expected to be measured in the facility and assessed by the wound nurse with proper documentation. Education includes the importance of scheduling follow-up appointments. This is an oversight by the wound care nurse. The in-service period is ongoing, ending 4-9-2026. Wound nurse and DON were in-serviced 3-26-26 by the corporate nurse this inservicing also includes the need to schedule follow-up appointments. How the corrective action will be monitored to ensure the deficient practice will not recur. Weekly audits 5x week for 4 weeks per wound nurse /designee for residents with wounds. The audit includes observation of the wound and documentation.to ensure wounds are being accurately and continually assessed and the cause of trauma is being documented. The daily audit of all shower sheets to identify any new skin concerns to ensure there is no skin issue that goes without being identified and treated, reported to MD and the responsible party. The daily shower sheet is are audited by the wound nurse, and the wound nurse reports findings from the daily audit sheets in the morning clinical meeting. Weekly assessment of skin for all residents per wound nurse/designee. The shower sheet audit is reported in the morning clinical meeting and if any issues are identified, the wound nurse immediately calls the CNP and educates caregivers. Audits for skin are 5x week, ongoing. Results submitted to the QAPI committee. any concerns corrected and reeducation completed. Wound clinic appointments are monitored by the wound nurse and schedule is reported in morning clinical. monitored weekly by DON.
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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