Unqualified G-tube Replacement with Urinary Catheter Leading to Complications
Summary
The facility failed to ensure that care was provided by qualified staff according to a resident's written plan of care when the DON replaced a gastrostomy tube (g-tube) without documented training, competency, or adherence to facility policy. The DON reported that a nurse approached her stating the family wanted the g-tube changed, and she proceeded with the change as a "routine procedure" under what she described as a standing order, without contacting the resident's physician. She replaced the resident's existing 16 French g-tube with a 20 French urinary catheter, stating the stoma had stretched and that the larger size would make feeding easier. The DON acknowledged that changing g-tubes was not normally done at this facility, that there was no facility policy or procedure for changing g-tubes, and that she had no certification for this procedure, only hands-on training from a previous employer, which could not provide any documentation of competencies. The resident had a history of a major cerebrovascular accident with right-sided hemiparesis and aphasia and was admitted to the hospital from the facility for a leaking g-tube, fever, and an episode of vomiting. The resident’s son, who is the power of attorney, reported that the facility had changed the g-tube and placed a 20 French urinary catheter, and that it had been leaking since that time. Hospital evaluation found the g-tube displaced into the proximal jejunum, with labs showing an elevated lipase consistent with pancreatitis and a CT scan confirming the tube’s position. A procedure note documented that the balloon of the old g-tube (a urinary catheter placed through the gastrostomy stoma) was deflated and that the catheter had migrated into the jejunum, with only the tip visible at the skin site, causing partial bowel obstruction and substantial leakage from the stoma. The facility’s written policy on feeding tubes specified that only tubes designed for enteral feeding would be used except under extenuating circumstances and for the shortest time possible, and that directions would be provided regarding when and by whom tubes could be replaced, including when replacement must occur in another setting.
Penalty
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Uncertified LPNs performed CPR on a full-code resident after the resident was found unresponsive on the floor, not breathing, and without a pulse with a cord wrapped around the neck. LPNs #5, #11, and #12 all participated in compressions and related resuscitative efforts, but the facility had no documentation that they held current CPR certification; one LPN said hands-on training was not complete, another said they did not have current certification, and the DON stated noncertified staff could perform CPR under the good Samaritan law.
A resident with a G-tube, dysphagia, anorexia, GERD, and gastroparesis had orders for bolus enteral feedings with residual checks before feeding. A family member observed a student nurse start a bolus feeding without the instructor or an RN/LVN present and without checking residuals, with the instructor arriving only near the end. Staff gave conflicting accounts about whether checked-off students could perform the task independently, and the DON and Administrator stated the facility had no protocol or policy for student nurses providing care on their own.
A resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II DM had a physician order for nursing staff to apply bilateral elastic compression bandages from the dorsum of the feet to below the knees each morning and remove them at bedtime. Review of the Treatment Administration Record for the month showed multiple missed leg wrap treatments, with no corresponding documentation of refusals or physician notification. The DON confirmed that nurses are required to document treatments on the TAR, notify the physician of refusals, and that the resident’s legs were to be wrapped daily per the physician’s order.
Unlicensed CNA applied a prescribed Lidocaine patch to a resident with cerebral palsy and back pain after a bed bath, even though facility policy allowed only licensed nurses or certified medication technicians to administer medications. The surveyor observed the patch application without a licensed nurse present, and the DON confirmed the CNA was not authorized to administer meds and that the patch was a physician-ordered medication.
Unqualified staff assisted with resident transfers and repositioning involving mechanical lifts. An Activity Aide with no CNA training helped operate a sit-to-stand lift for a resident who required lift assistance, and a BOM with no CNA training helped reposition another resident with severe contractures using a fireman method after staff could not safely position the Hoyer sling. During that repositioning, staff heard a popping sound in the resident’s arm, and an x-ray later showed a humerus fracture.
QMAs failed to practice within their scope when administering PRN narcotic pain medications and performing advanced wound care. A resident with chronic pain and another with diabetes and depression received PRN narcotic analgesics from a QMA without documented RN/LPN assessment, nurse authorization, or nurse initials on the controlled substance records, despite facility policy requiring nurse assessment and co-signature for PRN administration. In addition, a resident with a stage 4 sacral pressure ulcer had complex wound treatments and wound monitoring signed off by QMAs, even though the facility’s QMA scope of practice prohibits QMAs from providing treatments for stage II–IV pressure ulcers or independently assessing residents’ conditions.
Uncertified LPNs Performed CPR on Full-Code Resident
Penalty
Summary
The facility failed to ensure that services provided or arranged were delivered by qualified persons when three LPNs performed CPR on Resident #1 without valid CPR certification. Resident #1 had diagnoses including Huntington's disease, suicidal ideations, and post-traumatic stress disorder, and had a physician order for full code status with no limitation on medical interventions. On the morning of the event, the resident was found lying on the floor next to the bed, unresponsive, not breathing, and without a pulse, with a cord wrapped around the neck. A code blue was called and staff began CPR before the resident was transferred to a hospital. Staff statements documented that LPN #5 found the resident on the floor during a medication pass, saw the red full-code wristband, called the code blue, and participated in CPR with other nurses and an AED until paramedics arrived. LPN #11 stated they responded to the code blue, found the resident without pulse or respirations, and performed multiple rounds of compressions, with LPN #12 taking over compressions while suctioning was performed. LPN #12 stated they entered the room and saw LPN #11 performing compressions and assisted until EMS took over. The facility provided a list of staff with current CPR certification, but there was no documented evidence that LPN #5, LPN #11, or LPN #12 were certified. LPN #5 stated they had completed online CPR modules but had not finished hands-on training and were not currently certified, LPN #11 stated they did not possess a current CPR certification, and the DON stated staff without CPR certification could perform CPR under the good Samaritan law.
Student Nurse Performed G-Tube Feeding Without Required Supervision
Penalty
Summary
The facility failed to ensure care and services were provided by qualified persons in accordance with the written plan of care for a resident with a G-tube. The resident’s record showed diagnoses including dysphagia, anorexia, encounter for attention to gastronomy, GERD, and gastroparesis, and the care plan identified that the resident required use of a feeding tube. The order summary included enteral feeding orders for bolus feedings four times a day and instructions to check residuals before feeding, return gastric contents if over 100 mL, withhold medication, and notify the physician. A family member stated they observed a student nurse enter the resident’s room with feeding supplies and begin a bolus feeding without the instructor or a nurse present. The family member stated the student nurse did not check for residuals before starting the feeding, and that the instructor arrived only near the end of the feeding and assisted with the last portion of formula and water. The family member stated the resident was not in distress during the event. Staff interviews showed differing understandings of whether student nurses could perform bolus feedings independently once checked off. LVN staff stated students were allowed to do the task alone after competency validation and that they would later check on the resident. The clinical instructor stated students were checked off in skills lab and again at the facility and were competent to perform the skill without supervision. The DON and Administrator stated the facility did not have a protocol or policy regarding student nurses performing tasks independently, and the facility record review confirmed there was no policy in place regarding student nurses providing care to residents.
Failure to Follow Physician Orders for Daily Leg Wrap Treatments
Penalty
Summary
Failure to provide care by qualified persons according to a resident’s written plan of care occurred when nursing staff did not consistently implement a physician’s order for daily bilateral leg wraps. A cognitively intact resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II diabetes mellitus had a physician order directing nursing to wrap both legs with elastic compression bandages from the dorsum of the feet to below the knee every morning and remove them at bedtime. Review of the Treatment Administration Record for April 2026 showed seven missed treatments for the ordered leg wraps between 4/1/26 and 4/23/26. The Director of Nurses confirmed that nurses are required to document treatments on the TAR, to notify the physician if residents refuse treatments, to document refusals in the medical record, and that this resident’s legs were to be wrapped daily per the physician’s order. These findings demonstrate that the ordered leg wrap treatments were not provided and/or not documented as required, and that there was no documented physician notification or refusal documentation corresponding to the missed treatments, resulting in a failure to follow the resident’s plan of care and physician orders.
Unlicensed CNA Applied Prescribed Lidocaine Patch
Penalty
Summary
The facility did not ensure that only qualified persons administered medications according to residents’ plans of care when an unlicensed CNA applied a Lidocaine external patch 4% to R27’s lower back. The facility policy titled "Administering Medication," revised 01/22/2024, states that only licensed staff may administer or record the administration of medications, and certified medication technicians may administer specific medications only if competency has been determined. R27 was admitted with diagnoses of cerebral palsy and back pain and had a physician’s order for Lidocaine external patch 4% to be applied to the lower back twice daily for pain. On 04/21/2026 at 9:05 AM, the surveyor observed CNA D apply the Lidocaine patch to R27’s lower back after a bed bath. CNA D stated that nurses give the patch to her to put on. The patch had been observed at R27’s bedside before application, and no licensed nurse was observed in the room during the application. The MAR showed RN D’s initials for administration of the Lidocaine patch that morning. Facility staffing records showed CNA D was not a medication administration technician. RN C and DON B both stated that only licensed nurses and certified medication technicians could administer medications, and DON B confirmed CNA D was not allowed to administer medications and that the Lidocaine patch was considered a medication ordered by a physician.
Unqualified staff assisted with mechanical lift transfers and repositioning
Penalty
Summary
The facility did not ensure residents received services by qualified persons according to their written plans of care for two residents who required mechanical lift-related assistance. For one resident with dementia, Parkinson’s disease, and degenerative back and neck disorders, an Activity Aide who was not a CNA and had no documented competency for transfer assistance assisted a CNA with a sit-to-stand mechanical transfer. The aide pushed the button on the lift while transferring the resident on and off the toilet, and both the aide and the DON stated the aide was not trained to use the lift but could assist by pressing the button. For another resident with spastic quadriplegic cerebral palsy, contractures of the left wrist and hand, and cervical disc degeneration, the care plan directed a Hoyer total assist. During an incident, the resident was sliding down in a wheelchair and staff attempted to reposition the resident using a Hoyer sling, but the sling was too far down to safely move the resident. A CNA and the Business Office Manager, who had no CNA training, then used a fireman method to boost the resident by lifting under the arms and pulling on the resident’s pants/briefs. As they lifted the resident, they heard a popping sound in the resident’s right arm, and an x-ray the next day showed a fracture of the surgical neck of the right humerus. Interviews confirmed that non-nursing staff were involved in resident repositioning and lift-related tasks. The NHA stated non-nursing staff were allowed to assist with repositioning because it was not considered direct patient care, and the BOM stated she had no CNA training and had only been shown how to reposition residents by the NHA. The BOM also stated that non-nursing staff are allowed to help with boosts, and the DON stated that for sit-to-stand lifts, one staff member needs to be qualified while the other does not.
QMAs Functioning Outside Scope for PRN Narcotics and Stage 4 Wound Care
Penalty
Summary
The deficiency involves failure to ensure qualified medication aides (QMAs) practiced within their defined scope and that care was provided by qualified persons according to each resident’s written plan of care. For one resident with rheumatoid arthritis, chronic pain, and osteoarthritis, a physician’s order directed PRN oxycodone 5 mg every 4 hours for pain. Documentation showed that a QMA administered the PRN narcotic, but the clinical record lacked evidence of a licensed nurse’s initials on the controlled substance record, a documented nursing assessment prior to administration, and documented permission from a licensed nurse, contrary to facility practice as described by an LPN. For another resident with a stage 4 sacral pressure ulcer, the physician’s order required cleansing with normal saline, packing with Dakin’s-soaked gauze, and covering with an ABD pad twice daily, and a separate order required monitoring the sacral wound for signs of infection or decline. The treatment administration record showed QMAs signed off as having completed the stage 4 wound treatment and the monitoring of the stage 4 sacral wound, despite the QMA scope of practice prohibiting them from performing treatments involving stage II–IV pressure ulcers. A third resident with diabetes and major depression had a physician’s order for PRN hydrocodone-acetaminophen 5-325 mg every 8 hours for pain. Records indicated a QMA administered the PRN narcotic, but the clinical record again lacked documentation of a licensed nurse’s initials on the controlled substance record, a nursing assessment prior to administration, and documented permission from a licensed nurse. The facility’s QMA Parameters and Scope of Practice, provided by the DON, specified that QMAs may not assess a resident’s condition and may administer previously ordered PRN medications only after contacting a licensed nurse, documenting the contact, symptoms, permission, and time, and ensuring the record is co-signed by the nurse by the end of the shift or next tour of duty. The same scope document also stated that QMAs may not administer treatments involving advanced skin conditions, including stage II, III, and IV pressure ulcers. These documented practices and omissions show that QMAs performed tasks outside their authorized scope and without required licensed nurse assessment and documentation.
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