Failure to Initiate Code Blue and Notify Physician for Full-Code Resident
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice for a resident whose advance directives and physician’s orders identified the resident as a full code. The resident had multiple diagnoses including dementia, Alzheimer’s disease, adult failure to thrive, osteomyelitis of the right ankle and foot, hyperlipidemia, anxiety, severe protein-calorie malnutrition, and pressure ulcers. The facility’s Code Blue policy required staff who find a resident unresponsive to call a Code Blue overhead twice, including unit and room number, and specified that the first responding nurse would determine code status, lead the code, and remain with the patient throughout the event. On the night of the incident, a CNA performing rounds around 4:45 A.M. observed that the resident was lying in bed on his/her back, with eyes half open, not looking well, and not responding to verbal stimuli. The CNA asked a second CNA to assess the resident; the second CNA also felt the resident did not look well and reported to the nurse that the resident looked like he/she was dead. The second CNA stated that the nurse then asked her to bring the crash cart to the resident’s room. The first CNA reported that the nurse did not instruct her to call a Code Blue or 911. According to the nurse’s progress note and interview, around 5:00 A.M. he was notified that the resident was unresponsive. On entering the room, he found the resident unresponsive to verbal and tactile stimuli, with no response to sternal rub, not breathing, without a pulse, cold to the touch, and stiff. He verified that the resident was a full code and began CPR, and asked for the crash cart, but he did not call a Code Blue, did not activate 911, and did not direct CNAs to do so. While performing CPR, he stopped to redirect another resident who entered the room. He acknowledged that he knew the facility’s policies for Code Blue and CPR, and that once CPR is started it should not be stopped until EMS or other staff arrive. He sent a text message to the physician, DON, and unit manager and contacted another nurse to complete an RN pronouncement, but there was no documentation that he spoke with the physician to obtain an order for the pronouncement, and the physician was not notified of the change in condition prior to discontinuation of CPR.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with respiratory history and anemia had oxygen equipment in the room and said they used oxygen at night, but there were no active oxygen orders, no care plan for oxygen use, and no documented SAT monitoring. Another resident with dementia was repeatedly observed without hearing aids despite orders and a care plan directing staff to place and charge them, while staff reported the aids did not work and the resident did not wear them.
A resident with severe cognitive impairment, aphasia, dementia, and a history of stroke received clopidogrel, Senexon S, and amlodipine crushed together and mixed with applesauce during med pass before there was an order authorizing crushed meds. The RN said the meds were crushed because it was ordered, while the DON stated meds requiring crushing must have a provider order and that meds should not be crushed without one. The resident's chart lacked authorization to crush meds until later that day, and the facility policy required provider awareness and separate crushing/administering of each medication.
False documentation of ordered Ace wrap treatments. Staff charted that an LPN had applied ordered Ace wraps to a resident with edema and heart failure even though observations showed the wraps were not on the resident. The resident said the wraps were supposed to be done daily but rarely were unless he reminded staff, and an LN acknowledged charting the treatment as completed despite it not being provided.
Medication administration did not follow physician orders for two residents. One resident's traMADol dose was documented in the eMAR as given even though the controlled substance record did not show the afternoon dose as dispensed, and the DON stated it was not administered. Another resident received midodrine on multiple occasions when BP readings were above the ordered parameters, and the DON stated the medication was given outside of parameters.
A resident with cerebral palsy, dysphagia, and a PEG tube had NPO orders, but also had oral medication orders for a probiotic and Milk of Magnesia. An RN was observed giving the probiotic via PEG tube, and the DON later stated the resident should have nothing by mouth. The facility failed to clarify the physician orders to verify the correct route of medication administration.
Admission Assessment Completed by LPN Without RN Oversight: An LPN completed a resident’s admission assessment and documented multiple skin findings, including skin tears, redness, and discolorations on several body areas. An RN stated that the full admission assessment, including skin, pain, fall risk, Braden, and oral assessments, is the responsibility of the nurse assigned to the resident’s room and that an LPN cannot complete the admission assessment without RN oversight.
Failure to Provide Ordered Oxygen Therapy and Hearing Support
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards for a resident with anxiety disorder, a history of respiratory disease, and anemia. The resident stated they used oxygen at night or during naps, and observations showed an oxygen concentrator and nasal cannula in the room not in use on multiple occasions. The EHR showed the resident received oxygen therapy on the MDS, but there were no active oxygen orders in the chart, and the smoking care plan only noted that the resident was not on oxygen while out of bed. Staff stated the resident said they used oxygen at night, but there was no assessment, provider order, care plan, or oxygen saturation monitoring documented for that use. The facility also failed to provide hearing support in accordance with professional standards for a resident with dementia. The resident was observed stating they could not hear, and hearing aids were not seen in place during multiple observations. The current plan of care and provider orders directed staff to place the hearing aids in the morning and remove them at night to charge, and the MAR documented that this was done from 06/01/2026 through 06/18/2026. However, staff told surveyors the hearing aids did not work, the resident did not like wearing them, and the resident’s son may have taken them home because they did not help. The resident’s roommate also stated the resident did not wear the hearing aids.
Crushed medications given without prior provider authorization
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during medication administration for a resident with severe cognitive deficits who required assistance with all ADLs and had diagnoses including aphasia, anemia, hypertension, non-Alzheimer's dementia, generalized muscle weakness, and a history of stroke with right-sided weakness. The resident's care plan identified a texture-modified diet and antiplatelet therapy, but it lacked indication prior to 6/3/26 that medications were authorized to be crushed. During a medication observation, the resident was given clopidogrel 75 mg, Senexon S 500 mg/8.6 mg, and amlodipine 10 mg crushed together and mixed with applesauce and administered orally. The RN stated the medications were crushed and mixed with applesauce because it was ordered by the provider. Later the same day, the DON stated all medications requiring crushing were to have an order in place and that this was important to determine whether medications could be crushed based on timed-release status, protective coating, and similar factors. The DON stated she was unaware whether orders were in place for the resident, but affirmed medications were not to be crushed without provider orders. The resident's progress notes showed that an order to crush meds due to history of stroke and seizure was not received until later that day, and the cumulative orders lacked authorization to crush medications before that time. The facility policy stated the attending provider must be aware of the need to crush medications so the appropriate form can be ordered, and that best practice is to separately crush each medication and separately administer each medication with food.
False documentation of ordered Ace wrap treatments
Penalty
Summary
The facility failed to follow standards of practice when staff documented that they had applied ordered Ace wraps to a resident even though the wraps had not actually been provided. The resident had documented diagnoses of edema, heart failure, and urinary retention, and the quarterly MDS noted intact cognition, independence in toileting, personal hygiene, and mobility, supervision with transfers, lower functional impairment on both sides, and daily diuretic use. The care plan directed staff to inspect the resident’s skin daily, administer medications as ordered, monitor vital signs and laboratory results, and monitor and report dependent edema, but it did not include direction about wrapping the resident’s legs with Ace wraps or that he refused them. The physician order required Ace wraps to be applied up to mid-thigh in the morning and removed at bedtime, and the June 2026 TAR documented that staff applied the wraps on two days. However, on multiple observations the resident was wearing gripper socks and did not have the Ace wraps on as ordered. The resident stated that his legs were supposed to be wrapped every day but that it rarely happened unless he reminded staff. An LN stated that staff tried to get him to wear the wraps every day but he would refuse, and that she had charted the wraps as applied even though they had not been on the resident. The LN then questioned whether she should change the charting, and an Administrative Nurse stated that if the resident did not want the wraps, staff should document refusal and not chart that they were applied when they were not.
Medication Administration Outside Physician Orders
Penalty
Summary
The facility failed to ensure medications were administered and assessments were completed in accordance with physician orders for 2 residents reviewed for nursing professional standards of practice. One resident had an order for traMADol 50 mg by mouth three times daily for pain, scheduled for 7:00 AM, 2:00 PM, and 9:00 PM. The controlled substance proof of use record showed doses dispensed at 7:59 AM and 8:10 PM on 5/25/26, but the 2:00 PM dose was not documented as dispensed. The medication administration record, however, documented all 3 doses as administered that day. The DON stated the nurse documented the afternoon dose in the eMAR but did not sign it out on the controlled substance record and did not administer the medication. Another resident had an order for midodrine 2.5 mg by mouth three times daily with parameters to hold for SBP >100 and give if diastolic was below 50. Review of the blood pressure summary and medication administration record showed the medication was administered on multiple dates when the resident's blood pressure readings were above the ordered systolic parameter, including readings of 113/65, 111/76, 108/76 and 113/57, 135/69, 115/70, 113/53, and 107/55. The DON stated the midodrine was administered outside of parameters and that education was initiated regarding following provider orders and the risks associated with administering cardiac medications outside ordered parameters.
Unclarified medication route orders
Penalty
Summary
The facility failed to ensure physician orders were clarified to verify the correct route of medication administration. Based on observation, record review, the NCSBN website, and staff interview, it was determined that staff did not clarify an order before administering medication, despite the professional obligation to verify any incomplete, inaccurate, unclear, or contraindicated order before implementation. The facility policy for administering medications stated medications are to be given safely and as prescribed, and that the right method (route) of administration must be checked before giving the medication. Resident #2 was admitted with multiple diagnoses including cerebral palsy and dysphagia and had a PEG tube for medication, nutrition, and hydration. The resident had an order for NPO to texture, diet, and consistency, yet also had orders for a probiotic oral capsule to be given by mouth and Milk of Magnesia oral suspension to be given by mouth as needed. During observation, an RN administered a probiotic via PEG tube. The DON later stated the resident was NPO and should have nothing by mouth.
Admission Assessment Completed by LPN Without RN Oversight
Penalty
Summary
The nursing facility failed to provide services that met professional standards of quality when an LPN completed the admission assessment for one resident. The report states that R5 was admitted to the facility on 5/1/26, and the admission assessment documented multiple skin findings, including a right elbow skin tear that was closed, coccyx redness, a left forearm skin tear with dressing in place and unable to assess, multiple discolorations to both upper extremities and the right chest, redness to the sacrum, a right forearm closed skin tear with a scabbed area, small discoloration to both lower extremities, and an upper arm skin tear with transparent dressing in place. During interview, the LPN stated he completed the admission assessment for R5 and that any skin areas noted on admission would have been documented in the assessment. He also stated he recalled multiple areas on both arms and both legs, did not recall bruises on the abdomen, and said he would have a CNA complete the skin assessment so all areas would be identified. An RN stated that the nurse assigned to the resident's room is responsible for completing the fall risk, pain, skin, Braden, oral, and full admission assessment when the resident is admitted, and that an LPN cannot complete an admission assessment without RN oversight. Another RN confirmed she was working when R5 was admitted and was responsible for entering new physician orders, but did not complete any assessments when R5 was admitted.
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