Failure to Apply ACE Wraps per Physician Orders
Summary
Nursing staff failed to ensure that ACE wraps were applied and used according to physician orders for 11 of 14 residents identified in the report. The deficiency involved residents with diagnoses including lymphedema, edema, heart failure, hypertension, COPD, Parkinson’s disease, kidney failure, pulmonary fibrosis, cancer, and coronary artery disease. The report states that the facility failed to ensure nursing staff possessed the specific competencies and skill sets related to the use of ACE wraps. For Resident R16, the physician ordered ACE wraps to the left ankle in the morning and off in the evening, but observations showed the wraps were not on at times they should have been applied, and on one occasion they were wrapped on the foot and calf with no coverage at the ankle and visible swelling between the wrapped areas. For Resident R32, the order was for ACE wraps to both lower extremities every morning, but repeated observations showed the wraps were not on, and the resident stated, “I don't think they have thought about it. It is hit or miss.” For Resident R50, the order was for an ACE wrap to the left foot in the morning and off in the evening, but observations showed the wraps were not on on multiple occasions, and when present they were not wrapped correctly; the resident’s feet were also described as grossly swollen. For Resident R62, the order directed bilateral ACE wraps from distal to proximal, starting from the bottom of the toes and wrapping to above the knee, but observations showed the wraps were loosely applied or not on, with visibly swollen legs when absent. For Resident R74, the order was for bilateral wraps from the base of the toes upward to the knee, but the wraps were not on at one observation and were applied in an up-then-down pattern at another. For Resident R97, the order was for ACE wraps to both lower extremities on in the morning and off at bedtime, but observations showed the wraps were not on, were loosely applied, and were later found wrapped from the ankle; the resident stated the wraps had remained on since the previous morning, and when removed by the Assistant Director of Nursing, they caused a tourniquet effect with a deep indentation at the ankle and the feet were grossly swollen and painful to touch. For Resident R117, the order required bilateral ACE wraps every morning and off every evening, but the wraps were not on during several observations, and when applied they started at the ankle with visibly swollen feet. For Resident R123, the order required ACE wraps to both lower extremities every evening and night shift for lymphedema, but the wraps were not on during observation. For Resident R130, the order required bilateral ACE wraps on in the morning and off at night, but the wraps were not on during several observations and were later observed wrapped from the ankle with the feet grossly swollen and painful to touch. For Resident R147, the order required ACE wraps to both lower extremities for edema on in the morning and off at night, but the wraps were not on during observations. For Resident R174, the order required ACE wraps to both lower extremities on in the morning and off at bedtime, but the wraps were not on during observations. The Assistant Director of Nursing confirmed that the facility failed to follow physician orders and/or failed to apply ACE wraps appropriately for these residents.
Penalty
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Lack of Current Gait Belt Competency for RNA: The facility failed to ensure an RNA/CNA with restorative training had current gait belt training and competency for resident transfers and ambulation. The IPN found no current gait belt competency in the employee file, with the last documented training on file being from 2021. The DON stated the facility’s Professional Standards policy required staff to be trained before using equipment, annually, or as needed, and the ADM stated the facility assessment identified the DSD/designee as responsible for staff training and yearly competencies.
The facility failed to maintain documented CNA competency checklists for multiple CNAs. Personnel files for four CNAs lacked evidence of completed skills and techniques competency, and HR confirmed the checklists were not completed. The DON stated there had been a period of about a month when CNA competency checklists were not maintained, despite the facility orientation policy requiring staff to demonstrate competency in all skills needed for their role.
A resident with heart and vascular disease was readmitted with orders to stop Clopidogrel and ASA and start Apixaban, but the RN entered the new orders without removing the discontinued meds. The EMR generated interaction alerts for Apixaban with ASA and Clopidogrel, but the RN did not recognize or address them, and the night RN supervisor did not complete the required secondary review of readmission orders. The resident continued receiving Clopidogrel and ASA for several doses, and the MD identified the error as significant.
A CNA was observed standing over a resident while assisting with breakfast instead of sitting at eye level. The CNA described meal-assistance practices, while the RNS and DON stated that staff are expected to sit at eye level with the resident for dignity and respect. The facility's policy required nursing staff to meet competency requirements and provide residents with a dignified dining experience.
A resident with significant cardiac history had a documented HR of 131 and low BP, but an LPN did not notify a provider or document a repeat assessment for hours. The resident later developed SOB, chest pain, and low O2 sat, was sent to the hospital, and died there the same evening. The report also found an RN competency assessment with multiple below-standard scores that lacked required reassessment and completion documentation.
LPN lacked documented competency for PICC IV medication administration and gave an IV antibiotic through a PICC without checking for blood return before starting the infusion. The resident had an order for Meropenem IV, and the DON confirmed no competency or skills test had been completed for the LPN, despite facility policy requiring IV education and competency before providing IV services.
Lack of Current Gait Belt Competency for RNA
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents when the Restorative Nursing Assistant (RNA), a CNA with extra training, did not have current training and competency documentation for the proper use of a gait belt for resident transfers and/or ambulation. During interview and record review, the Infection Prevention Nurse stated there was no current gait belt training in the RNA’s employee file and that the last documented gait belt training was dated 11/1/2021. The Infection Prevention Nurse also stated gait belt training was supposed to be completed annually for resident safety so staff would know how to use the equipment properly and prevent possible accidents and harm to residents. During interview and record review with the DON, the facility’s job description for the Director of Staff Development was reviewed, and the DON stated it was an essential function of that role to participate in the annual facility assessment by providing staff analysis, competency reports, and a gap analysis of training requirements, as well as overseeing and maintaining personnel records. The DON also reviewed the facility’s Professional Standards policy and stated it was not followed, explaining that staff were supposed to be trained before using equipment initially upon hire, annually, or as needed. The Administrator reviewed the facility assessment and stated it identified that the Director of Staff Development and/or designee were responsible for providing training and education to newly hired, current, and registry/contract staff, and that skills competencies were completed yearly and as needed.
Missing CNA Competency Documentation
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had documented competency in the skills and techniques needed to meet residents' needs. Review of personnel files showed that CNA #201, CNA #202, CNA #203, and CNA #205 each had a hire date listed in their records, but their files did not contain a CNA checklist showing competency in skills and techniques. The report states this deficiency had the potential to affect all residents, and the facility census was 65. During interview, Human Resources stated that nursing completed the competency checklist for CNAs and then filed it in the employee personnel record, but verified that CNA #201, CNA #202, CNA #203, and CNA #205 did not have a completed competency skills checklist. The DON stated that due to staffing changes, there was a period of about a month when CNA competency checklists were not maintained. The facility policy titled Orientation stated that departmental orientation would continue until staff demonstrated competency in all skills necessary for their role and to meet resident needs.
Failure to Reconcile Readmission Med Orders and Respond to EMR Interaction Alerts
Penalty
Summary
Licensed nursing staff failed to accurately reconcile and transcribe hospital discharge medication orders for a resident with atherosclerotic heart disease, peripheral vascular disease, anemia, and intact cognition who returned to the facility with a suprapubic catheter and dependence for multiple activities of daily living. The hospital referral report directed discontinuation of Clopidogrel 75 mg and Aspirin 81 mg and initiation of Apixaban 5 mg, but the physician orders entered into the facility record did not include discontinuation orders for Clopidogrel or Aspirin. The resident’s medication administration record showed continued administration of Aspirin for 3 doses and Clopidogrel for 2 doses after those medications should have been stopped. The electronic medication record generated an order note alert identifying drug interaction warnings when Apixaban was added, including interactions with Aspirin and Clopidogrel, but the admitting RN stated she was not aware the system alerted to the potential interaction and did not address it. The Assistant DON stated the facility policy required medication reconciliation by the licensed staff member and a secondary verification of readmission orders by the 11:00 PM to 7:00 AM shift supervisor, but both steps were not followed. The DON stated the readmitting RN was responsible for reconciling the hospital discharge summary with current orders, removing discontinued medications from the active profile, and cross-referencing readmission orders, while the night supervisor was responsible for independently verifying all readmission orders. The newly assigned agency RN supervisor was on only her second shift at the facility and her first 11:00 PM to 7:00 AM shift, and the DON stated the admitting RN was responsible for orienting her to night shift responsibilities, including the required secondary review of readmission orders. The DON further stated there was no formal checklist to ensure shift-specific responsibilities were reviewed, and the required secondary verification was not completed. As a result, the resident continued to receive Clopidogrel and Aspirin after the hospital had discontinued them, and the medical director identified the medication error as significant.
Inadequate CNA Competency During Meal Assistance
Penalty
Summary
The facility failed to ensure nursing staff met the specific competency requirements of their licensure and certification for one sampled staff member, CNA 1, according to the facility's policy titled Competency of Nursing Staff, revised 1/29/2026. During an observation in Resident 2's room, CNA 1 was seen standing over Resident 2 while assisting her with breakfast. When interviewed, CNA 1 stated that when assisting residents with eating, she should make sure the resident swallows, keep the head of bed high, ensure the resident is comfortable, and provide privacy. During interviews, RNS 1 stated that staff should be at eye level with the resident when assisting with eating by keeping the bed at the same height as the staff member and avoiding leaning over. The DON also stated that the expectation when assisting a resident with eating is that staff should be sitting down at eye level with the resident, not standing, for dignity and respect. The facility's Dignity policy stated that residents are to be treated with dignity and respect at all times and that the facility culture supports dignity and respect, including providing a dignified dining experience.
Failure to Recognize and Report Significant Change in Condition; Incomplete Nurse Competency Validation
Penalty
Summary
The facility failed to ensure nurses were competent to recognize and act on a significant change in condition for a resident with extensive cardiac history. The resident had diagnoses including atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome, a prosthetic heart valve, and bacteremia. The resident’s care plan noted cognitive intactness, IV antibiotics, a diuretic, and an anticoagulant, with a goal of returning home. A nursing note documented a heart rate of 131 beats per minute and blood pressure of 98/53, but there was no documentation that a provider was notified or that the nurse further assessed the elevated heart rate. Approximately seven hours later, the next clinical entry was from an on-call provider documenting shortness of breath, chest pain, and not feeling well. The provider note included a pulse of 80 and oxygen saturation of 77, but there was no indication the nurse had informed the provider of the resident’s cardiac history, the recent hospitalization for atrial fibrillation with rapid ventricular response, or the earlier heart rate of 131. The record also did not show whether the resident remained stable during the intervening hours or whether the resident was checked during that period. The resident was later sent to the hospital and expired there the same evening. The nurse involved stated that after seeing the pulse of 131, she rechecked the resident and obtained 87, found the resident fine, and did not document the recheck. She stated that later in the evening the resident complained of shortness of breath and heart racing, at which time she assessed the resident and sent the resident out. The nurse’s file contained orientation documentation and a copy of the notification-of-changes policy, but there were no dates or signatures showing when it was reviewed and no evidence of hands-on skills validation. The report also identified that an RN’s competency assessment showed scores below expected standards in multiple skills areas, but the required reassessment and completion documentation were left blank and no further training records were found.
LPN Lacked PICC Line IV Competency
Penalty
Summary
The facility failed to ensure nursing staff were competent to administer IV medications through a PICC line for one resident. The resident had an order for Meropenem 500 mg in sodium chloride 50 mL IV to infuse over 30 minutes. During observation of the medication administration, an LPN cleansed the PICC site, flushed the line with 10 mL of saline, prepared the medication and tubing, attached the tubing to the resident, set the infusion pump, and documented the medication administration in the eMAR. However, the LPN did not check for blood return before starting the infusion, and later confirmed that this was the first time giving the IV antibiotic to the resident since the resident returned from the hospital. Record review showed the facility policy required LPNs to complete IV education and competency with an RN before providing peripheral IV services and on an annual basis, and the nursing procedure reference stated that blood return and catheter patency must be confirmed before initiating infusion through a PICC line. The DON stated there were no competencies completed when the LPN was hired and that no competency skills day had been completed for staff yet that year. The DON also confirmed there was no competency or skills test completed for the LPN in the file, and the MDS Coordinator stated that IV orders were rare and that review with LPNs each time IV medications were ordered would be best.
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