Failure to manage skin integrity and specialty mattress use
Summary
The facility failed to ensure professional standards of care were followed for residents at high risk for skin injury. Resident #4 had cognitive impairment, limited range of motion, dependence on staff for toileting, bathing, and lower body dressing, incontinence of bowel and bladder, and was identified as high risk for pressure ulcers. During interview and observation, the resident reported not being changed or repositioned since the prior evening, stated the bottom was burning with each incontinent episode, and was observed with a dark purple coccyx pressure injury and an open area on the left buttock with yellow dead tissue and red tissue at the edges. The resident had an air foam mattress in use, while a low air-loss mattress was present but initially not in use, and later was observed set at an incorrect weight setting for the resident's actual weight. For Resident #4, the physician orders reviewed did not include wound care orders for the coccyx or buttocks wound, no order for repositioning every two hours and as needed, and no order for a low air-loss mattress. The care plan identified existing skin impairment under the breasts, abdominal fold, and right hip surgical wound, but did not include the coccyx wound or the resident's pressure ulcer risk, and did not identify the preventive measures staff were to implement. Facility staff interviews confirmed that pressure injury prevention should begin on admission, that new wounds should be reported the same shift they are discovered, and that nurses should check low air-loss mattress settings daily, but the resident's new wound was not recognized by nursing until later and the mattress was not properly set up or in use when observed. Resident #3 had severe cognitive and mobility impairment, was dependent on staff for bathing, toileting, and lower body dressing, and had diagnoses including right femur fracture and protein-calorie malnutrition. The resident was admitted with wounds to the bilateral heels, right buttocks, and mid back, and a new right ankle wound and right lateral ankle wound were documented without treatment orders being obtained. The care plan addressed pressure areas and skin integrity issues to both feet and nutritional risk, but did not include individualized pressure-relieving interventions or address the right ankle wounds. Observations showed the resident in a recliner without a pressure-relieving cushion, the ordered low air-loss mattress not in place on the bed, and offloading boots left in the corner on the floor while the resident was in bed. The facility also failed to properly set up and maintain specialty equipment for other residents. Resident #5, who had severe cognitive impairment, dependence on staff, malnutrition, cancer, and Alzheimer's dementia, had a care plan that did not list a low-air loss mattress or specialty pressure-reducing mattress as an intervention. The resident's physician orders did not include a low-air loss mattress, yet the resident was observed lying on one that remained set at 300 pounds despite a recorded weight of 96.7 pounds. Resident #8, who had severe cognitive impairment, significant weight loss, malnutrition, diabetes, and non-Alzheimer's dementia, also had no low-air loss mattress or specialty mattress listed in the care plan and no physician order for one, yet was observed on a low-air loss mattress set for 215 pounds despite a recorded weight of 106 pounds. Staff interviews confirmed that a physician order is required for specialty mattresses, that the mattress setting must match the resident's actual weight, and that incorrect setup can cause too much pressure or leave the resident lying on the bed frame.
Penalty
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The facility failed to meet professional standards for wound care and feeding tube management. Two residents with skin tears had wound care entered and carried out without proper provider notification and without documentation of assessments or family notification, while a cognitively intact resident with a feeding tube was documented as receiving Glucerna enterally even though staff and the resident stated it was being taken orally and no enteral supplies were observed.
Failure to Follow Physician Orders for Insulin and BP Medication: Two residents had medication orders not carried out as directed. One resident with diabetes had Novolog and Lantus insulin doses held for blood sugar readings without documented MD orders to hold them. Another resident with HTN had Metoprolol held with an order for VS monitoring and provider review, but the required VS were not documented and the medication was restarted without communication with the MD.
Failure to Assess Pain and Maintain PICC Dressing Care: One resident developed abdominal pain, received Norco without a documented pain assessment or follow-up assessment, then had vomiting and left for hospital evaluation the same day. A second resident with a PICC line had a dressing that was not changed as ordered; the infusion center found multiple layers of tape over an old dressing and sent the resident for ER evaluation and redressing. The DON acknowledged the missed documentation and missed dressing changes.
Medication administration documentation was not completed correctly for two residents. One resident with DM, schizoaffective disorder, depression, anxiety, GERD, hyperlipidemia, neuropathy, and pain had multiple missed doses later signed off on the MAR, including one gabapentin entry that was pre-signed before it was due. Another resident with schizophrenia had multiple missed doses for psychotropic, cardiac, thyroid, eye drop, and other medications, and the paper MAR showed later sign-offs and pre-signing of timolol, gabapentin, and Valium before they were due. Staff and the DON acknowledged that medications were documented after the fact and, in some cases, before administration.
A former RN failed to follow professional nursing standards when she gave a resident edible marijuana that was not ordered by the physician. An LPN observed the RN cut up what appeared to be candy in the resident’s room, then identify it as marijuana gummies and place pieces within the resident’s reach. The resident had osteoarthritis, mild cognitive impairment, anxiety disorder, and PRN pain orders including tramadol, acetaminophen, heat or ice, and morphine.
A resident with moderate cognitive impairment and diagnoses including a femoral neck fracture and pain had Norco delivered to the facility, but the narcotic was not properly signed into the cart or reconciled. When the resident later requested PRN pain medication, none was available, and the facility’s investigation found that an RN failed to complete the narcotic sign-in process and the medication was never located.
Failure to Document and Follow Ordered Wound and Tube Feeding Care
Penalty
Summary
The facility failed to provide services that met professional standards of quality for resident skin issues and feeding tube management. For one resident with metabolic encephalopathy, dysphagia, dementia, aphasia, and weakness, staff found a skin tear on the bilateral forearms with dressings already in place and entered wound care orders in the computer without documenting a progress note or contacting a provider to report the findings or confirm the order. The resident’s record showed prior and current wound care orders for skin tears, but there was no documentation in the progress notes from early June through mid-August regarding notification to a provider or the resident representative about the wounds or dressings. A second resident, admitted for orthopedic aftercare and with diagnoses including weakness, difficulty walking, COPD, anxiety, depression, heart failure, PTSD, and excoriation disorder, had a skin tear to the left lateral ankle. The wound care nurse entered a verbal order for wound care, and the MAR/TAR documented daily dressing care, but the progress notes contained no documentation of the skin tear, notification to family or provider, or treatment orders. The resident was cognitively intact, and during observation had a bordered gauze dressing to the left lower extremity. The facility policy required verification of the provider’s order and timely documentation of assessments, observations, and services provided. For a third resident with a feeding tube, intracerebral hemorrhage, cerebral edema, diabetes, morbid obesity, atrial fibrillation, gastrostomy status, and hypertension, the record showed an order for bolus Glucerna 1.5 by enteral route when meals were eaten at less than 75%, with water flushes before and after bolus feedings. However, staff documented the Glucerna as being administered enterally on the MAR/TAR while also stating that the resident was drinking the Glucerna orally. The resident stated she was taking medications and Glucerna by mouth and nothing was going through the feeding tube, and no feeding pump or enteral supplies were observed. The DON stated that if the resident preferred to take the feeding orally, the physician should be notified and the order updated, but the record showed the ordered route was not followed as documented.
Failure to Follow Physician Orders for Insulin and Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that care and services were provided according to accepted standards of practice for two residents. For one resident with diabetes who was cognitively intact and receiving insulin, physician orders included Novolog insulin with meals and Lantus insulin every 12 hours. The medication administration record showed multiple instances in which Novolog was held for blood sugar readings of 98, 86, 84, and 85 mg/dl, and Lantus was held for blood sugar readings of 71 and 94 mg/dl. The Nursing Home Administrator confirmed that the insulin doses were held without physician orders to do so and without documented evidence that the physician had given such orders. For another resident with diagnoses including hypertension, the physician ordered Metoprolol Tartrate 25 mg every morning and bedtime, then later ordered staff to hold the medication, obtain vital signs twice daily for seven days, and have the provider assess the appropriateness of Metoprolol by reviewing the resident's vital signs. There was no documented evidence that the ordered vital signs were obtained, and the medication was resumed without communication with the physician. The Director of Nursing confirmed that the facility failed to communicate with the provider before restarting the Metoprolol order.
Failure to Assess Pain and Maintain PICC Dressing Care
Penalty
Summary
Licensed nursing staff failed to provide nursing services in accordance with professional standards of quality for two residents. One resident was admitted with diagnoses including high blood pressure, a history of falling, and adult failure to thrive, and was her own health care decision maker. On 6/23/26, she developed abdominal pain at 2:45 p.m. and was given Hydrocodone Acetaminophen (Norco) 5/325 mg, but there was no documentation of a pain assessment or pain level before or after the medication was administered. RN A confirmed that no documentation was completed regarding the resident’s pain assessment, and the medication administration record did not contain an entry showing that Norco had been administered. The same resident continued to have pain, had one episode of vomiting, requested transfer to the hospital, and left the facility at 5:05 p.m. the same day. The DON confirmed that the resident reported abdominal pain, had green-colored vomiting, received Norco as ordered, and then requested hospital transfer for evaluation. The DON later stated that documentation of the resident’s pain should have been entered in the nursing progress notes and that ongoing assessments were required, including use of a pain scale and a full gastrointestinal assessment with bowel sounds and abdominal palpation. A second resident was admitted with diagnoses including UTI, liver disease, and AKI and had physician orders for PICC line dressing changes on admission, then weekly and as needed, and for PICC site assessment every shift. The infusion center documented on 7/20/26 that the resident’s PICC dressing had multiple layers of tape over the original dressing dated 6/27/26, and the infusion center RN recommended emergency room evaluation and a dressing change. The resident stated that staff were not changing the PICC dressing as often as they should have been, and the DON acknowledged that the dressing changes were not performed as required.
Medication Administration Documentation Not Completed Correctly
Penalty
Summary
The facility failed to follow its Medication Administration Policy and did not ensure timely and correct documentation of medication administration for two residents. The policy required staff to follow the six rights of medication administration, administer medications before documenting them, and report and document refusals or adverse effects. Surveyors found that medication administration records for both residents showed multiple missed opportunities that were later signed off as administered on paper MARs, and in some instances the documentation was entered before the medication was due. One resident had diagnoses including diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, GERD, hyperlipidemia, polyneuropathy, and low back pain. Review of the July 2026 eMAR showed multiple missed administrations across several scheduled medications, including atorvastatin, ezetimibe, Farxiga, gabapentin, Invega, lisinopril, mirtazapine, omeprazole, sertraline, clonazepam, topiramate, fiber, and tramadol. The paper MAR printed later showed that a CMT signed off as administering all of the missed opportunities for many of these medications, and also pre-signed gabapentin before the medication was due. The CMT stated that the documentation was completed on the paper MAR after the fact and that staff should never document a medication as given before it was actually administered. The second resident had diagnoses including schizophrenia, and the July 2026 eMAR showed missed administrations for atorvastatin, furosemide, latanoprost, levothyroxine, olanzapine, Paxil, trazodone, brimonidine, Depakote, medroxyprogesterone, timolol, gabapentin, and Valium. The paper MAR received for this resident showed only one page and included signatures indicating that missed doses had been administered, while timolol, gabapentin, and Valium were pre-signed before they were due. Staff interviews confirmed that the internet outage affected documentation, that some staff used hotspots while others used paper MARs, and that the DON directed staff to sign the paper MARs later. The DON acknowledged that staff should not document medication administration before the medication is actually administered and that the residents should have had completed documentation at the time of administration.
Unauthorized Marijuana Given to Resident
Penalty
Summary
The facility failed to ensure staff provided care and services according to professional standards of quality for one resident reviewed for medication administration. Resident 4 was admitted with diagnoses including osteoarthritis, mild cognitive impairment, and anxiety disorder, and had a care plan addressing pain management, including monitoring for side effects of pain medication and offering non-pharmacological pain interventions. The resident also had physician orders for tramadol, acetaminophen, ice or heat application, and morphine sulfate oral concentrate as needed for pain. A former RN provided Resident 4 with edible marijuana that was not ordered by the resident’s physician. An LPN who was receiving orientation from the RN observed the RN cut up what appeared to be candy in the resident’s room, then heard the RN identify it as edible marijuana gummies and acknowledge that she was giving them to the resident. The LPN observed the RN place pieces of the gummies within the resident’s reach. The RN later stated she had provided edible marijuana to the resident and had not given it to other residents.
Failure to Secure and Track a Resident’s Narcotic Medication
Penalty
Summary
The facility failed to maintain professional standards of nursing practice for the storage, tracking, and reconciliation of a scheduled controlled substance for one sampled resident. The resident had been admitted with diagnoses including left femoral neck fracture, muscle wasting and atrophy, and unspecified pain, and the admission MDS reflected a BIMS score of 9, indicating moderate cognitive impairment. Review of the facility policy showed it did not specifically address new narcotic medication security after delivery from the pharmacy, and the DON stated the facility did not have a policy for checking in narcotic medications or a drug diversion policy. The resident’s Norco 7.5 mg 30-count blister pack was delivered to the facility, but it was not properly signed into the medication cart and was later found missing when the resident requested PRN pain medication and none was available. Interviews and the facility’s investigation showed an LPN received the narcotic medication and asked a KMA to assist with logging it in, the KMA placed it in the cart and told the oncoming RN that the RN would need to complete the blue and white narcotic sheets, and RN 2 failed to sign the medication into the cart as requested. The investigation also noted RN 2 had suspicious behavior, had accidentally taken home a resident’s medication on another occasion, and the missing Norco was never located.
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