Two residents’ changes in condition were not properly identified and assessed, and both later died. One resident with DNR/comfort care status had an unwitnessed fall, vomiting, and then developed stroke-like symptoms including facial droop, unilateral weakness, slurred speech, and altered responsiveness; an LPN did not complete a full neuro assessment when notified and left the room after stating the resident was on comfort care. Records and staff interviews showed delayed escalation and inconsistent communication before the resident was sent to the hospital, where CT findings showed a large intracranial hemorrhage. The deficiency was cited at IJ level.
A resident with multiple chronic conditions and moderate cognitive impairment developed persistent left foot and leg pain, swelling, discoloration, weak pulses, and cool tissue while in the facility. Staff documented pain medication use, an x-ray with no fracture, and a steroid injection order, but the resident’s condition continued to worsen until hospital evaluation found major arterial occlusion and a nonviable, critically ischemic leg. The resident later died, and the death certificate listed infection and dead tissue as the cause of death.
A resident with cognitive impairment, orthostatic hypotension, an artificial hip joint, and blood thinner therapy had an unwitnessed fall that led to a right hip fracture and scalp swelling. Staff started neuro checks, but the required Q4 hour check was not completed, and an LPN did not notify the provider after the resident later said they may have hit their head and reported head soreness. The resident also had right hip pain, decreased ROM, and a skin tear after the fall.
Failure to separate two residents after an alleged sexual contact incident. A resident reported that another resident touched them in the chest/breast area during a smoke break, and the other resident had documented dementia, sexual disorder diagnoses, and hypersexual behaviors in the care plan. Despite staff awareness that the residents were to be kept apart, an observation later showed them seated next to each other in the smoking area, and staff interviews showed the separation instruction was not consistently communicated or followed.
Failure to carry out ordered blood glucose monitoring: A resident with type 2 DM, hypoglycemia, and severe cognitive impairment had an MD order for AM blood glucose checks with notification if results were above 250, but the order did not appear on the June MAR. An LPN stated orders were entered into the electronic record and should flow to the MAR, while the DON confirmed the order was in the order summary but not on the MAR and stated staff were expected to enter orders correctly and ensure they were carried out.
A resident with DM and intact cognition was using a blood sugar sensor device, but the order was not documented on the physician orders or MAR. Staff observed the sensor patch on the resident’s arm, and LPNs said the resident’s blood sugars were checked through the device and the patch was changed every 10 days. Pharmacy records confirmed repeated fills, while the DON and Medical Director acknowledged the device should have been reflected in the physician orders.
A resident with COPD and moderate cognitive impairment was not provided oxygen equipment care per orders, and a nebulizer treatment was given while the nurse left the room. The resident was not care planned to self-administer medications, yet staff did not remain present during the inhaled treatment, and the oxygen tubing and humidifier bottle were observed dated beyond the ordered change interval. The RN stated she did not check the humidifier water daily and changed tubing monthly, while the DON stated the nurse should stay in the room during the treatment and follow the ordered oxygen care schedule.
A resident with peripheral vascular disease, prior toe amputation, and malnutrition had multiple lower extremity wounds managed by an external Wound Care Clinic, which issued detailed written orders for cleansing, specific dressings, and compression. Facility TAR entries showed generalized leg treatments on a fixed schedule instead of the ordered every-other-day frequency, did not distinguish between multiple wounds on the same leg, omitted documentation of ordered transfer foam and a compression stocking, and added self-adherent wrap that was not ordered. Interviews with the TN and DON confirmed that the TN was responsible for entering and carrying out clinic orders, and leadership could not produce documentation that all ordered treatments were provided or explain the altered treatment frequency, contrary to facility policy requiring treatments to follow provider orders.
A resident with COPD and a UTI had two antibiotics ordered, but one was not given during med pass and one was missing from the med cart. The antibiotics were delivered and signed for by an LPN, then left in the overflow box for several days before administration began. The RN supervisor entered the order duration without verifying it, and the actual directions were different from what was entered in the EHR.
A resident with COPD, anxiety disorder, malnutrition, and a history of alcohol abuse in remission, who was receiving benzodiazepine anti‑anxiety medication and had no order or care plan allowance for alcohol, was found multiple times to have consumed alcohol in the facility. CNAs and LPNs discovered empty and full alcohol bottles in the resident’s room and observed the resident appearing drunk, groggy, confused, lethargic, and slurring words, with noted balance and behavioral changes. The APRN documented increased drowsiness, equilibrium concerns, and later confusion and auditory disturbances, and held the anti‑anxiety medication after learning of intoxication. The DON and Administrator reported that the resident identified a CNA as the source of the alcohol, and the CNA admitted to bringing alcohol to the resident on two occasions, resulting in intoxication within the facility, contrary to the resident’s orders and care plan.
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