Failure to Address Endocrinology Consultation for Resident
Summary
The facility failed to ensure that a recommendation for a resident to be seen by an endocrinologist was addressed. The resident, who had a history of diabetes, was seen by the facility endocrinologist, who recommended a follow-up in 2-4 weeks and advised the facility to contact them sooner if there were any concerns or changes in the resident's health status related to diabetes. Despite this, there was no evidence in the clinical record that the nursing staff scheduled an appointment or contacted the endocrinologist, even after a psychiatric nurse practitioner noted that the resident's behaviors might be linked to low blood sugar levels and advised consulting endocrinology. The resident exhibited various behaviors, including aggression towards staff and other residents, refusal of meals, and medication non-compliance, which were documented in multidisciplinary notes. The psychiatric nurse practitioner highlighted that the resident's condition worsened when blood sugar levels were low and recommended frequent blood sugar checks and a urinalysis to rule out other medical causes. However, these recommendations were not acted upon, and the Director of Nursing confirmed that the endocrinologist was not contacted regarding the resident's diabetes management concerns.
Plan Of Correction
The Facility does and shall ensure that endocrinologist services were provided for all residents to meet their spatialized health needs. All nursing staff have/will be educated regarding timely dental services for all residents. Monitoring and random checks will be conducted by supervisors/Unit Managers once a day for 2 weeks and 1 time a week for 6 weeks. Findings and ongoing monitoring will be reported to the CQI Committee for a period deemed appropriate by the CQI Committee. Monitor: Unit Managers/shift Supervisor/DON
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with vertigo and multiple comorbidities, including Type 2 DM with neuropathy, heart failure, and CKD stage 3A, missed a scheduled ENT appointment when transportation arrived but the resident had not been informed of the appointment and was not prepared to go. The resident reported being told the appointment would be rescheduled, but this did not occur. An RN confirmed the appointment had to be rescheduled and that Medical Records staff handle such scheduling, while the CNA/Medical Records staff stated she was not aware the appointment needed rescheduling and later did not complete the task due to lack of time. The DON stated that appointments are expected to be followed up on timely, and the facility’s Transportation Services policy requires coordination with the Medical Records designee and timely rescheduling, which did not occur in this instance.
A resident with a suprapubic catheter missed outside ophthalmology and urology appointments. The resident said he needed eye care for his vision and monthly urology follow-up, but the transportation log and appointment binder had no entries for him, and records noted a missed urology visit due to transport issues. Staff interviews showed the facility relied on nursing, medical records, and MAR-based coordination, but the process did not result in the resident’s appointments being arranged and completed as expected.
A resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic/proximal tracheal stenosis had a provider order for an ENT referral and a subsequent NP note calling for ENT f/u. The Transportation Driver sent the referral to an ENT office, which refused to schedule due to the resident’s lack of active insurance and self-pay status, and the driver documented unsuccessful attempts to reach the family to confirm payment. The Business Office Manager later stated the resident was Medicaid pending and that the facility would have been responsible for payment if an outside provider would not accept that status, but she was never informed that the ENT would not see the resident for this reason. Consequently, the ordered ENT evaluation for the resident’s tracheostomy and tracheal stenosis was not obtained.
Failure to Reschedule ENT Appointment: A cognitively intact resident with CHF, MDD, and DM2 refused an ENT visit and asked for it to be rescheduled, but the appointment was not found in the chart or unit appointment book for a period of time. The nurse documented a call to the physician’s office, the NP noted ongoing nasal congestion and prior cancellation, and the Unit Manager later confirmed she could not locate a rebooked appointment before obtaining one.
A resident with COPD and obstructive sleep apnea was ordered to have a follow-up sleep study at a sleep disorder center. Facility documentation showed that after the resident reported ear pain, the sleep study was put on hold pending pulmonology input. The facility contacted the sleep center and learned the center could not provide needed ADL and transfer assistance, but there was no evidence that the facility arranged nursing support or other outside resources to assist the resident during the study, and the appointment was cancelled without being rescheduled.
Two residents did not receive necessary outside professional services when staff failed to coordinate and follow through on podiatry and dermatology consults. One resident, who could not trim her own long, uncomfortable toenails, had a nursing note indicating need for a podiatry referral, but her name was never added to the podiatry visit list and no further action was documented. Another resident with morbid obesity, diabetes, and kidney failure had ongoing severe dry, itchy, scaly skin, with physician orders for dermatology consultation, follow-up, and ammonium lactate lotion, yet the MAR/TAR showed no treatment provided during the review period and there was no documentation of dermatology visits. The SSD reported relying on nursing to notify her of needed referrals, while nursing and leadership interviews revealed lack of awareness and verification of consult orders, resulting in missed or unconfirmed specialty services.
Failure to Coordinate and Reschedule ENT Appointment for Resident with Vertigo
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and follow through with an outside Ear, Nose and Throat (ENT) medical appointment for one resident. On 04/08/2026, the resident was observed in bed in a nightgown and reported having vertigo and being scheduled to see an ENT specialist. He stated that on the day transportation arrived for the appointment, he was not ready because no one at the facility had informed him of the appointment, and that this occurred about a month prior. He further stated the facility told him the appointment would be rescheduled, but it never occurred. Record review showed the resident was originally admitted on 10/10/2023 and readmitted on 02/26/2026 with diagnoses including Type 2 DM with diabetic neuropathy, heart failure (unspecified), and CKD stage 3A. An order summary dated 04/08/2026 showed an ENT appointment scheduled for 02/11/2026 at 11:00. In an interview, an RN confirmed the resident had an ENT appointment on 02/11/2026 for vertigo that had to be rescheduled and stated that Medical Records staff are responsible for scheduling appointments, but she did not know if the appointment was ever rescheduled. The CNA/Medical Records staff member reported that the NP had informed her that the resident wanted to see the ENT, but she was not made aware that the appointment needed to be rescheduled after it was missed. She stated that on a Monday shortly before the survey, the NP asked if she had rescheduled the ENT appointment, and she told the NP she would get to it but did not reschedule it because she did not have time. The DON stated his expectation that appointments should be followed up on timely. The facility’s Transportation Services policy, dated 02/2025, states that the facility will arrange transportation services as needed to ensure each resident receives a complete continuum of service consistent with the plan of care and outlines procedures for notifying the Medical Records designee and rescheduling appointments when necessary, which were not followed in this case.
Missed Outside Appointments Due to Scheduling and Transportation Failures
Penalty
Summary
The facility did not ensure outside physician appointments were arranged and scheduled in a timely manner for one resident who had a suprapubic catheter and reported needing monthly urology follow-up, as well as an ophthalmology appointment for vision concerns. During interview, the resident stated he had missed an outpatient ophthalmology appointment and also missed his monthly urologist appointment for March. An appointment card showed an ophthalmology visit scheduled for 01/16/2026, and the resident stated he needed to be seen by his eye doctor for his vision. Record review showed the resident declined the scheduled ophthalmology appointment on 01/16/2026, after which a new appointment was arranged for 02/02/2026. Progress notes also showed the resident returned from a urology appointment on 01/12/2026 with a follow-up scheduled for 02/02/2026, and later a nurse practitioner note stated the resident missed a recent urology appointment due to transport issues. Interviews with the RN/UM, ADON, and DON showed the facility used a transportation binder, nursing staff, medical records staff, and MAR entries to coordinate appointments and transportation, but the transportation log for January, February, and March had no entries for the resident and the March binder had no appointment entry for him.
Failure to Secure ENT Evaluation for Resident With Tracheostomy and Tracheal Stenosis
Penalty
Summary
The facility failed to obtain outside professional ENT services for a resident when it did not employ a qualified professional to provide the required service. The resident was admitted with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Hospital records documented that the resident previously had a tracheostomy exchange by ENT due to hemoptysis, experienced a respiratory arrest with a dislodged trach, and had significant subglottic and proximal tracheal stenosis. ENT had recommended against trialing a Passy Muir Valve and advised changing the trach every three months. A physician order for an ENT referral related to stenosis and tracheostomy status was initiated, and a later nurse practitioner note documented the need for follow-up with ENT for subglottic and tracheal stenosis. The Transportation Driver documented that an order for the ENT visit was received and sent to the ENT office, but the office reported the resident did not have insurance and would require self-pay, and therefore would not schedule the appointment without confirmation from the family. The Transportation Driver reported multiple unsuccessful attempts to contact the family and did not secure an appointment. The Business Office Manager stated the resident was Medicaid pending, that she had been in contact with Medicaid since admission, and that if an outside provider would not accept a Medicaid pending resident, the facility would be responsible for payment. The Business Office Manager also stated she was not informed that the ENT provider would not see the resident due to Medicaid pending status and that, had she known, she would have discussed payment with the Administrator so the resident could be seen by ENT. As a result, the resident did not receive the ordered ENT evaluation for tracheostomy and tracheal stenosis.
Failure to Reschedule ENT Appointment
Penalty
Summary
The facility failed to arrange a rescheduled ENT specialist appointment for one resident after the resident refused the originally scheduled visit. The resident was admitted with diagnoses including chronic diastolic congestive heart failure, major depressive disorder, and type 2 diabetes, and was cognitively intact with a BIMS score of 15 out of 15. During an interview, the resident stated that the ENT appointment had been asked to be rescheduled a couple of months earlier because of snow, and that the Unit Manager said it would be rescheduled but it had not been. The clinical record showed a nurse progress note documenting that the resident refused the ENT appointment and requested it be rescheduled for another day and in the afternoon, with a call placed to the physician’s office and a call back pending. A later NP note stated the resident continued to have nasal congestion and had previously canceled the ENT appointment, with discussion about following up with nursing regarding rescheduling. Review of the clinical progress notes and unit appointment book did not show a rescheduled ENT appointment, and the Unit Manager stated she was unsure whether it had been rebooked and could not find an appointment in the appointment book. The Unit Manager later obtained an ENT appointment for the resident.
Failure to Coordinate Outside Services for Resident Sleep Study
Penalty
Summary
The facility failed to employ or obtain outside professional resources to provide required services for a resident with obstructive sleep apnea. The resident’s comprehensive MDS showed they were cognitively intact and had a diagnosis of obstructive sleep apnea, and the care plan documented altered respiratory status/difficulty breathing related to COPD. An After Visit Summary from a Sleep Disorder Center indicated the resident was to have a follow-up sleep study. A progress note documented that the DON and nursing supervisor met with the resident, who reported right ear pain, and the resident was informed that the sleep study would be put on hold pending an update from pulmonology. The same progress note showed that the facility contacted the sleep center and informed them the resident required assistance with ADLs, but the sleep center stated they could not provide transfer or care assistance. The resident later reported in interview that the sleep study appointment was cancelled and that the facility did not further coordinate to reschedule the appointment. Review of the clinical record revealed no documentation that the facility coordinated nursing services to assist the resident during the sleep study and no evidence that the sleep study was rescheduled with the center, resulting in a failure to ensure use of outside resources when the facility could not provide the needed service.
Failure to Coordinate Podiatry and Dermatology Consults for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure outside professional resources were obtained and coordinated for required services, specifically podiatry for one resident and dermatology for another. One resident reported to nursing staff that her toenails were very long, that she could not cut them herself, and that they were uncomfortable. A nursing progress note documented on 2/16/2026 that this resident’s nails were very long and that she needed a referral to a podiatrist. However, there was no further follow-up in the medical record regarding a podiatry referral, and the resident’s name did not appear on the podiatry visit list for the provider’s 2/18/2026 visit. Another resident, who was cognitively intact and had diagnoses including morbid obesity, Type 2 diabetes, and unspecified kidney failure, was observed in bed scratching and itching her arms and upper body, with scaly, dry, rough skin and small fishlike flakes. The resident stated she was supposed to see a dermatologist, that her family had discussed this with the facility the previous Friday, and that she was only using regular store lotion, which was not helping, while her itching was getting worse. Physician orders included a dermatology consultation for body itching, a follow-up with dermatology, and an order for ammonium lactate lotion to be applied twice daily for dry skin. Review of the MAR and TAR showed the resident was not receiving any treatment for the ongoing itching condition during the reviewed period. The facility’s own consult policy stated that Social Services would coordinate most resident referrals (such as podiatry and vision), that referrals should be based on physician evaluation and orders, and that Social Services would document referrals and maintain a listing of referral agencies. In practice, the Social Services Director reported that nursing staff were expected to notify her of residents needing podiatry so they could be added to the list, but there was no evidence this occurred for the resident with long nails. For the resident with dermatologic issues, the Social Services Director stated dermatology appointments were scheduled by nursing and that she had not been informed of any concerns, family complaints, or need for dermatology, and no grievance had been initiated. Nursing staff and the ADON were not aware of or did not verify dermatology orders or visits, and record review showed no documented dermatology visits or physician notes beyond a single prior encounter, indicating a lack of coordination and follow-through with outside dermatology services despite existing orders and ongoing symptoms.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
