Inadequate Staffing Leads to Resident Injury
Summary
The deficiency involved a failure to provide adequate staffing to ensure the safety of a resident during bed mobility, which was consistent with the assessed and care-planned needs. The resident, who was non-verbal and dependent on staff for all care, required the assistance of two staff members for bed mobility. However, on the day of the incident, the facility was understaffed due to call-offs, and only one CNA was available to assist the resident. This resulted in the resident falling from the bed and sustaining a head injury, which required a transfer to a higher level of care. The CNA involved in the incident admitted to attempting to care for the resident alone, despite knowing that the resident required two-person assistance. The CNA stated that she tried to lower the bed and call for help when the resident began to fall, but was unable to prevent the fall. The facility's staffing issues were highlighted by multiple staff members, who reported that understaffing was a common problem and that the administration often allowed shifts to continue without adequate replacements. The facility's policies and procedures for care planning and staffing were not effectively implemented, as evidenced by the unresolved care plan issues and the lack of timely reporting and investigation of the incident. The care plan for the resident was not active at the time of the incident, and staff were not aware of the resident's transfer status. Additionally, the facility's administration failed to promptly report the incident to the appropriate authorities, and the investigation was delayed due to the absence of key personnel.
Plan Of Correction
This plan of correction is submitted as required under state and federal laws. The submission of this plan of correction does not constitute an admission on the part of the skilled nursing facility as to the accuracy of the surveyor's findings or the conclusion drawn there from. The plan of correction does not constitute a deficiency or that the scope and severity regarding any of the deficiencies cited are correctly applied. Any changes to facility policy and procedures should be considered remedial measures as that concept is employed in rule 407 of the federal rules of evidence and should be inadmissible in any proceeding on that basis. The facility submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the facility or any employee, agent, officer, director, or shareholders of the facility. The facility has not waived any of its rights to contest any of these allegations or any allegation or action. #1's care plan was reviewed and updated as indicated. Nursing Home Administrator (NHA) and/or Director of Nursing (DON) conducted an audit of resident grievances and/or incidents to ensure that there were no concerns identified related to insufficient staffing levels. No new concerns were identified. Element #2. A review of facility staffing levels was completed to ensure adequate staffing levels in place to meet the needs of the residents. No additional opportunities identified. An evaluation of current residents was conducted by the Director of Nursing (DON) and/or designee to ensure that no additional residents were by the alleged deficient practice. No other opportunities were identified. Element #3. Current licensed nursing staff were in-serviced on the facility's Policy and Procedure and Neglect, and Policy as it relates to providing necessary assistance with activities of daily living, prevention, and potential for resident harm. Nursing Home Administrator (NHA) and Director of Nursing (DON) were in-serviced by Regional Nurse Consultant and/or Regional Director of Operations Consultant regarding the requirement that a daily staffing meeting/review is completed to ensure that daily minimum staffing levels are met and maintained. A plan was developed and implemented to enhance the hiring of registered, licensed, and certified nursing staff as required to assist with maintaining daily minimum staffing levels. Recruitment efforts continue. Element #4. The Director of Nursing (DON) and/or designee will audit staffing levels three times a week for the next 60 days to ensure that staffing levels are appropriate to meet the needs of the residents. Findings will be brought by the Nursing Home Administrator (NHA) and/or designee to the Quality Assessment and Assurance Committee monthly meeting for three months for further comments and/or recommendations. Element #5. Facility's Allegation of Compliance Date is , 20225.
Penalty
A resident with dementia and other medical conditions was physically abused by a mental health technician, who roughly pulled the resident from a chair, resulting in a fall and subsequent injuries. The incident was witnessed by another resident and confirmed through interviews and review of facility records, revealing that the staff member's actions were rough and unnecessary, causing physical harm.
A nurse administered Melatonin and Benadryl to several residents without physician orders, using these medications to induce sleep during the night shift. This led to changes in resident behavior, including increased confusion and drowsiness, and was reported by staff and residents. The facility's investigation confirmed that the medications were not ordered for the affected residents and that the actions violated residents' rights to be free from chemical restraints and abuse.
A resident did not receive timely toileting assistance during the night shift, resulting in being found wet and soiled in the morning, with no documentation of care or refusals. Additionally, two residents experienced discrepancies in the administration and documentation of controlled substances, with records showing more doses given than prescribed and illegible, altered logs. Staff interviews confirmed these failures, and one LPN was linked to multiple documentation issues.
Two CNAs engaged in neglectful and verbally abusive behavior toward multiple residents, including leaving them in soiled briefs, failing to provide proper hygiene, and making derogatory comments. Several residents, many with significant care needs, reported being ignored or made to feel like a burden, while staff interviews confirmed a pattern of unprofessional conduct and lack of timely care. The issues were known among staff but not effectively addressed by management, resulting in ongoing neglect and mental abuse.
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving CNAs who were verbally and physically rough with residents. A resident reported being handled roughly during a shower by a CNA, who also used inappropriate language. Another incident involved two residents who felt intimidated by a CNA's aggressive behavior. Despite reports and witness accounts, the facility's investigation was inconclusive, and the CNA's employment was terminated based on customer service concerns. The facility did not adequately communicate with residents about the outcomes, leaving them in fear.
The facility failed to protect residents from neglect in medication management and lab follow-up, affecting eleven residents. A resident experienced serious harm due to unmonitored medication levels and lack of provider consultation. The facility's lab process was described as broken, with no clear responsibility for overseeing lab orders and results, leading to missed or delayed lab draws and inadequate care.
Resident Physically Abused by Staff Member
Penalty
Summary
A deficiency occurred when a staff member physically abused a resident, violating the resident's right to be free from abuse. The incident involved a mental health technician who, according to multiple interviews and a now-overwritten video recording, engaged in rough physical handling of a resident on the facility's patio. The resident, who had diagnoses including dementia, psychosis, depression, and a history of falls, was moderately cognitively impaired but independent in activities of daily living. During the incident, the staff member pulled the resident out of a chair, and after a series of escalating interactions, the resident fell to the floor and was subsequently dragged or escorted to their room by the staff member. The resident sustained physical injuries, including bruises on the left knee and right forearm, and reported pain in the left knee. A physical assessment was performed, and the resident was found to be upset and yelling after the incident. The event was initially reported by another resident to the unit manager, who then assessed the resident and escalated the report to facility leadership. The incident was corroborated by interviews with the unit manager, DON, administrator, and social services director, all of whom reviewed the available evidence and confirmed the staff member's actions as physical abuse. The facility's own policies require staff to be able to identify and prevent abuse, but in this case, the staff member's actions were not reported by the perpetrator and only came to light through a third-party report. The incident was verified through internal investigation and interviews, and the staff member involved was found to have acted in a manner that was rough and unnecessary, resulting in physical harm to the resident.
Plan Of Correction
Plan of Correction - Complaint Investigations for #2025010806 and 2025010894 was conducted on July 28, 2025 - July 29, 2025. Citation: F600 (D/ N204-Class: III, Isolated) Corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 07/22/2025, after reporting the incident, Resident #1 had a head-to-toe assessment and pain assessment completed; Medical Doctor and Psychiatrist were notified; NP ordered X-rays and no fractures were identified. The facility reported the abuse reported to Adult Protective Services (DCF), police, and reported the event to AHCA on 07/22/2025, in accordance with the regulations. On 07/28/2025, Staff A (Mental Health Technician) was terminated from employment. On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse; abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis); and reporting of abuse. Identification of other residents having potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 7/24/2025, the ADON interviewed other residents to ensure that they had not been subject to abuse from Staff A or other members of facility staff. No additional complaints were identified. Measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: On 7/23/2025, the Risk Manager of the facility conducted in-service education for all staff members on abuse, abuse prevention (handling difficult resident/residents with dementia or other challenging mental health diagnosis), and reporting of abuse. The ADON, or designee, will conduct random interviews with current residents to identify any abuse/neglect/mistreatment. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and appropriate actions will be taken as necessary. The Abuse Coordinator, or designee, will conduct random interviews with staff members on abuse, abuse prevention, and reporting requirements. No less than 10 interviews will be completed weekly for 4 weeks. Any problems identified will be investigated, and any appropriate actions will be implemented as necessary. All interviews will be submitted to the ADON, or designee, weekly for evaluation of trends and any educational needs. Ongoing frequency of interviews, after the initial 4 weeks, will be determined by the QAPI and QAA Committees. Corrective actions will be monitored to ensure the deficient practice will not recur. The findings from the interviews, along with any identified trends, educational needs, and any corrective actions taken as a result of the findings, will be submitted by the Administrator, or designee, to the QA and QAPI Committees monthly for 6 months, then quarterly for 4 quarters. Correction Date: 08/15/2025
Unauthorized Administration of Chemical Restraints
Penalty
Summary
A deficiency occurred when a nurse administered over-the-counter medications, specifically Melatonin and Benadryl, to multiple residents without physician orders and for non-medical reasons, such as to induce sleep during the night shift. The facility's policy clearly states that residents have the right to be free from chemical restraints imposed for discipline or staff convenience, and that any use of such medications must be authorized in writing by a physician for a specific and limited period or in an emergency, with proper documentation and immediate physician consultation for chemical restraints. However, the investigation revealed that the nurse gave these medications to residents without proper authorization, and the medications were not ordered for those residents at the time of administration. The incident was brought to light when staff members reported unusual resident behaviors, such as increased confusion, excessive drowsiness, decreased participation in activities, and changes in mood or behavior that correlated with the nights the nurse in question worked. Statements from staff and residents indicated that some residents received medications they were not supposed to get, and in some cases, residents could recall being given something to help them sleep. The facility's investigation found that bottles of Melatonin were placed in medication carts and that a significant number of pills were unaccounted for. The nurse involved denied giving sleep aids but later admitted to administering Melatonin and Benadryl to residents without current orders. Clinical record reviews confirmed that the affected residents did not have active orders for the medications administered. Several residents experienced notable changes in their cognitive and physical status, such as increased confusion, inability to walk, and behavioral changes. The Director of Nursing verified that the allegations of abuse were substantiated, and it was unclear how many residents received unauthorized medications. The facility's failure to ensure that medications were only administered as ordered by a physician and not for staff convenience resulted in a violation of residents' rights to be free from chemical restraints and abuse.
Plan Of Correction
N: 0204 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? On 7/9/25, Nurse A was suspended pending investigation related to the administration of Melatonin and Benadryl. Nurse A resigned on 7/15/25. Resident 999 was evaluated by a licensed nurse on 7/11/25, and notified the Healthcare Provider (HCP), and the resident's representative of the medication error. No new orders were obtained. Resident 900 was reviewed on 7/11/25 by the Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the med error. No new orders were obtained. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. On 7/15/25, current residents with a BIMS of 12 or higher were interviewed by Social Services regarding medications and if they were offered sleep medications. No further residents were identified. Between 7/10/25 and 7/15/25, eight (8) family members were interviewed by the Executive Director or designee for any concerns in care, medications, or changes in their loved ones. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? On 7/18/25, the Assistant Director of Clinical Services provided re-education to licensed nurses on Melatonin and Benadryl administration, 7 rights of medication administration, physician notification on missed/refused medication, PRN medication administration, abuse, and neglect. On 7/8/25, Melatonin was counted by the DCS or designee. Upon further staff interviews, on 7/9/25, daily Melatonin counts expanded to all nurse carts, and daily Benadryl counts were added. On 7/28/25, the DCS or designee changed the Melatonin and Benadryl from stock bottles to individual bubble cards filled through the pharmacy. Social Services and/or designee will review the Behavior Report in Daily Stand Up to assist with identification of new changes in residents' behaviors that may require an additional review. How will the facility monitor its performance to make sure that solutions are sustained? To assist with compliance, the DCS or designee has audited the count for Melatonin, daily beginning on 7/8/25. The DCS or designee has audited daily the count for Benadryl beginning on 7/9/25. Daily audits continued through 7/27/25 with no discrepancies noted. Audits are conducted twice a week for two weeks, then weekly for a total of 12 weeks. Social Services or designee will conduct two resident interviews weekly with residents BIMS 12 or higher for 12 weeks. The Assistant Director of Clinical Services or designee will conduct one medication pass observation per week for 12 weeks. The DCS or designee will review findings of the audits monthly in the Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. Discipline Responsible: The Director of Clinical Services or designee will be responsible for compliance.
Failure to Prevent Neglect and Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect residents' rights to be free from neglect and misappropriation of property, as evidenced by two main deficiencies. One resident, who was care planned for overactive bladder and required a two-person assist for transfers and toileting, reported that he called for help throughout the night but did not receive assistance. Multiple staff interviews and the facility's own investigation confirmed that the resident was found in the morning with a full urinal, wet bed, and wet brief, and that there was no documentation of care provided or refusals during the night shift. Staff acknowledged that it was not uncommon to find residents wet and call lights on at shift change, and the Director of Nursing confirmed a lack of documentation for care provided on multiple shifts. Additionally, the facility failed to have effective processes in place to prevent the misappropriation of controlled substances for two residents. Pharmacy records and controlled substance logs revealed that one resident received more doses of a controlled medication than prescribed, with documentation showing up to 11 doses in a single day when only four were ordered. The logs were found to be illegible, with dates scribbled over and not in order, and similar discrepancies were found for another resident's controlled medication. The pharmacy consultant and facility staff confirmed that the counts were correct, but the administration records were inaccurate and not properly reconciled. Interviews with staff, including the DON, Risk Manager, and LPNs, revealed that one LPN was associated with multiple documentation discrepancies, including altered dates and signatures she could not recall. The facility's investigation verified these issues, and the LPN denied taking any pills or overmedicating residents. The lack of accurate documentation and oversight led to the inability to ensure that residents received medications as ordered and that their property was safeguarded.
Failure to Protect Residents from Neglect and Mental Abuse by Staff
Penalty
Summary
Surveyors identified a deficiency in the facility's failure to protect residents from neglect and mental abuse by two Certified Nursing Assistants (CNAs), referred to as Staff A and Staff B. Multiple residents reported being left in soiled briefs for extended periods, not being cleaned properly, and being made to feel like a burden when requesting assistance. Residents also described disrespectful and unprofessional behavior from the staff, including name-calling, derogatory comments about residents' weight and abilities, and discussing other residents and staff in a negative manner during care. These actions were corroborated by staff interviews and written statements, which described a pattern of rude, verbally aggressive, and neglectful behavior by Staff A and B, particularly when they worked together. The affected residents had significant care needs, including dependence on staff for toileting, hygiene, and mobility due to conditions such as hemiplegia, aphasia, obesity, and limb amputations. Several residents were cognitively intact and able to articulate their experiences, while others had severe cognitive impairment. The neglect included failure to provide timely and adequate personal care, such as not changing soiled briefs, not cleaning residents properly, and leaving residents unattended in the shower. Some residents reported that their call lights were ignored or turned off without their needs being met, and that they were made to wait for the next shift for care. Staff interviews revealed that the issues with Staff A and B were known among other staff members, who reported the behavior to management and described a hostile work environment. Written statements and interviews indicated that Staff A and B would avoid caring for certain residents, complain openly about their assignments, and disappear during critical care times. Despite these reports, there was a lack of effective follow-up or intervention by facility management prior to the survey, allowing the neglectful and abusive behavior to persist and affect multiple residents on the same unit.
Plan Of Correction
1. Residents #1, 2, 3, 4, 5, 6, 8, and 9 have been assessed by nursing and no adverse effects noted. Psych services offered to residents. Social services continue to offer support services to residents. Activities staff has worked with residents to ensure additional support is provided. There are no adverse effects noted and residents remain safe in the center. Residents interviewed by NHA and all stated that they feel safe and are grateful in the response from administration regarding the situation. 2. Resident interviews completed for residents with above 10. Interview conducted questioned residents if they had witnessed with any other residents or were abused at any time. Skin assessments were completed for residents with a less than 10. Interviews and assessments completed and no additional findings at the time of the interviews and assessments. Any concerns noted in the interviews were reviewed by NHA, and NHA ensured that the concerns were previously addressed. 3. Education was completed with staff in conjunction with posttest and scenarios. Education provided by IDT members to staff. IDT educated by company VP of Risk Management. Education will continue at times of allegations of and during new hire orientation. A sample of residents will be interviewed monthly by IDT to ask questions related to care/treatment and potential concerns. Room rounds continue to be completed five times a week by IDT to ensure resident is monitored and has no concerns. Audit of interviews will be completed by NHA or designee to ensure that there are no outstanding concerns. 4. Audits will be reviewed at the QAA/QAPI meeting monthly for three months or until substantial compliance is achieved. The audits will be presented by the Administrator or designee.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse and neglect, as evidenced by multiple incidents involving inappropriate and rough handling by certified nursing assistants (CNAs). Resident #699 reported that CNA Staff A was verbally abusive and physically rough during a shower, failing to follow proper hygiene procedures and leaving the resident feeling afraid and intimidated. The resident was not informed of the CNA's termination, leaving her in fear of potential retaliation. Resident #700 corroborated the account, describing the CNA's aggressive demeanor and improper care practices. In another incident, Residents #800 and #850 raised concerns about CNA Staff B's aggressive behavior. Resident #850 reported feeling intimidated and uncomfortable due to the CNA's rough handling and verbal aggression. Central Supply Staff D witnessed the CNA's inappropriate behavior and reported it to the nurse on duty. Despite these reports, the facility's investigation was inconclusive, and the CNA's employment was terminated based on customer service concerns rather than confirmed abuse. The facility's response to these allegations was inadequate, as there was no documentation of increased monitoring or protective measures for the affected residents. The Administrator acknowledged the need for improved customer service and staff education but did not provide evidence of effective measures to prevent future incidents. The lack of communication with residents about the outcomes of investigations contributed to their ongoing fear and discomfort.
Plan Of Correction
Tag Cited: F-600 Free from and Neglect CFR(s): 483.12(a)(1) 1. Immediate action(s) taken for the resident(s) found to have been affected include: CNA Staff A and CNA Staff B were immediately removed from the schedule and terminated from employment and reported to board. Affected residents (R899, R700, R800, R850) received assessments from Social Services and were offered ongoing emotional support. The facility formally notified residents R699, R700, R800, and R850 (and/or their representatives) that CNA Staff A and B were no longer employed. 2. The Identification of other residents having the potential to be affected was accomplished by: Starting a facility-wide audit of grievance reports and residents with of 12 or higher was conducted by Social Services to identify any other concerns related to or neglect and was completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On Human Resources re-conducted Prevention Training and Customer Service education for all staff to be completed. by Any staff who are unable to meet the compliance date will be educated prior to their next working shift. All new hires must complete Prevention and Customer Service modules in Rellas during orientation. The facility doesn't currently utilize agency staffing at this time. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will complete 10 resident interviews weekly for 2 weeks, and then 5 residents weekly for 4 weeks to monitor any concerns about staff behavior or. With any allegation of or neglect a licensed psychologist/social Worker will conduct an initial interview and determine plan for resident(s) emotional or needs. Customer service satisfaction rounds will be completed 5x weekly by the Department Heads for a total of 80 residents by the end of the week and submitted to the Administrator and/or Designee for review by the end of each day 5 x weekly for 6 weeks. The Administrator will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25.
Neglect in Medication Management and Lab Follow-Up
Penalty
Summary
The facility failed to protect the residents' right to be free from neglect, particularly in the area of medication management and follow-up laboratory orders for medication therapeutic levels. Eleven residents were affected, with serious harm occurring to one resident whose medication levels were not monitored, and consultation was not obtained as requested by the provider. This resident experienced a significant medical event and had to be transferred to a higher level of care. The report details multiple instances where residents' medication levels were not properly monitored, and laboratory results were not communicated to the appropriate medical personnel. For example, one resident's medication levels were consistently low, yet there was no evidence that the physician was notified of these results. Additionally, there were lapses in ensuring that lab orders were entered into the lab portal, leading to missed or delayed lab draws. The Director of Nursing acknowledged a system failure in the facility's lab process, which contributed to these deficiencies. Interviews with staff revealed a lack of clear responsibility for overseeing lab orders and results. The facility's process for managing lab work was described as broken, with no designated person to ensure that lab results were reviewed and communicated to providers. This systemic issue resulted in residents not receiving the necessary medical oversight, leading to potential harm and inadequate care.
Plan Of Correction
1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How you will identify other residents who have the potential to be affected by the same deficient practice and what corrective actions will be taken. A facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that consultation orders were completed as indicated. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put in place or what systematic changes you will make to ensure that the deficient practice does not recur. Director of Nursing/Designee will educate licensed nursing staff on the lab monitoring process to include ensuring that residents' medication receive proper lab monitoring, physician notification of abnormal lab values or refused labs, documentation of physician notification and new orders is recorded in the resident clinical record, and consultation orders for are properly executed. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur. Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.
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.
