Failure to Honor Resident's Advance Directive
Summary
The facility failed to honor a resident's advance directive choices, leading to a deficiency in providing adequate and appropriate health care. The incident involved a resident who was found unresponsive by staff. Despite having an order documented in the electronic health record, the staff did not follow the procedure to verify the code status before initiating emergency measures. The staff nurse, upon finding the resident unresponsive, checked the electronic record and the backup code status binder but did not find the necessary documentation in the binder, leading to the initiation of emergency procedures contrary to the resident's wishes. The resident, who had been admitted with multiple diagnoses, including Type 2 diabetes, was care planned for a specific code status. However, due to human error, the staff nurse second-guessed the electronic record and relied on the absence of a document in the binder, which was supposed to be the primary source of validation. The Social Service Director later acknowledged that the document might have been removed for scanning and not replaced, which contributed to the confusion and subsequent actions taken by the staff. Interviews with various staff members, including the Director of Nursing, Unit Manager, and Risk Manager, revealed that the root cause was identified as human error. The staff nurse involved had been trained on the facility's Advance Directive policy, which emphasized the electronic health record as the primary source for code status verification. Despite this, the nurse did not communicate the resident's code status to emergency services, resulting in actions that were not aligned with the resident's documented wishes.
Plan Of Correction
Resident #1 was transferred to Good Samaritan Hospital and was pronounced at 5:51AM in the ER by Hospital personnel. No further corrective action could be taken. An audit was completed on current residents by the Unit Managers to ensure that residents have Form 1896 with appropriate signatures and date in their medical record and a copy in a red binder located at each nurses station. Irregularities were immediately corrected. Code status for new admissions and re-admissions will be reviewed daily Monday to Friday in AM clinical meetings by the Inter Disciplinary Team and on weekends by the Nursing Supervisor to ensure medical records reflect accurate code status and a copy of Form 1896 that is appropriately signed and dated is uploaded in the EHR and a copy is in the binder at the nurses station if there is an order present. An audit of crash carts located on each nurses station was completed by the Director of Clinical Services to ensure equipment was readily available in an emergency. An audit was completed by the HR Manager to ensure that current Licensed Nurses have a valid license in place. One nurse had no current license on file but has since been completed. Newly hired Licensed Nurses' cards will be verified during the Orientation process. Current team members were reeducated starting on by the Director of Education and/or Designee on code status, policy, and neglect and validation of code status in PCC. 100% compliance was achieved on Licensed Nurses Education to include policy and procedure written post quiz on code status and code procedures for all licensed nurses, checking code status in PCC by a Licensed nurse if a resident was discovered to be pulseless prior to initiating Attestations that were signed for acknowledgement and understanding of policy. New hires will be educated on the policy during the orientation process by the Director of Education/designee, with written post quiz to ensure competency. Enhanced Code blue drills were conducted starting on the shift, every shift x 7 days, then every other day on different shifts x 7 days, then weekly x 7, then one on each shift monthly to include weekends by the Director of Education and/or designee. Re-education post drills as needed. Code Blue Drills will continue monthly by the Director of Education/designee one on each shift to include weekends and holidays. Results will be presented at monthly QAPI meetings to ensure ongoing compliance. The Social Service Director/designee will continue weekly audits of orders to ensure that orders are accurate, and that Form 1896 is appropriately signed and dated and is in place in the EHR, and a copy is in the red binder at the nurses station in the event of a PCC or power outage. New hires will be educated on the center's policy during the Orientation process by the Director of Education or designee with written post quiz and attestations to ensure competency. Results of audits will be presented at the Monthly QAPI meeting to ensure ongoing compliance.
Penalty
A resident with a right nephrostomy was observed with an old dressing showing bloody drainage that had not been changed since return from the hospital, despite physician orders for daily site care. Admission documentation failed to record the nephrostomy, even though other records identified it, and there were no nephrostomy site care orders or documented dressing changes for an extended period after admission. Later, when orders for daily cleansing and bandage application were in place, LPNs acknowledged they had not actually performed some documented dressing changes. These actions and omissions were inconsistent with facility policies on indwelling catheter and wound care, which required appropriate assessment, orders, performance, and documentation of treatments.
A resident was repeatedly observed in heavily soiled clothing and on soiled bedding with a strong urine odor over multiple days, despite stating they had requested assistance with changing and hygiene. The resident, who had moderate cognitive impairment and occasional incontinence but required staff help with bathing, grooming, toileting, and incontinence care, was left in the same dirty clothes and linens, and at one point reported having to change themselves due to lack of staff response. The care plan did not specify the level of ADL assistance needed, laundry was left in bags for nursing staff to distribute rather than returned to the room, and the DON reported expectations for 2-hourly rounding and ADL care but confirmed there were no written ADL or resident care policies.
Surveyors found that the facility failed to provide adequate nail care, implement diet-related physician orders, and support a resident’s right to seek outside medical care. One resident with quadriplegia had fingernails grown to about one to one and a half inches despite repeatedly requesting trimming over several days; documentation showed no nail care for about a month, and staff could not clearly identify where such care was recorded. The same resident had an order for double portions at all meals, but only breakfast trays reflected large portions because the order was mis-entered under a non-dietary category and never properly communicated to dietary staff. In a separate case, a post-surgical resident with pancreatic disease developed abdominal pain, vomiting, and diarrhea and repeatedly requested to go to the ER; the family reported begging staff to send her out, while notes showed calls to the MD, medication changes, and a delay until the resident ultimately called 911 herself, after which hospital evaluation revealed postoperative fluid collections and systemic symptoms.
A resident with a history of valve replacement was prescribed an anticoagulant with specific dosing and INR monitoring orders, but staff failed to follow these orders and professional standards. INR labs were initially invalid, and although subsequent results showed elevated and then critically high INR values, nurses documented administering ordered doses without evidence of contacting the physician for guidance. Ordered follow-up INR labs after a critically high result were not drawn on the specified days, and there was no documented follow-up with the lab. Pharmacy records showed that nearly all dispensed tablets were returned despite MAR entries indicating multiple doses were given, and the DON confirmed the lapses in lab completion, physician notification, and medication administration documentation.
A resident had a vascular access device in place for eleven days without any physician orders for its care, maintenance, or removal, despite facility policy requiring such orders. The device was not in use, and staff failed to document or communicate its presence or need for removal, resulting in the device remaining in place until surveyor intervention.
Two residents did not receive timely and appropriate healthcare services due to delays in notifying providers of critical laboratory results. In one case, a resident with respiratory symptoms had a stat D-dimer test with elevated results that were not communicated to the physician until the next day. In another case, a resident's lab results were not documented as reviewed or communicated to the provider. Staff interviews and record reviews revealed inconsistent processes and documentation for lab result notification.
Failure to Provide Ordered Nephrostomy Care and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate health care related to nephrostomy care for one resident with an indwelling nephrostomy catheter. On observation, the resident was noted sitting up in bed with a gauze pad and transparent occlusive dressing over the right lower back nephrostomy insertion site that had a half-dollar sized area of bloody drainage and was dated several days earlier. The resident stated that she had previously gone to the hospital because there was blood in her nephrostomy drainage bag and the tube had been pulled out, and that the dressing had not been changed since her return from the hospital. The resident’s records showed an admission date of 4/14/2026 with diagnoses including a left femur neck fracture, other artificial openings of urinary tract status, and local skin and subcutaneous tissue infection. Her most recent MDS documented that she was cognitively intact (BIMS 15/15) and had both an indwelling catheter and an ostomy (right nephrostomy). The Medical Certification for Medicaid LTC Services also documented a right nephrostomy. However, the Nursing Admission Assessment documented that she did not have a catheter and contained no documentation of the nephrostomy. From 4/14/2026 through 4/27/2026 there were no physician orders for nephrostomy site care and no nephrostomy dressing changes documented on the MAR/TAR during that period. Physician orders later included instructions to empty the nephrostomy bag every shift and, beginning 4/27/2026 and again on 4/28/2026, to cleanse the nephrostomy site with normal saline, pat dry, and apply a bandage daily on night shift and as needed. MAR/TAR review from 5/01/2026 through 5/05/2026 showed documentation of daily nephrostomy dressing changes, but two LPNs interviewed admitted they had not actually performed the dressing changes on specific dates despite having checked them off. The DON stated that the expectation was for the admitting nurse to obtain nephrostomy care orders and for nurses to follow those orders. Facility policies on indwelling catheters and wound care required appropriate documentation, daily care as ordered, admission skin/pressure risk assessment, identification of pre-existing conditions, and performance and documentation of wound care per physician orders, which were not consistently followed in this case.
Failure to Provide Timely Personal Care and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate health care and personal care services to maintain grooming and hygiene for one resident. Surveyors observed the resident on multiple occasions in visibly soiled clothing with a strong odor of urine. On one afternoon, the resident was seen standing in his doorway with navy pants wet from the seat down to both calves, reporting he had been waiting for staff to change his clothes. Later that same day, he was still in the same soiled pants and shirt while seated in a wheelchair near the nurses’ station. The following day, the resident was again observed wearing the same soiled clothes, smelling of urine, with his shirt soiled with food and a dark liquid. His room had a strong urine odor, and his bed was soiled with urine. Only two pairs of pants were seen in the room, and no other clothing was observed. On a subsequent observation, the resident was seated on the edge of his bed wearing khaki pants and no shirt, with yellow-soiled sheets beneath him and his previously soiled red shirt and navy pants on the floor at the end of the bed. The resident stated he had requested assistance with changing clothes but staff had not come, so he changed himself. Record review showed a history of multiple medical conditions and a recent Quarterly MDS indicating a moderate level of cognitive impairment, with the resident moderately independent for toileting, personal hygiene, and other ADLs, and occasionally incontinent. The resident’s care plan did not specify the level of staff assistance required for personal care and ADLs. An LPN familiar with the resident stated he required staff assistance with bathing, grooming, toileting, and incontinence care, did not refuse care, and appropriately requested help. The LPN also explained that laundry staff left clean, labeled clothing in bags in the linen room for nursing staff to distribute. The DON stated that staff were expected to perform rounds every two hours and as needed, keep residents clean and dry, and provide all needed ADL care, but acknowledged the facility had no written ADL, resident care, or quality of care policies.
Failure to Provide Nail Care, Implement Diet Orders, and Support Resident’s Right to Outside Medical Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate health care and services, including basic ADL support and implementation of physician diet orders, as well as failure to support a resident’s right to seek outside medical care. For one resident with quadriplegia and muscle wasting, surveyors observed fingernails approximately one to one and a half inches long. The resident reported he had been asking his assigned CNA for nail trimming for three days, but was repeatedly told to wait because the CNA was on break or it was change of shift. He stated his nails had last been cut by a family member about six weeks earlier, which the family member confirmed. Documentation of nail care tasks over the prior 30 days showed no nail care provided, with only one entry indicating resident refusal, and the facility could not produce a policy specific to ADLs or nail care. Staff interviews further showed inconsistent understanding and implementation of nail care. The CNA typically assigned to this resident stated nail care should be done every weekend or as needed and that staff should cut nails whenever a resident asks, but also reported staffing shortages that delayed nail care. She acknowledged the resident’s nails had last been cut by family about a month earlier and that nail care was considered a PRN task documented in the Kardex, although the DON and RN/Unit Manager were unsure where nail care completion was documented. The DON stated nail care was part of hygiene and infection control, should be done when requested, and that refusals should be documented, but she could not confirm documentation of prior refusals for this resident. The resident’s care plan identified ADL self-care deficits related to quadriplegia and the need for assistance with ADLs, but there was no evidence that requested nail care was provided or consistently documented. The same resident also had a physician order for double portions for all meals, which was not fully implemented. The medical record showed a house diet with specific restrictions and an order allowing double portions for all meals six times a day. The nutrition evaluation documented that the resident requested large entrée portions and that large portions were to be provided. However, observation of a lunch meal showed the tray ticket did not indicate large or double portions. The Food Service Manager reported the resident received large portions at breakfast only, and review of meal tickets confirmed that only breakfast was marked for large portions, while lunch and dinner were not. The FSM explained that diet orders entered in the EMR automatically transfer to the meal tracker system and that he could not adjust them; he stated the double-portion order had been categorized under “other” rather than dietary, so it did not appear correctly in the dietary system. The DON confirmed that the double-portion order had been miscategorized and that a dietary slip should have been written and handed to dietary staff but was not. A separate deficiency involved the facility’s failure to protect a resident’s right to seek medical services outside the facility, resulting in delayed emergent care. One resident, admitted with diagnoses including pancreatic disease, immune disorder, anemia, and muscle wasting, had undergone a distal pancreatectomy with partial gastrectomy and later had a surgical drain removed. According to the resident’s family member, the resident developed pain, bloating, vomiting, and diarrhea and requested to go to the hospital, but a nurse stated the in-house doctor would assess first. The family member reported that the resident was given nausea medication, continued to have symptoms through the night and into the next day, and that he repeatedly begged the nurse to send the resident out. He stated the resident had a pail of vomit at bedside and that he eventually called non-emergency police for a wellness check and advised the resident to call 911 herself, after which she was transported to the hospital. Progress notes documented that a call was placed to the MD regarding the resident’s condition, that later that evening the resident complained of pain and vomiting and the MD was notified, resulting in a change in pain medication frequency and an order for milk of magnesia. The note also indicated a request to obtain an order for IV fluids to prevent dehydration per family request, but stated the MD was called with no response. The following day, documentation showed the resident complained of stomach pain and insisted on going to the hospital, with vital signs recorded and the doctor paged. A later note recorded that paramedics were at the resident’s room and that the resident had called them to be taken to the hospital. Hospital records from that day showed the resident presented with worsening abdominal pain, swelling, systemic symptoms, leukocytosis with left shift, and CT findings of gastritis with inflammation near the prior drain site and postoperative fluid collections or possible pseudocysts. Staff interviews revealed gaps in assessment, monitoring, and support for the resident’s request to go to the ER. The RN/Unit Manager stated that when a resident has a change and wants to go to the ER, the nurse should assess, review vital signs, and determine if the issue can be treated in the facility, and acknowledged the resident was given pain and nausea medications and ultimately went to the hospital after calling 911 herself. She stated she did not know what happened at the time of transfer. CNAs recalled the resident as ambulatory and noted she was “getting sick towards the end” and “throwing up all the time,” but did not recall the exact timeline or whether she was sent out immediately. The DON stated she had heard police were involved for this resident but did not get details, and confirmed that if a resident wants to go to the hospital, the nurse should assess, notify the physician, document vitals and monitoring, and assist with transfer. She agreed that if it was not documented, it did not happen, and acknowledged the resident has a right to seek medical care and should be assisted in doing so.
Plan Of Correction
Corrective Action for Resident Affected: Nail care was provided to Resident#4. Identification of Other Residents at Risk: Director of Nursing or designee conducted a house-wide audit to identify residents in need of nail care. Any identified concerns were addressed, and nail care services were provided as indicated. Systemic Changes Implemented: The Director of Nursing or designee re-educated the Licensed nurses and certified nursing assistants on resident nail care requirements, including timely identification and reporting of nail care needs. Licensed Nurses and Certified Nursing Assistants were educated on documenting completion of nail care in the electronic health record and communicating unmet care needs to nursing supervision. Monitoring to Ensure Compliance: The Director of Nursing or designee will conduct weekly audits of residents requiring nail care needs are addressed and documented appropriately. Random audits will be completed weekly for four weeks, then monthly for two months. Findings will be reviewed during the facility's Quality Assurance Committee meetings, until substantial compliance is met.
Failure to Follow Anticoagulation Orders and INR Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident on anticoagulation therapy received necessary treatment and care in accordance with professional standards, including ordered monitoring, medication administration, and accurate documentation. The resident was admitted with a history of valve replacement and was prescribed a specific anticoagulant dosage regimen and associated lab monitoring (INR and CMP) beginning on designated dates. Initial INR labs were reported as invalid, and subsequent orders included holding the anticoagulant pending INR results, then resuming at adjusted doses based on those results. The MAR shows nurses initialed doses of 2.5 mg and 5 mg as administered on multiple days. Documentation reflects that on one date the resident’s INR was 3.38 and on a later date the INR was 9.12, yet the 5 mg dose was still administered despite the elevated INR, and there is no evidence that the physician was contacted at those times for guidance regarding whether to administer the medication. When the resident’s INR later reached a critically elevated level of 17.63, the physician ordered vitamin K 10 mg injection and daily INR labs for two days. Review of lab results and records shows no evidence that these ordered labs were drawn on the specified days, nor that staff followed up with the lab to ensure the orders were carried out; labs were not completed until several days later. By that time, the resident had a documented change in condition, becoming nonresponsive and not eating, which led to additional interventions and eventual transfer to the hospital. The DON confirmed that the ordered labs were not drawn on the specified days, that there was no evidence nurses contacted the physician before administering the anticoagulant when the INR was elevated, and that pharmacy records showed 20 of 21 dispensed 5 mg tablets were returned upon discharge despite MAR entries indicating four doses had been given. The DON also reported that no tablets were removed from the emergency drug kit and that the facility had not had any residents on this medication in over a year.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies. this plan of correction is prepared and/or executed solely because it is required (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? A. On [R] , resident #1 was discharged from facility to Lawnwood Regional Medical Center. B. As of [R] , there are no residents on [R] . No additional residents were identified as negatively [R] . (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: A. On [R] , the Director of Nursing/Designee identified and reviewed current residents receiving [R] . the review included verification of current physician orders, review of INR results and therapeutic ranges, confirmation of timely laboratory draws, and verification of appropriate medication and documentation. At the time of review, there were no residents in the facility receiving [R] ; however, all other [R] therapies were reviewed. Any discrepancies identified during the review were immediately corrected, including physician notification and clarification of orders. (3) What measures will be put into place or what systematic changes you will make to ensure A. By [R] , License Nursing staff will have been educated by the Director of Nursing/Designee on the components of N0201, including the use of the [R] management protocol, documentation of indication and monitoring, appropriate response to laboratory results, and timely physician notification, with an emphasis on avoidance of unnecessary drugs and compliance with monitoring requirements for [R] B. Newly hired license nursing staff will receive education by the Director of Nursing/Designee on the components of N0201, including the use of the [R] management protocol, documentation standards, critical lab value reporting and escalation processes, and physician communication expectations during orientation as part of the facility's systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, ie., what quality assurance program will be put in place: A. The Director of Nursing/designee will conduct [R] monitoring audits weekly for 4 weeks, then biweekly for 4 weeks, and monthly x 1 month. Audits will review appropriate drug use, compliance with laboratory monitoring, timely physician notification, and accuracy of documentation. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Obtain Physician Orders for Vascular Access Device Management
Penalty
Summary
The facility failed to obtain physician orders for the care, maintenance, or removal of a vascular access device for a resident. Upon review of the facility's policy and procedure, it was found that the policy requires nurses to obtain and/or verify physician orders for the type of solution or medication, dose, rate, length of treatment, and for the removal of such devices. However, for this particular resident, there were no physician orders documented for the discontinuance, care, or maintenance of the device, despite it being in place for an extended period without use. Observations revealed that the resident had a vascular access device in the left upper arm, which had not been used for medication administration since admission. The site was noted to have brownish discoloration and a small, darkened area in the tubing. The resident reported not knowing why the device was still in place, as she had not received any medication through it since admission. Record reviews, including the Medication Administration Record (MAR) and Treatment Administration Record (TAR), confirmed the absence of any orders related to the device's care or removal. Interviews with nursing staff indicated a lack of awareness regarding the presence and management of the device. One RN admitted she did not recall if the resident was admitted with the device in place and acknowledged that only oral medications had been administered. Another staff member who had changed the device dressing failed to notify the oncoming nurse, the DON, or the physician to obtain appropriate orders, stating she had forgotten to do so. There was no documentation in the nursing admission progress notes, ongoing nursing progress, baseline care plan, or comprehensive care plan regarding the existence or management of the device. The device remained in place and unused for eleven days, with no physician order for its removal until prompted by surveyor inquiry.
Plan Of Correction
Resident #111 was removed /2026 per physician orders. A quality audit of current residents was conducted to ensure that no [R] noted without a physician order place. The Director of Nursing educated licensed nurses on ensuring that a physician order is obtained for residents with [R] lines. The Director of Nursing and/or designee will conduct weekly audits for 4 weeks and randomly thereafter for 2 months to ensure that a physician order is obtained for residents with [R] lines. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met. Audits will be reported to the Quality Assurance Performance Improvement Committee monthly x3 months or until substantial compliance has been met.
Delayed Provider Notification of Laboratory Results
Penalty
Summary
The facility failed to ensure that two residents received appropriate and adequate healthcare services due to delays in notifying the ordering provider of laboratory results. For one resident, who had a history of a motor vehicle accident resulting in fractures and was experiencing respiratory symptoms, a stat D-dimer test was ordered by the physician. The lab specimen was collected and the results, which were significantly elevated, were reported to the facility in the evening. However, there was no documentation that the physician was notified of these results until the following morning, resulting in a delay in further medical evaluation and intervention. For another resident, laboratory tests were ordered and completed, with results received and reviewed by staff. Despite this, there was no documentation that the physician or provider was notified of the results or that the results were reviewed by the provider. Progress notes and interviews confirmed the absence of documentation regarding provider notification or review of the lab results, even though the resident had a complex medical and behavioral history and was undergoing medication changes that warranted close monitoring. Interviews with nursing staff and the Director of Nursing revealed inconsistencies and gaps in the process for tracking, documenting, and communicating laboratory results to providers. Staff described reliance on verbal handoffs and incomplete use of lab tracking logs, and acknowledged that results were sometimes not promptly communicated to physicians. The facility's own policy required prompt notification of lab results to providers, but this was not consistently followed, as evidenced by the delays and lack of documentation in these two cases.
Plan Of Correction
N201 Right to Adequate and Appropriate Health Care Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. F773 Lab Services Physician Order/Notify of Results 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1, the lab was reviewed by the physician no changes made to current order. Physician progress note completed that labs were reviewed for resident #1 and no changes made. Resident #2 discharged from the facility. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. Other current residents with lab orders in the last 30 days from , were reviewed by the DON/Nursing Administration team to ensure review of lab results and physician notification with documentation was completed. 3. What measures will be put in place or what systematic changes will you make to ensure that deficient practice does not occur. Nurse leadership staff will be educated by the DON/designee regarding daily lab order review, and timely notification to physicians of results with supporting documentation by. Education completed by DON/designee to the licensed nurses regarding daily review of lab orders and timely notification of lab results reported to the physician of results with supporting documentation by. Education completed by the DON/designee to physicians for review of labs and notation that the lab was reviewed by. 4. How will the corrective actions be monitored to ensure the practice will not recur, what quality measures will be put into place? Random audits of lab orders, physician notification of lab results, and supporting documentation will be completed by the DON/designee on 20 residents, weekly x4 weeks then monthly x2 months. The results of the random audits will be presented to the QAPI committee monthly x3 months and as needed for review and follow-up recommendations as indicated. N0201
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