Unqualified G-tube Replacement with Urinary Catheter Leading to Complications
Summary
The facility failed to ensure that care was provided by qualified staff according to a resident's written plan of care when the DON replaced a gastrostomy tube (g-tube) without documented training, competency, or adherence to facility policy. The DON reported that a nurse approached her stating the family wanted the g-tube changed, and she proceeded with the change as a "routine procedure" under what she described as a standing order, without contacting the resident's physician. She replaced the resident's existing 16 French g-tube with a 20 French urinary catheter, stating the stoma had stretched and that the larger size would make feeding easier. The DON acknowledged that changing g-tubes was not normally done at this facility, that there was no facility policy or procedure for changing g-tubes, and that she had no certification for this procedure, only hands-on training from a previous employer, which could not provide any documentation of competencies. The resident had a history of a major cerebrovascular accident with right-sided hemiparesis and aphasia and was admitted to the hospital from the facility for a leaking g-tube, fever, and an episode of vomiting. The resident’s son, who is the power of attorney, reported that the facility had changed the g-tube and placed a 20 French urinary catheter, and that it had been leaking since that time. Hospital evaluation found the g-tube displaced into the proximal jejunum, with labs showing an elevated lipase consistent with pancreatitis and a CT scan confirming the tube’s position. A procedure note documented that the balloon of the old g-tube (a urinary catheter placed through the gastrostomy stoma) was deflated and that the catheter had migrated into the jejunum, with only the tip visible at the skin site, causing partial bowel obstruction and substantial leakage from the stoma. The facility’s written policy on feeding tubes specified that only tubes designed for enteral feeding would be used except under extenuating circumstances and for the shortest time possible, and that directions would be provided regarding when and by whom tubes could be replaced, including when replacement must occur in another setting.
Penalty
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A resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II DM had a physician order for nursing staff to apply bilateral elastic compression bandages from the dorsum of the feet to below the knees each morning and remove them at bedtime. Review of the Treatment Administration Record for the month showed multiple missed leg wrap treatments, with no corresponding documentation of refusals or physician notification. The DON confirmed that nurses are required to document treatments on the TAR, notify the physician of refusals, and that the resident’s legs were to be wrapped daily per the physician’s order.
Unlicensed CNA applied a prescribed Lidocaine patch to a resident with cerebral palsy and back pain after a bed bath, even though facility policy allowed only licensed nurses or certified medication technicians to administer medications. The surveyor observed the patch application without a licensed nurse present, and the DON confirmed the CNA was not authorized to administer meds and that the patch was a physician-ordered medication.
QMAs failed to practice within their scope when administering PRN narcotic pain medications and performing advanced wound care. A resident with chronic pain and another with diabetes and depression received PRN narcotic analgesics from a QMA without documented RN/LPN assessment, nurse authorization, or nurse initials on the controlled substance records, despite facility policy requiring nurse assessment and co-signature for PRN administration. In addition, a resident with a stage 4 sacral pressure ulcer had complex wound treatments and wound monitoring signed off by QMAs, even though the facility’s QMA scope of practice prohibits QMAs from providing treatments for stage II–IV pressure ulcers or independently assessing residents’ conditions.
A resident with ESRD on dialysis, diabetes with CKD, and chronic venous insufficiency was admitted with an unstageable right heel pressure ulcer with 100% eschar, which was initially assessed by an RN and care planned with interventions including ordered treatment and referral to a wound specialist. Facility policy required weekly wound rounds and assessment by qualified staff, but a subsequent weekly wound evaluation was performed and documented solely by an LPN acting in a leadership role, without an RN or wound provider present. The LPN recorded wound measurements and characteristics and noted treatment response, yet there was no documentation that a wound provider or RN assessed the ulcer at that time. Interviews and state scope-of-practice guidance confirmed that LPNs may collect wound data but may not perform nursing assessments, and leadership and the wound provider acknowledged that the weekly assessment should have been completed by an RN, demonstrating that the resident’s pressure ulcer was not assessed by a qualified person as required by the care plan and regulations.
A resident with atrial fibrillation, hypertension, and hypotension had a physician order for metoprolol succinate ER 25 mg with instructions to hold the dose if BP was below 100/50 mm/Hg and/or pulse was below 60 bpm. Review of the MAR showed the medication was administered on two occasions when the resident’s documented BP and/or pulse were below the ordered parameters. The DON confirmed the medication should not have been given under those conditions, contrary to the facility’s policy on following physician orders and parameters.
An LPN was hired and allowed to work independently on multiple units without verification of an active nursing license, contrary to facility policies and job requirements that mandate proof of current licensure and adherence to professional standards and state regulations. Review of the personnel file showed no documentation of a valid license, and the Administrator acknowledged that licensure had not been confirmed before the LPN provided nursing care to residents.
Failure to Follow Physician Orders for Daily Leg Wrap Treatments
Penalty
Summary
Failure to provide care by qualified persons according to a resident’s written plan of care occurred when nursing staff did not consistently implement a physician’s order for daily bilateral leg wraps. A cognitively intact resident with hypertensive heart and chronic kidney disease with heart failure, hypertension, atrial fibrillation, and type II diabetes mellitus had a physician order directing nursing to wrap both legs with elastic compression bandages from the dorsum of the feet to below the knee every morning and remove them at bedtime. Review of the Treatment Administration Record for April 2026 showed seven missed treatments for the ordered leg wraps between 4/1/26 and 4/23/26. The Director of Nurses confirmed that nurses are required to document treatments on the TAR, to notify the physician if residents refuse treatments, to document refusals in the medical record, and that this resident’s legs were to be wrapped daily per the physician’s order. These findings demonstrate that the ordered leg wrap treatments were not provided and/or not documented as required, and that there was no documented physician notification or refusal documentation corresponding to the missed treatments, resulting in a failure to follow the resident’s plan of care and physician orders.
Unlicensed CNA Applied Prescribed Lidocaine Patch
Penalty
Summary
The facility did not ensure that only qualified persons administered medications according to residents’ plans of care when an unlicensed CNA applied a Lidocaine external patch 4% to R27’s lower back. The facility policy titled "Administering Medication," revised 01/22/2024, states that only licensed staff may administer or record the administration of medications, and certified medication technicians may administer specific medications only if competency has been determined. R27 was admitted with diagnoses of cerebral palsy and back pain and had a physician’s order for Lidocaine external patch 4% to be applied to the lower back twice daily for pain. On 04/21/2026 at 9:05 AM, the surveyor observed CNA D apply the Lidocaine patch to R27’s lower back after a bed bath. CNA D stated that nurses give the patch to her to put on. The patch had been observed at R27’s bedside before application, and no licensed nurse was observed in the room during the application. The MAR showed RN D’s initials for administration of the Lidocaine patch that morning. Facility staffing records showed CNA D was not a medication administration technician. RN C and DON B both stated that only licensed nurses and certified medication technicians could administer medications, and DON B confirmed CNA D was not allowed to administer medications and that the Lidocaine patch was considered a medication ordered by a physician.
QMAs Functioning Outside Scope for PRN Narcotics and Stage 4 Wound Care
Penalty
Summary
The deficiency involves failure to ensure qualified medication aides (QMAs) practiced within their defined scope and that care was provided by qualified persons according to each resident’s written plan of care. For one resident with rheumatoid arthritis, chronic pain, and osteoarthritis, a physician’s order directed PRN oxycodone 5 mg every 4 hours for pain. Documentation showed that a QMA administered the PRN narcotic, but the clinical record lacked evidence of a licensed nurse’s initials on the controlled substance record, a documented nursing assessment prior to administration, and documented permission from a licensed nurse, contrary to facility practice as described by an LPN. For another resident with a stage 4 sacral pressure ulcer, the physician’s order required cleansing with normal saline, packing with Dakin’s-soaked gauze, and covering with an ABD pad twice daily, and a separate order required monitoring the sacral wound for signs of infection or decline. The treatment administration record showed QMAs signed off as having completed the stage 4 wound treatment and the monitoring of the stage 4 sacral wound, despite the QMA scope of practice prohibiting them from performing treatments involving stage II–IV pressure ulcers. A third resident with diabetes and major depression had a physician’s order for PRN hydrocodone-acetaminophen 5-325 mg every 8 hours for pain. Records indicated a QMA administered the PRN narcotic, but the clinical record again lacked documentation of a licensed nurse’s initials on the controlled substance record, a nursing assessment prior to administration, and documented permission from a licensed nurse. The facility’s QMA Parameters and Scope of Practice, provided by the DON, specified that QMAs may not assess a resident’s condition and may administer previously ordered PRN medications only after contacting a licensed nurse, documenting the contact, symptoms, permission, and time, and ensuring the record is co-signed by the nurse by the end of the shift or next tour of duty. The same scope document also stated that QMAs may not administer treatments involving advanced skin conditions, including stage II, III, and IV pressure ulcers. These documented practices and omissions show that QMAs performed tasks outside their authorized scope and without required licensed nurse assessment and documentation.
Unqualified Wound Assessment for Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s pressure ulcer was assessed by a qualified person in accordance with the written plan of care and facility policy. The resident was admitted with end stage renal disease on dialysis, diabetes with chronic kidney disease, and chronic peripheral venous insufficiency, and had an unstageable pressure ulcer with 100% black/brown eschar on the right heel identified on admission by a registered nurse. The care plan for alteration in skin integrity documented an actual pressure injury to the right heel with eschar and included interventions such as applying treatment per order and referring to a wound care specialist as needed. Facility policy on Wound Identification and Wound Rounds required that residents with pressure injuries be identified, assessed, and managed in accordance with current standards of practice, with the Wound Nurse/Designee, wound care provider, and registered dietitian notified and the resident scheduled for weekly wound rounds. On 9/19/2025, an interdisciplinary high-risk meeting was held for the resident, during which it was documented that the resident had a right heel pressure ulcer and would be referred to the in-house wound provider. The initial wound evaluation on 9/18/2025 was completed by a registered nurse, who documented the unstageable right heel ulcer with 100% eschar and no visible wound bed. However, the weekly wound evaluation dated 9/25/2025 was documented by an LPN, who recorded the same measurements, 100% black/brown eschar, no exudate or odor, and noted that treatment was in place with an improved response, adding a comment to refer to the wound care provider. There was no documented evidence that the in-house wound care provider or any other qualified person, such as a registered nurse, assessed the resident’s right heel pressure ulcer on that date. Interviews confirmed that the LPN who completed the 9/25/2025 weekly wound evaluation was functioning as a travel resource nurse and acting Assistant Director of Nursing, and that a registered nurse was not present with them during the wound assessment for this resident. The LPN stated they evaluated the wound alone, documented what they observed, and did not refer the resident to the wound care provider on that date because there was no change in the wound, although they indicated the nurse practitioner should have been notified and should have assessed the resident. The DON acknowledged that LPNs could measure but could not assess wounds and were supposed to document observations in a nursing progress note, and the wound care provider stated it was unacceptable for there to be no weekly assessment by a registered nurse when the wound care provider did not see the resident. Information from the New York State Education Department clarified that LPNs may collect and report clinical data but may not perform nursing assessments or determine nursing diagnoses, and that RNs are responsible for assessing wounds and determining the plan of care, underscoring that the 9/25/2025 wound assessment was not performed by a qualified person as required.
Failure to Follow Hold Parameters for Cardiac Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order with specific vital sign parameters for a resident’s cardiac medication. The resident had diagnoses including atrial fibrillation, hypertension, and hypotension. A physician order dated 3/14/26 directed that metoprolol succinate ER 25 mg be given once daily by mouth, with instructions to hold the medication if the resident’s blood pressure was less than 100/50 mm/Hg and/or pulse was less than 60 beats per minute. Review of the March 2026 Medication Administration Record showed that on 3/17/26 the resident’s blood pressure was documented as 96/48 mm/Hg and pulse as 54 beats per minute, yet the metoprolol succinate ER was administered. Further review of the Medication Administration Record indicated that on 3/19/26 the resident’s pulse was documented as 56 beats per minute, and the metoprolol succinate ER was again administered despite the physician’s hold parameters. During an interview, the DON confirmed that the metoprolol succinate ER 25 mg should not have been given on those dates due to the low pulse rate and/or low blood pressure, as specified in the physician’s order. The facility’s current policy titled “Following Physician orders/Parameters,” dated April 2024, states that its purpose is to administer resident care in a safe and effective manner and to follow physician orders and ordered parameters, which was not done in this case.
Unverified LPN Licensure Resulting in Unqualified Nursing Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing care was provided by qualified personnel in accordance with each resident’s written plan of care. During review of an employee file for an LPN hired in late September and terminated in early November, surveyors found no documentation of an active LPN license. The Administrator reported that the LPN had been hired without verification of licensure and that the facility was unable to confirm that this individual ever held an active nursing license. The Administrator further indicated that the LPN worked on all units in the facility and provided dates on which the LPN worked independently after an initial orientation period. The facility’s own documents required proof of current licensure upon application for employment and at least annually thereafter, and the LPN job description specified that the position required a current, unencumbered state LPN license. Additional policies and role descriptions referenced that an LPN must accept assignments consistent with education, training, and competency, and adhere to professional standards, facility policies, and applicable state laws and regulations. Despite these written requirements, the LPN’s personnel file lacked evidence of a valid license, and the Administrator acknowledged that licensure had not been verified before the LPN was allowed to work and provide nursing care to residents on multiple units.
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