Accordius Health At Rose Manor Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Durham, North Carolina.
- Location
- 4230 North Roxboro Street, Durham, North Carolina 27704
- CMS Provider Number
- 345081
- Inspections on file
- 24
- Latest survey
- December 15, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Accordius Health At Rose Manor Llc during CMS and state inspections, most recent first.
A resident with multiple medical conditions rolled off her bed and sustained pain after a nurse aide failed to position herself correctly and guide the resident during incontinence care. The aide was on the opposite side of the bed and had not begun the turning process when the resident, holding the transfer bar, rolled off and fell. The incident resulted in the resident being transported to the hospital for evaluation.
The facility did not ensure that cleaned dishes were air dried and instead stacked wet dishes, failing to follow professional standards. Dishwashing equipment did not consistently reach the required minimum temperature or sanitization level, and staff continued to use and serve dishes that had not been properly sanitized or dried. These deficiencies were observed and confirmed through staff interviews and review of temperature logs.
The facility did not maintain an effective pest control program, as evidenced by repeated observations of live cockroaches in the kitchen, hallways, and resident rooms, ongoing sanitation issues such as spilled food and incomplete repairs, and poor communication between pest control, maintenance, and dietary staff regarding problem areas and follow-up actions.
The facility failed to accurately code MDS assessments for four residents, including not documenting a fall for a resident with a recent incident, and not properly recording antipsychotic use and GDR status for three residents receiving such medications. The errors were due to incomplete review of medical records and lack of interdisciplinary review before MDS submission.
Surveyors observed that two of three dumpsters had doors left open after waste disposal. The dumpsters, shared by all departments, were supposed to have doors closed after use, as confirmed by the CDM. On the day of the incident, a housekeeper left the doors open by mistake, and the Administrator was not present to check the area.
A resident with multiple serious diagnoses had conflicting code status information in the medical record due to a failure to promptly communicate and update a change from DNR to full code after a new MOST form was signed. The Social Worker obtained the updated form but did not notify nursing leadership as required, resulting in inconsistent documentation.
A resident was admitted with depression and later diagnosed with bipolar disorder, leading to a new prescription for an antipsychotic. Despite this significant change, the required PASRR Level II referral was not resubmitted because the new diagnosis was not communicated to the staff responsible for initiating the process.
A resident was readmitted with multiple diagnoses and began receiving Risperdal for a new diagnosis of bipolar disorder. The care plan was not updated to address the antipsychotic use or the new mental health diagnosis, as required. Staff interviews revealed that this omission resulted from a breakdown in communication and lack of notification to the MDS Nurse.
A resident with a history of stroke and depression was prescribed Risperdal for a newly documented bipolar disorder, but the facility failed to provide supporting documentation or evaluation for the new diagnosis. Multiple psychiatric NPs referenced the diagnosis without clear evidence of its origin, and the DON was not notified, resulting in incomplete medical records and lack of proper communication among staff.
A resident with hemiplegia, contractures, and cognitive impairment did not receive a physician-ordered right-hand palm guard as required. Staff failed to apply the device at night and did not document refusals, with the order missing from the MAR and confusion among staff about responsibility for its use. The deficiency was identified through observations, interviews, and record review.
The facility did not follow its abuse policy by failing to immediately report and investigate abuse allegations involving two residents. In one instance, a resident's report of being struck by a nurse aide was not promptly escalated to the Administrator, causing delays in required notifications. In another case, a resident's post-discharge allegation of inappropriate touching by a staff member was not reported internally or investigated until authorities notified the facility. Staff interviews revealed confusion about reporting responsibilities, leading to delayed action.
Surveyors found that multiple resident rooms had unaddressed maintenance and cleanliness issues, including scraped paint, wall damage, a persistent black film in a bathroom sink, and a red splattered substance on a wall. Staff interviews confirmed that repairs and deep cleaning had not been completed in these rooms, and maintenance records showed no recent work for the affected areas.
Resident Fall During Incontinence Care Due to Improper Supervision and Positioning
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had diagnoses including a left lower leg wound, anxiety disorder, and arthritis, rolled off her bed while receiving incontinence care from a nurse aide. The incident happened as the nurse aide was preparing to assist the resident with turning, but had not yet started the usual countdown or physically assisted the resident. The resident, while holding the transfer bar, moved her legs off the bed and subsequently rolled off, landing on the floor and hitting her face against the wall. The nurse aide was positioned on the opposite side of the bed at the time and had intended to move to the other side before turning the resident. Following the fall, the resident complained of significant knee pain and was unable to be moved back to bed by staff due to her discomfort. Emergency Medical Services were called, and the resident was transported to the hospital for evaluation. Medical assessments, including imaging and laboratory tests, were performed and found to be negative for acute injury. The resident reported pain in her head, back, and knees, and subsequently refused to return to the facility, remaining in the hospital awaiting alternate placement. Interviews with staff and the resident revealed inconsistencies in the sequence of events, but it was confirmed that the nurse aide did not follow proper procedure by ensuring the resident was turned towards her and by not being on the correct side of the bed during care. The Director of Nursing and the facility administrator both acknowledged that the nurse aide should have positioned herself appropriately and guided the resident through the care process to prevent such an accident.
Failure to Air Dry Dishes and Maintain Proper Dishwashing Temperature and Sanitization
Penalty
Summary
The facility failed to implement proper procedures for air drying cleaned dishes and did not follow the manufacturer's instructions for minimum temperature and sanitization levels in the dishwashing process. Observations revealed that cleaned dishes, including plate warmers, domes, bowls, coffee cups, and juice cups, were stacked while still wet and nesting, rather than being air dried. Staff interviews confirmed that the Certified Dietary Manager (CDM) instructed dietary aides to stack dishes immediately after cleaning due to limited space, and that air drying was not practiced as required. Further observations and interviews indicated that the dish machine was not consistently reaching the required minimum temperature of 120 degrees Fahrenheit, with recorded temperatures as low as 115.7 degrees Fahrenheit. Additionally, the sanitization level did not meet the minimum requirement of 50 parts per million (ppm) during several checks, as indicated by testing strips that showed no color change. Staff members, including dietary aides, were aware of the temperature and sanitization deficiencies but continued to use the dish machine and serve dishes that had not been properly sanitized or dried. The maintenance assistant was not informed of the dish machine's failure to meet temperature and sanitization requirements on the day of the observations, and the temperature monitoring equipment was not always functional. The administrator later acknowledged that dishes should have been air dried and that available kitchen space could have been used for this process. The issues with the dish machine were attributed to a malfunctioning heating unit and improper chemical flow, which were not addressed in a timely manner.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by repeated observations and documentation of cockroach activity and unsanitary conditions. Pest control invoices from February to April 2025 consistently noted sanitation issues in the kitchen, such as spilled food material on the floor that remained untouched for months, as well as structural concerns like loose or missing floor tiles, baseboards, and gaps near doors and equipment. Despite the pest control service not observing cockroach activity during their visits, the facility's pest activity logs recorded multiple sightings of cockroaches in various areas, including resident rooms, activity rooms, nursing stations, and conference rooms. Direct observations by staff and surveyors further confirmed the presence of live cockroaches in the facility. On several occasions, live roaches were seen in the kitchen, CDM's office, hallways, and resident rooms. Staff interviews revealed that sightings were not always reported, and there was a lack of consistent communication between the pest control technician, maintenance, and dietary staff regarding problem areas and necessary cleaning or repairs. The pest control technician reported that identified issues, such as spilled food and structural gaps, had not been addressed over several months, and that staff did not accompany him during his visits to ensure follow-up on recommendations. Maintenance staff indicated that some repairs had been made, such as sealing holes and replacing tiles and baseboards, but these repairs were often incomplete, with visible gaps remaining. There was also a lack of documentation or work orders to verify completed repairs. The kitchen continued to have food debris and structural deficiencies, and staff reported ongoing sightings of cockroaches, particularly in the kitchen and tray line areas. The lack of effective coordination and follow-through on pest control recommendations contributed to the ongoing pest problem within the facility.
Inaccurate MDS Coding for Falls, Antipsychotic Use, and GDR Documentation
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in the areas of falls, gradual dose reduction (GDR), and diagnoses. For one resident with a history of falls and a recent fall incident, the MDS was not updated to reflect the fall, despite documentation in the progress notes and care plan. The MDS Coordinator acknowledged that the assessment should have been coded for falls, and the DON confirmed the expectation for accurate and timely MDS completion. Another resident, who was receiving antipsychotic medication for paranoid schizophrenia, was incorrectly coded on the MDS as not receiving an antipsychotic. The MDS Nurse admitted to missing the correct coding for antipsychotic use and GDR questions, citing being the sole MDS nurse for an extended period. The DON and Administrator both stated that the MDS should have been coded accurately and that the interdisciplinary team should have reviewed the assessment. Two additional residents receiving antipsychotic medications were coded on their MDS assessments as not having a GDR attempted and without documentation of a GDR being clinically contraindicated, despite psychiatric notes indicating that a GDR was contraindicated. The MDS Nurse did not identify the documentation in the medical record, and both the DON and Administrator indicated that the MDS should have reflected the clinical contraindication for GDR. All errors were attributed to incomplete review of the medical records and lack of interdisciplinary review prior to MDS submission.
Failure to Properly Close Dumpster Doors After Waste Disposal
Penalty
Summary
The facility failed to ensure that the doors to dumpsters containing waste were properly closed, as observed during a survey. Specifically, both doors to the middle dumpster and the right door to the far-left dumpster were left open. The dumpsters were shared by all facility departments, and staff had been educated to keep the doors closed. During the observation, a housekeeper was seen discarding trash and left the doors open by mistake. The Certified Dietary Manager confirmed the expectation for all staff to close the dumpster doors after use. The Administrator stated that he routinely checked the dumpsters to ensure compliance but was not present at the time of the incident.
Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status information was consistent throughout the medical record. The resident, who had diagnoses including lung cancer, brain metastasis, cerebral edema, and seizure disorder, was cognitively intact and had previously signed an Advance Directive and had physician orders indicating Do Not Resuscitate (DNR) status. However, a later signed Medical Orders for Scope of Treatment (MOST) form indicated a change to full code status, meaning resuscitation should be attempted. Despite the resident's clear communication and understanding of the change in code status, the updated MOST form was not promptly communicated to the appropriate nursing staff or reflected in the electronic medical record (EMR). The Social Worker obtained the new MOST form but did not verbally notify anyone about the change. The facility's process required immediate notification of the DON or Unit Manager for such changes, but this did not occur, resulting in inconsistent documentation of the resident's code status across the medical record.
Failure to Resubmit PASRR Level II After New Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II referral was resubmitted after a resident received a new mental health diagnosis. The resident was originally admitted with a diagnosis of depression and had a PASRR Level I completed, with a Level II process that was halted. Upon readmission, the resident was diagnosed with bipolar disorder and was prescribed Risperdal, an antipsychotic medication, for this new diagnosis. Medical records and assessments confirmed the new diagnosis and the administration of antipsychotic medication. Despite these significant changes, the required PASRR Level II resubmission was not initiated. Interviews with facility staff, including the psychiatric nurse practitioner, DON, and Administrator, revealed that the new diagnosis was not communicated to the appropriate personnel responsible for initiating the PASRR Level II process. As a result, the necessary referral and review were not completed in a timely manner following the resident's change in mental health status.
Failure to Revise Care Plan for Antipsychotic Use and New Mental Health Diagnosis
Penalty
Summary
The facility failed to revise the care plan for a resident who was readmitted with diagnoses including stroke and depression, and who subsequently received a new diagnosis of bipolar disorder. A physician ordered Risperdal, an antipsychotic, for the resident, and a psychiatric nurse practitioner documented that a gradual dose reduction (GDR) was clinically contraindicated. However, the resident's annual MDS assessment indicated the use of an antipsychotic without a GDR attempt and lacked documentation from the physician stating that a GDR was clinically contraindicated. Record review revealed that the resident's care plan was not updated to address the new diagnosis of bipolar disorder or the initiation of Risperdal. Interviews with the MDS Nurse and DON confirmed that the care plan should have included both the antipsychotic medication and the associated diagnosis, but these were omitted due to a breakdown in communication and lack of notification to the MDS Nurse about the changes. The administrator also acknowledged that the care plan should have reflected these updates.
Lack of Documentation for New Mental Illness Diagnosis with Antipsychotic Use
Penalty
Summary
The facility failed to provide adequate documentation supporting a newly diagnosed mental illness for a resident who was prescribed an antipsychotic medication. The resident, who had a history of stroke and depression, was readmitted and later assessed by a psychiatric nurse practitioner (NP) who noted auditory hallucinations and continued Risperdal, but did not document the basis for a new bipolar disorder diagnosis. The order for Risperdal was entered for bipolar disorder, but the supporting evaluation or rationale for this diagnosis was missing from the medical record. Subsequent psychiatric assessments referenced the bipolar disorder diagnosis, but the origin and justification for the diagnosis were unclear, and the diagnosis appeared to be automatically generated in documentation without direct clinical substantiation. Interviews with psychiatric NPs, the pharmacist, and the Director of Nursing (DON) revealed that the new diagnosis was not communicated to the DON, and there was no evidence that the diagnosis was properly assessed or documented. The pharmacist relied on the presence of the diagnosis in the order without further verification, and the DON was unaware of the new diagnosis, which prevented appropriate updates to the resident's medical record and notifications to relevant staff. The annual MDS assessment also indicated the use of an antipsychotic without a documented attempt at gradual dose reduction or a clinical contraindication, further highlighting the lack of comprehensive documentation and communication regarding the resident's mental health status and medication management.
Failure to Apply Physician-Ordered Palm Guard for Resident with Contractures
Penalty
Summary
A deficiency occurred when staff failed to apply a physician-ordered right-hand palm guard (green carrot) for a resident with a history of cerebral infarction, hemiplegia affecting the left side, contractures, and cognitive communication deficit. The order specified that the palm guard should be placed on the resident's right hand at night and removed in the morning. However, observations and interviews revealed that the device was not applied as ordered, and there was no documentation of refusal by the resident. Record reviews showed that the order for the palm guard was not present on the Medication Administration Record (MAR) for April and part of May, and there was no documentation in the nursing progress notes regarding the resident's refusal to use the device. Staff interviews indicated confusion about which shift was responsible for placing and removing the palm guard, and some staff were unaware of the resident's needs or the location of the device. The palm guard was found in the resident's nightstand rather than in use, and the resident confirmed that it had not been applied as ordered. Further interviews with nursing assistants, the unit manager, and the DON confirmed that the palm guard was not consistently applied or documented. The occupational therapy director stated that the nursing staff had been in-serviced on the use of the device, but the resident was not currently on therapy caseload. The lack of application and documentation of the palm guard represented a failure to provide appropriate care to maintain or improve the resident's range of motion and prevent complications associated with contractures.
Failure to Immediately Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its abuse policy regarding the immediate reporting and investigation of abuse allegations for two residents. In the first case, a cognitively intact resident was alleged to have been struck by a nurse aide. The incident was initially reported by a nurse aide to a nurse, but there was confusion among staff about who was responsible for escalating the report. As a result, the Administrator was not notified until several hours after the initial disclosure, and the required notifications to authorities were delayed until the Administrator became aware of the incident. In the second case, another cognitively intact resident reported to Adult Protective Services and law enforcement after discharge that a female staff member had inappropriately touched him. The police investigator attempted to contact the facility's Administrator but was unsuccessful and instead spoke with the Social Worker Director, who did not recognize the staff description and did not report the allegation internally. The Director of Nursing and Administrator were unaware of the allegation until it was reported by the state, and no internal investigation was initiated until that point. Both cases demonstrate that the facility did not follow its own policy requiring immediate reporting of abuse allegations to the Administrator or management, nor did it ensure timely initiation of investigations. Staff interviews revealed a lack of clarity and communication regarding the proper procedures for reporting abuse, resulting in delayed notifications and investigations.
Failure to Maintain Safe and Clean Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in several resident rooms. Specific deficiencies included missing and scraped paint on doorways, bathroom doors, and walls; a red splattered substance on a wall; and a bathroom sink with a persistent black film. These issues were identified in three out of seven resident rooms reviewed on one of four halls. The observations were confirmed on two separate dates, indicating that the deficiencies were ongoing and had not been addressed between visits. Interviews with the Maintenance Director and Housekeeping Manager revealed that while there was an ongoing process to repaint and repair resident rooms, progress was slow due to resident preferences and competing maintenance priorities. The Housekeeping Manager acknowledged that certain cleaning tasks, such as removing the black film from the sink, required specific tools and had not been completed with routine cleaning. Review of work history reports showed no documented repairs for the affected rooms during the relevant period. The Administrator confirmed that there was an established cleaning process and that room improvements were being prioritized alongside other major repairs.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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