Autumn Care Of Salisbury
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, North Carolina.
- Location
- 1505 Bringle Ferry Road, Salisbury, North Carolina 28146
- CMS Provider Number
- 345269
- Inspections on file
- 25
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Autumn Care Of Salisbury during CMS and state inspections, most recent first.
A resident with dementia and hemiplegia repeatedly indicated that a male NA had hit her face, while multiple staff and the resident’s representative observed her crying and noted redness, swelling, or possible bruising on one side of her face. Staff reported the allegation to the Administrator and Unit Manager and wrote statements, but no abuse allegation or related assessment was documented in the medical record, and the NP, SW, ADON, and DON were not promptly notified or formally involved. The Administrator briefly questioned the resident, demonstrated how an arm might rest against the resident’s jaw during incontinence care, concluded the allegation was not valid due to the resident’s cognition, did not submit a 24‑hour abuse report, and did not suspend or interview the alleged perpetrator, who continued working multiple shifts. These actions and inactions show the facility did not follow its abuse policy for immediate reporting, investigation, documentation, and protection of the resident after an abuse allegation.
The facility failed to label and date leftover food, remove spoiled items, and prevent staff food storage in resident nourishment room refrigerators. Observations revealed unlabeled and undated food items, including croutons, strawberries, blueberries, and a microwavable dinner tray with signs of spoilage. Additionally, a container of cream of mushroom soup with an expired discard date was found in the walk-in cooler. Staff responsible for daily checks admitted to lapses in protocol.
Three residents did not receive their scheduled showers due to miscommunication involving an agency NA, who was incorrectly informed that no showers were scheduled for the hall. This led to the residents' preferences being disregarded, causing them distress.
Two residents receiving enteral feedings had their syringes improperly stored with plungers inside, risking bacterial growth. Nurses were unaware of the correct storage procedure, which was confirmed by the DON and acknowledged by the Administrator.
The facility failed to maintain clean air intake filters on oxygen concentrators for two residents requiring oxygen therapy. Observations revealed significant dust accumulation on the filters, and staff interviews indicated confusion over cleaning responsibilities. The DON and Administrator confirmed that nursing staff should clean the filters weekly, but this was not being done.
A resident with Parkinson's Disease experienced a grievance related to medication administration that was not promptly resolved by the facility. The resident's Responsible Party filed a grievance expressing concerns about the unavailability of medications and preferred email communication, which was not accommodated by the facility. The DON's attempts to contact the Responsible Party by phone were unsuccessful, and the Administrator did not pursue the grievance further, leaving the issue unresolved.
A resident with cognitive impairments became agitated during care, leading to an incident where one nurse aide allegedly slapped the resident while another held the resident's hands. The resident, who had a history of aggressive behavior, was not protected according to their care plan, resulting in a deficiency in safeguarding the resident from abuse.
A resident in a LTC facility was subjected to inappropriate handling by two NAs during care. The resident, who was combative and verbally abusive, had their hands restrained by one NA, while the other allegedly slapped the resident on the thigh. The incident was not reported immediately, allowing the NAs to continue their shift, contrary to the facility's abuse policies.
A resident with Parkinson's disease was not transported to a scheduled neurologist appointment due to a transportation conflict at the facility. The family member had informed the facility of the appointment in advance, but alternative transportation could not be arranged, resulting in a significant delay in the resident's care. The facility's physician believed the missed appointment did not impact the resident's care, but the family member was upset about the delay.
A resident with Parkinson's disease did not receive their prescribed Carbidopa-Levodopa medication due to unavailability. Despite efforts by nursing staff to notify the pharmacy and the Director of Nursing, the medication was not delivered on time, resulting in missed doses. The Physician's Assistant and Director of Nursing were unaware of the issue, and no hold order was documented, leading to a deficiency in care.
A resident with Parkinson's disease did not receive six doses of Carbidopa-Levodopa due to medication unavailability. Despite efforts by nursing staff to resolve the issue, the medication was not delivered promptly, and there was a lack of communication and documentation regarding hold orders. The Physician's Assistant noted potential impacts on the resident's health, although no immediate harm was reported.
Failure to Implement Abuse Reporting and Investigation Procedures After Resident Allegation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and procedures for reporting, investigating, and protecting a resident after an allegation of abuse. The facility’s written policy required that all allegations, suspicions, and incidents of abuse, neglect, involuntary seclusion, exploitation, misappropriation of property, and injuries of unknown origin be immediately reported to the Administrator/Abuse Coordinator, that an investigation be initiated immediately, that applicable state and local agencies be notified, and that any accused staff member be removed from resident care and placed under supervision pending the outcome of the investigation. The policy also required notification of the resident’s responsible party and attending physician, documentation of assessments and notifications in the medical record, and involvement of social services when appropriate. The resident involved was readmitted with hemiplegia, diabetes, and dementia and was assessed as moderately cognitively impaired, with clear but sometimes difficult speech, adequate vision and hearing, and a need for substantial assistance with toileting and bed mobility. On the morning after a night shift, multiple staff members, including the Activities Director, Activities Assistant, Environmental Supervisor, and nursing assistants, independently encountered the resident crying, upset, patting the left side of her face, and repeatedly saying “hit-hit” or similar phrases, sometimes naming a male staff member. Several staff observed the resident’s left cheek as pink, swollen, or puffy, and one NA reported seeing a bruise under the left eye. These staff documented handwritten statements and reported the allegation to the Administrator and Unit Manager. The resident’s representative also observed the resident upset with a pink cheek and reported that the resident indicated she had been hit. Despite these reports, the medical record contained no nursing notes documenting an allegation of abuse, and the nurse assigned to the resident on the day of the allegation stated she was told by the DON not to worry about charting because the DON would take over the investigation. The Unit Manager and another nurse reported performing skin assessments, but documentation was delayed or absent, and the Unit Manager stated she was waiting for direction from the Administrator regarding documentation. The Administrator, after a brief interaction with the resident in which she physically demonstrated how an arm might rest against the resident’s jaw during incontinence care and asked if that was what happened, concluded the allegation was not valid due to the resident’s cognitive status, did not treat it as an abuse allegation, did not suspend the alleged perpetrator, and did not complete or submit an initial 24‑hour abuse report to state agencies. The alleged staff member continued to work multiple 12‑hour shifts, was never interviewed or asked for a written statement about the incident, and social services, the NP, ADON, and DON were not promptly or formally engaged in a documented investigation. Several leaders, including the DON and ADON, later reported that they had been told by the Administrator that the incident was already determined to be related to incontinence care and that the investigation was complete, and the HR Director reported that staff were upset that an investigation had not been completed in the manner they expected. These actions and omissions demonstrate the facility’s failure to follow its own abuse policy regarding immediate reporting, thorough investigation, documentation, and protection of the resident after an allegation of abuse.
Failure to Properly Label, Date, and Store Food Items
Penalty
Summary
The facility failed to properly label and date leftover food items, remove spoiled food, and prevent staff food from being stored in resident nourishment room refrigerators. During an observation in the 600 Hall nourishment room refrigerator, a bag of croutons was found unlabeled and undated, along with a quart-sized sealed plastic bag containing strawberries and blueberries that showed discoloration and a fuzzy white substance. Additionally, a microwavable dinner tray with meat and broccoli was observed with discoloration and a fuzzy substance, and an unlabeled and undated plastic container contained a white substance resembling mold. Nurse Aide #4 admitted to placing her lunch bag in the fridge, acknowledging it should not be there. Both Nurse Aide #4 and Nurse Aide #5 were responsible for checking the nourishment rooms daily to ensure items were labeled, dated, and discarded appropriately. In the kitchen, a container of leftover cream of mushroom soup with a discard date that had already passed was found in the walk-in cooler. The Dietary Manager admitted the soup should have been discarded and was missed during checks. The Dietary Manager also revealed that Dietary Aide #1 was responsible for checking nourishment rooms over the weekend but was unavailable for an interview. The Administrator confirmed the expectation that nourishment rooms be checked daily and that food items be stored and labeled correctly.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of three residents, all residing on the 200 hall, on 2/28/25. Resident #32, who was moderately cognitively impaired, expressed that choosing between a shower and a sponge bath was very important. Despite being scheduled for a shower on that day, she did not receive one, which upset her. Similarly, Resident #77, also moderately cognitively impaired, did not receive her scheduled shower and expressed her dissatisfaction. Resident #24, who was cognitively intact, also did not receive her scheduled shower and was upset as she expected to be offered one later in the day. The issue arose due to a miscommunication involving Nursing Assistant (NA) #3, an agency staff member who was reassigned to the 200 hall on the day in question. NA #3 reported being informed by other staff that there were no showers scheduled for the hall, leading her not to offer showers to the residents. The Director of Nursing confirmed that NA #3 received inaccurate information and that the residents should have been offered showers as per their preferences. The Administrator also confirmed the expectation that residents receive showers on their scheduled days if they desire them.
Improper Storage of Enteral Feeding Syringes
Penalty
Summary
The facility failed to properly store enteral feeding syringes for two residents, leading to potential bacterial growth and contamination. Resident #44, who was admitted with diabetes and difficulty swallowing, received a significant portion of her nutrition and fluids through enteral feedings. Observations on two consecutive days revealed that her enteral feeding flush syringe was stored with the plunger inside the syringe, which contained a thick white liquid. Nurse #1, responsible for administering medication and flushes, was unaware that the syringe should be stored separately from the plunger to prevent bacterial growth. Similarly, Resident #65, admitted with dementia and difficulty swallowing, also received a significant portion of her nutrition and fluids through enteral feedings. Observations showed that her enteral feeding flush syringe was stored improperly with the plunger inside. Nurse #2, who was about to use the syringe, was also unaware of the correct storage procedure. The Director of Nursing confirmed that the syringes should be washed and stored with the plunger separated to allow drying and prevent bacterial growth. The Administrator acknowledged the oversight by the nursing staff.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to maintain clean air intake filters on oxygen concentrators for two residents, both of whom required oxygen therapy due to respiratory conditions. Resident #34, who was cognitively intact, was observed with an oxygen concentrator that had a significant layer of black dust on the air intake filter. This condition persisted over multiple observations, and staff interviews revealed a lack of clarity regarding who was responsible for cleaning the filters. Nurse #1 was unaware of the cleaning responsibilities, and the Director of Nursing indicated that the assigned nurse should clean the concentrators weekly. Similarly, Resident #44, who was moderately cognitively impaired, was also observed with a dusty air intake filter on her oxygen concentrator. Interviews with Nurse #1 and the Housekeeping Supervisor further highlighted the confusion over cleaning duties, with the Housekeeping Supervisor stating that nursing staff were responsible. The Administrator confirmed that nursing staff should clean the machines and filters at least weekly, yet this was not being done, leading to the deficiency.
Failure to Resolve Grievance Regarding Medication Administration
Penalty
Summary
The facility failed to promptly resolve a grievance filed on behalf of a resident with Parkinson's Disease, who was admitted to the facility in June 2022. The grievance was filed by the resident's Responsible Party, who expressed concerns about the resident's medication administration, specifically the unavailability of Parkinson's medications. The grievance was assigned to the Director of Nursing (DON) on the same day it was filed, but the DON documented unsuccessful attempts to contact the Responsible Party by phone, and the grievance remained unresolved. The Responsible Party reported that he had communicated his concerns through email to the Social Worker (SW) and verbally to other staff members, including the floor nurse and care planner, but received no resolution. He preferred email communication due to his busy schedule, but the facility did not accommodate this preference. The DON was unaware of the Responsible Party's preference for email communication until after her attempts to reach him by phone, and she did not follow up with an email. The Administrator and the DON did not effectively coordinate to address the grievance. The Administrator believed that email was not an appropriate medium for discussing grievances and did not attempt to contact the Responsible Party. The grievance process was further complicated by the transition of responsibilities to a new social worker, SW #2, who was not involved in handling the grievance. As a result, the facility did not make prompt efforts to resolve the grievance, leaving the Responsible Party's concerns unaddressed.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to protect a resident's right to be free from staff-to-resident abuse. During an incident involving two nurse aides providing care to a cognitively impaired resident, the resident became agitated and combative. One of the nurse aides, NA #7, allegedly slapped the resident on the left upper thigh, while the other aide, NA #6, held the resident's hands to prevent further aggression. This incident was reported by NA #6, who stated that the resident had been aggressive and used racial slurs during the care process. The resident involved in the incident was admitted with multiple diagnoses, including cerebral infarction, major depressive disorder, and dementia, and required extensive assistance for mobility and transfers. The resident's care plan indicated a risk of adjustment issues and potential for aggressive behavior, with interventions in place to approach the resident calmly and report any mood changes. Despite these interventions, the resident's behavior during the incident was combative, and the aides continued care without following the protocol to walk away when residents are combative. The incident was reported to the facility administration, and an investigation was conducted. Statements from the involved staff members revealed discrepancies in their accounts of the event, with NA #7 denying any aggressive behavior. The facility's Director of Nursing and Administrator were informed of the incident, and NA #7 was removed from the floor pending investigation. The report highlights a failure in adhering to the resident's care plan and the facility's protocol for handling combative behavior, resulting in a deficiency in protecting the resident from abuse.
Failure to Report and Address Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse policies concerning identification, protection, and reporting, as evidenced by the incident involving Resident #3. During the incident, Nurse Aide (NA) #6 and NA #7 were providing care to Resident #3, who became combative and verbally abusive. Despite the resident's aggression, NA #6 restrained Resident #3's hands, and NA #7 allegedly slapped the resident on the thigh. Neither NA intervened or reported the incident immediately, allowing both aides to continue working their shift, potentially putting other residents at risk. The facility's policy requires immediate reporting of any suspected abuse, neglect, or mistreatment, and mandates the removal of the accused staff member from resident care areas. However, NA #6 did not report the incident until several hours later, and NA #7 continued to work until she was removed from the floor by Nurse #7. The delay in reporting and failure to follow protocol highlights a significant lapse in the facility's abuse prevention and reporting procedures. Resident #3, who was not cognitively intact and had a history of being combative, was subjected to inappropriate handling by the staff. The incident was not addressed promptly, and the staff involved did not follow the established guidelines for managing combative behavior, such as walking away or seeking assistance. This deficiency in handling the situation and reporting it in a timely manner reflects a breach in the facility's duty to protect its residents from abuse and ensure their safety.
Failure to Transport Resident to Neurologist Appointment
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was transported to a scheduled neurologist appointment. The resident, who was admitted to the facility with a diagnosis of Parkinson's disease, was supposed to attend a neurologist appointment for medication adjustments and therapy recommendations. The family member of the resident had informed the facility of the appointment in advance, but two days before the appointment, the facility notified the family member that they could not provide transportation. This resulted in the appointment being rescheduled to a later date, causing a significant delay in the resident's care. The Transporter, who was responsible for the facility's transportation, realized a week before the appointment that she could not transport the resident due to a scheduling conflict. Attempts to arrange alternative transportation through a contracted company were unsuccessful as they were fully booked. The facility's Director of Nursing and Administrator acknowledged the transportation conflict and the failure to arrange alternative transportation, but the facility's physician believed the missed appointment did not impact the resident's care. Despite this, the family member was upset about the delay in the resident's neurologist visit.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease and a neurocognitive disorder with dementia received their prescribed medication, Carbidopa-Levodopa, as ordered by the physician. The resident was admitted with a physician's order for Carbidopa-Levodopa to be administered four times a day. However, on multiple occasions, the medication was not available for administration. On 11/10/2024, Nurse #7 discovered the medication was not available and notified the Director of Nursing and the pharmacy. Despite these efforts, the pharmacy indicated the medication would not be sent until a week later. The nurse documented the missed doses and informed the Physician's Assistant, but no hold order was given. Further issues occurred on 11/11/2024 and 11/20/2024, where the medication was again unavailable, and doses were missed. Nurse #6 documented that the medication was on hold, but no physician's order was found to support this action. Interviews with the Physician's Assistant and the Director of Nursing revealed a lack of communication and awareness regarding the unavailability of the medication. The Director of Nursing stated that the nursing staff should have ensured the medication was sent promptly and notified the provider, but this did not occur, leading to the deficiency.
Failure to Administer Essential Parkinson's Medication
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was free from significant medication errors. The resident was not administered six doses of Carbidopa-Levodopa, a medication critical for managing Parkinson's disease symptoms. The medication was ordered to be given four times a day, but due to unavailability, the doses were missed on multiple occasions. The issue began when a nurse discovered that the medication was not available and could not be obtained from the facility's electronic emergency medication system. Despite notifying the Director of Nursing and the pharmacy, the medication was not delivered promptly. The pharmacy indicated that a 'Refill Too Soon' form was needed before the medication could be sent. The nurse documented the unavailability of the medication and the ongoing efforts to resolve the issue, but the medication remained unavailable for several doses. Interviews with the nursing staff, Physician's Assistant, and the Director of Nursing revealed a lack of communication and documentation regarding the hold orders for the medication. The Physician's Assistant and the Director of Nursing were not aware of the missed doses, and there was no documented order to hold the medication. The Physician's Assistant acknowledged that the missed doses could have affected the resident's mobility, breathing, and swallowing, although no immediate harm was reported. The Director of Nursing stated that the nursing staff should have ensured the medication was available and notified the provider promptly.
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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