Autumn Care Of Saluda
Inspection history, citations, penalties and survey trends for this long-term care facility in Saluda, North Carolina.
- Location
- 501 Esseola Circle, Saluda, North Carolina 28773
- CMS Provider Number
- 345351
- Inspections on file
- 25
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Autumn Care Of Saluda during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia, bipolar disorder, and documented elopement risk exited the building unsupervised after exhibiting increased exit-seeking behavior. The resident’s care plan and elopement assessment identified exit-seeking, verbalizations about going home, and independence with ambulation, with interventions focused on redirection and 1:1 approach during elopement attempts. On the day of the incident, the DON and Administrator discussed the resident’s escalated behaviors in morning clinical meeting and instructed staff to increase observation, but the resident was intermittently monitored while staff also cared for other residents. During a period of frequent vendor and staff traffic through a keypad-locked side common area door, the resident was able to follow or be let out with a vendor or staff member and was later found outside in the driveway, away from the building, without staff knowledge of his exit.
A nurse in an LTC facility misappropriated controlled narcotic medications prescribed to three residents. The nurse signed off on the removal and wasting of medications without a second nurse's witness signature, violating facility policy. The discrepancies were discovered when staff noticed double signatures and unknown witness signatures on narcotic medication records. An investigation confirmed the diversion of five narcotic medications, leading to criminal charges against the nurse.
The facility was found deficient in food storage and handling practices. Spoiled cucumbers and bell peppers were discovered in the walk-in refrigerator, and undated sandwiches were found in the kitchen refrigerator. Additionally, a dented can of catsup was improperly stored on the canned goods rack. The Certified Dietary Manager acknowledged these oversights, and the Administrator confirmed expectations for proper food storage and dating.
The facility failed to notify the physician of a fall and a delay in a STAT x-ray order for a severely cognitively impaired resident on blood thinner. The resident experienced a fall during a transfer, which was not reported by the CNAs involved. The resident later showed signs of pain and decreased mobility, leading to a delayed STAT x-ray that revealed a hip fracture. The lack of communication and proper notification procedures contributed to the resident's prolonged pain and delayed treatment.
A resident was injured after staff failed to follow the care plan requiring a total mechanical lift and two-person assistance for transfers. The resident was transferred using a sit-to-stand lift, resulting in a fall and a fractured left hip. The resident underwent surgery and was later discharged to hospice care, where she expired shortly after.
A resident was not assessed by a nurse after a fall and was moved without proper evaluation. The following day, a STAT x-ray order was delayed, and the facility did not inform the NP. The x-ray revealed a hip fracture, leading to delayed hospital transfer.
A resident with severe cognitive impairment fell and fractured their hip after a nurse aide used an incorrect mechanical lift for transfer. The incident was not reported, leading to a delay in medical assessment and treatment. The resident later underwent surgery and was discharged to hospice care, where they expired.
The facility failed to ensure that all nursing staff, including agency staff, received proper orientation and competency verification before providing care to residents. An agency NA improperly transferred a resident using a sit-to-stand mechanical lift instead of the required total mechanical lift with two-person assistance, resulting in the resident suffering an acute hip fracture. The incident revealed significant lapses in staff training and awareness of resident care plans.
Failure to Supervise Elopement-Risk Resident During Vendor Traffic
Penalty
Summary
The deficiency involves the facility’s failure to effectively supervise a cognitively impaired resident who was assessed as being at risk for elopement and who exited the building unsupervised and without staff knowledge. The resident had diagnoses including dementia, bipolar disorder, panic disorder, and anxiety disorder, and an MDS documented severe cognitive impairment with a need for supervision for mobility and transfers. The resident’s care plan, initiated and updated prior to the incident, identified risk of elopement with behaviors such as standing by exit doors, verbalizing intent to walk out, and attempting to follow staff as they exited. Interventions on the care plan included 1:1 approach during elopement attempts, redirection from the front door area with offers of coffee, snacks, walks in the courtyard, or return to the room, and maintaining a calm environment. An elopement assessment completed prior to the incident documented that the resident was independent with ambulation and exhibited exit-seeking behaviors, including verbalizing a desire to go home or go on a trip, and not accepting the current residence. Despite this, the immediate intervention listed was to continue the current plan of care. On the morning of the elopement, the DON and Administrator reported that the resident had shown increased exit-seeking behavior, including asking about leaving and standing near common area doors that were locked with a keypad. This escalation was discussed in the morning interdisciplinary team meeting, and staff were informed they needed to increase observation and redirection of the resident due to the heightened behaviors. On the day of the incident, Nurse #1 reported that around 10:10 a.m. the resident was inquiring about leaving the facility; she told him he needed to talk to the physician and that it was almost time to go smoke. The resident then left the nurse’s station and went to his room, where he lay on his bed. NA #1 stated that at approximately 10:30 a.m. the resident was in his room sitting on his bed after she had redirected him with an offer of coffee when he asked how he could get home. NA #1 acknowledged she was aware of his exit-seeking behavior and the need to keep an eye on him but stated she had other residents to care for and could not continuously watch him. At 10:42 a.m., Nurse #1 saw the resident outside, midway down the facility driveway, approximately 150 feet from the building and about 50 feet from the road, and immediately brought him back inside. The facility’s investigation concluded that, on a day when multiple vendors and staff were entering and exiting through a side common area door, the resident was able to leave the building by following or being let out by a vendor or staff member through that door, resulting in an unsupervised exit despite his known elopement risk and recent increase in exit-seeking behavior. Interviews with the NP indicated that during prior visits the resident had always been observed sitting on his bed and had not shown exit-seeking behavior to her. However, staff interviews and documentation on the Kardex and elopement assessment confirmed that exit-seeking behaviors were known and that the resident was identified as at risk for elopement. The side common area doors used by vendors were locked with a keypad, and only certain management staff had the code, but on the day of the incident vendors and staff were going in and out through those doors, and the resident was able to leave undetected. The combination of known elopement risk, documented increased exit-seeking behavior that morning, reliance on intermittent observation rather than continuous supervision, and active vendor traffic through a secured exit led to the resident’s unsupervised departure from the facility.
Misappropriation of Controlled Narcotics by Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled narcotic pain medications, affecting three residents. Nurse #1 was involved in the misappropriation of medications, as evidenced by discrepancies in the controlled narcotic medication declining records. Nurse #1 signed off on the removal and wasting of medications without a second nurse's witness signature, which is against the facility's policy. This was observed in the records of three residents who were prescribed opioid medications for pain management. Resident #46, who had intact cognition, was prescribed hydrocodone-acetaminophen for hip pain. On a specific date, Nurse #1 signed for the removal of one tablet and claimed it was wasted without a witness, and later removed two more tablets, claiming both were administered. Similarly, Resident #1, with severely impaired cognition, was prescribed oxycodone-acetaminophen for chronic pain. Nurse #1 signed for the removal of two tablets on two occasions, claiming one was wasted each time, with one instance lacking a witness signature. Resident #18, with intact cognition and chronic pain, was prescribed oxycodone extended release. Nurse #1 signed for the removal of two tablets, claiming one was wasted with an unknown witness signature. The facility became aware of the alleged drug diversion when staff noticed double signatures and unknown witness signatures on the narcotic medication records. An investigation revealed that Nurse #1 admitted to signing as a witness without another nurse present and could not account for the wasted medications. The facility reported the incident to law enforcement and the state agency, and Nurse #1 faced criminal charges. The investigation confirmed that five narcotic medications were diverted, and the facility took steps to address the issue, including notifying relevant authorities and conducting audits.
Deficiency in Food Storage and Handling
Penalty
Summary
The facility failed to properly manage food storage and handling, as observed during a survey. In the walk-in refrigerator, cucumbers and green bell peppers were found with signs of spoilage, having been received on dates far exceeding the recommended storage period. The cucumbers were shriveled with white on the surface, and the bell peppers were shriveled with black on the surface. Additionally, in the kitchen refrigerator, a ham and cheese sandwich and a peanut butter and jelly sandwich were found without any date labels, indicating a lapse in the facility's protocol for dating food items. Furthermore, the canned goods rack contained an unopened can of catsup with a significant dent, which should have been placed in the damaged goods return area. Interviews with the Certified Dietary Manager (CDM) and the Administrator revealed that the vegetables should have been discarded after seven days, and the sandwiches should have been dated when made. The CDM acknowledged the oversight and indicated that the dented can of catsup was improperly returned to the shelf instead of being set aside for return. The Administrator confirmed that the expectation was for food to be stored and dated according to regulatory standards, and spoiled vegetables should be discarded.
Failure to Notify Physician of Fall and Delay in STAT X-ray Order
Penalty
Summary
The facility failed to notify the physician of a fall and a delay in a STAT x-ray order for a severely cognitively impaired resident on blood thinner. The resident experienced a fall while being transferred to the toilet using a sit-to-stand mechanical lift. The CNAs involved did not report the incident to a nurse or physician, and the resident was moved without a proper assessment. The resident later displayed signs of pain and decreased range of motion in her left hip, leading to a STAT x-ray order that was delayed without notifying the physician of the delay. The x-ray eventually revealed an acute fracture of the left hip, and the resident was transferred to the ER for further evaluation and treatment. The resident underwent surgery and was later discharged to hospice care, where she expired. The incident began when an agency CNA was lowering the resident to the toilet, and the resident's foot slipped, causing her to be lowered to the floor. The CNA did not report the incident to a nurse, believing it was not a fall. Another CNA assisted in moving the resident back to her chair without notifying a nurse for an assessment. The following day, the resident's decreased mobility and pain were noticed, and a STAT x-ray was ordered. However, the x-ray was delayed, and the physician was not informed of the delay. Interviews with the involved staff revealed a lack of communication and understanding of the facility's protocols for reporting falls and changes in condition. The CNAs did not recognize the incident as a fall and failed to notify the appropriate medical personnel. The delay in the STAT x-ray order was not communicated to the physician, resulting in a delay in the resident's diagnosis and treatment. The facility's failure to follow proper notification procedures contributed to the resident's prolonged pain and delayed medical intervention.
Removal Plan
- The facility failed to notify the MD/NP and RP when Resident #1 fell and failed to notify the NP when there was a delay in a stat x-ray order. C.N.A. #1 and C.N.A #2 failed to notify a Nurse/MD or NP when Resident #1 fell and failed to notify before moving Resident #1 off the floor. C.N.A. #2 informed the NP that Resident #1 was having issues with her foot dragging. C.N.A #2 did not notify the NP of the fall. NP performed an assessment on Resident #1, no bruising or swelling was noted. NP ordered stat x-ray and changed scheduled Tylenol to three times daily for pain. Radiology contacted facility and notified the floor nurse that they would not be able to obtain the stat x-ray. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on proper notification of MD for any delay in stat orders. X-ray results revealed acute fracture of left hip. Facility notified Nurse Practitioner and received orders to send resident to the hospital for evaluation and treatment.
- Director of Nursing and/or designee completed education with all licensed nurses and CNA's including agency staff on notification to MD/NP and RP of all incidents or falls and accidents.
- Director of Nursing and/or designee completed education with all licensed nurses including agency staff on notification to MD/NP on delay of stat x-rays orders. Interviews were conducted with communicative residents. These interviews were conducted to determine if any issues regarding care and services would be identified. No other issues were identified. Unit managers completed skin checks on all residents. Skin checks were completed to ensure there were no signs of injury from an unreported fall, no negative findings were noted. Director of Nursing checked for any other stat x-ray orders and there were none.
- The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses including agency staff on reporting of incidents and accidents and reporting protocols and change in condition to physician or nurse practitioner. New hires to the facility are educated with the onboarding procedures. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff including agency staff on reporting of accidents and incidents. The Director of Nursing and/or their designee educated all licensed nurses including agency nurses on stat orders and procedures. This education included notification to physician or NP on a delay of stat orders or other changes of condition for the residents.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders from NP. Director of Nursing and/or their designee will audit results daily for 12 weeks to ensure order for x-rays are completed as ordered. NP was notified of this process. Director of Nursing and/or their designee will audit change of condition and incident reports daily for 12 weeks to ensure physician notification of incidents/accidents and falls has been completed. Director of Nursing and/or designee will have daily huddles with licensed nurses and C.N.A.'s at beginning and end of shift to discuss any change in condition or incidents that may have occurred throughout the shift in order to ensure proper notifications have been made. This is to ensure that MD/NP have been notified of any incidents. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when staff disregarded the resident's plan of care and transferred the resident without the use of a total mechanical lift and two-person assistance. During the first transfer, the resident was assisted to the floor. The following day, the Nurse Practitioner was asked to assess the resident due to her left foot dragging on the floor, and x-ray results revealed an acute fracture of the left hip. The resident underwent surgery to repair the left hip fracture and was later discharged to hospice care, where she expired shortly after. The incident began when a Nurse Aide transferred the resident independently using a sit-to-stand mechanical lift instead of the required total mechanical lift with two-person assistance. During the transfer from the toilet to the sit-to-stand mechanical lift, the resident's foot slipped, and the Nurse Aide had to lower the resident to the floor. Another Nurse Aide was called to assist, and they both helped the resident off the floor without using the proper mechanical lift. Transfers continued without using the total mechanical lift and assistance from two people. The following day, a Nurse Aide reported to the Nurse Practitioner that the resident's left foot was dragging on the floor when in a wheelchair but did not inform the Nurse Practitioner of the fall. The Nurse Practitioner assessed the resident and ordered immediate x-rays, which revealed an acute fracture of the left hip. The Director of Nursing was notified, and the resident was sent to the hospital for further evaluation and treatment. The resident underwent surgery and was later discharged to hospice care, where she expired shortly after.
Removal Plan
- The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift.
- X-ray was obtained which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. The Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room, and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at the facility, CNA #2 has been terminated.
- The Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from the therapy department. Unit managers cross-referenced the lift status to the Kardex and Care Plans.
- The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents and reporting protocols. Agency staff will be educated prior to the first shift working on proper lifts, facility policies, and reporting all incidents and changes in condition. New hires to the facility are educated with the onboarding procedures. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers and proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s, reporting of accidents and incidents, following the Kardex for proper transfers and change in condition. The Director of Nursing and/or their designee educated all facility staff on abuse and neglect, definition of abuse/neglect and facility policy for reporting. Staff educated that facility has no tolerance for abuse/neglect and will result in immediate termination. Director of Nursing and/or their designee educated agency staff on abuse/neglect policy, reporting and consequences of abuse/neglect. New staff will be educated upon hire by the Director of Nursing and/or their designee.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice.
- To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week to ensure residents requiring assist utilizing lifts are receiving the proper transfer. Unit Mangers will select 5 residents weekly that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy.
- Administrator and/or their designee will audit five (5) random staff members weekly to ensure that they understand the definition abuse/neglect and the reporting requirements for abuse/neglect.
- The Social Services Director and/or their designee will interview 5 alert residents and 5 responsible parties per week to ensure that no abuse/neglect is occurring.
- Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed.
Failure to Assess Resident After Fall and Delay in STAT X-ray Order
Penalty
Summary
The facility failed to assess a resident by a nurse after a fall and prior to getting her off the floor. On the day of the incident, a nurse aide transferred the resident from her bed to a sit-to-stand lift and then to the shower room. During a transfer in the shower room, the resident's foot slipped, and the nurse aide had to lower the resident to the floor. The nurse aide called for assistance from another nurse aide, but neither of them notified a nurse about the fall. Consequently, an assessment for injury was not completed by a nurse before the resident was moved back to her wheelchair. The following day, the nurse practitioner placed a STAT order for a left hip x-ray due to the resident's decreased range of motion and pain. However, there was a delay in executing the STAT x-ray order, and the facility did not inform the nurse practitioner about the delay. The x-ray results, which revealed a fracture of the resident's left hip, were not available until the next day. The delay in obtaining the x-ray results led to a delay in sending the resident to the hospital for further evaluation and treatment. Interviews with the involved staff revealed that they did not consider the incident as a fall and therefore did not follow the proper protocol of notifying a nurse and having the resident assessed before moving her. The nurse aides involved admitted to not reporting the incident to the nurse or the nurse practitioner, which contributed to the delay in care. The facility's failure to ensure timely assessment and execution of the STAT x-ray order resulted in delayed care for the resident, who suffered a hip fracture.
Removal Plan
- The facility failed to have resident assessed by a nurse after the fall and prior to getting her off the floor. The facility failed to report the fall and improper transfer when CNA #2 reported the resident having issues with her foot dragging. Nurse Practitioner was notified by C.N.A. #2 that resident could not move her left foot. Nurse Practitioner performed an assessment on resident, no bruising or swelling was noted. Nurse Practitioner ordered stat x-ray and changed Tylenol order to three times daily for pain. Radiology contacted facility and notified the floor nurse that they would not be able to obtain the stat x-ray. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on proper notification to MD for any delay in stat orders. X-ray results revealed acute fracture of left hip. Facility notified Nurse Practitioner and received orders to send resident to the hospital for evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. Director of Nursing conducted an interview with C.N.A. #2 which revealed the incident and a conclusion on how the fracture occurred. C.N.A. #2 confirmed that resident was on the floor in the shower room and C.N.A #2 assisted C.N.A #1 in returning resident to chair. C.N.A #1 cannot return to the facility, CNA #2 has been terminated from the facility.
- Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any unreported incidents or other injury of unknown origin. No other issues were identified by residents. Head to toe skin assessments were completed on all residents by Unit Managers. This was done to ensure there were no signs or symptoms of injuries related to incidents not being reported. No negative findings were noted from residents. The Director of Nursing checked for any other stat x-ray orders and there were none.
- The Director of Nursing and/or their designee completed education of 100% C.N.A.'s and licensed nurses which included, safe transfers, reporting of incidents and accidents, and reporting protocols and change in condition. This includes having a licensed nurse assess a resident after all falls and/or incidents. Agency staff will be educated prior to first shift working on proper lifts, facility policies, and reporting all incidents and change in condition. New hires to the facility are educated with the onboarding procedures. The Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on reporting of incidents and accidents and the definition of a fall. Agency staff were educated prior to taking an assignment. The Director of Nursing and/or their designee completed 100% education of all licensed nurses on stat orders. This education included notification to MD/NP if stat order has been delayed. Agency nurses are educated on STAT orders prior to first shift working.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders daily from NP. Director of Nursing and/or their designee will audit results daily to ensure orders for x-rays are completed as ordered. NP was notified of this process. Director of Nursing and/or their designee will randomly audit five (5) staff members weekly to monitor knowledge of reporting of incidents, falls and what is considered a fall. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed.
Failure to Safely Transfer Resident Resulting in Injury
Penalty
Summary
The facility failed to safely transfer a resident from the toilet to the shower chair, resulting in the resident falling to the floor. A nurse aide used a sit-to-stand mechanical lift instead of the total mechanical lift as indicated in the resident's care plan, which required two-person assistance. During the transfer, the resident's foot slipped, and the nurse aide had to lower the resident to the floor. Another nurse aide assisted in manually lifting the resident off the floor without using a mechanical lift, and the incident was not reported to a nurse for assessment. The resident, who had severe cognitive impairment and required total dependence on staff for mobility, was later found to have an acute fracture of the left hip. The injury was discovered after a nurse aide noticed the resident's foot dragging while in a wheelchair and reported it to the nurse practitioner. The resident was sent for an x-ray, which confirmed the fracture, and was subsequently transferred to the hospital for surgery. The resident was later discharged to hospice care and expired. Interviews with staff revealed that the nurse aide who performed the transfer had not received proper orientation or education on resident transfers or lift equipment from the facility. Additionally, the nurse aides involved did not follow the care plan or report the incident, leading to a delay in the resident receiving appropriate medical attention. The facility's failure to ensure proper use of mechanical lifts and adequate supervision during transfers directly contributed to the resident's injury and subsequent decline in health.
Removal Plan
- The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift. X-ray was obtained which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at facility, CNA #2 has been terminated.
- Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from therapy department. Unit managers cross referenced the lift status to the Kardex and Care Plans.
- The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents, reporting protocols, and what constitutes a fall, which is a change of plane. Director of Nursing and/or their designee educated agency staff on proper lifts, facility policies, reporting all incidents and accidents, change in condition and what constitutes a fall, which is a change of plane. New hires to the facility are educated with the onboarding procedures by the Director of Nursing and/or their designee. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers. Education also included proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s. Staff were educated on how to report accidents and incidents, how to understand the Kardex for proper transfers, and how to report change of condition with residents. Director of Nursing and/or designee educated Agency staff prior to taking an assignment on the units and completed return demonstration to ensure understanding and compliance with education.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice. To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week to ensure residents utilizing a lift are receiving the proper transfer. Unit Mangers will select 5 residents weekly that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed. Corrective action will be completed. The facility alleged a IJ removal date.
Failure to Ensure Staff Competency and Proper Resident Transfers
Penalty
Summary
The facility failed to ensure that all nursing staff, including agency staff, received proper orientation and competency verification before providing care to residents. Specifically, Nurse Aide (NA) #1 transferred a resident using a sit-to-stand mechanical lift, contrary to the resident's care plan, which required a total mechanical lift with two-person assistance. This improper transfer resulted in the resident's foot slipping, causing the resident to be lowered to the floor and subsequently lifted manually by NA #1 and NA #2 without using the appropriate mechanical lift. The resident later suffered an acute fracture of the left hip, underwent surgery, and was eventually discharged to hospice care, where they expired shortly after. The incident highlights a significant lapse in ensuring that staff were adequately trained and aware of the resident's specific care requirements as outlined in their care plan and Kardex system. The competency checklist for NA #1 from the agency indicated previous training and experience in patient transfers but lacked specific information on using mechanical lifts. NA #1 admitted to not receiving orientation or education on resident transfers or lift equipment from the facility and was unaware of how to access resident care plans or the Kardex system. NA #2, who assisted NA #1, also did not provide proper guidance on the required transfer method for the resident. The Director of Nursing (DON) and the Scheduler failed to verify NA #1's competency in using mechanical lifts before allowing her to provide care, relying instead on a general skills checklist from the staffing agency. Interviews with various staff members, including the DON, Scheduler, and other nurses, revealed a lack of consistent orientation and competency verification for agency staff. The DON acknowledged that agency staff were given only basic resident care information and were expected to seek guidance from nursing staff if needed. The Administrator admitted that the incident was avoidable if the staff had followed the care plan, indicating a systemic issue in ensuring that all staff, including agency staff, were adequately trained and aware of the specific care needs of residents. This deficiency in staff training and competency verification directly led to the resident's fall and subsequent injury.
Removal Plan
- Director of Nursing and/or their designee completed education with facility licensed nurses and C.N.A.'s on lift competency with return demonstration. Licensed agency nurses and C.N.A.'s were educated on proper lift competency with return demonstration. Education was also provided on where licensed nurses and C.N.A.'s can locate current lift status.
- Director of Nursing and/or their designee educated all licensed nurses and C.N.A.'s, including agency staff on location of resident care guides.
- All new facility licensed nurses and C.N.A.'s will receive education from the unit managers on the location of the resident care guides during their orientation. Unit Managers were notified of this responsibility.
- All licensed nurses and C.N.A.'s from an agency are required to come in prior to their first shift to receive lift training and review facility policies. This training is completed by the Director of Nursing and/or their designee. The nursing scheduler is responsible for scheduling agency staff for this orientation. The nursing scheduler notified the agencies of this requirement. Each agency staff is now required to read through facility policies and procedures related to resident care which are located at each nurse's station in the Agency Orientation book. They are to acknowledge understanding of these policies by signing the Policy Acknowledgement Sheet. Agency staff are required to complete lift competency prior to working, this is completed by the Director of Nursing and/or their designee. The facility is requiring the agency to provide the skills checklist of each agency staff member for review prior to working. The Director of Nursing and/or their designee will review the skills check list to ensure that they have the skills to meet the needs of our residents.
- The Director of Nursing and/or their designee completed lift competencies with return demonstration for all licensed nurses and C.N.A.'s and agency staff.
- New hires will be educated Director of Nursing and/or designee on facility policies and lift competencies upon hire.
- The facility made the decision to have an ad hoc QAPI (Quality Assurance and Process Improvement) committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks.
- The Director of Nursing and/or their designee will audit five (5) agency staff, licensed staff and C.N.A.'s, to the location of the care guides for the residents.
- The Director of Nursing and/or their designee will audit five (5) facility and agency C.N.A.'s weekly for 12 weeks observing lift transfers. Any negative observations will be corrected immediately.
- Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and or their designee for review and/or revision as needed for three (3) months.
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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