Autumn Care Of Waynesville
Inspection history, citations, penalties and survey trends for this long-term care facility in Waynesville, North Carolina.
- Location
- 360 Old Balsam Road, Waynesville, North Carolina 28786
- CMS Provider Number
- 345110
- Inspections on file
- 20
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Autumn Care Of Waynesville during CMS and state inspections, most recent first.
A nurse failed to wear a gown while providing wound care to a resident with a chronic wound, despite the facility's Enhanced Barrier Precautions policy requiring both gloves and a gown for high-contact care activities. The nurse acknowledged forgetting to don the gown, and facility leadership confirmed she had received appropriate infection prevention training.
The facility failed to follow its abuse prevention and reporting policies in two cases involving residents with cognitive impairment. In one instance, a resident was struck by a staff member and the incident was not immediately reported, allowing the accused staff member to continue working. In another case, an abuse allegation reported to APS was not documented or communicated to the administrator or DON, and no internal investigation or required notifications were made.
A resident with advanced dementia was allowed to sign her own admission paperwork without the facility verifying or involving her designated legal representative, despite clear indications of cognitive impairment. The admission coordinator relied on the resident and her spouse's statements and did not obtain power of attorney documentation until discharge, resulting in the resident's legal representative not being included in the admission process.
A resident with severe cognitive impairment and dementia was physically struck on the arm by a nurse aide during care after becoming agitated and combative. The incident was witnessed by another aide, who delayed reporting the abuse due to fear of confrontation. The resident's care plan included interventions for managing agitation, but these were not followed, resulting in physical abuse that was not immediately reported or addressed.
A resident with severe cognitive impairment and on hospice care continued to receive PRN Lorazepam for anxiety and restlessness without a required 14-day stop date, despite repeated pharmacist recommendations. Nursing staff and the DON believed hospice residents were exempt from this requirement, resulting in the medication order remaining active for several months without the mandated stop date.
Four containers of expired fortified nutritional shake with nectar consistency were found stored in a nourishment room. The Dietary Manager, who inspects the nourishment rooms daily, was unaware of how the expired products were missed and suggested that newer staff may have stocked items incorrectly. The Administrator confirmed that expired products should be removed.
The facility failed to remove medication patches as ordered for two residents. One resident was found with two clonidine patches due to a missed removal, while another had a lidocaine patch left on overnight. The DON noted unclear orders may have contributed to the oversight.
The facility failed to ensure that a nurse and a paramedic completed their Skills Competency and required orientation before taking resident assignments independently. This led to a delayed medical response for a resident, who was later transferred to the hospital and subsequently passed away. The Director of Nursing and Staff Development Coordinator admitted to oversight in ensuring these competencies were completed.
Nursing staff failed to properly monitor and respond to changes in condition for diabetic residents, leading to critical health issues. One resident was not assessed in a timely manner and experienced a severe drop in blood sugar, while another resident's insulin was not administered as ordered, resulting in dangerously high blood sugar levels. Additionally, the facility did not assess a resident for significant weight gain and edema.
A resident experienced a medical emergency and was only responsive to painful stimuli, but EMS was not called until three hours later. The resident was diagnosed with metabolic encephalopathy due to a UTI and possibly cellulitis or hypoglycemia. The delay in initiating EMS and lack of ongoing assessment contributed to the resident's deteriorating condition and eventual death. The facility's staff failed to perform necessary assessments and timely communication with EMS.
A resident with a hinged knee brace developed a pressure injury that worsened due to inconsistent wound care and lack of initial padding on the brace. The facility staff failed to perform regular skin assessments and wound care as prescribed, leading to an infected wound with dead tissue. Key staff members were unaware of the injury, and there was no documentation of the brace being evaluated upon admission.
The facility failed to prevent injury during the transfer of a resident from a wheelchair to the bed, resulting in a laceration caused by a protruding screw. Additionally, the facility used an altered sit-to-stand lift for another resident, compromising safety and violating manufacturer instructions.
The facility failed to maintain clean and sanitary kitchen conditions, with observations of wet-nested and dirty dishware, debris on the kitchen floor, and dried food particles on various surfaces. The Dietary Manager attributed these issues to short staffing and rushing by the dietary staff.
A facility failed to accommodate a bariatric resident's transfer needs by not providing a suitable mechanical sit-to-stand lift. The resident experienced discomfort and pain due to an ill-fitting knee brace, and the use of pillows for padding compromised the lift's safety. Despite being aware of the issue, the facility did not take appropriate action to resolve it.
A resident with moderate cognitive impairment was moved to a new room without prior written notice, causing significant distress. Facility staff admitted to only providing verbal notifications, which contradicted the family's statements and violated the resident's rights.
The facility failed to accurately document the code status of a resident on the MOST form and did not provide EMS with a resident's advanced directive during an emergency transfer. These deficiencies involved incorrect documentation and missing DNR forms, leading to potential risks during emergency situations.
The facility failed to implement abuse and neglect policies by not submitting an Initial Allegation Report within two hours of being notified of neglect and allowing involved staff to continue working. Additionally, the facility did not report an allegation of staff-to-resident abuse immediately and failed to notify law enforcement.
The facility failed to maintain communication with the dialysis center, assess a resident post dialysis, and implement orders for fluid restrictions and a renal diet. The resident's care plan lacked necessary assessments, and the facility's staff were unaware of the resident's dietary and fluid restriction needs due to poor communication with the dialysis center.
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. A resident received an incorrect concentration and infusion rate of Meropenem, and the IV was not flushed as required. Nurse #11 was unaware of the need to flush the IV and assumed the premixed solution from the pharmacy was correct. The Pharmacy Consultant admitted an oversight, and the Medical Director confirmed the need for IV flushing.
A resident with severe cognitive impairment was found with unsecured medications at her bedside. The nurse responsible admitted to leaving the medications unattended, contrary to facility policy, which requires nurses to observe residents during medication administration.
The facility failed to initiate Enhanced Barrier Precautions (EBP) for a resident with a Permacath used for dialysis access. Observations and staff interviews revealed a lack of PPE and confusion about EBP requirements. The ADON and DON acknowledged the resident should have been on EBP, especially considering the need for assistance post-dialysis.
The facility failed to notify emergency contacts when a resident was sent to the ER and did not inform the provider of another resident's significant weight gain. The DON and Administrator confirmed that immediate notification protocols were not followed.
The Governing Body failed to have the Business Office Manager sign a Duty to Disclose Conflict of Interest form and approve or deny a plan to purchase property from a resident. The Business Office Manager facilitated the sale without disclosing the transaction to the Corporate Human Resources Representative or the Former Administrator, leading to a potential conflict of interest situation.
The facility failed to display survey results in a location accessible to residents during multiple observations. The survey results, previously kept in a blue notebook in the front lobby, were found in the receptionist's office due to an oversight.
The facility failed to provide a written notice of transfer/discharge to a resident and their representative and did not send a copy to the local Ombudsman. The resident was transferred to the hospital due to a change in condition, but the required notice was not completed by the nurse on duty. The Business Office Manager sent the notice the next business day but did not inform the Ombudsman.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Nurse #1 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during wound care for a resident with an unstageable pressure injury. According to the facility's policy, staff are required to don both gloves and a gown when performing high-contact care activities for high-risk residents, such as those with chronic wounds. During an observation, Nurse #1 entered the resident's room, performed hand hygiene, and wore gloves throughout the wound care process, but did not wear a gown at any point. The resident involved had a documented unstageable pressure injury and was considered high-risk under the facility's EBP policy. Nurse #1 acknowledged during an interview that she had received training on EBP and was aware of the requirement to wear a gown during wound care, but stated she forgot due to being nervous. The Director of Nursing and the Administrator confirmed that Nurse #1 had been trained and should have worn a gown during the procedure.
Failure to Implement Abuse Reporting and Protection Procedures
Penalty
Summary
The facility failed to follow and implement its abuse policy and procedures in two separate cases involving residents with cognitive impairments. In the first case, a resident with severe dementia was struck on the arm by a nursing assistant during care. Another nursing assistant witnessed the incident but did not immediately intervene or report the abuse to the on-duty nurse or administrator. Instead, the witness left the facility at the end of her shift and only reported the incident to the DON after arriving home. As a result, the accused staff member continued to work on the floor with access to other residents until the DON was notified and took action to remove her from the building. The incident was not reported immediately as required by facility policy, and the initial response was delayed. In the second case, an allegation of staff-to-resident abuse was reported to Adult Protective Services (APS) by a resident's roommate. The APS social worker visited the facility to investigate, but the facility's social worker and unit manager did not document or report the allegation to the administrator, state agency, or law enforcement as required. The administrator and DON were unaware of the allegation and the APS investigation until months later, when a letter from APS was found in the social worker's desk. There was no record of the incident in the facility's reportable incidents log, and the required internal investigation and notifications were not completed. Both cases demonstrate failures in immediate reporting, protection of residents, and adherence to established abuse policies. Staff did not follow procedures for timely intervention, reporting, and investigation, resulting in lapses in resident protection and regulatory compliance.
Failure to Verify Resident Representative for Cognitively Impaired Resident Admission
Penalty
Summary
The facility failed to determine whether a resident with advanced dementia had a designated Resident Representative before allowing the resident to sign admission paperwork. The resident, who had a diagnosis of advanced dementia as documented in a hospital discharge summary, was admitted to the facility and subsequently discharged to another skilled nursing facility. The resident's face sheet listed her as the primary contact for financial matters, with a family member as the emergency contact and another family member as the Resident Representative. Despite this, the admission paperwork was signed by the resident herself and witnessed by the former Admission Coordinator. Interviews revealed that the resident's family member, who was her legal representative, was not involved in the admission paperwork process and only became aware of the issue after the resident was transferred to another facility. The family member expressed concern that the resident, due to her dementia, would not have understood the documents she signed. The family member also noted that the resident's spouse, who was present during the signing, was overwhelmed and would not have understood the paperwork either. The family member stated she was available and could have signed the paperwork if contacted. The former Admission Coordinator acknowledged being aware of the resident's dementia diagnosis but stated she was not aware of its severity. She reported that both the resident and her spouse denied having a power of attorney at the time of admission. The Admission Coordinator allowed the resident to sign the paperwork based on her own assessment and the spouse's suggestion. It was only near the time of discharge that the facility received documentation of the legal representative's authority. Both the DON and the Administrator confirmed that the admission paperwork should have been signed by the resident's legal representative due to the resident's cognitive impairment.
Failure to Protect Resident from Physical Abuse by Staff
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident with dementia and hypertension was not protected from physical abuse by a staff member. During evening care, the resident became agitated and combative while being assisted by three nurse aides. According to direct observation by one nurse aide, another nurse aide struck the resident on the left lower arm with an open hand after the resident had hit her. The resident did not respond verbally or physically to being struck, and no injuries were observed during a subsequent assessment. The incident was witnessed by one nurse aide, who did not immediately report the abuse to the on-duty nurse due to fear of confrontation with the involved staff member. Instead, the witness left the facility at the end of her shift and reported the incident to the Director of Nursing after arriving home. Another nurse aide present in the room stated he did not observe the physical abuse but heard the involved aide express frustration toward the resident. The on-duty nurse and Director of Nursing were not made aware of the incident until after the witness had left the facility. The resident's care plan included specific interventions for managing cognitive loss and agitation, such as being patient, breaking tasks into subtasks, and gently redirecting inappropriate actions. Despite these interventions, the staff member's response to the resident's behavior resulted in physical abuse, which was not immediately reported or addressed by those present at the time.
Failure to Implement Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, Lorazepam, prescribed for anxiety and restlessness, had a required 14-day stop date for a resident who was severely cognitively impaired and receiving hospice care. Despite multiple monthly drug regimen review consultation reports from the Consultant Pharmacist recommending discontinuation or the addition of a stop date, the Lorazepam order remained active without a stop date for several months. The physician initially accepted the pharmacist's recommendation but did not specify a stop date, and subsequent recommendations were either not implemented or declined with the rationale that the resident was on hospice care. Interviews with nursing staff and the DON revealed a misunderstanding among staff that hospice residents were exempt from the requirement for PRN psychotropic medication stop dates. The DON was unaware of this belief among staff and was not aware that the medication order lacked a stop date. The Administrator also believed hospice residents should continue their psychotropic medications but acknowledged awareness of the regulatory requirement for stop dates on PRN psychotropic medications.
Expired Nutritional Shakes Found in Nourishment Room
Penalty
Summary
Surveyors observed that four containers of fortified nutritional shake with nectar consistency, all past their use-by date, were found stored in one of the two nourishment rooms. The expired products were discovered during an inspection of the east side nourishment room. The Dietary Manager, when interviewed, stated she was unaware of how the expired containers were missed, despite conducting daily inspections of both nourishment rooms. She suggested that newer staff may have stocked the room incorrectly by placing newer products in front of older ones, which could have led to the expired items being overlooked. The Administrator confirmed awareness of the expired products and stated that all food products should be inspected and removed if expired.
Failure to Remove Medication Patches as Ordered
Penalty
Summary
The facility failed to properly manage the medication regimen for two residents, leading to the presence of unnecessary drugs. Resident #1, who was admitted with heart failure and high blood pressure, had an order for a clonidine patch to be applied once every seven days. However, on 08/25/24, Resident #1 was found with two clonidine patches with different application dates upon arrival at the emergency department. This occurred after Medication Aide #1 was unable to locate the previously applied patch on 08/21/24 and assumed it had fallen off, leading to the application of a new patch without removing the old one. Resident #2, admitted with lower back pain, had an order for a lidocaine patch to be applied daily and removed at bedtime. On 11/26/24, during a medication pass observation, Nurse #3 discovered that the previous day's patch had not been removed as ordered. Nurse #4, who was responsible for Resident #2's care on the evening of 11/25/24, was unaware of the removal order, indicating a lack of communication or clarity in the medication orders. The Director of Nursing acknowledged that the order for lidocaine patch removal was unclear, which may have contributed to the oversight. Both incidents highlight a failure to adhere to physician orders regarding medication administration, resulting in residents having unnecessary medications applied.
Failure to Complete Competency Checks and Orientation
Penalty
Summary
The facility failed to ensure that Nurse #1 and Paramedic #1 had completed their Skills Competency and required floor/unit orientation days with a preceptor before taking a resident assignment independently. Nurse #1 was informed by another nurse that Resident #280 had been excessively sleepy but failed to assess the resident until several hours later. When Nurse #1 finally assessed Resident #280, the resident was only responsive to painful stimuli. Despite being instructed to transfer the resident to the hospital, Nurse #1 did not notify Emergency Medical Services (EMS) and assumed that the oncoming staff member, Paramedic #1, would do so. Paramedic #1 also failed to assess the resident promptly and only called EMS hours later, resulting in a delayed transfer to the hospital where the resident later died. A review of Paramedic #1's job description and Orientation and Skills Competency Checklist revealed that several critical competencies were not completed, including knowledge of tube feeding, resident-centered care, and emergency procedures. The Director of Nursing (DON) had signed off on the checklist despite these gaps. Similarly, Nurse #1's Orientation and Skills Competency Checklist showed that she had not been checked off on essential skills such as Pharmacy Services, Emergency Medications, and Head to Toe Assessment. Both the Staff Development Coordinator (SDC) and the DON admitted to oversight in ensuring these competencies were completed. Resident #280 had a medical history that included a fracture, type 2 diabetes, atrial fibrillation, and heart disease. The resident's condition deteriorated due to the delayed medical response, leading to a hospital transfer where she was diagnosed with metabolic encephalopathy due to a urinary tract infection and possibly other conditions. The resident was later discharged to hospice and subsequently passed away. Interviews with facility staff, including the DON, SDC, and the Administrator, confirmed that the required competencies and orientation were not completed for Nurse #1 and Paramedic #1, leading to the deficient practice and the resident's adverse outcome.
Removal Plan
- Nurse #1 will complete the required days of floor/unit training with a preceptor prior to her next shift assigned to work.
- The Director of Nursing or Designee will sign off competencies for Nurse #1 on the Pharmacy Services, use of emergency medication back up kit, and or electronic medication dispenser (Omni Cell), Stat Meds, Diagnosis for Medication, Review of Required Assessments (paper or EHR), Head to Toe Assessment and Documentation, Device List, Vital Signs prior to next shift assigned to work.
- The Director of Nursing released Paramedic #1 before his notice expired.
- The Director of Nursing or Designee audited the employee files of licensed staff and Paramedics to ensure orientation and skills competency checklist were completed, any negative findings will be corrected immediately, and staff placed back into orientation or skills check off completed for any area missed during orientation.
- The Regional Director of Clinical Services educated the Director of Nursing, Assistant Director of Nursing, Administrator, Scheduler and Human Resources on the orientation process to include the required days of floor/unit training with a preceptor and completion of the skills competency checklist.
- The Director of Nursing or Designee will ensure all newly hired licensed staff have completed the required days of floor/unit training with a preceptor prior to being given an assignment.
- The Assistant Director of Nursing or Designee will complete the skill competency checklist for all newly hired licensed staff and Paramedics. The Director of Nursing or Designee will ensure all newly hired licensed staff and Paramedics have completed skills competency checklist prior to being given an assignment.
- Ad Hoc QAPI was completed related to following orientation policy and ensuring the skill checklist is completed for licensed staff and Paramedics prior to taking their first assignment.
Failure to Monitor and Respond to Diabetic Residents' Conditions
Penalty
Summary
Nursing staff failed to identify the seriousness of a change in condition for a resident with insulin-dependent diabetes and provide thorough ongoing monitoring and comprehensive assessments. On one occasion, a nurse reported that a resident was sleepy all day, but the resident was not assessed until several hours later, at which point she was only responsive to painful stimuli. The nurse did not check the resident's blood sugar and there was a significant delay in contacting Emergency Medical Services (EMS), resulting in the resident being transferred to the emergency room in an unresponsive state with a blood sugar level of 74 mg/dL. The resident was later diagnosed with metabolic encephalopathy and expired after being transferred to hospice care. Another resident with insulin-dependent diabetes was admitted to the facility, but the facility failed to administer sliding scale insulin as per the hospital discharge summary or monitor blood sugar levels according to physician orders. The resident reported extreme thirst and requested a blood sugar check, which revealed a dangerously high level of 548 mg/dL. This indicated a potential diabetic ketoacidosis, a life-threatening complication of diabetes. The facility's failure to monitor and administer insulin as ordered contributed to the resident's critical condition. Additionally, the facility failed to assess a resident for the cause of significant weight gain and edema. The deficient practices occurred for three sampled residents, highlighting a pattern of inadequate monitoring, assessment, and communication among nursing staff. These failures led to immediate jeopardy situations for the residents involved, necessitating corrective actions to address the deficiencies and prevent recurrence.
Removal Plan
- The Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found.
- The Director of Nursing or Designee audited Nursing progress notes to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found.
- The Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately and if they felt they had a delay in treatment.
- The Director of Nursing or Designee audited Nursing progress notes of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted.
- The Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions that were not addressed. No negative findings were noted.
- The Director of Nursing or Designee educated all Certified Nursing Assistants on reporting any change of condition of residents to the nurse immediately. The Director of Nursing or Designee will ensure Certified Nursing Assistants that were not working will be educated prior to their next shift.
- The Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temperature, Oxygen Saturation and Blood Sugar if resident is a Diabetic. The Licensed Nurses and Paramedics that were not working will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working will be educated prior to their next shift.
- Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The staff that were not working will be trained prior to their next shift. The Director of Nursing or Designee will ensure all staff that were not working will be educated prior to their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working will be educated prior to their next shift. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working will be educated prior to their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on recognizing serious decline of cognition and responsiveness of resident as an emergent occurrence and to contact provider and transfer to hospital immediately. The Director of Nursing or Designee will ensure Licensed Nurses and Paramedics that were not working will be educated prior to their next shift.
- Ad Hoc QAPI was completed regarding effective communication between staff in Medical Emergencies, timeliness of assessment, monitoring, and following provider orders to include transferring resident to hospital related to change of condition.
- The Regional Director of Clinical Services educated the Administrator, Director of Nursing, Assistant Director of Nursing, Scheduler and Human Resources on the orientation process that will include education on recognizing change of condition, effective communication during a Medical Emergency, timely assessment and monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation, and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee will ensure newly hired Licensed Nurses or Paramedics receive education during Orientation on the Effective Communication during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee will ensure Agency Staff receive education on Effective Communication during a Medical Emergency, timely assessment, monitoring, and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic prior to first shift of working in facility.
Failure to Provide Timely Emergency Medical Services
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when a resident experienced a medical emergency and emergency medical services (EMS) were not promptly provided. The resident was only responsive to painful stimuli around 5:00 PM, but 911 was not initiated until 8:10 PM. The resident was transferred to the hospital and diagnosed with metabolic encephalopathy due to a urinary tract infection and possibly due to cellulitis/infected lower extremity wounds or hypoglycemia. The resident was later discharged to hospice care and subsequently expired. This incident occurred for one of three residents reviewed for neglect. The resident was admitted to the facility with diagnoses including a fracture of the right fibula, type 2 diabetes, atrial fibrillation, and heart disease. On the day of the incident, the resident was reported to be excessively sleepy, and by 5:00 PM, was only responsive to painful stimuli. Nurse #1, who was responsible for the resident, did not check the resident's blood sugar and only obtained vital signs once. Despite being advised by the on-call provider to send the resident to the emergency room at 6:30 PM, Nurse #1 did not call EMS and left the facility, assuming that Paramedic #1 would handle it. Paramedic #1, who took over the shift, also failed to call EMS immediately and only did so at 8:10 PM after realizing that EMS had not been contacted. The delay in initiating EMS and the lack of ongoing assessment and monitoring contributed to the resident's deteriorating condition. The resident was found to be unresponsive and hypoglycemic by EMS and was transferred to the hospital, where she was diagnosed with metabolic encephalopathy. The facility's Director of Nursing and Administrator acknowledged the errors made by Nurse #1 and Paramedic #1, including the failure to perform head-to-toe assessments, ongoing vital signs, and timely communication with EMS. The incident highlighted significant lapses in the facility's emergency response and monitoring protocols, leading to the resident's decline and eventual death.
Removal Plan
- The Regional Director of Clinical Services educated Nurse #1 and Paramedic #1 on effective communication between staff during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee immediately audited the Situation, Background, Assessment and Recommendation and progress notes of residents sent to hospital to confirm that no delay in assessment, monitoring or transfer to hospital occurred. No negative findings were found.
- The Director of Nursing or Designee audited Nursing progress notes to ensure no change of conditions were found and not followed up on in a timely manner. No negative findings were found.
- The Social Worker/Administrator or Designee interviewed residents with a BIMS of 12 or above regarding if they have had a change of condition that was not followed up on immediately, if they had any concerns of neglect and if they felt they had a delay in treatment. No negative findings were noted.
- The Director of Nursing or Designee audited Nursing progress notes of residents with a BIMS of less than 12 to ensure residents had no change of condition that was not followed up on immediately. No negative findings were noted.
- The Director of Nursing or Designee interviewed all nursing and therapy staff regarding knowledge of any residents having change of conditions that were not addressed and if they were aware of any resident neglect. No negative findings were noted.
- The Director of Nursing or Designee educated all staff on reporting any change of condition to the nurse immediately. The Staff that were not working will be educated prior to start of their next shift.
- The Director of Nursing or Designee educated all staff on effective communication between staff members during a Medical Emergency. The Staff that were not working will be educated prior to start of their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on observing and assessing residents for change of condition from baseline and communicating to provider for follow up and treatment in a timely manner. The Licensed Nurses and Paramedics that were not working will be educated prior to the start of their next shift.
- The Director of Nursing or Designee educated all Licensed Nurses and Paramedics on recognizing serious decline of cognition and responsiveness of resident as an emergent occurrence and to contact provider and transfer to hospital immediately. The Licensed Nurses and Paramedics that were not working will be educated prior to the start of their next shift.
- The Director of Nursing or Designee educated Licensed Nurses and Paramedics on timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic and the Abuse and Neglect Policy. The Licensed Nurses and Paramedics that were not working will be educated prior to the start of their next shift.
- The Director of Nursing or Designee educated all staff on the Abuse and Neglect Policy. The Staff that were not working will be educated prior to start of their next shift.
- Ad Hoc QAPI was completed regarding Abuse and Neglect. In addition, effective communication between staff in Medical Emergencies, timeliness of assessment and monitoring of change of conditions to include transferring resident to hospital.
- The Regional Director of Clinical Services educated the Administrator, Director of Nursing, Assistant Director of Nursing, Scheduler and Human Resources on the Orientation Process that will include education on recognizing change of condition, effective communication during a Medical Emergency, timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic.
- The Director of Nursing or Designee will ensure newly hired Licensed Nurses or Paramedics receive education on the Effective Communication during a Medical Emergency, Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic in Orientation.
- The Director of Nursing or Designee will ensure Agency Staff receive education on Effective Communication during a Medical Emergency, the Abuse and Neglect Policy and timely assessment and monitoring and assessment of change of condition including Blood Pressure, Pulse, Respirations, Temp, oxygen saturation and Blood Sugar if resident is a Diabetic prior to first shift of working in facility.
Failure to Prevent Pressure Injury from Hinged Knee Brace
Penalty
Summary
The facility failed to prevent a pressure injury for a resident wearing a hinged knee brace. The resident, who had a right proximal tibia fracture and required a hinged knee brace, developed an open pressure injury that became infected. The care plan included skin checks and monitoring for changes, but no skin assessments were completed for the right lower extremity initially. The wound was first documented on 1/30/2024, and wound care orders were given, but there were multiple instances where wound care was not documented as performed according to the prescribed schedule. The wound worsened over time, increasing in size and developing dead tissue. Despite the worsening condition, wound care documentation was inconsistent, with several dates missing. The resident's wound care was not consistently performed, and the knee brace was not padded initially, which contributed to the development and worsening of the wound. The Physical Therapy Director was asked to pad the brace only after the wound was identified, and there was no documentation that the brace was evaluated upon the resident's admission. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition. The Paramedic who acted as the Wound Care Nurse did not consistently perform wound care, and the Director of Nursing and Administrator were unaware of the pressure injury. The Physical Therapy Director confirmed that Occupational Therapy should have evaluated the brace upon admission, but no documentation was provided to support that this was done.
Failure to Ensure Safe Transfers for Residents
Penalty
Summary
The facility failed to prevent injury during the transfer of Resident #280 from a wheelchair to the bed, resulting in a laceration to the resident's left lower leg. The incident occurred when two Physical Therapy Assistants (PTAs) were assisting the resident, and a screw protruding from the wheelchair leg caused the injury. Despite the presence of the family member who witnessed the screw, the wheelchair was not taken out of service immediately, and the PTAs did not acknowledge the screw as the cause of the injury. The resident required emergency medical treatment, including sutures for the laceration, and the wheelchair was only padded after the incident occurred. In another incident, the facility failed to provide a safe transfer for Resident #60 by using a sit-to-stand lift that was not suitable for the resident's size. The resident's legs did not fit into the knee brace molds of the lift, and pillows were used to pad the knee brace, which altered the lift and compromised its safety. Despite the Director of Rehabilitation and the Administrator being aware of the issue, the lift was used with the modifications, and the leg safety straps could not be fastened correctly. This practice was against the manufacturer's instructions and posed a risk of injury to the resident. Interviews with staff, including the Director of Nursing (DON) and the Quality Assurance (QA) nurse, revealed that the use of pillows to pad the knee brace was not authorized and was considered unsafe. The sit-to-stand lift company representative confirmed that any modifications, such as adding pillows, would jeopardize the safety of the lift. Despite these concerns, the facility continued to use the altered lift for Resident #60, leading to a deficiency in providing adequate supervision and safe transfer practices.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain clean and sanitary kitchen conditions, as evidenced by debris on the kitchen floor and in the tile grout, dried food particles on a utility cart used to store clean dishware, and dried debris on the steam table hood and outside oven surfaces. Additionally, the facility did not ensure that ready-for-use metal pans, insulated dome plate covers, insulated plate under liners, and dishware were clean and not stacked wet. These issues were observed during two separate kitchen inspections, indicating a pattern of non-compliance with professional standards for food storage, preparation, and service. During an initial tour of the kitchen, it was observed that dishware ready for use was stacked wet and dirty. Specific instances included wet-nested divided plates, insulated plate under liner bottoms, and metal pans. Dirty dishware with yellow, black, brown, and white particles was also noted. The utility cart used to store clean dishes was found to be dirty with loose and dried food particles. The kitchen floors had loose trash and food debris, and the oven and steam table hood had dried food particles and crusted debris. The Dietary Manager (DM) acknowledged these issues, attributing them to short staffing and rushing by the dietary staff. A follow-up observation revealed continued issues with wet-nested and dirty dishware. Despite the DM's education of dietary staff on proper procedures, the problems persisted. Interviews with the DM and a Dietary Aide confirmed the process for cleaning and inspecting dishes, but the staff failed to ensure that dishes were clean and dry before stacking them. The Administrator expressed surprise at the findings and attributed the issues to the kitchen being shorthanded and rushing to complete tasks.
Failure to Accommodate Bariatric Resident's Transfer Needs
Penalty
Summary
The facility failed to accommodate the needs of a bariatric resident who required a mechanical sit-to-stand lift with a larger knee brace for transfers. The resident, who weighed 340.8 lbs and had a history of morbid obesity and nontraumatic intracranial hemorrhage, experienced discomfort and pain during transfers due to the ill-fitting knee brace molds on the sit-to-stand lift. Despite the resident's complaints and the addition of pillows for padding, the discomfort persisted, and the safety of the lift was compromised as the leg safety straps could not be fastened correctly with the added pillows. Interviews with various staff members, including the Director of Rehabilitation, the Maintenance Director, the Quality Assurance nurse, and the Director of Nursing, revealed that the facility was aware of the issue but did not take appropriate action to resolve it. The Maintenance Director had contacted the lift supply company, which did not rent bariatric lifts but sold them. However, no further efforts were made to find a suitable lift from other retailers. The Director of Nursing and the Quality Assurance nurse both acknowledged that using pillows to pad the knee brace was unsafe and altered the lift, yet the practice continued. The Administrator was aware of the resident's discomfort and the need for a bariatric sit-to-stand lift but relied on the Rehabilitation Director's recommendation to use pillows for padding. The lift company representative confirmed that the facility's sit-to-stand lift had an older knee brace model and recommended against using pillows, as it jeopardized the safety of the lift. The failure to provide a suitable lift and the continued use of an altered lift led to the deficiency in accommodating the resident's needs.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to provide Resident #230 with a written notice of a room change, including the reason for the change. Resident #230, who was moderately cognitively impaired and had diagnoses including acute gastric ulcer with perforation, major depressive disorder, and hypertension, was moved from one room to another without prior written notification. The resident was informed verbally by an unknown staff member on the morning of the move, which caused significant distress. The resident's family members were also not properly notified, either verbally or in writing, about the room change. Interviews with facility staff, including the Social Worker, Admissions Director, and Director of Nursing, revealed that the facility's practice was to provide verbal notifications only and that written notices were not given for internal room changes. The Social Worker claimed to have verbally informed a family member, but this was contradicted by the family member's statement. The Admissions Director also stated that a progress note was written for each room change, but no written documentation of the notice was found in the electronic health record. This lack of proper notification violated the resident's right to receive written notice before a room change.
Failure to Accurately Document and Provide Advanced Directives
Penalty
Summary
The facility failed to accurately document the code status of Resident #12 on the Medical Orders for Scope of Treatment (MOST) form. Despite having a Do Not Resuscitate (DNR) order dated 10/6/2023 and a care plan indicating no chest compressions, the MOST form dated 1/24/2024 incorrectly indicated that Resident #12 was a full code. This discrepancy was confirmed by the Social Worker (SW), who admitted to making a mistake on the form. The Nurse Practitioner (NP) and Director of Nursing (DON) were unaware of the inconsistency, and the SW did not document any education provided to the resident or family regarding advanced directives in the medical record. For Resident #280, the facility failed to provide Emergency Medical Services (EMS) with a copy of the resident's advanced directive when she was transferred to the emergency room after being found unresponsive. Despite having a DNR order dated 1/11/2024, the EMS assessment documented that no advanced directives were provided, and the DNR form could not be found. Interviews with the paramedic, SW, Medical Records Coordinator, and QA Nurse revealed that the DNR form was not scanned into the Electronic Health Record (EHR) and was not in the advanced directive book at the nurse's station. The DON was also unaware that the DNR form was missing during the transfer. These deficiencies highlight a lack of proper documentation and communication regarding residents' advanced directives. The facility's staff, including the SW, NP, DON, and Medical Records Coordinator, failed to ensure that the residents' code status and advanced directives were accurately documented and readily available, leading to potential risks during emergency situations.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement their abuse policies and procedures by not submitting an Initial Allegation Report within two hours of being notified of resident neglect. On 4/30/2024 at 6:10 PM, the facility was informed of neglect involving a resident who was only responsive to painful stimuli. Nurse #1 did not initiate Emergency Medical Services (EMS) or perform necessary assessments and monitoring. Paramedic #1, who took over the shift, also failed to perform required assessments and did not notify EMS until 8:10 PM. Despite being aware of the neglect, the facility allowed both Nurse #1 and Paramedic #1 to continue working, placing residents at further risk. The required Initial Investigation Report was not completed promptly, and the facility did not list the accused employees in the report. The Administrator and Regional Nurse Consultant admitted to not following the mandatory two-hour reporting requirement and failing to suspend the involved staff immediately. In another incident, the facility failed to report an allegation of staff-to-resident abuse to administration immediately and did not notify law enforcement. On 1/26/2024, a resident wheeled herself into the nursing station and refused to leave when instructed by Nurse #14. The nurse forcibly removed the resident, leading to a physical altercation. The incident was reported to the Director of Nursing (DON) two days later, who then contacted the administrator. The facility did not notify law enforcement, believing a crime had not been committed. Nurse #14 was terminated during the investigation, but the delay in reporting and failure to notify law enforcement were significant lapses in protocol. These deficiencies highlight the facility's failure to adhere to its abuse and neglect policies, including timely reporting to the Department of Health and law enforcement, and taking immediate steps to protect residents. The lapses in communication and procedural adherence placed residents at risk and demonstrated a lack of proper oversight and response to serious allegations of neglect and abuse.
Failure to Maintain Communication and Implement Dialysis Orders
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis center, assess a resident post dialysis, and implement orders from the dialysis center for fluid restrictions and a renal diet for a resident with end-stage renal disease. The resident's care plan included hemodialysis care and nutrition interventions, but it did not include assessing the dialysis access site, obtaining weight, or vital signs post dialysis. The resident's electronic medical record (EMR) lacked documentation of post dialysis nursing notes, vital signs, and weights for several dates in March and April 2024. Interviews with facility staff revealed that there was supposed to be a communication folder sent back and forth between the facility and the dialysis center, but this was not consistently done. The dialysis center nurse confirmed that the resident had orders for a renal diet and fluid restrictions, which were not communicated to or implemented by the facility. The facility's registered dietician (RD) had not communicated with the dialysis center RD for six months and was unaware of the resident's need for a renal diet and fluid restrictions. The facility's nurses and director of nursing (DON) acknowledged the lack of communication and documentation regarding the resident's dialysis care. The medical director and administrator also confirmed the absence of communication from the dialysis center about the resident's dietary and fluid restriction needs. The facility did not receive routine notes or lab results from the dialysis center unless specifically requested, and there was no special monitoring for the resident when she refused to go to dialysis.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate. This was observed during a medication pass for a resident with diagnoses including diabetes, genitourinary conditions, and a UTI. The resident had a physician's order for Meropenem 1 gram IV to be infused every 8 hours, mixed with 100 mL of 0.9% Normal Saline, and to be infused over 3 hours. However, Nurse #11 administered the medication using a premixed solution from the pharmacy that contained only 50 mL of Normal Saline and programmed the infusion rate incorrectly. Additionally, Nurse #11 failed to flush the IV before administering the medication, as required by the physician's order. Interviews with Nurse #11, the Pharmacy Consultant, the Medical Director, and the Director of Nursing revealed that Nurse #11 was unaware of the need to flush the IV and had assumed the premixed solution from the pharmacy was correct. The Pharmacy Consultant admitted that the pharmacy should have advised the facility to change the order and infusion rate. The Medical Director confirmed that the dose and rate administered would not have been harmful but acknowledged the need for IV flushing. The Director of Nursing reported that Nurse #11 had self-reported the medication errors. These actions and inactions led to the facility's failure to maintain the required medication error rate, affecting the resident's care.
Failure to Secure Medications at Bedside
Penalty
Summary
The facility failed to secure medications found at the bedside for one resident. Resident #53, who was admitted with diagnoses including unspecified dementia, hypertension, and anxiety, was observed with a cup of medications on her bedside table. The resident, who was severely cognitively impaired according to a recent MDS assessment, was unaware of the medications or the need to take them. Nurse #8, responsible for administering medications on the 500 hall, admitted to leaving the medications unattended. The Director of Nursing confirmed that it was against facility policy to leave medications at the bedside and that nurses are expected to observe residents while administering medications.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Device
Penalty
Summary
The facility failed to initiate Enhanced Barrier Precautions (EBP) for a resident with an indwelling vascular access device, specifically a Permacath used for dialysis access. Observations revealed that there was no personal protective equipment (PPE) located outside or inside the resident's room, and staff interviews indicated a lack of clarity and consistency regarding the use of EBP for residents with indwelling devices. The facility's policy required EBP for high-contact care activities for residents with chronic wounds and indwelling devices, but this was not implemented for the resident in question. Interviews with nursing staff and nursing assistants revealed confusion about the necessity of EBP for the resident with the Permacath. Nurse #2 and NA #3 both indicated that they were unsure or had been misinformed about the requirements for EBP, believing it was only necessary for residents with catheters and wounds. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) also acknowledged that the resident should have been on EBP, especially considering the resident's need for assistance with activities of daily living (ADLs) after returning from dialysis. The Medical Director and the facility Administrator confirmed that residents with indwelling devices should be on EBP. The ADON admitted that she had not considered the resident's increased need for assistance post-dialysis when deciding against EBP. The DON also recognized that the resident should have been on EBP if staff had to reinforce the dressing or assist with care when the resident was weak after dialysis. The lack of EBP implementation for the resident with the Permacath represents a failure to adhere to the facility's infection prevention and control program.
Failure to Notify Emergency Contacts and Provider of Significant Changes
Penalty
Summary
The facility failed to notify the emergency contacts when a resident had a change in condition and was sent to the emergency room. Resident #280 was found lethargic and barely arousable, prompting Nurse #1 to contact the on-call physician, who advised sending the resident to the hospital. However, Nurse #1 did not notify the resident's representative of the change in condition or the transfer. Paramedic #1 attempted to call the first emergency contact but only left a generic voicemail and did not make further attempts to contact other emergency contacts. The resident's representative was not aware of the transfer until the hospital ICU nurse called the next day. Both the DON and the Administrator confirmed that the family should have been notified immediately and that multiple attempts should have been made to reach emergency contacts if the first contact was unreachable. The facility also failed to notify the provider of a significant weight gain for another resident, Resident #18, who required diuretic medication. Resident #18 experienced a 7.38% weight gain over a 30-day period, but there was no documentation that the provider had been notified. The QA nurse admitted to not specifically reviewing the weights with the NP or MD and did not remember notifying them of the significant weight gain. The Medical Director and NP were unaware of the weight gain until much later, and both stated that the provider should have been notified sooner. The DON confirmed that the weight gain should have been discussed in clinical meetings and conveyed to the NP/MD promptly. Both deficiencies highlight a failure in communication and notification protocols within the facility. In the case of Resident #280, the lack of immediate notification to the family and multiple emergency contacts was evident. For Resident #18, the significant weight gain and associated health risks were not promptly communicated to the provider, delaying necessary medical intervention. These lapses in protocol were acknowledged by the facility's staff, including the DON and the Administrator.
Failure to Disclose Conflict of Interest in Property Purchase
Penalty
Summary
The Governing Body or its designated person failed to have the Business Office Manager sign a Duty to Disclose Conflict of Interest form and approve or deny a plan to purchase property from a resident. The facility's Ethical Business Practices and Conflicts of Interest policy requires employees to disclose any financial interest or relationship with residents, vendors, or competitors. However, the Business Office Manager did not disclose her interest in purchasing property from a resident, leading to a potential conflict of interest situation. Resident #8, who was cognitively intact and had no exhibited behaviors, sold a double wide, an old house, and a portion of land to the Business Office Manager in May 2023. The resident did not have an advocate during the process and could not recall the sale amount. The Business Office Manager facilitated the sale quickly, involving her spouse and an attorney, without disclosing the transaction to the Corporate Human Resources Representative or the Former Administrator, as required by the facility's policy. Interviews with various staff members, including the Former Nurse Aide, Former Administrator, and Current Administrator, revealed that the Business Office Manager did not follow the facility's conflict of interest policy. The Corporate Human Resources Official confirmed that the Business Office Manager had not submitted any conflict-of-interest documentation and was unaware of the property purchase. The Register of Deeds verified the property transfer to the Business Office Manager and her spouse, further confirming the deficiency in policy implementation.
Failure to Display Survey Results in Accessible Location
Penalty
Summary
The facility failed to display survey results in a location accessible to residents during five observations. During a tour of the facility, the survey results were not observed in the common areas, including the front lobby where a small table under a television screen was empty. Subsequent tours confirmed the absence of survey results in accessible locations. During a Resident Council group meeting, residents indicated that the survey results used to be in a blue notebook in the front lobby. An interview with the DON revealed that the blue notebook was intended to be in the lobby. However, an observation and interview with the Administrator revealed that the survey results were found on a bookshelf in the receptionist's office, which had been moved from the front lobby, and this was an oversight.
Failure to Provide Timely Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a written notice of transfer/discharge to the resident and resident representative and did not send a copy of the notice to the local Ombudsman for one resident reviewed for discharge. Resident #280, who was cognitively intact, was transferred to the hospital due to a change in condition. The nurse on duty did not complete the required notice of transfer/discharge form and was not familiar with the form. The Business Office Manager completed the form the next business day and sent it via certified mail to the resident's home address but did not send a copy to the Ombudsman, as she was unaware of this requirement. Interviews with staff, including the paramedic, nurse, Business Office Manager, Director of Nursing, and Administrator, revealed a lack of understanding and communication regarding the proper procedure for completing and distributing the notice of transfer/discharge form. The Ombudsman confirmed that she had not received any transfer/discharge notices from the facility since January 2024. The Resident Representative received the notice of transfer/discharge on 3/26/2024, significantly later than the transfer date.
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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