Azalea Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, North Carolina.
- Location
- 3800 Independence Boulevard, Wilmington, North Carolina 28412
- CMS Provider Number
- 345557
- Inspections on file
- 25
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Azalea Health & Rehab Center during CMS and state inspections, most recent first.
A resident with osteomyelitis and discitis was admitted with a hospital discharge summary that included a recommendation for IV Penicillin G, but staff failed to transcribe and administer the antibiotic due to its omission from the new medications list. Nursing staff did not clarify the missing order, resulting in six missed doses and unnecessary removal of the PICC line, requiring the resident to return to the hospital for line replacement.
Nursing staff administered a blood pressure medication to a resident despite physician orders to hold the medication if systolic blood pressure was below a specified threshold. The medication was given multiple times when the resident's blood pressure was under the ordered limit, and staff interviews revealed confusion or lack of awareness regarding the correct parameters.
A resident with hypertension had a physician order for Metoprolol Succinate to be held if systolic blood pressure was below 110 mm/Hg. On multiple occasions, staff documented that the medication was administered despite recorded blood pressures below the hold parameter. Interviews confirmed these were documentation errors, with staff acknowledging inaccurate recording of medication administration and blood pressure values.
A resident with dementia and a recent hip fracture was left unattended in a facility van during summer heat, with temperatures between 92 and 94 degrees Fahrenheit. The transporter, distracted by a phone message and frustrated by parking issues, forgot the resident in the van for 10 to 30 minutes. The resident, unable to unhook himself, experienced panic and shortness of breath. The facility staff did not notice the resident was missing until a family member raised the alarm. The resident was eventually found and assessed, with no physical injuries reported.
A resident was left unsupervised in a facility van for up to 10 minutes. Upon return, a Nurse Practitioner assessed the resident and instructed a nurse to obtain vital signs, which were not documented in the medical record. The nurse later found a sticky note with the vital signs but without a date, time, or resident name. The DON was unaware of the lack of documentation.
A resident experienced significant emotional distress due to the aggressive and rude behavior of a Nursing Assistant (NA). The NA's actions included throwing incontinence wipes at the resident and speaking derogatorily about her to other staff. The resident, who was already feeling weak after a recent hospital stay, was left crying inconsolably. The NA was later terminated for poor customer service and refusing to provide care.
The facility failed to have sufficient dietary staff, resulting in delayed meal delivery and incomplete meal trays for all 74 residents. Interviews and observations confirmed that the kitchen was understaffed due to budget cuts and difficulty retaining staff, leading to inconsistent meal times and missing items on meal trays.
The facility failed to maintain the cleanliness and proper closure of the dumpster area, leading to scattered debris and missing doors on dumpsters, which exposed trash to the elements and pests. The Environmental Services Department was understaffed due to the recent resignation of the Director, causing delays in maintenance tasks.
The facility's QAPI program failed to maintain procedures and monitor interventions, leading to repeated deficiencies in areas such as medication administration, weight recording, medication storage, dietary staffing, and food sanitation. These issues were attributed to staff turnover and reliance on agency staff, with efforts underway to recruit and educate new staff.
The facility failed to store hand-held plastic scoops outside of dry food bins and did not properly wash and sanitize dishes according to FDA Food Code recommendations. The concentration of the quaternary sanitizing solution was inadequate, and the kitchen's only red sanitizing bucket was found dry and empty.
The facility failed to provide effective leadership and implement systems to ensure the availability of essential supplies, affecting all 74 residents reviewed. Staff had to ration items like trash bags and medication cups due to supply shortages. The Medical Records/Central Supply Manager confirmed the issue, and various staff members, including nurses and housekeepers, reported ongoing supply shortages. The Director of Nursing acknowledged the problem, and the Administrator emphasized the need for better communication to address such issues.
The facility failed to provide the required CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) forms to residents prior to the termination of Medicare Part A skilled services. Specifically, two residents did not have the SNF ABN forms completed with the necessary options checked, and another resident and their representative were not provided with the CMS form 10123 prior to discharge.
The facility failed to prevent the DON from having a resident care assignment, including working on the medication cart, despite a census of over 60 residents. The DON was assigned to various shifts and halls, and her electronic signature was found on MARs for medication administration. Interviews confirmed that the DON worked on the medication cart due to staffing shortages and call-outs, despite regulations requiring the DON to be a full-time DON without performing patient care assignments.
The facility failed to provide physician-ordered low concentrated sweets (LCS) therapeutic diets to two diabetic residents, resulting in them receiving regular foods with high-sugar content. Staff interviews and observations confirmed that the facility's dietary practices did not align with the prescribed dietary guidelines.
The facility failed to obtain physician-ordered weights for seven residents and provide a nutritional supplement for one resident, leading to deficiencies in maintaining residents' health. The system for recording and monitoring weights was not effectively implemented, and the prescribed nutritional supplement was consistently missing from meal trays.
A facility failed to provide packed meals for a dialysis resident who left early in the morning and did not return until lunchtime. Despite the care plan indicating that a packed meal should be provided, the resident often had to request a bagged meal and sometimes could not find a staff member to assist. Interviews revealed a lack of communication and awareness among staff regarding the preparation and provision of bagged meals.
The facility failed to implement the treatment protocol for a newly acquired nephrostomy tube for a resident following hospitalization. The nephrostomy tube and insertion site were not monitored for 8 days, and there were no physician orders or documentation for its care. Staff interviews revealed a lack of awareness and implementation of the care protocol.
The facility failed to store an opened bottle of lorazepam in a locked box and did not label a bottle of lispro insulin with an opened date. Staff were aware of the broken lock but did not report it, and the DON admitted to breaking the key weeks ago without securing the narcotics properly. Additionally, an open vial of insulin was found without an opened date.
The facility failed to administer prescribed medications according to physician orders for two residents. One resident did not receive the full course of a topical antibiotic ointment following a dermatology procedure, and another resident did not receive the full course of antibiotic ophthalmic drops for episcleritis. There was no documentation explaining the missed doses, and the responsible nurses could not be contacted. Both residents did not experience adverse outcomes, but the facility failed to follow physician orders and properly document medication administration.
The facility failed to follow physician orders for the administration method of enteral feeding and the calculated amount of water flush for two residents. One resident did not receive enteral feeding via pump as prescribed, and another resident's gastrostomy tube was not flushed as required for four days following admission.
The facility failed to post accurate nurse staffing information for 15 out of 84 days reviewed. The daily posted staffing sheets were either blank or incomplete, lacking details such as the number of licensed and unlicensed staff members working each shift, the hours worked, and the resident census. The Unit Manager responsible for this task was not in the facility on the missing dates and no back-up person was assigned.
The facility failed to complete discharge MDS assessments for three residents who were discharged to the hospital or community. Interviews with the MDS Nurse and MDS Coordinator revealed uncertainty about why the assessments were not completed, and the Administrator confirmed that the assessments should have been done within the required timeframes.
The facility failed to accurately code the MDS assessments for two residents, resulting in incomplete evaluations for cognition and mood due to the absence of the social worker. The Administrator confirmed that MDS assessments are expected to be completed as per Federal guidelines.
Missed IV Antibiotic Orders Due to Incomplete Discharge Summary Review
Penalty
Summary
A deficiency occurred when facility staff failed to thoroughly review a hospital discharge summary and clarify physician orders for a newly admitted resident with diagnoses of osteomyelitis and discitis. The discharge summary, spanning 14 pages, included a recommendation for Penicillin G IV every 4 hours for 6 weeks, but this order was not listed on the new medications list. Staff transcribed and administered only the Heparin and Sodium Chloride flushes for the resident's PICC line, omitting the antibiotic order. Nurse #6, responsible for the admission, reviewed the new medications list and discussed it with the on-call Physician Assistant, but did not identify or clarify the missing antibiotic order. Nurse #5, who performed a second check, also failed to locate the antibiotic order and, based on the absence of an explicit order and an instruction to remove the PICC line after the last antibiotic dose, removed the PICC line. This action was taken without confirming with the physician whether the antibiotic course was complete, despite the discharge summary containing instructions to call with any questions regarding antibiotics. The omission resulted in the resident missing six doses of Penicillin G and necessitated a return to the hospital for PICC line replacement. Interviews with staff and the DON confirmed that the antibiotic order was present in the discharge summary but not clearly listed, leading to confusion and lack of clarification. The resident, who was severely cognitively impaired, did not experience further complications from the missed doses, but the error was attributed to incomplete review and failure to clarify ambiguous or missing orders.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
Nursing staff failed to follow physician-ordered parameters for administering a blood pressure medication to a resident with a history of hypertension and episodes of low blood pressure. The physician's order specified that Metoprolol Succinate 25 mg should be held if the resident's systolic blood pressure (SBP) was less than 110 mm/Hg. Despite this, medication administration records showed that the medication was given on multiple occasions when the resident's SBP was below the ordered threshold. Specific instances included administration when SBP readings were 101, 105, 93, 103, 97, and 109 mm/Hg, all of which were below the 110 mm/Hg parameter set by the physician. Interviews with nursing staff revealed a lack of awareness or misunderstanding of the specific hold parameters, with one nurse incorrectly recalling the threshold as 100 mm/Hg and another unable to explain why the medication was administered outside the parameters. The nurse practitioner and Director of Nursing both confirmed that the medication should not have been given when the SBP was below 110 mm/Hg, as per the physician's order. The failure to adhere to the medication hold parameters resulted in the resident receiving unnecessary doses of blood pressure medication.
Inaccurate Documentation of Blood Pressure Medication Administration
Penalty
Summary
The facility failed to maintain a complete and accurate medication administration record for a resident with a diagnosis of high blood pressure. Physician orders specified that Metoprolol Succinate 25 mg should be held if the resident's systolic blood pressure (SBP) was less than 110 mm/Hg. However, review of the medication administration records for April and May 2025 showed that the medication was documented as given on several occasions when the recorded SBP was below the specified threshold. Specifically, on three separate dates, the medication was signed off as administered despite SBP readings of 105/60 mm/Hg, 105/58 mm/Hg, and 108/64 mm/Hg, all of which were below the hold parameter. Interviews with the involved nursing staff and medication aide revealed that these were documentation errors. Staff admitted to inaccurately recording that the medication was given when it should have been documented as held, or to recording the wrong blood pressure value. The nurse practitioner and Director of Nursing both stated that they expect accurate documentation of medication administration, as this information is relied upon for clinical decision-making and ongoing care.
Resident Left Unattended in Facility Van
Penalty
Summary
The facility failed to prevent a resident from being left unsupervised in the facility's transportation van. The incident occurred when the transporter left the resident in the van with the doors and windows closed and the engine turned off during midday in the summer heat. The resident, who had a diagnosis of dementia, right hip fracture, and muscle weakness, was left in the van for approximately 10 to 30 minutes, with outside temperatures ranging from 92 to 94 degrees Fahrenheit. The resident was not discovered missing until a family member arrived at the facility and could not locate him. The transporter, who had been employed at the facility for six years and had been the transporter for two years, forgot the resident in the van after becoming frustrated with the parking situation and distracted by a message on her phone. The transporter had parked the van in an unshaded area and left the resident secured in his wheelchair, unable to unhook himself or open the emergency window fully. The resident reported feeling panicked, short of breath, and scared, believing he was going to die due to the heat. The facility staff did not realize the resident was missing until the family member raised the alarm. The transporter eventually remembered the resident was in the van and brought him inside, where he was assessed by the Nurse Practitioner. The resident did not sustain any physical injuries, but the situation posed a high likelihood of serious harm, including heat stroke. Interviews with various staff members revealed a lack of awareness and communication regarding the resident's whereabouts during the incident.
Removal Plan
- All future appointments for Resident #1 will be scheduled with a contract transportation company.
- The root cause analysis was completed by the Administrator and determined that the normal drop-off area was blocked. After an extended wait time in the transport area, Transporter #1 left the transport area and parked the van in the parking lot near the maintenance shed and forgot Resident #1 was on the van.
- The Administrator reviewed the transportation schedules and interviewed all alert and oriented residents to ensure there were no additional residents left unattended on the facility van.
- The Director of Nursing and Unit Manager reviewed the medical record of all cognitively impaired residents that were transported by the facility to identify any change in condition that may have been the result of being left unattended on the facility van. No additional residents were affected.
- In-house transport was ceased. All resident transportations were completed by a contract transportation company.
- Signs were added to the resident drop-off area to discourage visitors and staff from blocking the entrance.
- The Administrator educated Transporter #1 regarding the new process of ensuring a second staff member validates and signs off on the transport log when residents return to the facility.
- Administrative staff, which include the Business Office Manager, the Social Worker, the Scheduler, the Activity Assistant, the Admissions Coordinator, the Maintenance Assistant, the facility Receptionist and the Minimum Data Set Nurse were educated on performing a second check upon any resident return from transport by the Administrator.
- The Maintenance Assistant is the only additional person that has been trained to transport residents and he was educated on the process change by the Administrator.
- The Quality Assurance Performance Improvement team reviewed the incident and decided on the plan of correction.
- The Administrator will review the transport logs 5 times per week for 6 weeks to ensure there is a second staff member validating the residents are brought into the facility immediately upon return.
- The audits will be reviewed by the Quality Assurance Performance Improvement committee monthly for two months to ensure the systemic change is sustainable.
- The first day of monitoring started when the facility resumed in-house transportation.
Failure to Document Vital Signs
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was left unsupervised in a facility van for up to 10 minutes. Upon the resident's return to the facility, a Nurse Practitioner assessed the resident but did not include vital signs in the assessment. The Nurse Practitioner instructed a nurse to obtain the resident's vital signs. However, the nurse did not document these vital signs in the electronic medical record. The nurse later found a sticky note in her bag with the resident's vital signs, but it lacked a date, time, and resident name. The Director of Nursing was unaware that the vital signs had not been documented and expected all vital signs to be recorded in the medical record. The nurse provided a written statement attesting to the accuracy of the vital signs taken.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a Nursing Assistant (NA) spoke to a resident in a manner that caused significant emotional distress. The resident, who was admitted with anxiety, worsening generalized weakness, peripheral numbness, and recurrent falls, was observed crying inconsolably following an interaction with the NA. The resident reported that the NA was aggressive, loud, heavy-handed, and rude, which made her feel nervous, anxious, and as if she was going to have a panic attack. The incident occurred when the resident, feeling weak after a recent hospital stay, used her call bell to request assistance. The NA responded aggressively, threw incontinence wipes at the resident, and spoke loudly about her to other staff members in a derogatory manner. The resident felt that the NA was frustrated with her for requiring assistance and made her feel bad. Another staff member had to take over the care for the rest of the shift. Interviews with other staff members corroborated the resident's account. Another NA who assisted during the incident observed the resident crying and noted that the NA in question was visibly frustrated. The NA in question admitted to having a poor rapport with the resident and acknowledged that she should not have been assigned to her. The NA also mentioned that she had a heart attack and could not pull on residents, which contributed to her frustration. The interim Director of Nursing (DON) and other staff members were informed of the incident, and the NA was suspended pending investigation and later terminated for poor customer service and refusing to provide care. The facility's response included interviews with other residents and staff to identify any additional issues, but no other problems were found. The facility also conducted skin checks on cognitively impaired residents to ensure there were no signs of mistreatment. The incident was reviewed by the Quality Assurance Performance Improvement (QAPI) committee, and corrective actions were implemented to prevent future occurrences. The facility provided education and training on resident rights and the treatment of residents with dignity and respect to all staff members, including agency staff.
Inadequate Dietary Staffing Leading to Delayed Meal Delivery
Penalty
Summary
The facility failed to have sufficient dietary staff to ensure meals were delivered at the posted mealtimes, impacting all 74 residents who received oral nutrition. The Dietary Manager (DM) reported that two kitchen staff called out on the morning of the survey, leaving only one kitchen aide and himself to prepare and clean up after breakfast and lunch. The DM disclosed that the kitchen was understaffed due to budget cuts and difficulty in retaining staff, leading to meals being served late. Observations and interviews with residents and staff confirmed that meal delivery times were inconsistent, and residents often did not receive their meals on time or as ordered, such as missing nutritional shakes on meal trays for Resident #274 on multiple occasions. Interviews with various kitchen staff revealed that the kitchen had been short-staffed for over six months, with the situation being known to upper management. Staff reported working long hours and double shifts to compensate for the lack of personnel, but still struggled to deliver meals on time. The Dietary Manager confirmed that the kitchen required at least three kitchen aides, one cook, and himself to operate efficiently, but often had only one or two staff members per shift. The Administrator, who had been in her role for five months, acknowledged the staffing issues and stated that she had been actively recruiting to fill the vacancies. A review of the dietary staff schedules over a 93-day period showed multiple instances of inadequate staffing, with some days having only one or two kitchen staff scheduled for the entire day. The posted meal schedule indicated specific times for breakfast, lunch, and dinner, but observations and resident interviews confirmed that these times were not consistently met. The deficiency in staffing led to significant delays in meal delivery and incomplete meal trays, directly impacting the residents' nutrition and overall well-being.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure the area surrounding dumpsters remained free of garbage and debris and to close and/or replace all missing doors to the dumpsters that contained waste. During an observation with the Dietary Manager, it was noted that there was scattered debris, branches, and leaves around the sides and back area of the dumpster enclosure. Additionally, both the right dumpster sliding door and the right half of the gate to the dumpster enclosure were missing, leaving trash contents and large amounts of debris exposed to the elements and available to pests and rodents. Interviews with the Dietary Manager and the Environmental Services Department Assistant revealed that it was the responsibility of the Environmental Services Department to maintain the cleanliness and proper closure of the dumpster area. The Environmental Services Department Director had recently resigned, leaving the assistant to manage the department and causing delays in maintenance tasks. The Administrator confirmed that they were in the process of hiring a new Environmental Services Department Director and expected maintenance to keep the dumpster area clean and free of debris.
Repeated Deficiencies in QAPI Program and Resident Care
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program failed to maintain implemented procedures and monitor interventions following multiple surveys and complaint investigations. These deficiencies were noted in areas such as Quality of Care, Nutrition/Hydration Status Maintenance, Labeling and Storing Drugs & Biologicals, Sufficient Dietary Support Personnel, and Food Procurement, Storage, Preparation, and Serving. Specific incidents included the failure to administer prescribed medications correctly, obtain and record accurate weights, store medications properly, and maintain sufficient dietary staff to ensure timely meal delivery. Additionally, the facility failed to adhere to proper food storage and sanitation practices, such as storing hand-held plastic scoops outside of dry food bins and maintaining appropriate sanitizing solutions in the kitchen. The deficiencies were observed across multiple surveys, indicating a pattern of non-compliance. For instance, the facility failed to administer a topical antibiotic ointment and ophthalmic drops as prescribed for two residents, and did not obtain physician-ordered weights for several residents. The facility also failed to store medications securely and label them with the opened date. Furthermore, the facility did not have enough dietary staff to deliver meals on time and did not follow proper food storage and sanitation protocols. Interviews with the Administrator and Corporate Nurse Consultant revealed that these issues were primarily due to increased staff turnover and reliance on agency staff, with ongoing efforts to recruit new staff and provide continued education to ensure adherence to policies and procedures.
Improper Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to store hand-held plastic scoops outside of two out of three dry food bins containing flour and sugar. During an initial tour, it was observed that the scoops were stored directly in the food items. The Dietary Manager (DM) confirmed that the expectation was for scoops to be stored in a closed container outside of each bin. The Administrator also confirmed that dietary staff were expected to follow the facility's sanitation guidelines. Additionally, the facility did not properly wash and sanitize dishes in the three-compartment sink according to Food and Drug Administration Food Code recommendations. The concentration of the quaternary sanitizing solution was found to be less than 50 parts per million (ppm), and the kitchen's only red sanitizing bucket was dry and empty. The DM admitted to using a store-bought bleach disinfectant spray instead, which could not be tested for ppm effectiveness. Follow-up observations revealed that the DM later corrected the sanitizing solution concentrations and placed filled red buckets under the food preparation tables, but initially, the sanitizing practices were inadequate.
Facility Fails to Maintain Essential Supplies
Penalty
Summary
The facility failed to provide effective leadership and implement effective systems to ensure the availability of essential supplies such as garbage liners, toilet tissue, paper towels, and medication cups. This deficiency affected all 74 residents reviewed for Administration. An anonymous grievance filed on 09/05/23 highlighted that the facility often ran out of supplies, forcing staff to ration items like trash bags, straws, and medication cups. The Medical Records/Central Supply Manager (CSM) confirmed that the supply delivery truck comes once a week, and she was responsible for ordering supplies for both housekeeping and maintenance after the Environmental Services Director resigned. Despite ordering supplies on 03/20/24, the delivery was still pending, leading to a shortage of essential items like toilet paper and trash bags. A tour of the facility's main supply room on 03/26/24 revealed a lack of large and medium trash can liners, toilet paper, and paper towels, although there were 800 plastic medication cups available. Interviews with various staff members, including nurses and housekeepers, confirmed the ongoing issue of supply shortages, which affected their ability to perform their duties effectively. The Director of Nursing (DON) acknowledged the supply issues and stated that existing staff were working hard to order the necessary supplies. The Dietary Manager mentioned that he had to pick up trash can liners from a sister facility due to the shortage. The Administrator admitted that she was unaware of the staff's difficulties in obtaining supplies from the current vendor and emphasized the need for better communication to address such issues in the future.
Failure to Provide Required CMS Notices Prior to Termination of Medicare Part A Services
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) forms to residents prior to the termination of Medicare Part A skilled services. Specifically, Resident #18 and Resident #66 did not have the SNF ABN forms completed with the necessary options checked for the decision regarding continued Medicare Part A services. Additionally, Resident #324 and their representative were not provided with the CMS form 10123 prior to discharge from Medicare Part A skilled services. The facility Social Worker admitted to neglecting to have the Resident Representatives choose an option on the SNF ABN forms and was unable to locate the completed forms for Resident #324 due to being on leave during the discharge period. The facility Business Manager, who assisted during the Social Worker's absence, also could not locate the facility copies of the forms for Resident #324. Interviews with the facility Social Worker and Administrator confirmed that the proper procedures for completing and documenting the SNF ABN and NOMNC forms were not followed. The Social Worker stated that her usual process involves contacting the Resident's Representative to inform them of the end of Medicare Part A services and providing the necessary CMS forms, either in person or via mail. However, this process was not adhered to in the cases of Residents #18, #66, and #324, leading to a failure in ensuring that residents and their representatives were adequately informed about their Medicare coverage and potential liability for services not covered.
DON Assigned to Resident Care Duties Despite Staffing Regulations
Penalty
Summary
The facility failed to prevent the Director of Nursing (DON) from having a resident care assignment, including working on the medication cart, despite having a census of greater than 60 residents. This occurred for seven days as evidenced by the facility assignment sheets and Medication Administration Records (MAR) reviewed. The DON was assigned to various shifts and halls, and her electronic signature was found on MARs for medication administration on multiple occasions. Interviews with the Administrator, interim DON, facility scheduler, and Regional Nursing Consultant confirmed that the DON had been working on the medication cart due to staffing shortages and call-outs, despite the regulation requiring the DON to be a full-time DON without performing patient care assignments. The Administrator and interim DON were unaware of the regulation prohibiting the DON from working on patient care assignments. The facility scheduler and Regional Nursing Consultant also confirmed that the DON had been working on the medication cart frequently due to sudden nurse departures and staffing issues. The facility had recently switched to a different human resources system and renewed contracts with temporary agencies to address the staffing shortages. Despite these efforts, the DON continued to be included in the on-call rotation and worked patient care shifts when needed, leading to the deficiency identified in the report.
Failure to Provide Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to provide physician-ordered low concentrated sweets (LCS) therapeutic diets to two diabetic residents. Resident #34, who was admitted with a diagnosis of diabetes and long-term insulin use, had a physician's order for an LCS diet. However, observations and interviews revealed that Resident #34 received regular foods with regular portion sizes, including high-sugar snacks and desserts. The Regional Dietary Manager and Dietary Manager confirmed that the facility provided liberalized diets and served smaller portions of sugary foods to residents on LCS diets, but this practice did not align with the physician's orders. The Registered Dietician acknowledged that residents on LCS diets should receive foods consistent with dietary guidelines, and the Nurse Practitioner was unaware that therapeutic diets were not being followed as prescribed. Similarly, Resident #48, who was admitted with a diagnosis of diabetes and a left below-knee amputation, had a physician's order for an LCS and no added salt diet. Despite this, Resident #48 reported receiving regular foods, including high-sugar items like jelly, syrup, and desserts. Observations confirmed that Resident #48's meals included regular portion sizes and high-sugar foods. The Registered Dietician indicated that Resident #48 should receive foods consistent with the prescribed diet, and the Director of Nursing attributed the inconsistency to high staff turnover in the kitchen. The Administrator expected therapeutic diets to be provided according to physician orders. The deficiency was further highlighted by interviews with various staff members, including a Dietary Aide/Cook who was unaware of the specific guidelines for diabetic diets versus regular diets. The facility's failure to adhere to physician-ordered therapeutic diets for diabetic residents was evident through multiple observations and staff interviews, indicating a systemic issue in the dietary management and compliance with prescribed dietary guidelines.
Failure to Obtain Physician-Ordered Weights and Provide Nutritional Supplements
Penalty
Summary
The facility failed to obtain physician-ordered weights for seven residents and provide a nutritional supplement for one resident, leading to deficiencies in maintaining residents' health. Resident #274, who was admitted with diagnoses including protein-calorie malnutrition and congestive heart failure, had a physician's order for daily weights that were not consistently recorded. Despite a care plan indicating the need for daily weights, the facility's system for recording and monitoring weights was not effectively implemented, leading to missed weight recordings. Interviews with staff revealed that the responsibility for obtaining and recording weights was not clearly defined, and the use of agency staff contributed to the inconsistency. Additionally, Resident #274 did not receive the prescribed nutritional supplement with meals. Observations of meal trays over several days showed that the 4-ounce nutritional shake was consistently missing, despite being listed on the meal tray tickets. Interviews with the resident, staff, and the Dietary Manager confirmed that the nutritional shake was not provided as ordered. The Dietary Manager acknowledged that the kitchen staff failed to include the shake on the meal trays, and the oversight was not corrected by the nurse aides responsible for checking the meal tickets. Other residents, including Resident #5, Resident #31, Resident #24, Resident #47, Resident #48, and Resident #26, also had issues with obtaining and recording weights as per physician orders. These residents had various diagnoses requiring close monitoring of their weights, but the facility's failure to consistently obtain and document weights compromised their nutritional and health status. Interviews with the Registered Dietician, Nurse Practitioner, and Director of Nursing highlighted the systemic issues in the facility's weight monitoring process, including staffing problems and lack of adherence to protocols.
Failure to Provide Packed Meals for Dialysis Resident
Penalty
Summary
The facility failed to provide packed meals for a dialysis resident who left the facility early in the morning and did not return until lunchtime three days a week. Resident #279, who had end-stage renal disease and was dependent on renal dialysis, did not receive breakfast before leaving for dialysis. Despite the care plan indicating that a packed meal should be provided on dialysis days, the resident reported that he often had to request a bagged meal and sometimes could not find a staff member to assist him. The dietary manager and staff were unaware that bagged meals were not consistently prepared and placed in the nourishment room the night before for early morning dialysis residents. Interviews with the dietary manager, nurse, and registered dietician revealed a lack of communication and awareness regarding the preparation and provision of bagged meals for dialysis residents. The dietary manager stated that bagged meals were supposed to be prepared the night before, but this was not consistently done. The registered dietician emphasized the importance of providing three meals a day to prevent protein deficiency. The administrator expected dietary staff to provide bagged meals without residents having to ask, but was unaware of the issue until it was brought to her attention.
Failure to Implement Nephrostomy Tube Care Protocol
Penalty
Summary
The facility failed to implement the treatment protocol for a newly acquired nephrostomy tube for a resident following hospitalization. The treatment protocol included monitoring the insertion site for signs and symptoms of infection, providing daily dressing changes, monitoring and recording urine output, and checking the tube for kinks or obstructions. However, the nephrostomy tube and insertion site were not monitored for 8 days after the resident's return from the hospital. The resident was uncertain if the dressing was being changed or if the urine collection chamber had been emptied. An observation revealed that the insertion site had no dressing, and the old dressing was found in the bed. The nurse on duty, who was an agency nurse, was unsure of the dressing change frequency and applied a clean dressing during the observation. The resident's physician orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) had no documentation for the care and treatment of the nephrostomy tube. Interviews with the staff revealed a lack of awareness and implementation of the nephrostomy tube care protocol. The nurse routinely assigned to the resident stated she did not have to do anything with the nephrostomy tube. The Director of Nursing (DON) confirmed that the facility had a protocol for nephrostomy tube care, which included monitoring the insertion site every shift, changing the dressing daily, and recording urine output. However, the admitting nurse did not implement these procedures upon the resident's return from the hospital. The Minimum Data Set (MDS) nurse later implemented a care plan that included nephrostomy tube care, but this was after the deficiency was identified.
Failure to Properly Store and Label Medications
Penalty
Summary
The facility failed to store an opened bottle of lorazepam in a locked box within the medication refrigerator and did not label a bottle of lispro insulin with an opened date in the Hibiscus Pharmacy Room. During an observation, it was found that the refrigerator in the medication storage room was unlocked, and an unlocked box inside contained two bottles of lorazepam, one of which was opened. Nurse #12 discovered that the key to the box was broken, and the issue had not been reported by the off-going nurse. The Corporate Nurse Consultant confirmed that narcotics should be double locked and immediately removed the bottles to a secure location. The Administrator and Unit Manager were unaware of the broken key and emphasized that the issue should have been reported immediately. Further interviews revealed that Nurse #8, who worked on the 100 hall, was aware of the broken lock but did not report it, assuming it was acceptable since the medication room was locked. Nurse #6 also knew about the broken lock but did not report it, believing it was the responsibility of another nurse. The Director of Nursing (DON) admitted to breaking the key in the lock several weeks ago and reported it to the previous DON and the pharmacy. However, the narcotics were not moved to a secure location, and the maintenance director was informed but did not replace the box. The Maintenance Assistant was only informed of the issue recently. Additionally, an open vial of lispro insulin for a resident was found without an opened date. Nurse #12 acknowledged that insulin should be dated when opened, and the DON and Administrator confirmed that they expected medications to be stored and labeled properly. The failure to store and label medications correctly was observed and confirmed through multiple staff interviews.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer prescribed medications according to physician orders for two residents. Resident #48, who was admitted with diagnoses including malignant melanoma and diabetes, did not receive the full course of a prescribed topical antibiotic ointment following a dermatology procedure. The medication was scheduled to be administered twice daily for three days, but only two out of six doses were given. There was no documentation explaining the missed doses, and attempts to contact the responsible nurses were unsuccessful. The Corporate Nurse Consultant and Director of Nursing confirmed the medication should have been administered as prescribed, but it was not, and there was no documentation to explain the missed doses. Resident #43, admitted with diagnoses including cerebral vascular accident and dementia, did not receive the full course of prescribed antibiotic ophthalmic drops for episcleritis. The medication was scheduled to be administered four times a day for five days, but only 15 out of 20 doses were given. The first five doses were missed, and there was no documentation explaining why. The Corporate Nurse Consultant stated the medication was not received until the night after it was ordered, and the administration dates should have been adjusted in the electronic medical record to ensure the full course was given. The Director of Nursing and Nurse Practitioner confirmed the medication should have been administered as prescribed, but it was not, and there was no documentation to explain the missed doses. Both residents did not experience any adverse outcomes from the missed doses, but the facility failed to follow physician orders and properly document the administration of medications. The lack of documentation and failure to administer the full course of prescribed treatments indicate deficiencies in the facility's medication administration and record-keeping processes.
Failure to Follow Physician Orders for Enteral Feeding and Water Flush
Penalty
Summary
The facility failed to follow a physician's order for the administration method of enteral feeding and the calculated amount of water flush for two residents. Resident #26, who had severe cognitive impairment and relied entirely on tube feeding for nutrition and hydration, did not receive the prescribed enteral feeding via pump. Instead, Nurse #1 administered the feeding using a syringe via gravity, estimating the amount of water rather than measuring it according to the order. This deviation from the physician's order was confirmed through interviews with the Nurse Practitioner, Director of Nursing, Registered Dietician, and Regional Nurse Consultant, all of whom expected the orders to be followed as written. Resident #274, admitted with a gastrostomy tube, did not have the tube flushed every six hours with 30 milliliters of water for four days following admission. The physician's order to flush the tube every shift with 100 milliliters of water was not entered into the electronic medical record until four days after admission. This oversight led to the gastrostomy tube not being flushed as required, which was confirmed through interviews with the resident, admitting nurse, Director of Nursing, and Corporate Nurse Consultant. The resident expressed concern about the tube getting stopped up due to the lack of flushing. Both deficiencies highlight a failure in the facility's protocol for managing enteral feeding tubes and ensuring physician orders are accurately followed. The Director of Nursing and other staff members acknowledged the lapses and indicated that the expected procedures were not adhered to, leading to potential risks for the residents involved.
Failure to Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate nurse staffing information for 15 out of 84 days reviewed from January 2024 through March 24, 2024. The daily posted staffing sheets for these dates were either blank or incomplete, lacking details such as the number of licensed and unlicensed staff members working each shift, the hours worked, and the resident census. Unit Manager #1, who was responsible for completing the daily posted staffing, was not in the facility on the dates the information was missing and was unsure who was responsible in his absence. The Administrator confirmed that no back-up person was assigned to post the staffing information when Unit Manager #1 was not available.
Failure to Complete Discharge MDS Assessments
Penalty
Summary
The facility failed to complete discharge Minimum Data Set (MDS) assessments for three residents who were reviewed for discharge. Resident #63 was admitted to the facility and discharged to the hospital on 10/2/23, but the MDS records did not include a discharge assessment for that date. Interviews with the MDS Nurse and MDS Coordinator revealed that they were unsure why the discharge assessment was not completed. The Administrator confirmed that the discharge assessment should have been completed within the required timeframes. Similarly, Resident #13 was admitted to the facility and discharged to the community on 10/23/23, and Resident #52 was admitted and discharged to the community on 10/16/23. Both residents' MDS records lacked discharge assessments for their respective discharge dates. Interviews with the MDS Nurse and MDS Coordinator indicated uncertainty about why these assessments were overlooked. The Administrator acknowledged that the discharge assessments should have been completed as required.
Incomplete MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for two residents, leading to deficiencies in their care assessments. Resident #38, who was admitted with diagnoses including dementia and depression, had a significant change in status MDS assessment that did not include an assessment for cognition. The cognition section was left incomplete, and the MDS nurse indicated that this should have been done by the facility social worker, who was out of the facility at the time. The Administrator confirmed that MDS assessments are expected to be completed as per Federal guidelines. Similarly, Resident #323, admitted with diagnoses including heart failure and depression, had two quarterly MDS assessments that were incomplete. The first assessment did not include an evaluation for cognition, and the second did not include an assessment for mood. Both sections were left incomplete, and the MDS nurse again indicated that these assessments should have been conducted by the social worker, who was absent. The Administrator reiterated the expectation for MDS assessments to be completed according to Federal guidelines.
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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