Biltmore Haven Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Arden, North Carolina.
- Location
- 3864 Sweeten Creek Road, Arden, North Carolina 28704
- CMS Provider Number
- 345477
- Inspections on file
- 22
- Latest survey
- May 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Biltmore Haven Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not accurately submit RN and licensed nurse staffing data to CMS through the PBJ system, as hours worked by salaried staff and nurses from sister facilities were not consistently recorded or manually adjusted, resulting in reported gaps in RN and 24-hour licensed nursing coverage.
Multiple residents were affected when controlled medications, including clonazepam and oxycodone, went missing after being removed from medication carts by the former DON. Documentation and interviews revealed that required procedures for tracking and returning controlled substances were not consistently followed, resulting in significant quantities of medication and their count sheets being unaccounted for. The facility's process failures allowed for the misappropriation of resident medications.
Staff failed to label and date opened multi-dose oral inhalers and eye drops on several medication carts, with multiple opened medications found undated and some lacking resident identification. Interviews with medication aides, a nurse, and the DON confirmed that all opened medications should be labeled with the date opened and the resident's name, but this was not consistently done.
The facility did not follow the posted menu when a cook ran out of regular consistency carrots during lunch meal service, resulting in 7-9 residents receiving a substitute vegetable instead. The cook did not notify the DM of the shortage until meal service had begun, preventing timely correction.
Surveyors found that bread and buns were stored past their use by dates in the dry goods area, and a walk-in refrigerator had a water leak dripping onto food containers and a circulatory fan cover with a thick buildup of debris. The Dietary Manager was responsible for ensuring timely removal or freezing of bread, and the fan cover was not on a regular cleaning schedule.
A resident with Parkinson's disease and impaired mobility did not receive scheduled bathing or shaving assistance as required by their care plan. The resident was observed with significant facial hair growth and reported not being bathed or shaved as expected. Documentation of ADL care was inconsistent, and the assigned NA declined to shave the resident due to personal limitations, failing to ensure the task was completed by another staff member.
Nurse aides did not have documented competency checks and failed to follow proper hand hygiene and infection control practices during incontinence and catheter care for a resident. One aide was observed not removing soiled gloves or performing hand hygiene before applying a clean brief and touching items in the environment, and also did not wear a gown during catheter care for a resident requiring enhanced barrier precautions.
The facility did not ensure that nurses documented essential information in the medical records for three residents, including details of admission, discharge, and death. In each case, required progress notes were missing, and staff interviews confirmed that these omissions were not in line with facility expectations.
A resident with intact cognition was not invited to participate in a care plan meeting after returning from a hospital stay, as the meeting was cancelled during hospitalization and not rescheduled. The responsible social worker acknowledged the oversight, and the administrator confirmed that no follow-up or care plan meeting occurred after the resident's return.
A resident with diabetes and GERD, who was cognitively intact, was found to have multiple medications at bedside and reported self-administering them as needed. There was no documented assessment or care plan for self-administration, and nursing staff were unaware the medications were present. The DON confirmed that required assessments and physician orders for self-administration were not completed, and that medications should not have been stored in the resident's room.
A resident with multiple complex diagnoses who wished to transfer to a SNF closer to family did not have a documented or effective discharge planning process. Despite repeated requests from the resident and family, referrals were inconsistently documented, lacked follow-up, and did not include responses from potential receiving SNFs, resulting in the resident's preferences not being met.
Two residents had inaccurate Minimum Data Set (MDS) assessments, with one resident's schizophrenia diagnosis omitted from a quarterly MDS despite ongoing antipsychotic therapy, and another resident incorrectly coded as having PTSD despite no supporting history. Staff interviews confirmed these were coding errors and not in line with facility expectations.
Several residents, including those with diabetes, respiratory failure, muscle weakness, colostomy, and dementia, did not have baseline care plans completed or accurately documented within 48 hours of admission. The DON and Administrator confirmed these omissions and oversights, with some baseline care plans missing entirely and others lacking critical information about residents' conditions.
A resident with chronic respiratory failure and COPD received supplemental oxygen without the physician's order specifying the flow rate or delivery method, and no cautionary signage was posted to indicate oxygen use in the room. The DON and administrator confirmed these omissions, noting the lack of signage was due to an after-hours admission and the incomplete order was an oversight.
A resident with hemiplegia and chronic pain was provided with quarter bed rails to assist with bed mobility, but the facility did not complete a required assessment for entrapment risk before installing or using the bed rails. Staff interviews revealed that the assessment was overlooked because the bed rails were ordered by Hospice, contrary to facility policy.
A nurse aide did not wear a gown while providing urinary catheter care to a resident on enhanced barrier precautions and failed to remove gloves and perform hand hygiene after cleaning stool and before touching other items in the environment. Facility leadership confirmed that these actions did not follow established infection control policies.
Surveyors found that personal care items in two shared bathrooms were not labeled or properly stored, and PTAC units in six resident rooms had multiple broken slats and other disrepair. The DON confirmed staff responsibility for labeling and covering items, while the Maintenance Director and Administrator acknowledged the PTAC issues had not been addressed or reported as expected.
Inaccurate PBJ Staffing Data Submission Due to Incomplete Manual Adjustments
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system for one of the three quarters reviewed. Specifically, the PBJ report for Quarter 1 of Fiscal Year 2025 showed missing Registered Nurse (RN) hours on several dates and indicated a lack of licensed nursing coverage for 24 hours on multiple days. However, a review of daily staff schedules and nursing staff time detail reports revealed inconsistencies, with some records showing RN presence for at least 8 hours and licensed nursing coverage, while others did not. The discrepancies were particularly noted for specific dates where either RN hours or 24-hour licensed nursing coverage were not properly documented. Interviews with facility leadership revealed that the Administrator and Director of Nursing, both RNs and salaried employees, often worked nursing shifts but did not clock in or out, resulting in their hours not appearing in the time detail reports. Additionally, when nurses from sister facilities worked at this location, their hours were not automatically recorded due to system limitations, requiring manual adjustments by the corporate office. The corporate office was not always consistent in manually inputting these hours, leading to inaccurate PBJ submissions and triggering findings of insufficient RN and licensed nursing coverage.
Failure to Protect Residents from Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect residents from misappropriation of their controlled medications, resulting in missing narcotics for four residents. The facility's policy required that all residents be free from misappropriation of property, including medications. However, for each of the four residents reviewed, there were significant discrepancies between the number of controlled substance tablets received from the pharmacy, the number documented as administered, and the number that should have remained in the facility. In each case, the controlled substances and their declining count sheets were removed from the medication cart by the former DON, with documentation indicating the medications were to be returned to the pharmacy, but there was no record of return and the medications could not be accounted for. For one resident with anxiety and bipolar disorder, 60 tablets of clonazepam were received, but only 5 were documented as administered, leaving 55 unaccounted for after the former DON removed the medication from the cart. For three other residents with chronic pain or recent fractures, similar patterns occurred with oxycodone: the number of tablets received, administered, and remaining did not match, and significant quantities of the medication were missing after being removed from the cart by the former DON. In all cases, the declining count sheets were also missing, and there was no evidence that the medications were returned to the pharmacy as required. Interviews and documentation revealed that the process for removing and returning controlled substances was not consistently followed, particularly the requirement for two signatures when removing narcotics from the medication cart. The facility's investigation, supported by pharmacy audits and interviews with staff and law enforcement, identified a breakdown in the process that allowed the medications to go missing. Law enforcement was unable to determine the exact circumstances of the diversion due to gaps in documentation and access, but confirmed that the facility's process failures contributed to the loss of resident medications.
Failure to Label and Date Opened Multi-Dose Medications on Medication Carts
Penalty
Summary
Surveyors observed that staff failed to properly label and date multi-dose oral inhalers and eye drops on three of four medication carts reviewed. Specifically, multiple opened bottles of eye drops and inhalers were found without opened dates or resident names, despite manufacturer recommendations to date these medications upon opening and discard them within specified timeframes. Some medications were also found unlabeled, lacking the resident's name. These observations were made in the presence of medication aides, nurses, and the Assistant Director of Nursing, who confirmed that all opened medications should be labeled with the date opened and the resident's name. Interviews with staff, including medication aides, a nurse, the DON, and the Administrator, revealed a lack of awareness or oversight regarding the requirement to label and date opened medications. The DON stated that third shift staff were responsible for checking medication carts nightly to ensure compliance, and the Administrator confirmed the expectation that all medications be labeled and dated at the time of opening. Despite these expectations, the deficiency was observed across multiple medication carts.
Failure to Follow Posted Menu Due to Insufficient Food Item
Penalty
Summary
The facility failed to follow the posted menu and meal spreadsheet when they ran out of regular consistency carrots while plating meals for lunch. The menu for the day specified Swedish meatballs with gravy, buttered noodles, and sliced carrots. During the lunch meal service, it was observed that the last serving of regular consistency carrots was plated before all residents on the 300 hall had been served, resulting in 7-9 residents not receiving the menu-specified carrots. Instead, capri vegetables (mixed vegetables) were prepared and served as a substitute. The cook reported that she normally needed six bags of carrots but only had five available for the meal. She did not notify the Dietary Manager about the shortage until the tray line had already started. The Dietary Manager confirmed that, had she been notified earlier, additional carrots could have been purchased to meet the menu requirements. The Administrator stated that the posted menu should be followed and that the cook should have communicated the shortage as soon as it was identified.
Deficient Food Storage and Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and sanitation practices in the kitchen, as observed during a survey. In the dry goods storage area, multiple loaves of sliced bread and packages of hamburger buns were found stored past their use by dates. The fill-in Dietary Manager stated that the procedure was to remove bread from the rack and freeze it before the use by date, and that the regular Dietary Manager was responsible for this task. The expired bread remained on the rack, indicating a lapse in following established procedures for food storage. Additionally, in the walk-in refrigerator, a steady drip of water was observed coming from a pipe connected to the refrigeration unit, with water dripping onto a container of pickles and pooling on the floor. The circulatory fan cover in the refrigerator was also found to have a thick buildup of a crumbly black and gray substance. The fill-in Dietary Manager was unaware of how long the water leak had been present and stated he would notify maintenance. The regular Dietary Manager confirmed that the fan cover should be included in a regular cleaning schedule and that he was responsible for ensuring bread was frozen by the use by date. The Maintenance Supervisor was not aware of the water leak prior to being notified and stated the fan cover was not on a routine cleaning schedule.
Failure to Provide ADL Care and Personal Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with Parkinson's disease and generalized muscle weakness, who required assistance with activities of daily living (ADLs), did not receive appropriate personal hygiene care. The resident's care plan specified the need for set-up or clean-up assistance with personal hygiene, including shaving and bathing on scheduled days. Despite these interventions, observations revealed the resident had not been shaved and had not received a bath for a week, as evidenced by the presence of long whiskers and beard hair. The resident reported a preference for being shaved and stated he was unable to shave himself, believing he had only been shaved once during the month. Review of facility records showed inconsistencies in documentation, with no record of showers or bathing for the resident throughout the month, despite shower sheets indicating otherwise. During an interview, the nurse aide assigned to the resident admitted to not feeling comfortable shaving him due to her own arm tremors and could not recall who, if anyone, was asked to complete the shaving. The aide also acknowledged sometimes forgetting to complete shower documentation. The Director of Nursing confirmed that shower sheets should be completed after each bath or shower and that the resident should have been shaved if requested.
Failure to Ensure Nurse Aide Competency and Adherence to Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated the necessary competencies and skills to provide individualized care, particularly regarding hand hygiene during incontinence care. Record reviews revealed that three nurse aides did not have documented evidence of skills or competency checks upon hire or at any time thereafter. Specifically, one nurse aide was observed not removing soiled gloves and not performing hand hygiene before applying a clean brief and touching other items in a resident's environment after providing incontinence care to a dependent resident. Additionally, the same nurse aide did not don a gown while providing urinary catheter care to a resident who required enhanced barrier precautions due to the presence of a urinary catheter. During an interview, the nurse aide stated she had not received any training from the facility regarding proper glove removal, hand hygiene, or the application of clean gloves after incontinence care. These findings were based on both employee file reviews and direct observation of care practices.
Failure to Document Key Resident Events in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents by not documenting key events such as admission, discharge, or death. For one resident, there was no progress note documenting her admission, including the time of arrival, condition, or care needs, despite her profile page indicating the admission date. The Director of Nursing (DON) confirmed that a progress note should have been written at the time of admission, and attributed the omission to the admission occurring after normal business hours. Another resident's medical record lacked documentation regarding the circumstances of his death, including how he was found, the time of death, and notifications made, even though the Minimum Data Set (MDS) indicated a death in the facility. Similarly, a third resident's record did not include a nurse's note about his discharge home, such as the time of departure, who accompanied him, or his condition at discharge, although all required discharge notices were issued. Staff interviews confirmed that nurses were responsible for these entries and were unable to explain the omissions.
Failure to Reschedule and Hold Care Plan Meeting After Hospitalization
Penalty
Summary
A resident with intact cognition was admitted to the facility and had previously attended care plan meetings, as documented in the records. A quarterly care plan meeting was scheduled but was cancelled due to the resident's hospitalization. Upon the resident's return to the facility, there was no documentation that the care plan meeting was rescheduled or that the resident was invited to participate in the care planning process. The resident expressed a desire to participate in care plan meetings and reported not having attended one during the current year. The social worker, who was responsible for scheduling care plan meetings and inviting alert and oriented residents, acknowledged that the meeting was not rescheduled after the resident's return from the hospital. The administrator confirmed that the failure to reschedule the care plan meeting was an oversight and that there was no follow-up note or meeting held with the resident after his return.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for the ability to self-administer medications, as required. The resident, who was admitted with diagnoses including type 2 diabetes and gastroesophageal reflux disease, had a physician's order for antacid medication. The resident was coded as cognitively intact on her most recent MDS assessment. However, there was no care plan or documented assessment for self-administration of medication in her medical record. During an observation, surveyors found multiple medications, including a partially used bottle of liquid bismuth, chewable antacids, and an unopened topical treatment, at the resident's bedside. The resident stated she took these medications when needed and had them delivered to her. Nursing staff confirmed that the resident was not assessed for self-administration and should not have had medications stored in her room. The assigned nurse was unaware of the presence of these medications and removed them upon discovery. The DON reported that the resident frequently ordered medications to be delivered and refused to allow staff to search her belongings. The DON also acknowledged that a self-administration assessment and a physician's order were required for the resident to self-administer medications, and that medications should be stored on the nurse's medication cart, not in the resident's room.
Failure to Document and Follow Up on Discharge Referrals
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident with complex medical needs, including quadriplegia, pressure ulcer, osteomyelitis, bipolar disorder, and anxiety disorder. The resident had an active care plan indicating a desire to transfer to a skilled nursing facility (SNF) closer to family. Documentation showed that only one referral was made to a nearby SNF at the family’s request, with no follow-up or record of the SNF’s response. There was no evidence of additional referrals or follow-up actions documented in the resident’s record over several months, despite ongoing requests from the resident and family. Interviews with the resident, family member, and social worker (SW) revealed that the family repeatedly requested referrals and follow-up, but the SNF in question had not received any referrals, and the SW did not return calls. The SW stated that she sent several referrals but did not document the names or contact information of the SNFs, only the cities, and did not follow up with the facilities after sending referrals. The administrator confirmed that while referrals were sent, there was no consistent documentation or follow-up process in place. This lack of documentation and follow-up resulted in the resident’s discharge preferences and needs not being adequately addressed.
Inaccurate MDS Coding for Active Diagnoses
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents, resulting in deficiencies related to the documentation of active diagnoses. One resident was admitted and re-admitted with a diagnosis of paranoid schizophrenia, which was present on admission and supported by physician orders for antipsychotic therapy. However, the resident's quarterly MDS assessment did not include an active diagnosis of schizophrenia, despite the annual MDS and physician orders indicating its presence. The MDS Nurse reported that she was directed by the corporate office not to code schizophrenia on the MDS after the annual assessment, citing insufficient supporting documentation at the time of admission, and acknowledged that the annual MDS had been incorrectly coded to include the diagnosis. Another resident was admitted with a diagnosis of depression, but the admission MDS assessment incorrectly indicated a diagnosis of post-traumatic stress disorder (PTSD). A psychiatry evaluation confirmed that the resident did not have a history of PTSD, and the MDS Coordinator acknowledged this was a coding error. Both the DON and the Administrator confirmed their expectation that MDS assessments should be coded accurately. These inaccuracies in MDS coding were identified through record review and staff interviews.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans addressing residents' immediate needs within 48 hours of admission for four residents. For one resident with diabetes, chronic respiratory failure, and COPD, no baseline care plan was initiated or completed within the required timeframe, despite the resident receiving insulin, antidepressants, and diuretics. The DON acknowledged that either she or the nurse should have completed the baseline care plan but could not explain the omission. Another resident with muscle weakness was admitted and later discharged home without a baseline care plan ever being included in the medical record. The DON confirmed this was overlooked, and the Administrator was unaware of the omission. A third resident admitted with a colostomy had a baseline care plan that did not reflect the presence of the colostomy, despite the admission MDS assessment indicating it. The DON stated this was an oversight. For a fourth resident with lack of coordination and dementia, no baseline care plan was found in the medical record, and the DON confirmed that the interdisciplinary team was responsible for its completion. The Administrator stated her expectation that baseline care plans be completed within 48 hours of admission and be accurate.
Failure to Post Oxygen Safety Signage and Incomplete Oxygen Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic respiratory failure and chronic obstructive pulmonary disease. The physician's order for supplemental oxygen did not specify the required flow rate or the delivery method, such as nasal cannula, for the resident. Despite the resident receiving oxygen via nasal cannula at a flow rate of 3 liters per minute, this information was not documented in the physician's order. The DON acknowledged that the omission of the flow rate in the order was an oversight when entering the information into the electronic medical record. Additionally, the facility did not post cautionary or safety signage indicating that oxygen was in use in the resident's room, on the door, or doorframe during multiple observations. The DON confirmed that signage should have been posted according to facility process, but it was overlooked, particularly because the resident was admitted after normal business hours. The administrator also confirmed that orders should include the amount of oxygen to be administered and that cautionary signage should be posted for residents receiving supplemental oxygen.
Failure to Assess for Entrapment Risk Prior to Bed Rail Use
Penalty
Summary
The facility failed to assess a resident for risk of entrapment prior to the installation and use of bed rails. A resident with a history of hemiplegia, hemiparesis, left knee contracture, and chronic pain was observed using quarter bed rails in the upright position on both sides of her bed. The resident reported using the bed rails to reposition herself while in bed. Review of the resident's electronic medical record revealed no documentation of an assessment for entrapment risk before the bed rails were installed or used. Interviews with staff indicated that bed rail assessments were typically completed when therapy recommended bed rails for independent bed mobility, and reassessments were conducted quarterly. However, the DON stated that an assessment was not completed in this case because the bed rails were ordered by Hospice. The Administrator confirmed that bed rail assessments were expected to be completed according to facility policy, but this was not done for the resident in question.
Failure to Implement Infection Control Policies During Catheter and Incontinence Care
Penalty
Summary
Nurse Aide (NA) #3 failed to follow the facility's infection control policies while providing care to a resident who required enhanced barrier precautions (EBP) due to the presence of a urinary catheter. During the observed care, NA #3 did not don a gown as required by the EBP policy when performing urinary catheter care, despite signage and supplies being available at the resident's door. The resident was on EBP, which mandates gown and glove use during high-contact activities such as device care, but NA #3 was unaware of this requirement. Additionally, NA #3 did not adhere to the facility's hand hygiene policy during incontinence care. After cleaning stool from the resident, NA #3 failed to remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment. Interviews with the NA, Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator confirmed that the expected procedures were not followed, as staff are required to remove gloves and perform hand hygiene after contact with stool and before touching other surfaces or items.
Failure to Label Personal Items and Maintain PTAC Units in Good Repair
Penalty
Summary
Surveyors observed that the facility failed to properly label and store personal care items in shared bathrooms and did not maintain packaged terminal air conditioners (PTACs) in good repair in several resident rooms. Specifically, in two shared bathrooms, items such as toothbrushes, bedpans, and denture cups were found unlabeled and, in some cases, uncovered, despite repeated observations over multiple days. The DON confirmed that nursing staff were responsible for ensuring personal items were labeled and covered, and that this should be monitored as staff entered and exited shared bathrooms. Additionally, in six resident rooms, PTAC units were found with multiple broken slats and, in one case, a control cover hanging off the front. These issues were observed repeatedly over several days. The Maintenance Director acknowledged being aware of the need for PTAC repairs but had not yet addressed the units on the affected hall. The Administrator was unaware of the PTAC issues and stated that management should have identified and reported these problems during daily room rounds.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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