Blumenthal Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 3724 Wireless Drive, Greensboro, North Carolina 27455
- CMS Provider Number
- 345006
- Inspections on file
- 26
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Blumenthal Health And Rehabilitation Center during CMS and state inspections, most recent first.
Three residents experienced missed doses of essential medications due to failures in medication acquisition, dispensing, and administration processes. One resident did not receive antiretroviral therapy for several days because of prescription and insurance delays, another missed a scheduled dose of Ozempic due to unavailability and documentation issues, and a third did not receive Fluticasone nasal spray as ordered because it was not on the correct medication cart and was incorrectly documented as administered.
A resident with HIV did not receive prescribed antiretroviral medication for several days due to exhaustion of the initial supply, insurance denial, and delays in obtaining and administering a refill. Multiple staff, including nurses, the Medical Director, and pharmacy personnel, were aware of the lapse, but the medication was not administered as ordered, and some staff inaccurately documented administration on the MAR.
A resident with HIV and cognitive impairment did not attend a scheduled infectious disease clinic appointment due to miscommunication and scheduling errors by staff. As a result, the resident missed doses of prescribed antiretroviral medication because the pharmacy required a clinic visit before refilling. The resident's guardian was not properly notified of the appointment changes, and the resident was placed on a waiting list for a new appointment.
A resident with a chronic unstageable pressure ulcer and multiple comorbidities experienced significant pain during a dressing change, as evidenced by facial grimacing, increased breathing rate, and verbal complaints. Despite having an as-needed order for pain medication, staff did not assess or administer pain relief before or during the procedure, and the dressing change was completed before pain medication was given. Staff interviews confirmed that pain management was not provided as expected.
Surveyors identified deficiencies in food service sanitation, including staff handling clean dishware with soiled gloves, improper storage of personal items in food prep areas, and significant grease and debris buildup on kitchen equipment. Wet and dirty plates were also found on the trayline, and staff training on cross-contamination was incomplete.
The facility did not consistently document whether COVID-19 vaccine education was provided or whether the vaccine was administered or declined for several residents and staff. In some cases, consent forms were incomplete or lacked signatures, and there was no evidence that education about the vaccine's benefits and side effects was given. Additionally, immunization records for two staff members were missing.
Three residents dependent on staff for ADLs did not receive required care, including incontinence care, meal assistance, and personal hygiene support. One resident with severe cognitive and physical impairments was left with an untouched meal tray and remained soiled for hours. Another resident on hospice care missed a meal due to lack of staff communication, and a third resident with hemiplegia did not receive needed help with shaving or nail care, despite repeated requests.
A resident with hemiplegia and psychosis, assessed as needing supervision and a smoking apron while smoking, was observed smoking in the designated area without staff supervision or the required apron. Staff and leadership interviews revealed inconsistencies in the implementation of smoking safety measures, confusion about resident requirements, and lapses in supervision, resulting in a failure to ensure accident prevention.
Surveyors found that the facility did not maintain accurate medical records for three residents, including missing or incorrect documentation of a PICC line dressing change, IV antibiotic administration, and blood sugar checks with insulin administration. Nurses confirmed that some care was provided but not properly recorded in the MAR, and facility leadership acknowledged that documentation should be accurate and complete.
A resident with multiple diagnoses, including a cognitive communication deficit, was found to be self-administering physician-ordered eye drops without an assessment or care plan for self-administration. Nursing staff were aware that the resident had eye drops at the bedside, brought in by the spouse, but did not report this or secure the medications. The DON and unit manager confirmed that medications should not be left at the bedside without a care plan, and the PA had not authorized self-administration.
The facility did not provide the required SNF-ABN notification to two residents who remained in the facility after their Medicare Part A skilled services ended. Record review and staff interviews confirmed that neither the residents nor their responsible parties received the necessary notice about the end of Medicare coverage and potential financial liability, as required by CMS guidelines.
Two residents did not have their annual MDS assessments completed within the required 14-day period after the ARD. Staff interviews confirmed that the assessments were delayed due to a backlog when new MDS nurses started, and the issue was known to facility leadership.
Two residents did not have their significant change in status MDS assessments completed within the required 14-day timeframe after the ARD. Staff interviews and record reviews confirmed that the assessments were completed late due to the MDS team being behind on their workload when they started their positions, and the facility was aware of the delays.
Surveyors identified that MDS assessments were inaccurately coded or left incomplete for three residents. One resident who was bedbound and on hospice was incorrectly documented as only occasionally incontinent, another was marked as having received antibiotics when none were administered, and a third had missing cognitive and pain assessments. Staff interviews confirmed these errors and omissions.
A resident with dementia and severe cognitive impairment, dependent on staff for bed mobility, did not have a fall mat in place as required by the care plan. Observations found the fall mat rolled up in the bathroom instead of beside the bed, and interviews with staff and the DON revealed a lack of awareness about the intervention, despite the resident's history of attempting to get out of bed.
The facility did not update the care plans for two residents to reflect changes in code status and the initiation of Hospice services. Despite physician orders and interdisciplinary team meetings intended to review and revise care plans, the documentation continued to show outdated information, such as a full code status instead of DNR, and lacked a care plan for Hospice care.
A resident with hemiplegia and hemiparesis following a stroke did not receive an activity assessment or individualized activities program to address his interests, such as reading and coloring, due to lack of staff awareness and documentation. The resident reported difficulty participating in preferred activities and was not offered accommodations or supplies to support his engagement.
A resident with multiple chronic conditions had a PICC line dressing that was not changed as ordered by the provider. Nursing documentation incorrectly indicated the dressing had been changed, but observations and staff interviews confirmed the dressing remained unchanged for over two weeks. The issue was identified when the dressing was finally changed and the original date was still present on the label.
Surveyors found expired medications, unlabeled and loose pills, and improper storage of drugs on medication carts and in the medication room. Staff confirmed that medications were not labeled with resident information, expired drugs were not discarded, and some medications were not stored according to manufacturer instructions.
The facility did not consistently document education on influenza and pneumococcal vaccines or record acceptance or declination of these vaccines for several residents. Incomplete or missing consent forms and lack of signatures, dates, and education records were identified, with one resident reporting not being offered the vaccines despite records indicating otherwise.
The facility did not maintain required documentation or provide written responses for grievances submitted by two residents' responsible parties regarding delays in incontinent care. Over a six-month period, no grievances were logged, and staff interviews revealed confusion and lack of accountability for grievance management following a transition to a new computer system and the departure of the Social Worker.
Two residents experienced sexual abuse from other residents, including unwanted touching and explicit comments, due to the facility's failure to identify behavioral risks and implement appropriate care plan interventions. Care plans lacked specific strategies to address or prevent inappropriate behaviors, and there was no evidence of a corrective action plan to address these deficiencies.
A resident with multiple health conditions experienced an unwitnessed fall and, despite initial assessment by a CNA and Unit Manager, did not receive required neurological checks or follow-up from nursing staff due to a communication breakdown. The incident was not documented or reported as required, and the lapse was only discovered after the resident filed a grievance.
Three residents received oxygen therapy without proper physician orders, with one resident receiving oxygen at a higher flow rate than prescribed and two residents using oxygen without any current order. Additionally, required cautionary signage for oxygen use was not posted for one resident. Staff interviews confirmed a lack of oversight and documentation regarding oxygen administration.
A resident with severe cognitive and physical impairments, including a stage 4 pressure ulcer, did not receive timely assistance with eating and incontinence care due to chronic short staffing. Staff interviews and documentation confirmed that nurse aides were assigned to care for an excessive number of residents, resulting in missed or delayed essential care tasks such as feeding and hygiene.
Staff failed to follow infection control policies during incontinence, ostomy, and wound care for two residents. A soiled brief was left on a nightstand after incontinence care, and a nurse did not use proper hand hygiene or PPE while providing ostomy and wound care, including not wearing a gown, not washing hands between glove changes, and using bare hands to apply an ostomy appliance. Facility leadership confirmed these actions did not comply with infection control protocols.
A facility with a census of 130 failed to employ a qualified full-time social worker after the previous social worker left, leaving the position vacant. The social work department assistant and regional social worker were not qualified, and although the President of Operations, who is qualified, assisted the department, she did not serve as the full-time social worker.
The facility did not provide written transfer/discharge notifications or bed hold policy information to representatives for three residents who were hospitalized. In each case, required documentation was missing or incomplete, and staff interviews revealed confusion about responsibility for these notifications. The affected residents included individuals with severe cognitive impairment and one who was cognitively intact.
Several quarterly MDS assessments were not completed within the required 14-day period after the ARD for multiple residents. Staff interviews and record reviews confirmed that assessments were overdue, with some not completed at all by the time of review. The MDS team reported inheriting a significant backlog and were still working to catch up, while facility leadership acknowledged awareness of the ongoing delays.
Two residents' discharge MDS assessments were not completed and submitted to the State within the required 7-day timeframe after discharge. Interviews with MDS staff and the Administrator confirmed that the assessments were completed late due to a backlog when new MDS nurses started their roles.
The facility did not accurately post daily nurse staffing information, with multiple discrepancies found between posted sheets and actual schedules for RNs, LPNs, and NAs. The Scheduler, responsible for updating these sheets, often made corrections after the fact and was unsure if other staff were trained to do so, leading to ongoing inaccuracies.
A resident with multiple chronic conditions and a recent surgical procedure developed a suspected deep tissue injury on the left heel, which was identified by the Wound Nurse but not promptly reported or treated due to a lack of immediate provider notification and treatment order. The delay in initiating care was confirmed through documentation and staff interviews, revealing a breakdown in the facility's protocol for pressure ulcer management.
A resident with cognitive impairment and a history of falls underwent a second x-ray for suspected illness without a documented provider order, and the results—showing multiple rib fractures—were not promptly communicated to the NP. The NP only became aware of the findings after the resident was transferred to the hospital for a change in condition. Staff interviews revealed gaps in the process for ensuring provider notification of radiology results.
A resident with a history of vascular dementia and other conditions experienced an unwitnessed fall, leading to a delayed diagnosis of a femur fracture due to the facility's failure to notify the physician of the resident's pain and a STAT x-ray delay. The resident's pain was not managed during night shifts, and the physician was not informed until days later, resulting in delayed medical intervention and surgery. The facility's communication failures contributed to the resident's prolonged pain and risk of complications.
A resident experienced neglect after an unwitnessed fall, where the facility failed to notify the physician immediately about the resident's pain and delayed a STAT x-ray. The x-ray revealed a left femur fracture, but the Nurse Practitioner did not communicate this to the Medical Director, delaying necessary orthopedic evaluation and surgery. The resident's pain was not managed effectively, and the Medical Director was unaware of the fracture until days later, leading to further complications.
A resident with a history of vascular dementia and muscle weakness fell and reported hip pain. A STAT x-ray revealed a nondisplaced femur fracture, but the facility delayed urgent orthopedic evaluation. The Medical Director was not informed until days later, leading to a delay in hospital transfer and surgery. Staff communication and timely action were lacking, contributing to the deficiency.
A resident with a history of vascular dementia and other health issues suffered a femur fracture after a fall. The NP failed to consult with the Medical Director, delaying appropriate medical intervention. The resident's pain became unmanageable, leading to a hospital transfer and surgery. The delay in treatment increased the risk of complications.
A resident with multiple health issues experienced inadequate pain management following a fall. Initially, the resident denied pain, but later reported hip pain, leading to delayed x-ray and pain relief orders. Inconsistent pain assessments and documentation, along with poor communication among staff, resulted in insufficient pain management, despite a confirmed femur fracture.
A facility failed to report an allegation of neglect to the state agency in a timely manner. A resident sustained a fall and did not receive necessary care for a fracture. The Administrator was informed of the neglect allegation but delayed reporting it to the state agency, assuming it was unnecessary as all parties were already aware.
A resident in an LTC facility experienced a fall resulting in a nondisplaced femur fracture. Post-fall documentation was found to be inaccurate, as the Night Nurse Supervisor and another nurse copied previous notes without conducting proper assessments. The resident, who was nonverbal, was not assessed for pain on multiple occasions, leading to a deficiency in maintaining accurate medical records.
The facility failed to implement a broad-based COVID-19 testing approach during an outbreak, leading to numerous cases among residents and staff. Infection control practices were inadequate, with staff not wearing masks properly and a nurse aide entering a COVID-positive room without eye protection. The facility's policies did not align with CDC guidelines, and vaccinations were not administered timely, increasing the risk of transmission.
The facility did not maintain licensed nursing coverage 24 hours a day for 17 days in a 120-day period, as required. Staffing data indicated gaps in coverage, and the facility could not provide documentation to verify staffing levels. Interviews with staff revealed a change in management and reliance on agency staff prior to June 2024, but current staff could not confirm past staffing practices.
The facility failed to maintain RN coverage for at least 8 consecutive hours per day for 17 days in a reviewed period. Staffing data indicated missing RN coverage, and the facility could not provide supporting documentation. Interviews with staff revealed a lack of confirmation on RN coverage and issues with record-keeping during a management transition.
A resident with diabetes and dementia experienced a significant medication error when their prescribed Humalog Insulin was administered over 2.5 hours late. The insulin, scheduled for 7:30 AM before breakfast, was given at 9:55 AM due to a heavy medication pass workload and COVID-related tasks. The DON noted that nurses have enough time to administer medications on schedule and can seek assistance if needed.
Two residents, both cognitively intact, were not assessed for self-administration of medications, leading to nurses leaving medications at their bedsides without supervision. This was against the facility's policy, which requires nurses to stay with residents during medication administration. The Unit Manager and DON confirmed no residents were authorized for self-administration.
A facility failed to complete a Significant Change in Status MDS assessment for a resident admitted to hospice services with a diagnosis of malignant neoplasm of the right lung. The MDS Coordinator, new to the facility, acknowledged the oversight, noting the absence of a dedicated MDS Coordinator for over a year, with reliance on traveling MDS Nurses and various staff for assessments.
The facility failed to accurately code MDS assessments for three residents, leading to deficiencies in areas such as range of motion and comprehensive assessments. A resident with hemiplegia was inaccurately coded as having no range of motion impairments, while another with Alzheimer's was not assessed for cognition and other critical areas. Additionally, a resident's psychiatric diagnoses were omitted from their MDS assessment. The lack of a consistent MDS Coordinator contributed to these inaccuracies.
A facility failed to apply a recommended right-hand grip splint for a resident with a contracture following a cerebrovascular accident. Despite occupational therapy recommendations, the care plan lacked instructions for the splint, and no physician order was present. Observations showed the resident's hand was fisted without a visible splint, and staff were unsure of its location. The Rehabilitation Director later found and applied the splint, but the resident's POA noted it hadn't been used in two years.
A resident with hypoxemia and congestive heart failure was observed receiving oxygen at 3.5 liters per minute instead of the prescribed 2 liters per minute. Despite no signs of respiratory distress, the discrepancy was noted, and staff did not document vital signs or check the concentrator settings due to visitor presence. The NP confirmed no symptoms of dyspnea, and the DON and Administrator emphasized adherence to physician orders.
A facility failed to maintain a complete medical record for a resident admitted with a fractured pelvis and septic shock. The resident's electronic medical record lacked the diagnoses of schizophrenia and PTSD, which were documented in the hospital discharge summary. This deficiency was identified during a review of the resident's medical records.
Failure to Ensure Timely Acquisition and Administration of Critical Medications
Penalty
Summary
The facility failed to provide uninterrupted pharmaceutical services for three residents, resulting in missed doses of critical medications. One resident with HIV did not receive the prescribed antiretroviral medication, Biktarvy, for several days due to a lapse in obtaining a new prescription and insurance approval. The medication was initially supplied by a hospital pharmacy, but when the supply was depleted, the facility pharmacy could not provide a refill without a new prescription and insurance authorization. Multiple staff members, including nurses, the Medical Director, and pharmacy personnel, were aware of the issue, but there was a lack of coordinated action to secure the medication in a timely manner. Documentation showed that the resident missed multiple doses, and there was confusion and miscommunication among staff regarding responsibility for obtaining the medication and ensuring its availability on the medication cart. Another resident with diabetes missed a scheduled dose of Ozempic because the medication was not available at the time of administration. The nurse reported the absence of the medication and contacted the pharmacy, but the medication was not delivered in time for the scheduled dose. Subsequent attempts to locate the medication for the next scheduled dose were unsuccessful, and the pharmacy indicated that a refill could not be processed because the facility should have had a dose available from a previous delivery. Despite documentation indicating delivery of the medication, there was no evidence that the resident received the dose, and staff interviews confirmed the medication was not administered as ordered. A third resident with allergic rhinitis did not receive the prescribed Fluticasone nasal spray as ordered. Although the medication administration record indicated that the medication was given, interviews with staff and the resident revealed that the medication was not available on the medication cart and had not been administered. Staff reported inadvertently documenting administration when the medication was not present, and pharmacy records showed that the facility had requested the medication before it was eligible for refill. The medication was eventually located in another unit's storage, but the resident had gone without the prescribed treatment for several days.
Failure to Administer Prescribed Antiretroviral Medication
Penalty
Summary
A significant medication error occurred when a resident with HIV did not receive their prescribed antiretroviral medication, Biktarvy, for several consecutive days. The resident was admitted with a hospital-supplied bottle of Biktarvy, but the facility staff were unsure of the quantity provided. Once the initial supply was exhausted, the facility was unable to obtain a refill due to insurance denial and lack of timely payment approval. Multiple staff members, including nurses, the Medical Director, the ADON, and the facility pharmacist, were aware of the medication lapse, but the issue persisted for several days. Documentation on the Medication Administration Record (MAR) showed that Biktarvy was not administered on multiple days, with progress notes indicating the medication was unavailable. Some staff documented administration of the medication when it had not actually been given, and others noted the medication was not on the cart. The facility pharmacy could not dispense the medication until insurance approval was obtained, and even after delivery, there was a delay in administration as the medication was not promptly placed on the medication cart. Interviews with staff confirmed that the medication was not available or administered as ordered during this period. The resident's medical history included HIV with an uncontrolled viral load and a low CD4 count, requiring strict adherence to antiretroviral therapy. The lapse in medication administration was known to several staff members, including the Medical Director, ADON, and pharmacist, but no effective action was taken to ensure the resident received the medication as prescribed. The infectious disease clinic provider was unable to determine the clinical consequences of the missed doses without recent laboratory testing, but the interruption in therapy was confirmed by multiple sources.
Failure to Ensure Resident Attended Infectious Disease Clinic Appointment
Penalty
Summary
The facility failed to ensure that a resident with HIV attended a scheduled infectious disease clinic appointment as ordered. The resident was discharged from the hospital with instructions for close follow-up at the infectious disease clinic and a prescription for Biktarvy, an antiretroviral medication. The resident, who had moderate cognitive impairment and a mental health disorder, was admitted to the facility with orders to continue Biktarvy and to manage chronic disease. The care plan included medication administration and monitoring for HIV complications. The Transportation Coordinator was responsible for arranging the resident's appointments and was aware that accompaniment was required per administrative policy. Attempts to contact the resident's guardian prior to the appointment were unsuccessful, and the appointment was cancelled and rescheduled. However, the Transportation Coordinator recorded the wrong date for the rescheduled appointment, resulting in the resident missing the actual clinic visit. The guardian was not notified of the correct appointment date and only learned of the cancellation and rescheduling after the fact. The resident was subsequently placed on a waiting list for a new appointment. Due to the missed appointment, the resident ran out of Biktarvy, as the pharmacy required a clinic visit before dispensing additional medication. Nursing staff and the nurse practitioner confirmed that the resident did not receive the medication for several days, and the infectious disease physician declined to refill the prescription without a recent clinic evaluation. The resident eventually resumed therapy after the facility pharmacy was able to obtain the medication, but the lapse in care occurred as a result of the missed appointment and communication failures among facility staff.
Failure to Provide Pain Management During Dressing Change
Penalty
Summary
A deficiency occurred when a resident with a chronic unstageable pressure ulcer on the left heel did not receive appropriate pain management during a dressing change procedure. The resident, who had a history of multiple medical conditions including recent fractures, atrial fibrillation, coronary artery disease, congestive heart failure, hypertension, dementia, and a significant pressure ulcer, was observed to experience significant pain during the dressing change. Despite having an as-needed order for hydrocodone-acetaminophen for pain, no pain assessment was conducted prior to the procedure, and pain medication was not administered before or during the dressing change, even as the resident exhibited clear signs of pain such as facial grimacing, increased breathing rate, shifting position, and verbal expressions of discomfort. During the observed dressing change, the staff involved were not familiar with the resident's wound care orders or pain management needs. The nurse and unit manager present did not assess the resident's pain before starting the procedure and proceeded with the dressing change despite the resident's repeated verbal and non-verbal indications of pain. The surveyor had to intervene and suggest pain medication, but the dressing change was completed before the medication was administered. The resident later rated his pain as an 8 out of 10 during the procedure. Interviews with staff, including the nurse, unit manager, DON, administrator, and nurse practitioners, confirmed that the expected practice was to assess and manage pain during such procedures. The staff involved acknowledged that pain management was not provided as it should have been, and the nurse admitted to being focused on the wound care rather than the resident's comfort. The deficiency was identified through direct observation, record review, and interviews, highlighting a failure to provide safe and appropriate pain management during a painful procedure.
Deficiencies in Food Service Sanitation and Cross-Contamination Prevention
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. Dietary staff were seen handling soiled dishware and then immediately handling clean glassware without removing soiled gloves or washing hands, indicating a lack of training on cross-contamination prevention. The staff member involved had only been employed for three days and had not yet received proper training due to the Dietary Manager's focus on timely meal delivery. Additionally, personal items such as travel mugs were found stored in food preparation areas, and staff were observed placing and using these items inappropriately within the kitchen environment. Further observations revealed significant cleanliness issues with food service equipment, including thick grease buildup on the stove and inside ovens, as well as dried stains inside the plate warmer where clean plates were stored. During meal service, wet and dirty plates with dried food particles were found stacked on the trayline. The Dietary Manager stated that deep cleaning was scheduled weekly, but the last cleaning of the ovens had occurred nearly two weeks prior. Audits of kitchen sanitation and safety were reportedly conducted weekly by the Registered Dietitian.
Failure to Document COVID-19 Vaccine Education and Status for Residents and Staff
Penalty
Summary
The facility failed to properly document the administration or refusal of the COVID-19 vaccine and the provision of education regarding its benefits and potential side effects for both residents and staff. For three out of five residents reviewed, there was either no documentation of vaccine education, no record of consent or refusal, or incomplete consent forms lacking signatures or identification of the responsible party. In one case, a resident's family member verbally declined the vaccine, but the consent form only had the word 'verbal' written on the signature line without the family member's name, and there was no documentation of education provided. Another resident, who was moderately cognitively impaired, was reported to have declined the vaccine, but the consent form was unsigned and undated, and the resident stated she was not offered the vaccine. For a third resident, there was no documentation of vaccine education, consent, or refusal in the medical record, and the facility could not provide evidence of these actions. Additionally, the facility was unable to provide evidence of COVID-19 immunization status or education for two of five staff members reviewed. The Infection Preventionist stated that she offered the vaccine to residents and recorded verbal responses but did not always obtain signatures, and she did not offer the vaccine to staff but kept records of their immunization status, which were missing for the two staff members in question. The Director of Nursing confirmed that all residents should be offered the vaccine and that documentation of education and consent should be maintained, but acknowledged that records were incomplete or missing.
Failure to Provide ADL Assistance, Incontinence Care, and Meal Support
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three residents who were dependent on staff. One resident with dementia, contractures, dysphagia, aphasia, and a stage 4 sacral pressure ulcer was observed to have not received assistance with lunch, as her meal tray remained untouched for hours. Staff interviews confirmed that the resident was not offered or assisted with her meal due to short staffing and lack of communication among staff. Additionally, this resident was found saturated in urine, with soiled linens and night clothes, and had not been cleansed or repositioned for an extended period, despite being dependent on staff for all ADLs and having a high risk for skin breakdown. Another resident, who was dependent on staff for all ADLs and on hospice care, experienced a failure in receiving assistance with meals. Although staff provided assistance during some meals, there was an incident where the resident's lunch tray was not served, and the meal was not offered until surveyor intervention. Staff interviews revealed a lack of communication regarding meal assistance assignments, resulting in the resident not being fed until the issue was brought to staff attention. The resident had a history of significant weight loss, and her family expressed concerns that she was not always being fed her meals. A third resident, with a history of stroke and hemiplegia, required set-up assistance for personal hygiene and was dependent on staff for bathing. Observations showed that the resident's facial hair was overgrown, fingernails were excessively long with debris underneath, and he had not received assistance with shaving or nail care despite requesting help from staff. The resident reported frustration at being unable to maintain his grooming due to lack of assistance. Staff interviews confirmed that shaving and nail care had not been offered or completed, and unit management was not monitoring the completion of these ADLs.
Failure to Provide Required Supervision and Safety Equipment for Smoking Resident
Penalty
Summary
A deficiency occurred when a resident with a history of stroke resulting in hemiplegia/hemiparesis and unspecified psychosis, who was assessed as requiring supervision and the use of a smoking apron for safety, was not provided with the necessary supervision or safety equipment while smoking. The resident's care plan and smoking safety assessment both indicated the need for supervision and a smoking apron, yet inconsistencies were found in the documentation, with the assessment at one point incorrectly stating the resident could smoke independently. The resident confirmed that he was not wearing a smoking apron and that aprons were not available in the courtyard until the morning of the survey, despite the requirement for their use. Observations revealed that the resident was present in the designated smoking courtyard without staff supervision and without wearing a smoking apron, even though his name was listed among those requiring supervision. Staff interviews confirmed that supervision and the use of smoking aprons were required for certain residents, but the implementation of these safety measures had only recently begun, and staff were unclear about which residents required which interventions. The facility had only started using smoking aprons the day before the survey, and there was confusion among staff regarding the supervision and safety requirements for smokers. Further interviews with facility leadership acknowledged inconsistencies in the implementation of smoking safety practices, including errors in the resident's assessment and care plan. The resident was able to access the smoking area and smoke without the required supervision or safety equipment, as staff responsible for supervision were not always present, and the resident did not notify staff before going out to smoke. This lack of supervision and failure to provide required safety equipment constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Maintain Accurate Medical Records for PICC Line, IV Antibiotics, and Insulin Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents in relation to PICC line dressing changes, intravenous antibiotic administration, and blood sugar assessment with insulin administration. For one resident with a peripherally inserted central catheter (PICC) line, the dressing was observed to be unchanged for an extended period, with the hand-labeled date on the dressing not matching the documentation in the Medication Administration Record (MAR). The nurse responsible confirmed that she had not performed the dressing change as documented, indicating an error in recordkeeping. Both the Administrator and Director of Nursing acknowledged that documentation should be accurate. For another resident receiving intravenous antibiotics, there were two instances where the MAR was not signed to indicate administration of the medication, despite nurses later confirming that the medication had been given but not documented. Similarly, a third resident with diabetes had multiple occurrences where blood sugar checks and insulin administration were not documented on the MAR. The nurses involved could not recall the reasons for the missing documentation. Interviews with the Physician's Assistant and Director of Nursing confirmed that medications and assessments should have been accurately documented as ordered.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including progressive supranuclear ophthalmalgia, type II diabetes, and cognitive communication deficit was admitted with active physician's orders for two types of eye drops. The resident was assessed as cognitively intact but required supervision or touching assistance with personal hygiene. Despite this, there was no assessment in the medical record for the resident's ability to self-administer medications, nor was there a care plan addressing self-administration of medication. Observations revealed that multiple bottles of eye drops, both opened and unopened, were present on the resident's nightstand, and the resident reported self-administering the drops as needed. Nursing staff were aware that the resident had eye drops at the bedside, with one nurse stating the resident's spouse brought them in, but did not report this to management or ensure the medications were secured. The unit manager and DON confirmed that medications should not be kept at the bedside without a care plan for self-administration, and the resident did not have such an order. The physician assistant also confirmed that no order had been written for self-administration and expressed uncertainty about the resident's ability to administer the drops correctly.
Failure to Provide SNF-ABN Notification to Residents Ending Medicare Part A Coverage
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 to two residents prior to the end of their Medicare Part A skilled services. Both residents were admitted to Medicare Part A skilled services and remained in the facility after their skilled coverage ended. Record reviews showed no documentation that either resident or their responsible parties received the SNF-ABN, which is necessary to inform them of the end of Medicare coverage and potential financial liability for continued services. Interviews with the previous facility Social Worker confirmed that issuing the SNF-ABN was her responsibility when a resident's Medicare Part A skilled services were about to end and the resident was staying in the facility. The Social Worker could not provide a reason for the oversight in both cases. The Administrator also confirmed that the Social Worker was responsible for issuing the SNF-ABN and acknowledged that both residents should have received the notice as required by federal guidelines.
Failure to Complete MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete annual Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for two residents. For one resident, the annual comprehensive MDS assessment had an ARD of 7/30/25 but was not signed as completed by the Registered Nurse (RN) MDS Coordinator until 9/3/25. Staff interviews confirmed that this assessment was completed late. For another resident, the annual MDS assessment had an ARD of 6/26/25 and was not completed until 8/15/25, with the Care Area Assessment (CAA) also completed on the same late date. Interviews with the MDS Coordinator and MDS Nurse #2 revealed that they were two months behind on completing MDS assessments when they began their positions at the facility and were still working to catch up. The facility's Administrator acknowledged awareness of the issue, noting that the new MDS nurses were behind on assessments upon starting. The Vice President of Operations confirmed that there was not a fully implemented Plan of Correction regarding the MDS assessments at the time of the survey.
Failure to Complete Significant Change MDS Assessments Timely
Penalty
Summary
The facility failed to complete significant change in status Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for two residents. For one resident, the significant change in status MDS assessment had an ARD of 6/26/25 but was not signed as completed until 8/18/25. For another resident, who was admitted to hospice care, the significant change in status MDS assessment had an ARD of 8/7/25 and was not completed until 9/8/25. These delays were confirmed through staff interviews and record reviews. Interviews with the MDS Coordinator and MDS Nurse revealed that they were behind on completing MDS assessments when they began their positions, and were still working to catch up. The facility's Administrator acknowledged awareness of the issue and confirmed that the new MDS nurses were behind on assessments upon starting. The VP of Operations also confirmed that a Plan of Correction had not yet been fully implemented regarding the MDS assessment process.
Inaccurate and Incomplete MDS Assessments Identified
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents in several key areas. For one resident with acute respiratory failure, non-Alzheimer's dementia, and who was bedbound and on hospice, the MDS inaccurately coded the resident as only occasionally incontinent of bladder and frequently incontinent of bowel, when in fact the resident was always incontinent of both. This was confirmed by the MDS nurse during an interview, who acknowledged the coding was incorrect. Another resident with chronic kidney disease and respiratory failure was incorrectly documented as having received an antibiotic during the 7-day look back period on the MDS, despite medication administration records showing no antibiotics were given during that time. Additionally, a third resident with multiple diagnoses, including gout, diabetes with polyneuropathy, and hemiplegia, had an annual MDS assessment that was incomplete, with cognitive and pain assessments marked as "not assessed, no information." Staff interviews confirmed these inaccuracies and omissions in the MDS assessments.
Failure to Implement Fall Mat Intervention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident with dementia and hypertension, who was assessed as severely cognitively impaired and dependent on staff for bed mobility. The resident's care plan, last revised on 7/9/25, included the use of a fall mat on the left side of the bed as a fall precaution. However, during multiple observations on 9/8/25 and 9/10/25, the fall mat was not in place as directed by the care plan; instead, it was found rolled up in the bathroom. The resident was observed positioned in the center of the bed, with the bed in the low position, and was reported by her representative and staff to be able to roll in bed. Interviews with the unit manager and nursing assistants revealed a lack of awareness regarding the fall mat intervention. The unit manager was unaware that the fall mat was not in place and could not explain why it had been removed. One nursing assistant was not aware that a fall mat was required, while another, who provided care almost daily, had not seen the fall mat in use and reported that the resident had attempted to get out of bed in recent months. The DON also confirmed he was not aware the fall mat was not in place and stated it should have been on the floor as per the care plan.
Failure to Update Care Plans for Code Status and Hospice Services
Penalty
Summary
The facility failed to revise and update the care plan for two residents as required. For one resident with diagnoses including diabetes and chronic lung disease, the Minimum Data Set (MDS) assessment documented that the resident was cognitively intact and had a life expectancy of less than six months, and was receiving Hospice services. Despite a physician order changing the resident's code status from full code to Do Not Resuscitate (DNR), the care plan continued to reflect the previous full code status and did not address the new DNR order. Additionally, after a physician order for a Hospice referral and subsequent admission to Hospice, there was no care plan in place addressing Hospice services for the resident. Interviews with the MDS nurse and the DON revealed that care plans were expected to be reviewed and updated daily during clinical care meetings with the interdisciplinary team. However, both staff members acknowledged that the care plan for this resident had not been updated to reflect the changes in code status or the initiation of Hospice services. The DON was not aware of the omissions until the time of the interview, despite regular care plan reviews being part of the facility's process.
Failure to Assess and Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide a record of an activity assessment and did not implement an ongoing, resident-centered activities program to meet the interests of a resident who did not participate in activities outside of his room. The resident, who was admitted with hemiplegia and hemiparesis following a stroke affecting his right dominant side, was cognitively intact and had documented preferences for books, music, animals, and being outside. The care plan noted a preference for self-directed activities such as reading and watching television in his room, but interventions were limited to reviewing these preferences as needed. During observation, the resident was found awake in his room with the lights and television off, and he reported difficulty engaging in reading due to his physical limitations and was unaware of available art supplies or accommodations for his interests. Interviews revealed that the Activity Director, who had recently started at the facility, was unaware of the resident's specific interests in coloring and reading and could not locate a completed activity assessment for the resident, which should have been done at admission. The resident stated that no one had discussed his activity preferences with him or offered supplies to support his interests, particularly in coloring, which he missed most. The lack of assessment and individualized activity planning resulted in the resident's needs and preferences not being addressed.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
A deficiency occurred when nursing staff failed to change the dressing for a peripherally inserted central catheter (PICC) line as ordered by the provider for a resident admitted with diagnoses including congestive heart failure, diabetes, chronic kidney disease, and cellulitis. Physician orders specified that the PICC line dressing should be changed on admission and then every seven days on the day shift, as well as as needed. Documentation on the Medication Administration Record (MAR) indicated that the dressing change was completed on a specific date, but the nurse responsible later confirmed that this was an error and the dressing had not been changed as documented. Observations over several days revealed that the PICC line dressing remained unchanged, with the original date still visible on the label. Interviews with nursing staff indicated a lack of familiarity with the resident's orders, and both the Administrator and DON confirmed that the expectation was for orders to be followed as written. The Nurse Practitioner and Medical Director also stated that weekly dressing changes were expected to prevent infection and maintain catheter integrity. The deficiency was identified when the dressing was finally changed, and it was confirmed that the previous dressing had not been changed for over two weeks.
Deficient Medication Storage, Labeling, and Expired Drug Removal
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and biologicals. On one medication cart, there were expired medications, including a bottle of calcium carbonate with an expiration date that had passed, and a bubble-pack card of nitroglycerin tablets without resident identification. Additionally, an unopened bottle of latanoprost eye drops, which should have been refrigerated according to manufacturer instructions, was found stored on the cart instead. Loose and unidentified pills of various shapes, sizes, and markings were also found in the drawers of two medication carts, with staff confirming that these should have been properly labeled with resident information. In the medication room, expired doses of meropenem, an antibiotic, were found stored in the refrigerator, with pharmacy labels indicating expiration dates that had already passed. Staff interviews confirmed that these expired medications should have been returned to the pharmacy. Throughout the observations, staff acknowledged that medications were not labeled or stored according to professional standards and manufacturer instructions, and that expired or unidentified medications were not properly discarded.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to properly document education regarding the benefits and potential side effects of influenza and pneumococcal vaccines, as well as the acceptance or declination of these vaccines, in the medical records of three out of five residents reviewed. For one resident who was severely cognitively impaired, the family refused both vaccines, but there was no documentation that education was provided to the family, and the consent form was incomplete, lacking a signature, date, and the name of the family member who declined. Another resident, who was moderately cognitively impaired, had a consent form indicating both vaccines were declined, but the form was missing a signature, date, and family member identification. This resident also reported not being offered the vaccines, despite the record indicating a declination. A third resident, who was cognitively intact, had no documentation in the medical record regarding education about the vaccines or a record of consent or declination. The Infection Preventionist stated that she would write 'verbal' on the consent form after speaking with residents, but not all forms were signed or dated, and some residents' records lacked any documentation of vaccine education or decision. The DON and Administrator both acknowledged that all residents should be offered the vaccines and that proper documentation should be maintained, but these requirements were not met for the residents reviewed.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain documentation of resolved grievances and evidence of the results of all grievances for multiple residents and over several months. Specifically, there was no documentation of resolved grievances for two residents who were not cognitively intact, despite their responsible parties reporting concerns about delays in incontinent care and submitting grievances to staff. The responsible parties did not receive any communication or written response from the facility regarding their grievances. Additionally, the facility's grievance log showed no entries for a six-month period, and the required documentation as outlined in the facility's grievance policy was not maintained. Interviews with staff revealed that the previous Social Worker was responsible for handling paper grievances and distributing them to department heads, but after the transition to a new computer system, there was confusion about who was responsible for managing grievances. The Social Worker left the facility, and no one was assigned to the role during the survey. The administrator confirmed that grievances from the specified period could not be located, and there was a lack of clarity regarding grievance management and documentation during the transition period.
Failure to Protect Residents from Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, resulting in two separate incidents involving inappropriate sexual contact and comments. In the first incident, a cognitively intact male resident made sexually explicit statements and touched a female resident's breasts without her consent on multiple occasions, both in the courtyard and near a nurse's station. The female resident reported that she had told the male resident to stop and had not consented to any such contact or conversation. Despite the male resident's care plan noting behavioral issues, it did not specify the nature of these behaviors or include targeted interventions to address the risk of inappropriate sexual conduct. The female resident's care plan also lacked any focus on behaviors or risk of abuse, despite her reports of ongoing unwanted attention and sexual comments from the male resident. In the second incident, a moderately cognitively impaired male resident was observed by a nurse aide with his hand on the genital area of a severely cognitively impaired, non-verbal female resident in the dining room. Both residents were fully clothed, and the female resident did not display any reaction or distress due to her advanced dementia. The male resident denied any inappropriate intent, claiming he was shooing a fly, and had no prior documented history of inappropriate behaviors toward other residents. The care plans for both residents did not address the risk of inappropriate behaviors or include interventions to prevent such incidents. In both cases, the facility's documentation and care planning failed to identify or mitigate the risk of resident-to-resident sexual abuse. There was a lack of specific behavioral interventions or monitoring for residents with known or potential behavioral issues. The facility did not provide evidence of a corrective action plan regarding its failure to protect residents' rights to be free from abuse, and the care plans did not reflect the residents' behavioral risks or needs for supervision in communal areas.
Failure to Monitor and Assess After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with a history of respiratory failure, generalized muscle weakness, and unsteadiness experienced an unwitnessed fall. The resident was found on the floor by a CNA and the Unit Manager, who performed an initial assessment and took vital signs. The Unit Manager instructed the hall nurse to conduct neurological checks, notify the resident's family and physician, and complete the necessary documentation and reporting. However, the hall nurse did not follow up with the resident as directed. The resident later reported that after the fall, no nurse came to assess her or follow up, and her fall was not documented in the facility's list of unwitnessed fall incidents. Interviews with staff revealed a breakdown in communication: the Unit Manager believed she had relayed the necessary information to the hall nurse, while the nurse stated she was not made aware of the fall until days later when the resident herself reported it. As a result, the required post-fall assessments, including neurological checks and notifications, were not completed in accordance with professional standards. The Director of Nursing confirmed that the facility failed to monitor and report the resident's unwitnessed fall, and that the expected protocol—comprehensive assessment, neurological checks, and proper documentation—was not followed. The incident was only brought to the facility's attention after the resident filed a grievance, highlighting the lack of immediate and appropriate follow-up care after the fall.
Failure to Ensure Safe and Ordered Oxygen Administration and Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not obtaining physician orders for oxygen administration, not administering oxygen at the prescribed rate, and not posting required cautionary signage. For one resident with a diagnosis of dyspnea, there was no physician order, care plan, or documentation supporting the use of oxygen therapy, yet the resident was observed with an oxygen concentrator in use on multiple occasions. Staff interviews confirmed a lack of awareness regarding the absence of an order, and no communication was found in the medical records or communication logs to justify the ongoing use of oxygen. Another resident, admitted with cardiac and dementia diagnoses, was also found to be using oxygen without a current physician order. Both the resident and her representative stated that oxygen was used primarily at night and during episodes of shortness of breath. Staff interviews revealed that the resident had been using oxygen for several months, but the physician assistant declined to provide a new order without supporting oxygen saturation data, and the DON could not locate a relevant protocol or standing order. A third resident with chronic respiratory failure and congestive heart failure had a physician order for continuous oxygen at 2 liters per minute, but observations showed the oxygen was being administered at 3.5 liters per minute. Additionally, there was no cautionary signage posted to indicate oxygen was in use. Staff interviews confirmed that nurses were responsible for checking oxygen flow rates and posting signage, but these actions were not performed as required. The DON and nurse practitioner both acknowledged the discrepancies in oxygen administration and signage.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of a resident who required extensive to total assistance with activities of daily living (ADLs), including toilet hygiene and eating. The resident, who had diagnoses such as dementia, contractures, dysphagia, aphasia, and a stage 4 pressure ulcer, was dependent on staff for all ADLs and was always incontinent. On one occasion, the resident's lunch tray remained untouched for several hours, and staff interviews confirmed that the resident had not been offered or assisted with lunch due to short staffing. The nurse aide responsible for the resident stated she was unable to provide timely assistance because she was assigned too many residents and did not ask for help as all staff were busy. Further documentation revealed that the resident was found saturated in urine and still in night clothes late in the day, with soiled linens and no evidence of having been cleansed or repositioned. The wound nurse who discovered this reported the incident, and the resident's roommate confirmed that care had not been provided throughout the day. Staff interviews indicated that nurse aides were frequently assigned to care for 20 to 40 residents per shift, making it difficult to complete essential care tasks such as bathing, feeding, and incontinence care in a timely manner. Multiple staff members, including nurse aides and unit managers, acknowledged that chronic short staffing led to delays in providing care, with some tasks being missed or only partially completed. The direct care staff reported that it was impossible to complete all required care for their assigned residents, especially when there were call outs and no additional help available. These staffing shortages directly resulted in the resident not receiving necessary assistance with eating and incontinence care.
Failure to Follow Infection Control Policies During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control policies in several instances involving both incontinence and wound care. In one case, a nurse aide provided incontinence care to a resident and left a soiled brief on the resident's nightstand for approximately 45 minutes, rather than disposing of it immediately in a trash bag as required by policy. The aide acknowledged she intended to return with a bag but did not do so until prompted. Facility leadership confirmed that the brief should not have been placed on the nightstand and that the surface should have been disinfected after the incident. In another instance, a nurse failed to follow proper hand hygiene and personal protective equipment (PPE) protocols while providing ostomy and wound care to a resident on enhanced barrier precautions. The nurse did not don a gown as required, used bare hands to measure the resident's stoma and apply the ostomy appliance, and failed to clean scissors after use. During wound care, the nurse did not consistently wash hands between glove changes and reached into a package of gauze with contaminated gloves, later discarding the remaining gauze. The nurse also did not always wash hands before donning new gloves during the procedure. Interviews with facility staff, including the unit manager, DON, and infection preventionist, confirmed that the observed actions were not in compliance with facility policies regarding regulated medical waste, standard precautions, hand hygiene, and enhanced barrier precautions. The staff involved were aware of the policies but did not adhere to them during the observed care activities.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker despite having a census of 130 residents, which exceeds the threshold requiring such a position. According to staff interviews, the previous social worker's last day was 8/15/25, and the position had not been filled at the time of the survey. The social work department assistant was not a qualified social worker, and the regional social worker also did not meet the qualifications. The President of Operations, who is a qualified social worker, had been assisting the department but was not serving as the full-time social worker. The deficiency was identified through interviews with staff and administration, confirming the absence of a qualified full-time social worker in the facility.
Failure to Provide Required Transfer/Discharge Notices and Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification to resident representatives regarding the reason for unplanned transfers or discharges to the hospital and did not supply the required bed hold policy information for three out of four residents reviewed for hospitalizations. In the case of one resident with severe cognitive impairment, there was no documentation that the bed hold policy had been provided to the resident or their representative, and the notice of transfer form was incomplete, with the section for mailing to the representative left blank. The resident's representative confirmed that neither a bed hold notice nor a letter of transfer was received during the hospitalization. For another resident who was cognitively intact, the clinical records did not show that the bed hold policy was provided when the resident was transferred to the hospital after becoming nonresponsive. Nursing staff reported that the bed hold policy was not included in the transfer packet, and the admissions director stated she was not responsible for providing this information at the time of hospital discharge. This resident did not return to the facility and was later admitted to hospice care. A third resident, also severely cognitively impaired, was transferred to the hospital and later returned, but there was no documentation of the reason for transfer or that bed hold information was sent to the representative. Interviews with staff revealed confusion and lack of clarity regarding responsibility for providing the bed hold policy and completing transfer/discharge notifications. The administrator acknowledged awareness of the need for such documentation but noted that recent staff changes had contributed to lapses in providing required notifications and bed hold information.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for eight residents. Record reviews and staff interviews confirmed that the MDS assessments for these residents were completed late, with some assessments being overdue by several weeks. In one case, an assessment had not yet been completed as of the date of the review, making it six days overdue. The MDS Coordinator and another MDS nurse confirmed during interviews that these assessments were not completed on time. The deficiency was identified through a combination of medical record reviews and staff interviews. The MDS Coordinator and MDS Nurse #2 reported that when they began their positions, they inherited a backlog of MDS assessments that were already two months behind schedule. Despite their ongoing efforts to catch up, several assessments continued to be completed outside the required timeframe. The Administrator and the company's VP of Operations were aware of the issue and acknowledged that the facility was behind on MDS assessment completion. Specific examples included assessments for multiple residents that were signed as completed well beyond the 14-day window after the ARD, and in one instance, an assessment was not completed at all by the time of the survey. The report documents that the facility did not have a fully implemented Plan of Correction regarding the timely completion of MDS assessments at the time of the survey.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to submit discharge Minimum Data Set (MDS) assessments within the required timeframe for two residents. For one resident, the discharge MDS assessment was completed and submitted more than a month after the resident was transferred to the hospital. For another resident, the discharge MDS was completed and submitted over a month after the resident was discharged to home. In both cases, the assessments were not encoded and transmitted to the State within the mandated 7-day period following the assessment reference date (ARD). Interviews with the MDS Coordinator and MDS Nurse revealed that they were behind on completing MDS assessments when they began their positions, and were still working to catch up. The facility's Administrator confirmed awareness of the backlog and stated that new MDS nurses had been hired due to the issue. The late completion and submission of the discharge MDS assessments were acknowledged by both the MDS staff and the Administrator during interviews.
Inaccurate Daily Nurse Staffing Information Posted
Penalty
Summary
The facility failed to accurately report daily nurse staffing information as required, as evidenced by discrepancies between the posted nurse staffing sheets and the actual nursing schedules for five reviewed dates. On each of these dates, the numbers and types of staff (RNs, LPNs, and NAs) listed on the posted sheets did not match the facility's internal schedules. For example, on one date, the posted sheet indicated more RNs and fewer NAs than were actually scheduled, while on another, the posted sheet showed fewer staff than were present according to the schedule. These inconsistencies were found across all reviewed shifts and dates. Interviews with the Scheduler revealed that she was responsible for updating and correcting the posted nurse staffing sheets, typically making adjustments during regular business hours and sometimes returning on weekends or the following Monday to finalize corrections. The Scheduler also reported uncertainty about whether nursing staff had been trained to update the posted sheets in her absence. The Administrator confirmed the expectation that posted nurse staffing sheets should accurately reflect actual staffing. No information about residents' medical history or conditions was included in the report.
Failure to Timely Obtain Treatment Order for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to obtain a treatment order for a suspected deep tissue injury (DTI) on a resident's left heel at the time it was first observed, resulting in a delay in the initiation of treatment. The resident had multiple chronic health conditions, including diabetes, chronic kidney disease, obesity, and recent left total knee arthroplasty, and was identified as being at risk for pressure ulcers. The care plan included interventions such as regular skin assessments and preventative measures, but when the DTI was identified during a skin assessment, no immediate treatment order was obtained or implemented. The Wound Nurse observed the suspected DTI on the resident's left heel during a skin assessment and believed an order had been placed, but there was no evidence of a treatment order in the resident's Treatment Administration Record (TAR) for January. The Wound Nurse was unsure why the order was not present. The Wound Nurse Practitioner (NP) was only informed of the DTI several days later during wound rounds, at which point a treatment order was finally placed and initiated. Interviews with facility staff, including the NP, DON, and Administrator, confirmed that the expected protocol was to notify a provider and obtain a treatment order immediately upon identification of a pressure ulcer. Documentation review showed that the resident's care plan was not updated to reflect the DTI until several days after its initial observation, and treatment was not started until after the Wound NP was notified. The delay in obtaining a treatment order and initiating care for the pressure ulcer was confirmed through interviews and record review, constituting a failure to provide timely and appropriate pressure ulcer care as required.
Failure to Obtain Provider Order and Notify Practitioner of X-ray Results
Penalty
Summary
The facility failed to obtain a provider's order prior to requesting radiology testing for a resident and did not notify the Nurse Practitioner (NP) when x-ray results revealing multiple rib fractures became available. A resident with a history of stroke, muscle weakness, and dementia experienced a fall and subsequently underwent x-rays. The initial x-ray did not show acute fractures, and the NP reviewed these results during a post-fall evaluation. Later, another x-ray was performed without a documented provider order, and this x-ray revealed multiple right-sided rib fractures. The nurse who requested the second x-ray did so based on her own assessment of the resident's symptoms, believing the resident might have similar symptoms to her own, but did not document a provider order. The nurse also could not confirm if she communicated the pending x-ray results to the oncoming nurse. The NP was only made aware of the x-ray results after the resident was sent to the hospital for a change in condition, at which point he discovered the rib fractures in the resident's electronic medical record. Interviews with facility staff confirmed that there was no system in place to ensure provider notification of radiology results when they became available, and the process relied on verbal handoff between nursing shifts. The Director of Nursing stated that all lab or radiology results should be communicated to the provider, but this was not consistently done in this case.
Failure to Notify Physician of Resident's Pain and X-ray Delay
Penalty
Summary
The facility failed to notify the physician at the onset of pain and when a STAT x-ray could not be completed immediately after a resident experienced an unwitnessed fall. The resident, who had a history of vascular dementia, muscle weakness, and other medical conditions, fell on a Sunday and was found sitting on the floor next to her bed. Initially, no injuries were noted, and the resident reported no pain. However, when the resident's responsible party arrived, the resident complained of pain, and a STAT x-ray was ordered. The x-ray was not performed until the following day, revealing an acute nondisplaced transverse left femur fracture. The physician was not informed of the fracture until several days later, delaying necessary medical intervention. The facility also failed to notify the physician when the resident's pain was not manageable during night shifts on two occasions. Despite the resident showing signs of pain and discomfort, such as refusing care and grabbing the aide's arm to stop, the nursing aides did not report these observations to the nurse or physician. This lack of communication further delayed the resident's care and treatment, as the medical director was not aware of the fracture or the resident's condition until he saw her days later. The delay in notifying the physician and the failure to manage the resident's pain appropriately resulted in the resident being sent to the hospital for surgery only after the medical director intervened. The resident underwent surgery for the fracture and experienced complications, including an aspiration event leading to acute hypoxic respiratory failure. The facility's inaction and communication failures contributed to the resident's prolonged pain and delayed treatment, putting her at high risk for further complications.
Removal Plan
- An incident report was completed by the charge nurse, based on information obtained from certified nursing aide.
- The Director of Nursing and Nurse Managers reviewed residents who have fallen to confirm that the Medical Director had been notified.
- The Director of Nursing and Nurse Managers reviewed diagnostic and laboratory testing to ensure they were obtained as ordered and the Medical Director had been notified.
- The Director of Nursing/Staff Development Coordinator began in person education for all nursing staff on the facility policy and procedures for physician notification.
- Licensed nurses were educated on utilization of the MD communication book to report diagnostic reports and other non-emergent resident issues.
- All nurse aides were educated on the process of notification to licensed nurse of any identified resident issues such as pain or other resident concerns.
- The licensed nurses will document in the residents' electronic medical record the notification to the medical provider and the plan of care.
- The Nurse Managers will review the residents electronic medical record daily and the documentation to ensure the medical provider was notified.
- Education will be provided for all new nursing staff and agency staff prior to the beginning of their first shift.
- Nurse Aides can report directly to the nurse or use the computer system which serves as an alert system within the resident's electronic record.
- The Director of Nursing educated Licensed Nurses regarding the requirements for notification of the Physician following a fracture and/or a significant change of condition.
- The Director of Nursing or designee will complete in person review with any staff that receive education by telephone to assure their understanding of the education received.
- The Staff Development Coordinator will be responsible for tracking which employees have received their education.
- The Director of Nursing and Administrator completed an Ad-Hoc QAPI to ensure that all components of the credible allegation were completed and followed.
- The Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.
Neglect in Timely Medical Intervention After Resident Fall
Penalty
Summary
The facility failed to protect a resident from neglect following an unwitnessed fall. After the fall, the resident reported pain in her left hip, but the facility did not notify the physician immediately. A STAT x-ray was ordered but not completed until the following day, revealing a nondisplaced transverse left femur fracture. The Nurse Practitioner did not communicate the x-ray results to the Medical Director, delaying the necessary orthopedic evaluation and surgical intervention. The resident's pain was not adequately managed, and the facility failed to notify the physician when the resident's pain was unmanageable during night shifts. The Medical Director was unaware of the fracture and the scheduled orthopedic consultation until several days later. Upon discovering the fracture, the Medical Director ordered the resident to be sent to the emergency department if she could not be seen by an orthopedist that day. The resident was eventually seen by an orthopedist and underwent surgery. The delay in treatment and lack of communication between the facility staff and medical providers resulted in the resident experiencing an aspiration event while hospitalized, leading to acute hypoxic respiratory failure. The facility's neglect in providing timely and appropriate care put the resident at high risk for complications, including deep vein thrombosis, pneumonia, and bed sores.
Removal Plan
- The Director of Nursing/Staff Development Coordinator began in-person education for all facility staff in all departments including agency and contract staff. Education included review of policy regarding abuse/neglect.
- Recognizing signs of abuse and neglect.
- Examples of neglect, including not providing necessary care and services.
- Reporting of abuse and neglect.
- Facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately.
- Notification to physician of any delays in physician orders including stat orders and delay in any physician ordered appointments and x-rays.
- Education to certified nurse aides on reporting identified pain and other abnormal events identified during delivery of care.
- Any nursing staff member that did not receive education will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received.
- All newly hired licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process.
- The DON or designee will verify the understanding of education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation.
- In person education was completed by the Director of Nursing to current medical providers including on-call providers, Nurse Practitioners and Medical Director. Education consisted of communication between all providers should be clear, concise and collaborative. Communication should include a discussion of treatment plans and seeking advice when necessary. Providers should participate in decision making in a timely manner.
- The Medical Director and the Physician Extenders agreed to meet with the Director of Nursing weekly to discuss abnormal labs, radiology or test results as a team.
- The Regional Director of Clinical Services informed the Staff Development Coordinator and/or the Director of Nursing to complete monthly training on abuse and neglect for 3 months and then quarterly ongoing. Education will ensure abuse and neglect is explained to all staff per federal guidelines, Neglect as defined at 483.12, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
- The Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.
Delayed Orthopedic Evaluation After Resident Fall
Penalty
Summary
The facility failed to recognize the seriousness of an injury sustained by a resident following a fall, which led to a delay in urgent orthopedic evaluation and treatment. The resident, who had a history of vascular dementia, muscle weakness, and other medical conditions, fell and reported pain in her left hip. A STAT x-ray was ordered but not completed until the following day, revealing a nondisplaced transverse left femur fracture. Despite the x-ray results, the resident remained in the facility awaiting an orthopedic consultation, which was initially scheduled for a week later. The Medical Director was not informed of the fracture until several days later, at which point he ordered the resident to be sent to the emergency department if she could not be seen by an orthopedist that day. The resident was eventually seen by an orthopedist and sent directly to the hospital for surgery. The delay in recognizing the need for urgent care and the failure to act promptly on the x-ray results contributed to the deficiency. Interviews with staff revealed a lack of communication and timely action regarding the resident's condition. The nurse who initially assessed the resident did not notify the on-call provider of the delay in obtaining the x-ray, and the NP did not send the resident to the hospital despite the fracture. The facility's failure to act on the x-ray results and the lack of immediate orthopedic evaluation put the resident at risk for complications.
Removal Plan
- The Director of Nursing, Unit Managers, and Regional Director of Clinical Services reviewed diagnostic results and progress notes for all residents to identify any instances of delay in carrying out orders, changes in condition, abnormal results, refusals, or other clinical conditions that had not been properly identified and acted upon.
- The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for Licensed Nurses, including agency nurses, on recognizing when to seek medical treatment for residents with fractures and changes in condition and notification to the Physician/Medical Director following an incident or change of condition and when receiving ordered diagnostic test results.
- Education included reporting of abnormal labs and x-ray results, if an order is not to be carried out as ordered by the physician or nurse practitioner, refusal of treatment plan by the resident or responsible party, and knowing the risk and benefits of not sending a resident out for treatment when needed.
- The Director of Nursing will ensure that no staff member works without receiving this education. The Staff Development Coordinator is responsible for tracking that all staff received the required education. Any new hires, including agency staff, will receive education prior to the start of their shift.
- The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers initiated in-person training for all Licensed Nurses, including agency nurses, to ensure they understand the requirements for orders received for diagnostic tests. If the diagnostic test is ordered stat and the mobile diagnostic company is unable to perform the study stat or in an acceptable time at the direction of the medical provider, the resident is to be sent to the hospital.
- The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift.
- The Staff Development Coordinator was informed of her responsibility. This education will also become a part of the new hire orientation process for all newly hired licensed nurses.
- The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for all Licensed Nurses, including agency nurses, on the procedure for handling abnormal x-ray results. The training emphasized that abnormal results must be reported to the Medical Director for further orders.
Failure in Communication and Collaboration Delays Resident's Fracture Treatment
Penalty
Summary
The deficiency involved a failure in communication and collaboration between a Nurse Practitioner (NP) and the Medical Director regarding the medical management of a resident who suffered an acute nondisplaced transverse left femur fracture following an unwitnessed fall. The NP did not consult with the Medical Director before deciding that the resident was probably not a surgical candidate and attempted to treat the resident in-house. This lack of communication resulted in the Medical Director being unaware of the fracture until several days later, delaying appropriate medical intervention. The resident, who had a history of vascular dementia, muscle weakness, and other significant health issues, experienced an unwitnessed fall and was initially assessed with no injuries noted. However, the resident later reported pain, and an x-ray confirmed a fracture. Despite this, the NP chose to manage the condition conservatively without consulting the Medical Director, who only became aware of the fracture days later when the resident's pain became unmanageable. The delay in appropriate medical management led to the resident being sent to the hospital for surgery only after the Medical Director intervened. The resident subsequently experienced complications, including an aspiration event resulting in acute hypoxic respiratory failure while hospitalized. The deficiency affected the resident's timely access to necessary orthopedic care and increased the risk of further complications.
Removal Plan
- The MD reviewed the NP's notes for the previous 30 days, including the on-call providers, to ensure the plan of care was appropriate for the residents. Any opportunities identified during this audit were corrected by the MD.
- The Regional Director of Clinical Services, Nurse Practitioner, Medical Director, and the Director of Nursing reviewed Resident #1's plan of care and collaborated on what the best course of treatment should have been for the resident.
- The Regional [NAME] President educated the Medical Director, NPs, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition.
- The Regional [NAME] President educated The Director of Nursing and the Administrator to participate in the meeting.
- The Medical Director reviewed the guidelines for how the Nurse Practitioners and other covering providers to communicate with the Medical Director. The Medical Director and Regional [NAME] President discussed this agreement with the NPs and other providers.
- The Regional Director of Clinical Services educated the Nurse Management Team and the Director of Nursing regarding the nurse practitioners' notes, including on call to ensure communication and collaboration is completed. The Director of Nursing, unit managers, staff development nurse and Assistant Director of Nursing will review and print the nurse practitioner notes, including the on-call providers daily and place them in the Medical Director's communication book. When the Medical Director is not in the facility, he will receive an electronic HIPAA compliant copy of the medical progress notes generated each day. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person.
- The Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.
Inadequate Pain Management Following Resident Fall
Penalty
Summary
The facility failed to effectively manage a resident's pain following an unwitnessed fall. The resident, who was admitted with multiple diagnoses including vascular dementia and a history of traumatic brain injury, was found on the floor by a nurse aide. Initially, the resident denied any pain or injury, and no immediate pain management was initiated. However, when the responsible party arrived, the resident reported pain in the left hip, prompting a delayed order for a STAT x-ray and Tylenol for pain relief. Despite the order for regular pain assessments, documentation revealed inconsistencies and omissions in pain management. Pain assessments were not thoroughly conducted, with some entries lacking numerical values or specific pain locations. The resident's pain levels fluctuated, with reports of significant pain on certain days, yet the administration of pain medication was not consistently documented. Interviews with staff indicated a lack of communication and follow-up regarding the resident's pain status, contributing to inadequate pain management. The resident's condition worsened, with a confirmed nondisplaced fracture to the left femur. Despite this, the resident remained in bed for several days, with limited mobility and ongoing pain. The facility's failure to conduct thorough and ongoing pain assessments, coupled with inadequate documentation and communication among staff, resulted in insufficient pain management for the resident. This deficiency highlights the need for improved protocols and staff training in pain assessment and management to ensure resident well-being.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency in a timely manner for a resident who was reviewed for neglect. The incident involved a resident who sustained a fall on November 17, 2024, and did not receive the necessary care and services for a fracture. The Administrator was informed of the neglect allegation on January 3, 2025, at 8:48 AM. However, the initial allegation report was not submitted to the state agency until January 6, 2025, at 2:15 PM. During an interview on January 6, 2025, the Administrator stated that the report was not sent on January 3, 2025, because he assumed it was unnecessary since all parties involved, including the state agency, were already aware of the allegation.
Inaccurate Post-Fall Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate medical record documentation for a resident following a fall. The resident, who was nonverbal, was admitted to the facility and experienced a fall, resulting in a nondisplaced fracture to the left femur. Documentation of the resident's condition post-fall was inconsistent and inaccurate, with several notes being copied from previous entries without proper assessment. Specifically, the Night Nurse Supervisor and Nurse #3 copied information from previous notes without conducting their own assessments of the resident's pain or condition. The Night Nurse Supervisor admitted to copying details from previous shifts' documentation to ensure some form of record was completed, despite not assessing the resident for pain on multiple occasions. Nurse #3 also failed to recall the documentation note and did not receive any notification from Nurse Aides regarding the resident's pain. The Director of Nursing confirmed that the nurses were expected to assess and document the resident's pain accurately during each shift, which was not done, leading to the deficiency in maintaining accurate medical records.
Inadequate COVID-19 Testing and Infection Control Measures
Penalty
Summary
The facility failed to implement a broad-based COVID-19 testing approach for staff and residents despite being in outbreak status since a staff member tested positive. Initially, only symptomatic individuals, roommates of positive residents, and staff who requested testing were tested. This approach did not align with CDC guidelines, which recommend a broad-based testing approach during outbreaks. As a result, the facility did not initiate broad-based testing until several days after multiple residents across different halls tested positive, leading to a significant number of COVID-19 cases among residents and staff. Additionally, the facility's infection control practices were inadequate, as observed by surveyors. Many staff members failed to wear surgical masks properly, with masks not covering both the mouth and nose, which is essential for source control to prevent transmission. Furthermore, a nurse aide entered a resident's room under transmission-based precautions without wearing the required eye protection. These lapses in infection control measures contributed to the potential for continued transmission of COVID-19 within the facility. The facility's policies and procedures for infection prevention and control did not conform to CDC guidance, particularly regarding outbreak testing and the use of personal protective equipment (PPE). The Infection Preventionist and Director of Nursing were aware of the outbreak but did not implement the necessary measures to control the spread effectively. The facility also failed to initiate the administration of the 2024-2025 COVID-19 vaccinations for residents in a timely manner, further exacerbating the risk of transmission.
Removal Plan
- The Director of Nursing and Infection Preventionist completed broad-based testing on all staff and residents within the facility. The facility will complete testing on all residents and staff twice per week until there is a 14-day interval of no new positive cases.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator/Infection Preventionist, and the Unit Managers regarding Special Droplet Contact Precautions when a resident tested positive for COVID-19.
- All staff, including medical director and Nurse Practitioner, will perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting the room.
- All staff, including medical director and nurse practitioner will wear a gown when entering the room, remove before exiting the room.
- All staff, including medical director and nurse practitioners, will wear an N95 when entering the room and remove before exiting the room.
- All staff, including the medical director and nurse practitioner will wear eye protection such as a face shield or goggles when entering the room and remove them before exiting the room.
- All staff, including the medical director and nurse practitioner will wear gloves when entering the room and remove them before leaving the room.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding source control to include wearing face mask throughout the building during outbreak status regardless of if they are in a covid positive room or not.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding Special Droplet Contact Precautions when a resident test positive for COVID-19.
- The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift in person.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly don Personal Protective Equipment.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly doff Personal Protective Equipment.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly don Personal Protective Equipment with current staff.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly doff Personal Protective Equipment with current staff.
Failure to Maintain 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to maintain licensed nursing coverage 24 hours a day for 17 out of 120 days reviewed, as required by regulations. This deficiency was identified through a review of staffing data submitted via the CMS Payroll-Based Journal system for the third quarter of 2024. Specific dates in April and May 2024 were noted where there was no licensed nurse coverage for the entire day. The facility was unable to provide supporting documentation such as staff schedules, timecard reports, or payroll reports for the period in question, which could have confirmed the presence or absence of licensed nursing staff. Interviews with facility staff revealed that there was a transition in management when a new company took over in June 2024. The Staff Development Coordinator, who also served as the Infection Preventionist and Assistant Director of Nursing, acknowledged the previous reliance on agency staff but could not confirm the staffing situation prior to the takeover. Similarly, the Facility Scheduler, who assumed her role in June 2024, was aware of the regulatory requirement for 24-hour licensed nurse coverage but was unable to provide information on staffing issues before her tenure.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week, for 17 out of 120 days reviewed. This deficiency was identified through a review of staffing data submitted via the CMS Payroll-Based Journal system for the third quarter of 2024. The specific dates without adequate RN coverage were listed, but the facility was unable to provide supporting documentation such as staff schedules, RN timecard reports, or payroll reports for the period from April 1, 2024, to June 30, 2024. Interviews with facility staff revealed that the Staff Development Coordinator, who also served as the infection preventionist and assistant director of nursing, could not confirm RN coverage for the specified days. The Facility Scheduler, who assumed her role in June 2024, was aware of the regulatory requirement but could not provide information on scheduling issues before her tenure. The facility Administrator, also new since June 2024, was unable to locate any relevant staffing documentation prior to that time, indicating a lack of continuity and record-keeping during the transition to new management.
Significant Medication Error Due to Late Insulin Administration
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident with diabetes mellitus and dementia. The resident was prescribed Humalog Insulin to be administered according to a sliding scale before meals and at bedtime. On a specific day, the resident's blood glucose level was checked at 9:50 AM, revealing a level of 252 mg/dL, which required the administration of 7 units of insulin. However, the insulin was not administered until 9:55 AM, more than 2.5 hours after the scheduled time of 7:30 AM, which was prior to the resident's breakfast. Nurse #4, responsible for administering the insulin, attributed the delay to a heavy medication pass workload and the additional time required to manage COVID-positive residents. The Director of Nursing (DON) later stated that nurses have sufficient time to pass medications within the required timeframes and that administrative nurses are available to assist if needed. The late administration of insulin was identified as a significant medication error due to the deviation from the prescribed schedule.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to assess and document the ability of two residents to self-administer medications. Resident #6, who was cognitively intact, did not have a care plan addressing self-administration of medications. Despite this, a medicine cup containing two stool softener tablets was left on Resident #6's overbed table by a nurse, who did not stay to observe the resident taking the medication. The nurse's actions were contrary to the facility's policy, which requires nurses to stay with residents while they take their medications. Nurse #9, who was not the administering nurse, later discarded the tablets, acknowledging that leaving medications in a resident's room was not standard practice. Similarly, Resident #12, also cognitively intact, did not have a care plan for self-administration of medications. A nurse left a medication cup containing gabapentin and a probiotic on Resident #12's overbed table while the resident was on a phone call. The resident took some of the pills independently, which was against the facility's policy. Interviews with the Unit Manager and the Director of Nursing confirmed that no residents were authorized to self-administer medications, and nurses were expected to stay with residents during medication administration. The facility's failure to assess and authorize self-administration of medications led to these deficiencies.
Failure to Complete Significant Change in Status MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for a resident who was reviewed for hospice services. The resident was admitted to the facility with a diagnosis of malignant neoplasm of the right lung and was later admitted to hospice services. However, a review of the MDS assessments revealed that a Significant Change in Status MDS Assessment was not completed after the resident's admission to hospice services. During an interview, the MDS Coordinator, who had been working at the facility for two months, acknowledged that the assessment should have been completed within fourteen days of the resident's admission to hospice. It was also revealed that the facility had not had a dedicated MDS Coordinator for over a year, relying instead on traveling MDS Nurses and various facility staff to conduct assessments and observations.
Inaccurate MDS Coding and Assessment Deficiencies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the areas of falls, range of motion, and comprehensive assessments. Resident #59, who was admitted with hemiplegia and a right-hand contracture, was inaccurately coded as having no range of motion impairments despite recommendations for a Functional Maintenance Program and the use of a splint. Observations revealed the resident's right hand was fisted, and the splint was not in use until located by the Rehabilitative Director. The MDS Director, who had been in the role for two months, was unable to explain the inaccuracies due to the previous use of traveling MDS nurses and lack of a consistent MDS Coordinator. Resident #69, diagnosed with Alzheimer's disease, was not assessed for several critical areas including cognition, mood, and functional abilities in their quarterly MDS assessment. The MDS Director acknowledged the absence of a dedicated MDS Coordinator for over a year, which contributed to the incomplete assessments. Additionally, Resident #42's admission MDS assessment failed to include psychiatric diagnoses of schizophrenia and PTSD, despite these being documented in the medical records and medication administration records. The MDS Coordinator recognized the error and was in the process of correcting it, while the Director of Nursing emphasized the need for accurate and complete diagnoses in resident charts.
Failure to Apply Recommended Splinting Device for Resident
Penalty
Summary
The facility failed to apply the right-hand grip splinting device as recommended by the occupational therapist for a resident with a contracture of his right hand. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebrovascular accident affecting the right dominant side and a right-hand contracture. Despite the occupational therapy discharge summary recommending a functional maintenance program with a right grip splint, the care plan did not include the application of the splinting device, and there was no physician order for it in the medical record. Observations revealed that the resident's right hand was fisted, and the splinting device was not visible in the room. Interviews with staff indicated uncertainty about the location and application of the splint. The Rehabilitation Director found the splint in the resident's nightstand and applied it, noting it fit comfortably, suggesting the resident's range of motion had been maintained. However, the resident's POA reported not seeing the splint on the resident's hand in two years, indicating a lapse in the consistent application of the recommended splinting device.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed rate for a resident diagnosed with hypoxemia and congestive heart failure. The resident was moderately cognitively impaired and required oxygen therapy at 2 liters per minute via nasal cannula, as per physician orders. However, during observations, the oxygen concentrator was set to deliver 3.5 liters per minute. Despite the resident showing no signs of respiratory distress, the discrepancy in oxygen delivery was noted. Nurse #4, who was responsible for the resident's care, did not document the resident's vital signs or check the oxygen concentrator settings due to the presence of visitors and the absence of respiratory distress. The Nurse Practitioner confirmed the resident had no symptoms of dyspnea and instructed staff to adhere to the prescribed oxygen rate. The Director of Nursing and the Administrator both emphasized the expectation for nursing staff to follow physician orders and monitor oxygen therapy settings.
Incomplete Medical Record for Resident Diagnoses
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was admitted following a fractured pelvis and septic shock, which resulted in generalized muscle weakness. Upon review, it was found that the resident's electronic medical record did not include the diagnoses of schizophrenia and post-traumatic stress disorder (PTSD) as noted in the hospital discharge summary. This omission was identified during a review of the resident's medical records, highlighting a deficiency in maintaining accurate and complete diagnoses in the resident's chart.
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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