Brunswick Cove Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Winnabow, North Carolina.
- Location
- 1478 River Road, Winnabow, North Carolina 28479
- CMS Provider Number
- 345318
- Inspections on file
- 22
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Brunswick Cove Nursing Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, failure to thrive, severe malnutrition, and psychosis exhibited escalating aggression despite non-pharmacological interventions. An NP gave a verbal order for Haldol 2 mg IM for agitation, but a unit manager nurse did not repeat back or verify the dose and instead retrieved four 5 mg/mL vials from the emergency supply and administered a total of 20 mg IM. The nurse initially reported the 20 mg dose to colleagues without it being questioned, only recognizing the tenfold error later while entering the written order into the record. The DON later identified the lack of read-back of the verbal order as a key process failure contributing to this significant medication error.
A resident receiving IV antibiotics via a PICC line did not have physician orders for required saline and heparin flushes, despite nursing staff administering these flushes according to protocol and pharmacy supply. Nursing staff relied on experience and available supplies but did not clarify or document orders in the eMAR, resulting in a deficiency related to the lack of proper physician authorization and documentation for catheter maintenance.
Two residents did not receive wound care and offloading interventions as ordered. One resident with a surgical hip wound did not have the Aquacel dressing changed per hospital discharge instructions, and staff failed to clarify or implement the correct protocol. Another resident with a neck/shoulder contracture did not consistently receive offloading or moisture-wicking interventions as ordered, with missed treatments documented and staff unable to confirm if care was provided.
A resident with quadriplegia and multiple pressure ulcers did not receive wound care as ordered by the physician. A nurse applied a petroleum gauze dressing to the right ankle, which was not prescribed, and failed to notify the wound care team that the wound had reopened. The Wound Treatment Nurse and DON confirmed that proper communication and adherence to orders were not followed, resulting in improper wound management.
A resident with COPD and chronic respiratory failure was observed receiving oxygen at 3 liters per minute via nasal cannula, despite a physician order for 2 liters per minute. Nursing staff did not verify the oxygen setting as required, and facility leadership confirmed that staff are expected to ensure oxygen is administered at the ordered rate.
A Wound Treatment Nurse provided wound care to a resident with a pressure ulcer without wearing the required protective gown, as mandated by the facility's Enhanced Barrier Precautions policy. The nurse only wore gloves and later admitted forgetting the gown, citing the absence of visible signage and accessible PPE in the room. Staff interviews confirmed that signage and PPE should have been present and that gowns and gloves are required for such care.
A resident with a history of subdural hemorrhage, syncope, and narcolepsy was not properly supervised while smoking, despite a care plan requiring supervision and a smoking apron after an incident where her clothing caught fire. Staff observations and interviews revealed the resident continued to smoke independently without the apron, and there was inconsistent awareness among staff about her supervision needs due to communication lapses.
The facility inaccurately coded MDS assessments for four residents, affecting areas such as medication, dental, and continence. A resident on antipsychotic medication was incorrectly recorded as not receiving it, while another with broken teeth was noted as having no dental issues. Additionally, a resident's continence status was misrepresented. These errors were attributed to human error, as confirmed by interviews with the MDS Coordinator and DON.
A resident with visual disturbances and a history of brain injury and Parkinson's Disease experienced delays in receiving ophthalmology and retinol specialist appointments. Despite multiple orders and requests, the resident was not seen by an ophthalmologist for several months, and the retinol specialist appointment was not obtained. Interviews revealed a breakdown in the facility's process for scheduling appointments, with staff unaware of orders and unable to provide documentation for the delays.
A facility failed to review and document pharmacy recommendations for a resident on antipsychotic medication. Despite multiple recommendations for an AIMS assessment by the Consultant Pharmacist, no documentation or response was recorded. Interviews confirmed that the assessment should have been conducted due to the resident's medication use.
A resident receiving olanzapine for delusions did not have an AIMS assessment completed, despite recommendations from the Consultant Pharmacist. The resident had severe cognitive impairment and was on antipsychotic and antianxiety medications. The Quality Assurance Nurse and DON acknowledged the oversight, citing a lack of automatic triggers in the computer system.
The facility failed to provide a CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents after their Medicare Part A skilled services ended. Both residents, one with moderate and the other with severe cognitive impairment, remained in the facility without receiving the necessary SNF ABN, despite signing a Notice of Medicare Non-Coverage (NOMNC). The Social Worker and Administrator were unaware of the requirement to issue the SNF ABN when residents stayed in the facility post-Medicare services.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. One resident's care plan did not include antidepressant or antiplatelet medication use, another's omitted bowel incontinence and antiplatelet medications, and a third's failed to mention an indwelling catheter. Interviews with the MDS Coordinator and DON confirmed that the care plans should have accurately reflected the residents' conditions and medication use.
The facility failed to display required oxygen use signage for two residents prescribed continuous oxygen therapy. One resident with asthma and another with chronic respiratory conditions were observed without signage outside their rooms and not wearing their oxygen as prescribed. Staff interviews confirmed the oversight, and the DON acknowledged the responsibility to place signage when oxygen orders were issued. Physicians noted no adverse outcomes as saturation rates were normal.
A resident in hospice care fell and sustained a head injury, but the facility failed to promptly notify the responsible party and the physician. The hospice nurse informed the responsible party, who opted for comfort measures. The facility's nurse practitioner and physician were not informed until the following day.
Significant Medication Error: Tenfold Haldol Overdose Due to Verbal Order Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when a nurse administered an incorrect dose of Haldol IM to a resident. The resident had recently been discharged from a hospital stay for hip pain following a fall and was admitted to the facility with diagnoses including Parkinson’s disease, adult failure to thrive, severe protein-calorie malnutrition, benign paroxysmal vertigo, history of falling, depression, and cognitive communication deficit. At hospital discharge, and on admission to the facility, the resident was prescribed multiple psychotropic medications, including clozapine for psychosis related to Parkinson’s disease, clonazepam as needed for anxiety, and Remeron for depression. The resident’s medical history also included recurrent falls, severe malnutrition, and a history of delirium and significant hallucinations. On the day after admission, the resident exhibited escalating aggressive behaviors toward staff, including punching and head-butting nurses and slapping a nurse on the buttocks. Staff attempted non-pharmacological interventions such as redirection, providing activities, offering food and drink, and toileting, but these measures did not reduce the behaviors. Nurse practitioners and nursing staff observed the resident kicking, punching, scratching, and grabbing at staff, and the NP decided to order Haldol 2 mg IM for agitation, fighting, and restlessness. The NP reported that she clearly gave a verbal order for Haldol 2 mg IM to a unit manager nurse and then wrote the order, leaving it at the nurse’s computer for later entry into the medical record. The medication error occurred when the unit manager nurse obtained Haldol from the emergency medication supply and administered 20 mg IM instead of the ordered 2 mg. The nurse stated she could not recall whether the NP had specified the dose and admitted she did not repeat the verbal order back to the NP. She reported that “20 mg” stuck in her mind, took four vials of Haldol 5 mg/mL from the emergency supply, and administered the full 20 mg dose to the resident. After giving the injection, she informed another nurse and the NP that she had administered 20 mg, and no one questioned the dose at that time. The nurse later realized the error while entering the written order into the medical record, recognizing that the ordered dose was 2 mg, not 20 mg. The facility’s DON identified the failure to repeat back the verbal order as a breakdown in the process that contributed to the medication error. The consultant pharmacist and medical director confirmed that the intended dose of 2 mg IM was appropriate for the resident’s acute behaviors and that the resident instead received a significantly higher single dose than ordered.
Failure to Obtain Orders for PICC Line Flushes During IV Antibiotic Therapy
Penalty
Summary
The facility failed to obtain physician orders for flushing a percutaneous intravenous central catheter (PICC) with normal saline and heparin for a resident receiving intravenous (IV) antibiotics. The resident, who had diagnoses including diabetic foot ulcer, osteomyelitis, and lower extremity impairment, was admitted with a PICC line for administration of IV antibiotics such as Meropenem and Vancomycin. While there were physician orders for the antibiotics and for monitoring and changing the PICC dressing, there were no documented orders for the administration of saline or heparin flushes to maintain catheter patency. Despite the absence of orders, nursing staff routinely used prefilled saline and heparin flushes labeled for the resident, following the SASH (saline, antibiotic, saline, heparin) protocol before and after administering IV antibiotics. Multiple nurses confirmed during interviews that they administered the flushes based on their training and experience, and because the pharmacy provided the flushes. However, they acknowledged that they should have clarified and obtained specific orders for these flushes from the physician and entered them into the electronic medical record (eMAR). The pharmacy technician stated that flushes were automatically sent when IV antibiotics were ordered, but it was the facility's responsibility to ensure orders for flushes were entered into the eMAR. Both the nurse practitioner and the physician confirmed that explicit orders for saline and heparin flushes should have been in place to ensure proper documentation and administration. The Director of Nursing also acknowledged that, although best practices were followed in administering the flushes, the lack of documented orders constituted a deficiency.
Failure to Provide Ordered Wound Care and Offloading Interventions
Penalty
Summary
The facility failed to provide wound care and offloading as ordered for two residents reviewed for skin integrity. For one resident who was admitted after a left total hip replacement, the hospital discharge summary included an order for Aquacel dressing to be changed every 5-7 days or as needed. However, this order was not transcribed into the facility's physician orders, and instead, a daily cleansing and dry dressing order was implemented. Multiple nurses observed the Aquacel dressing in place but did not clarify the discrepancy between the observed dressing and the written orders. Documentation in the Treatment Administration Record (TAR) and nursing notes reflected confusion and lack of action to clarify or implement the correct wound care protocol. The Aquacel dressing was not changed within the specified timeframe, and the correct order was only identified after review by the Wound Treatment Nurse several days later. Another resident with a left neck/shoulder contracture and a history of rheumatoid arthritis, diabetes, and cellulitis had a physician order to offload the contracture and keep the neck fold clean and dry every 8 hours. Observations and interviews revealed that the offloading and moisture-wicking interventions were not consistently implemented as ordered. Nursing staff failed to ensure that offloading devices or moisture-wicking fabric were in place, and documentation in the TAR showed missed treatments. Nurses interviewed could not recall if the interventions were performed and acknowledged missing the order. Both deficiencies were confirmed through record review, staff interviews, and direct observation. The failures included not following hospital discharge orders for wound care and not implementing or documenting offloading and moisture management for a contracture as ordered. These lapses were not questioned or clarified by nursing staff, leading to a lack of appropriate treatment and care as specified in the residents' care plans and physician orders.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for wound treatment for a resident with quadriplegia, a history of vertebral fracture, and chronic pain. The resident had a stage 3 pressure ulcer and an unstageable deep tissue injury, both not present on admission. The care plan required monitoring, documentation, and specific wound care interventions, including weekly measurements and reporting abnormalities. Physician orders specified the type of dressing and frequency for each wound site. During an observation, it was found that a nurse applied a petroleum gauze dressing to the resident's right ankle, which was not in accordance with any current physician order. The correct treatment for the right ankle, which had previously resolved, was not in place, and the nurse had mistakenly applied the dressing intended for a different wound site. The Wound Treatment Nurse was unaware that the right ankle wound had reopened and had not been notified by the nurse who performed the dressing change. The nurse who applied the dressing admitted to putting the wrong dressing on the wrong area, believing there was an order for the right ankle. The Director of Nursing confirmed that staff are expected to notify the physician and Wound Treatment Nurse of new wounds and to follow prescribed orders. The Wound Physician also stated that new wounds should be reported so appropriate treatment can be implemented. The lack of communication and failure to follow physician orders led to improper wound care for the resident.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure was not administered oxygen at the physician-ordered rate. The resident had a documented order for continuous oxygen via nasal cannula at 2 liters per minute, and the care plan reflected this intervention. However, during two separate observations, the oxygen concentrator was set at 3 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by a nurse who was responsible for the resident's care during the observed shifts, who admitted she had not checked the oxygen setting earlier that morning. Interviews with facility staff, including the nurse practitioner and the Director of Nursing, confirmed that the expectation was for nurses to ensure oxygen was set at the ordered rate and to contact the provider if adjustments were needed. The Director of Nursing stated that nurses should verify oxygen rates when assuming care and throughout their shift. The administrator also confirmed the expectation that nurses monitor oxygen settings to ensure compliance with provider orders. The failure to administer oxygen at the prescribed rate was identified through record review, direct observation, and staff interviews.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a pressure ulcer wound. During an observation of wound care, the Wound Treatment Nurse performed a dressing change for the resident without wearing the required protective gown, as stipulated by the facility's EBP policy. The nurse only wore gloves and did not don a gown at any point during the procedure, despite the resident having an open wound that required dressing. The nurse later acknowledged forgetting to put on the gown and indicated that the absence of visible signage in the resident's room contributed to this oversight. Further observations revealed that there was no visible personal protective equipment (PPE) such as gowns or gloves in the resident's room, nor was there appropriate signage posted to indicate the required PPE for high contact care activities. The only indicator present was a small magnetic banner on the door frame, which did not specify the PPE requirements. Interviews with staff, including the Wound Treatment Nurse and the DON, confirmed that signage and PPE should have been present and accessible, and that staff were expected to wear gowns and gloves for wound care under EBP. The lack of signage and accessible PPE contributed to the failure to adhere to infection control protocols during the observed care.
Failure to Supervise Resident Requiring Smoking Precautions
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure the use of a smoking apron for a resident identified as requiring supervision while smoking. The resident, who had a history of nontraumatic subdural hemorrhage, syncope, collapse, and narcolepsy, was initially assessed as safe to smoke independently. However, following an incident where the resident's clothing caught fire from a cigarette, a reassessment determined that supervision and the use of a smoking apron were necessary due to burn marks on her clothing. Despite the updated care plan and smoking assessment indicating the need for supervision and a smoking apron, the resident continued to smoke independently without staff supervision and did not wear the provided apron. Observations confirmed that the resident was able to access smoking materials, smoke outside without supervision, and did not use the smoking apron, which was found stored in her dresser drawer. Interviews with staff revealed inconsistent awareness of the resident's supervision status, with some staff considering her an independent smoker and others acknowledging the need for supervision after the incident. The Director of Nursing and Administrator acknowledged lapses in communication regarding the resident's supervision status, particularly following changes in key nursing personnel. The lack of consistent implementation of the updated care plan and supervision requirements resulted in the resident continuing to smoke unsupervised and without the required protective equipment, despite her medical history and recent incident involving fire.
Inaccurate MDS Coding for Medications, Dental, and Continence
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in areas including medication, dental, and continence. Resident #283, who was admitted with major depressive disorder, was prescribed Aripiprazole, an antipsychotic medication. However, the MDS assessment incorrectly indicated that no antipsychotic medication was received since admission. Similarly, Resident #115, who received olanzapine for delusions, had an MDS assessment that failed to reflect the receipt of antipsychotic medication during the lookback period, particularly in the section regarding gradual dosage reduction. Resident #99, admitted with conditions including diabetes and stroke, was observed to have multiple broken upper teeth, contrary to the MDS assessment which indicated no dental issues. Additionally, Resident #76, who was noted to be continent of bowel and bladder in a progress note, was incorrectly coded as occasionally incontinent of bowel in the MDS assessment. Interviews with the MDS Coordinator and the Director of Nursing revealed these errors were due to human error, and there was an expectation for MDS assessments to be completed accurately.
Failure to Schedule Timely Vision Care Appointments
Penalty
Summary
The facility failed to ensure that a resident received timely ophthalmology and retinol specialist appointments as ordered. The resident, who had a history of post-traumatic brain injury and Parkinson's Disease, experienced visual disturbances and was recommended for an ophthalmology consult on multiple occasions. Despite orders being entered by nurses and requests made by the physician and nurse practitioner, the resident was not seen by an ophthalmologist until several months later, and the recommended retinol specialist appointment was not obtained. Interviews with facility staff revealed a breakdown in the process for scheduling appointments. The Medical Records Specialist, responsible for coordinating ophthalmology visits, indicated that the facility's usual provider was unavailable, and the Director of Nursing was informed of this issue. The Transportation Specialist, tasked with scheduling appointments, was unable to provide documentation or recall why there was a delay in obtaining the ophthalmology appointment and was unaware of the retinol specialist order. The Director of Nursing acknowledged a system process failure in handling referrals and appointments. The process required nurses to complete an appointment tracker form and submit it to the Transportation Specialist, but this was not consistently followed. Additionally, the consult note from the ophthalmologist was not reviewed by the nurse practitioner or physician, further contributing to the delay in obtaining necessary specialist care for the resident.
Failure to Document Pharmacy Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and documented for a resident receiving antipsychotic medication. Resident #115, who was admitted with diagnoses including depression, dementia, and agitation, was prescribed olanzapine for psychotic disturbance and anxiety. Despite the Consultant Pharmacist recommending an AIMS assessment on multiple occasions, there was no documentation of the assessment being completed or any response to the recommendations. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed that an AIMS assessment should have been conducted due to the resident's antipsychotic medication use.
Failure to Complete AIMS Assessment for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was receiving psychotropic medications. The resident, who was admitted with diagnoses including psychotic disturbance with mood disturbance and anxiety, had been receiving olanzapine, an antipsychotic medication, since March 11, 2024, for delusions. Despite the resident's severe cognitive impairment and the use of antipsychotic and antianxiety medications, there was no record of an AIMS assessment being completed in the electronic medical record. The Consultant Pharmacist had recommended an AIMS assessment on multiple occasions, specifically on March 20, April 16, May 22, and June 17, 2024. Interviews with the Consultant Pharmacist, Quality Assurance Nurse, and Director of Nursing revealed that the assessment was overlooked. The Quality Assurance Nurse acknowledged responsibility for completing the AIMS when recommended, and the Director of Nursing confirmed that the assessment had never been completed, attributing the oversight to the computer system not automatically triggering the need for the assessment.
Failure to Provide SNF ABN to Residents Post-Medicare Part A
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents prior to the termination of their Medicare Part A skilled services. Resident #112, who had moderate cognitive impairment, was admitted to the facility and received Medicare Part A services until the end of April 2024. Although a Notice of Medicare Non-Coverage (NOMNC) was signed, there was no record of an SNF ABN being provided. During an interview, Resident #112 could not recall receiving any forms related to the end of Medicare Part A services. The facility's Social Worker admitted to not completing the SNF ABN form, citing a lack of awareness that it was necessary when a resident remained in the facility after Medicare Part A services ended. Similarly, Resident #115, who had severe cognitive impairment, was admitted to the facility and received Medicare Part A services until early February 2024. A NOMNC was signed, but no SNF ABN was provided. The Social Worker again acknowledged not completing the SNF ABN form due to unawareness of its necessity. The facility Administrator also stated a lack of awareness regarding the requirement for the SNF ABN form when residents remain in the facility post-Medicare Part A services. These oversights resulted in the facility's failure to properly inform residents of their potential financial liability for services not covered by Medicare.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical needs. Resident #76, who was admitted with depression, anxiety, and insomnia, was found to have a care plan that did not include focus areas for antidepressant or antiplatelet medication use, despite receiving these medications. The care plan also inaccurately reflected the resident's continence status, as the resident was able to take herself to the bathroom and was continent of bowel and bladder. Interviews with the MDS Coordinator and the DON confirmed that the care plan should have included these medications and accurately reflected the resident's condition. Resident #99, admitted with a history of stroke and peripheral vascular disease, had a care plan that failed to address bowel incontinence and the use of antiplatelet medications. The resident was frequently incontinent of bladder and always incontinent of bowel, yet the care plan only included bladder incontinence. Additionally, the care plan did not mention medications for constipation, which the resident was receiving. Interviews with the MDS Coordinator and the DON indicated that the care plan should have included bowel incontinence and the medications the resident was receiving. Resident #283, admitted with urinary retention, had a care plan that did not include the use of an indwelling catheter, despite having a physician's order for it. The care plan focused on bowel and bladder incontinence but omitted the catheter, which was a significant aspect of the resident's care. The MDS Coordinator and the DON acknowledged that the care plan should have included the indwelling catheter to accurately reflect the resident's condition.
Failure to Display Oxygen Use Signage for Residents
Penalty
Summary
The facility failed to apply appropriate signage indicating the use of oxygen outside the rooms of two residents who were prescribed continuous oxygen therapy. Resident #11, diagnosed with asthma, was admitted with an order for continuous oxygen at 2 LPM via nasal cannula. Observations on multiple occasions revealed that there was no signage outside her room indicating oxygen use, and she was not wearing her oxygen as prescribed. Interviews with staff, including a medication aide and a nurse, confirmed the absence of the required signage and the oversight in ensuring the resident was using her oxygen. The Director of Nursing acknowledged that the signage should have been placed when the oxygen order was written or when the concentrator was placed in the room. Similarly, Resident #112, with diagnoses including congestive heart failure and chronic respiratory failure, was also prescribed continuous oxygen at 2 LPM. Observations showed no signage outside his room, and he was seen without his oxygen while in the dining room. Interviews with the resident and nursing staff revealed that he would remove his oxygen when leaving his room, and the staff had not placed the necessary signage. The Director of Nursing confirmed the responsibility of the nursing staff to place the signage when the oxygen order was issued. Both residents' physicians noted that there were no adverse outcomes from the residents not wearing their oxygen, as their saturation rates remained within normal limits.
Failure to Notify Responsible Party and Physician of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party and the facility physician of a resident's fall and change in condition. Resident #89, who was in hospice care and had a do not resuscitate order, fell out of bed and sustained a laceration over her left eyebrow. Despite the presence of local family members, the facility did not inform the resident's designated responsible party, her daughter living in North Dakota, or the facility physician about the fall and subsequent change in condition until the following day. Interviews with staff and family members revealed that the hospice nurse was the first to inform the responsible party about the fall and the resident's unresponsive state. The hospice nurse arrived at the facility after being notified by the staff and found the resident unresponsive with fixed pupils. The responsible party was contacted by the hospice nurse, not the facility, and was informed of the resident's condition and the options for care. The responsible party decided against transferring the resident to a hospital, opting for comfort measures instead. The facility's nurse practitioner and physician were not informed of the resident's fall and change in condition until the day after the incident. The nurse practitioner learned of the situation during rounds, and the physician noted that there were no records of any calls from the facility regarding the incident. This lack of timely communication with both the responsible party and medical providers constitutes a deficiency in the facility's protocol for handling changes in a resident's condition.
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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