Brunswick Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bolivia, North Carolina.
- Location
- 1070 Old Ocean Highway, Bolivia, North Carolina 28422
- CMS Provider Number
- 345549
- Inspections on file
- 23
- Latest survey
- April 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Brunswick Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe and homelike environment, with issues such as a black greenish substance around commode bases, non-functioning overhead lights, and inadequate hot water temperatures in shower rooms. These deficiencies were observed across multiple hallways, indicating a widespread problem in maintaining the facility's infrastructure.
The facility failed to provide scheduled showers for three residents with cognitive impairments and did not perform timely incontinence care for a resident with urinary issues. Staff reported being too busy to complete these tasks, leading to unmet care needs.
A resident with muscle wasting, dysphagia, and dementia did not receive the recommended Arginaid supplement for wound healing due to a breakdown in communication and process within the facility. The Registered Dietician's recommendation was not processed, leading to the resident's worsening pressure wounds. Interviews revealed that the necessary steps to implement dietary recommendations were not followed, resulting in a significant lapse in care.
The facility did not notify the physician or nurse practitioner when a resident's blood pressure medication was repeatedly withheld or when another resident received a blood pressure-increasing medication outside of prescribed parameters. These actions were not communicated as required, though no significant outcomes were reported for the two residents involved.
The facility did not provide the required 8 hours of RN coverage on multiple days, as confirmed by staffing records and PBJ data. Despite recruitment efforts and use of agency staff, the facility was unable to consistently meet RN staffing requirements.
A consultant pharmacist did not identify or address that a resident's Carvedilol, prescribed for hypertension, was held 17 times in one month without physician-ordered parameters. The medication was withheld by nursing staff based on blood pressure readings, but the pharmacist's monthly review did not note or recommend action regarding this irregularity, and the physician was unaware of the frequent holds.
Nursing staff failed to follow physician orders for two residents, resulting in significant medication errors. One resident's antihypertensive medication was repeatedly withheld without physician notification or documentation, despite no hold parameters being ordered. Another resident received an antihypotensive medication outside of prescribed blood pressure parameters on multiple occasions, with no documentation or provider notification. Clinical leadership and the consultant pharmacist were unaware of these errors until after they occurred, and staff interviews confirmed the deviations from proper medication administration.
Surveyors found that food items in the kitchen's walk-in refrigerator, reach-in refrigerator, and dry goods pantry were not properly labeled, dated, or discarded when expired. Multiple items, including juices, fruit, hot dogs, and pantry goods, were observed without required dates or past expiration. Staff interviews confirmed that facility protocols for food safety were not followed, leading to the storage of expired and unlabeled food.
The facility repeatedly failed to sustain compliance in several areas, including monitoring hot water temperatures in shower rooms, providing incontinence care to dependent residents, maintaining required RN coverage, accurately documenting daily nursing hours, and ensuring proper labeling and discarding of food items. These deficiencies persisted due to ineffective monitoring and evaluation of corrective action plans under the QAPI program.
Staff failed to follow Enhanced Barrier Precautions by not wearing required gloves and gowns during high-contact care for residents with chronic wounds and invasive devices. A nurse provided wound care without PPE, and two nurse aides performed incontinence care for a resident with a pressure ulcer and feeding tube using gloves only, despite clear facility policy and signage.
A facility failed to protect a resident from neglect when a nurse did not perform daily wound care for an infected Stage IV pressure ulcer on the left heel and an unstageable wound on the right heel, both acquired in the facility. This deficiency was identified through observations, record reviews, and staff interviews, indicating a failure to follow the physician's orders for wound care.
A facility failed to provide sufficient nursing staff, resulting in delayed incontinence care for a resident. The resident, who required assistance due to impairments, was left in a saturated brief for an extended period. Despite ringing the call bell, timely care was not provided due to the overwhelming workload of the nurse aide responsible. The facility had only six nurse aides for 81 residents, leading to inadequate care provision.
A resident requiring extensive assistance and using a mechanical lift was not provided with their preferred two showers per week, receiving only one bath in a month despite no refusals. Staff cited the difficulty of providing showers as the reason, and the DON confirmed the resident should have received two showers weekly per preference, but this was not scheduled or provided.
A resident with advanced dementia, diabetes, and peripheral arterial disease did not receive daily wound care for bilateral heel ulcers as ordered by the physician. Documentation and staff interviews confirmed that wound dressings were not changed for over 48 hours, resulting in soiled and dislodged dressings, despite clear care plans and physician orders for daily treatment. The lapse was attributed to missed handoff, lack of documentation in the electronic record, and staff being too busy to complete the care.
Surveyors observed that the facility did not maintain a medication error rate below 5%, with three errors out of 25 opportunities. In one case, a nurse administered a blood pressure medication without checking the resident's blood pressure as required by the physician's order. In another case, a medication aide initially omitted two prescribed medications for a resident, only realizing the mistake after being questioned and correcting it before administration.
A resident with bilateral contractures, a feeding tube, and a history of malnutrition did not receive a timely occupational therapy evaluation as ordered by a provider. Staff were unaware of the OT order, and the process for communicating therapy referrals was inconsistently followed, resulting in the resident struggling to eat independently and not receiving needed adaptive equipment or assistance as outlined in the care plan.
The facility did not accurately document or post daily nurse staffing information on multiple occasions, including leaving reports blank, omitting shift data, and incorrectly recording RN coverage when none was present. These issues were confirmed through record review and staff interviews.
The facility failed to provide 8 hours of RN coverage on 28 of 45 days reviewed due to staff resignations and changes in employment status. Despite efforts to recruit new RNs, significant gaps in coverage, particularly on weekends, were not adequately addressed.
The facility failed to ensure refrigerated meat items stored in the walk-in refrigerator for resident sandwiches were dated and sealed. Two clear plastic bags of sliced sandwich ham were found not sealed or dated and were open to air. The Dietary Manager (DM) acknowledged that the items should have been dated and sealed, and the Administrator confirmed the expectation for kitchen staff to follow all regulatory guidelines for food and kitchen sanitation safety.
The facility's QAA program failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in nurse staffing information, medication administration, and medical record documentation. Issues included inaccurate daily nursing hours postings, failure to follow physician orders for insulin and Zoloft, and incorrect documentation in the eMAR.
The facility failed to accurately document the administration of as-needed narcotic pain medications in the eMAR for two residents. Nurses admitted to either forgetting to sign off the medications or being unable to unlock the eMAR for documentation. The Unit Manager and Administrator confirmed the expectation for accurate documentation in both the narcotic record and the eMAR.
The facility inaccurately documented Daily Nursing Hours postings, reporting RN coverage on two dates when no RN was present. This discrepancy was confirmed through record reviews and staff interviews.
Deficiencies in Facility Maintenance and Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In multiple resident rooms, a black greenish substance was found around the base of the commodes, indicating a lack of proper cleaning and maintenance. Additionally, overhead lights in some rooms were non-functioning, leaving residents to rely on natural light from windows and open doors. These issues were noted across three of the five hallways observed, highlighting a widespread problem in maintaining the facility's infrastructure. Furthermore, the facility failed to maintain appropriate hot water temperatures in the shower rooms on the 300-hall. The water temperatures in the showers fluctuated significantly, with readings well below the expected 114 degrees Fahrenheit, making it unsuitable for resident use. The Maintenance Director acknowledged the issue, attributing it to the distance the hot water had to travel from the boiler and the lack of monitoring due to an incomplete electronic maintenance log. These deficiencies indicate a failure in the facility's maintenance processes and oversight, impacting the residents' right to a safe and comfortable living environment.
Failure to Provide Scheduled Showers and Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate bathing and showering assistance to residents who were dependent on staff for activities of daily living (ADL). Resident #39, who was severely cognitively impaired and dependent on staff due to Alzheimer's disease and other health conditions, did not receive her scheduled shower on the night of 2/15/25. The nurse aides on duty reported being too busy to complete the showers, and the issue was not addressed by the staff on subsequent shifts. Similar failures occurred with Resident #53 and Resident #60, both of whom also required extensive assistance due to severe cognitive impairments and did not receive their scheduled showers. Additionally, the facility failed to provide timely incontinence care for Resident #7, who was cognitively intact but dependent on staff for ADL care due to impairments and a history of urinary tract infections. On 2/16/25, Resident #7 reported that her brief had not been changed since early morning, and she was found to be wet with urine. Despite ringing her call bell for assistance, the nurse aide did not return to change her brief until hours later, resulting in a saturated brief. The nurse aide admitted to being overwhelmed with the number of residents and not adhering to the facility's protocol of checking residents every 2-3 hours. The Director of Nursing confirmed that the nurse aides on duty chose not to perform the scheduled showers, and disciplinary actions were taken. The Administrator expected the nurse aides to maintain a schedule of checking and changing residents every 2-3 hours to ensure cleanliness and skin integrity, which was not followed in these instances.
Failure to Administer Nutritional Supplement for Wound Healing
Penalty
Summary
The facility failed to provide a nutritional supplement, Arginaid, as ordered for a resident at risk for malnutrition and with significant pressure wounds. The resident, who had diagnoses including muscle wasting, dysphagia, and dementia, was recommended by the Registered Dietician to receive Arginaid twice daily for wound healing. However, the Medication Administration Record and Treatment Administration Record showed no documentation of the supplement being administered over several months. The deficiency arose from a breakdown in communication and process within the facility. The Registered Dietician made recommendations for Arginaid, which were supposed to be emailed to the Director of Nursing (DON) and then forwarded to the Unit Manager for order processing. However, the Unit Manager did not receive the recommendation, and thus, the order was never entered into the electronic medical record. This oversight was not identified until the survey period, despite the resident's ongoing need for nutritional support for wound healing. Interviews with facility staff, including the Registered Dietician, DON, and Unit Manager, revealed that the process for implementing dietary recommendations was not followed, leading to the resident not receiving the necessary supplement. The Physician confirmed that she would have signed off on the recommendation had it been presented to her. The facility's failure to administer the supplement as ordered contributed to the resident's worsening pressure wounds, highlighting a significant lapse in care coordination and communication.
Failure to Notify Physician of Medication Administration Issues
Penalty
Summary
The facility failed to notify the physician or nurse practitioner when a resident's antihypertensive medication, Carvedilol 3.125 mg, prescribed for hypertension and scheduled twice daily, was held 34 times over a 77-day period. Additionally, the facility did not inform the physician or nurse practitioner that Midodrine, a medication prescribed to increase blood pressure, was administered outside of the prescribed parameters. These deficiencies were identified through record review and interviews with staff, the nurse practitioner, and the physician. The issues involved two residents: one who did not receive the prescribed Carvedilol doses and another who received additional doses of Midodrine when their systolic blood pressure was above the specified threshold. No significant outcomes were reported for the residents involved.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on 13 specific days out of 275 days reviewed, as evidenced by both Payroll Based Journal (PBJ) staffing data and verification of daily employee timecard punches. The PBJ reports indicated no RN coverage on several dates, and the Human Resources Director confirmed that on those dates, the facility did not meet the minimum RN staffing requirement. Although there were claims that an agency RN worked on some of the dates in question, the PBJ system did not recognize these hours, and the reason for this discrepancy could not be explained by the Human Resources Director. The Administrator acknowledged ongoing difficulties in hiring RNs and reported that even the agency used to supplement staffing was unable to consistently provide licensed RNs. Despite efforts to recruit RNs through various channels such as internet advertising, social media, college skills fairs, and signage, the facility was unable to maintain the required RN coverage on the identified dates. No information about specific residents or their conditions was provided in the report.
Pharmacist Failed to Address Frequent Withholding of Antihypertensive Medication
Penalty
Summary
A deficiency occurred when the facility's consultant pharmacist failed to identify and address the frequent holding of a resident's antihypertensive medication, Carvedilol 3.125 mg, during the monthly drug regimen review. The resident, admitted with a diagnosis of hypertension, had a physician's order for Carvedilol to be administered twice daily without any parameters for holding the medication. Despite this, the medication was held 17 out of 31 days in December, as documented in the Medication Administration Record (MAR), with nurses using chart codes indicating either vital signs outside of parameters or the medication being held. There were no documented parameters or physician orders to justify these holds, and the physician was not aware of the frequency with which the medication was withheld. The monthly pharmacy review for January did not include any recommendations or notations regarding the frequent withholding of Carvedilol. During interviews, the physician confirmed she was unaware of the situation and typically did not provide hold parameters for blood pressure medications. The consultant pharmacist acknowledged that the medication should not have been held without symptoms and that the physician should have been notified after the first held dose, but stated she did not realize the extent of the holds during her review. This failure to identify and address the irregularity during the required monthly review constitutes the deficiency.
Failure to Prevent Significant Medication Errors in Two Residents
Penalty
Summary
Nursing staff failed to properly administer and document medication for two residents, resulting in significant medication errors. For one resident with hypertension, Carvedilol was prescribed to be given twice daily without any hold parameters. Despite this, nurses repeatedly held the medication when the resident's blood pressure was perceived as low, without notifying the physician or documenting the rationale in the progress notes. The medication was withheld on numerous occasions over several months, and the physician, nurse practitioner, and consultant pharmacist were not made aware of the frequency with which the medication was being held. Interviews with nursing staff revealed that they believed it was appropriate to hold the medication based on their own judgment, even though the order did not specify parameters for withholding the drug. Another resident, diagnosed with hypotension and end-stage renal disease, was prescribed Midodrine with explicit instructions to hold the medication if the systolic blood pressure exceeded 130 mmHg. Despite these clear parameters, nursing staff administered the medication multiple times when the resident's systolic blood pressure was above the specified threshold. There was no documentation explaining why the medication was given outside the prescribed parameters, nor was the physician notified of these deviations. Nursing staff acknowledged during interviews that these administrations were errors and that they were aware of the hold parameters. In both cases, the failures involved not only improper medication administration but also a lack of communication and documentation regarding deviations from physician orders. The director of nursing and other clinical leaders were unaware of the frequency and extent of these errors until they were brought to their attention during the survey. The consultant pharmacist and medical providers confirmed that they had not been notified of the medication errors until after the fact, and there was no evidence of adverse outcomes for the residents involved.
Improper Food Labeling and Storage in Kitchen and Pantry
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling, dating, and discarding of food items in the kitchen's walk-in refrigerator, reach-in refrigerator, and dry goods storage pantry. Multiple food items, including juices, fruit, hot dogs, pudding, ground meat, and various pantry items, were found either without opened dates, without expiration dates, or past their expiration dates. These observations were made in the presence of the Dietary Manager in training, who was unable to explain why the required procedures for food labeling and discarding expired items were not followed. Interviews with the Dietary Manager in training, the Certified District Manager, and the Administrator confirmed that the facility's policy required all stored foods to be labeled, dated, and discarded when expired. However, the staff responsible for inventory and food safety did not adhere to these protocols, resulting in the storage of improperly labeled and expired food items. The deficiency was identified during the survey and had the potential to affect food served to residents.
Repeated QAPI Failures Lead to Multiple Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeated deficiencies across multiple areas during three federal surveys. Specifically, the facility did not sustain compliance with requirements related to maintaining appropriate hot water temperatures in resident shower rooms, providing incontinence care to dependent residents, ensuring adequate Registered Nurse (RN) coverage, accurately documenting daily nursing hours, and properly labeling and discarding food items in storage areas. These deficiencies were identified through record reviews and staff interviews, which revealed that previously developed action plans were not effectively monitored or evaluated for ongoing compliance. In the case of hot water temperature monitoring, the transition from paper logs to an electronic maintenance system led to the omission of shower rooms from the water temperature tracking form. As a result, water temperatures in these areas were not monitored, and the issue went unnoticed until the survey. For incontinence care, audits intended to ensure residents received timely assistance were discontinued after initial completion, with no further assessment to determine if the plan of correction was effective. The facility also experienced ongoing challenges in maintaining required RN coverage, with gaps in staffing persisting despite daily schedule reviews and the hiring of a weekend RN supervisor. Additional deficiencies included inaccurate documentation of daily nursing hours, as the Administrator ceased reviewing postings several months after the previous survey, resulting in blank entries. In the dietary department, the abrupt departure of the Dietary Manager led to lapses in the inspection and labeling of food items, with open and undated items found in storage areas. These repeated failures across multiple domains demonstrated the facility's inability to implement and sustain effective corrective actions through its QAPI program.
Failure to Follow Enhanced Barrier Precautions During High-Contact Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care of residents with chronic wounds and invasive devices. Specifically, a nurse provided direct care to a resident with Stage IV and unstageable chronic foot wounds without donning the required personal protective equipment (PPE), including gloves and gown. The nurse removed soiled dressings from the resident's wounds with bare hands, despite the facility's policy requiring gloves and gown for high-contact care activities such as wound care. The nurse later acknowledged awareness of the policy and training but did not initially follow the required precautions. Additionally, two nurse aides provided incontinence care to another resident with a Stage IV pressure ulcer and a gastrostomy tube, also failing to wear gowns as required under EBP. Both aides wore gloves but did not use gowns, despite signage and PPE supplies being available outside the resident's room. Interviews revealed that the aides misunderstood the PPE requirements, believing that gloves alone were sufficient. The facility's infection control policy, updated in October 2024, clearly stated that both gloves and gowns are required for high-contact care activities for residents under EBP.
Neglect in Wound Care Management
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when a nurse did not perform the required daily wound care for an infected Stage IV pressure ulcer on the resident's left heel and an unstageable pressure wound on the right heel. Both wounds were acquired within the facility. This deficiency was identified during observations, record reviews, and staff interviews, highlighting a lapse in following the physician's orders for wound care. The incident involved one of three residents reviewed for neglect, specifically focusing on wound care management.
Inadequate Staffing Leads to Delayed Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the incontinence care needs of a dependent resident, identified as Resident #7. Observations and interviews revealed that Resident #7, who was cognitively intact and required assistance with activities of daily living due to impairments, was left in a saturated brief for an extended period. The resident reported that her brief had not been changed since early morning, and despite ringing the call bell for assistance, she did not receive timely care. Nurse Aide #2, responsible for Resident #7, admitted to being overwhelmed with the number of residents assigned to her, which hindered her ability to provide timely care. The staffing assignment on the day in question showed that the facility had only six nurse aides available for 81 residents, as one of the scheduled aides was assigned to medication administration. This staffing level left each nurse aide responsible for 16 to 17 residents, which was reported by multiple staff members as insufficient to meet the residents' needs. Nurse Aide #2, who was assigned to the 100 Hall, expressed difficulty in managing her workload, which included 16 residents, and admitted to not being able to check on Resident #7 as frequently as required by the facility's protocol. Interviews with other staff members, including the scheduler and the administrator, confirmed that the facility was operating with minimal staffing levels. The administrator acknowledged the staffing situation but did not perceive it as a concern, despite staff reports of being unable to provide adequate care. The deficiency was highlighted by the failure to provide timely incontinence care to Resident #7, which was attributed to the insufficient number of nurse aides available to meet the needs of all residents effectively.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
A resident with diagnoses including spondylosis, muscle weakness, venous thrombosis, and anxiety, and who required extensive to total assistance with activities of daily living, was not provided with their preferred number of showers per week. The resident, who had no cognitive impairments and required two-person assistance with a mechanical lift for transfers and showers, was scheduled for only one shower per week and received only one bath during a 30-day period. Documentation showed no evidence of shower refusals, and the resident consistently expressed a desire for two showers per week, which was not accommodated by staff. Interviews with nursing staff and the DON confirmed that the resident should have been scheduled for two showers per week and that all residents should receive showers according to their preferences. However, staff reported that it was easier to provide bed baths due to the assistance required for showers, and the resident's requests for additional showers were not fulfilled. The administrator was unaware of any complaints regarding shower frequency, and the resident's care plan and facility policy were not followed in this instance.
Failure to Provide Physician-Ordered Wound Care for Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including peripheral arterial disease, diabetes, and advanced dementia, did not receive wound care for bilateral heel ulcers as ordered by the physician. The resident had a Stage IV pressure ulcer on the left heel and an unstageable deep tissue injury on the right heel, both requiring daily dressing changes with Santyl ointment and other specified dressings. The care plan and physician orders clearly indicated the need for daily wound care to prevent further decline and infection. Despite these orders, the Treatment Administration Record (TAR) showed that the wound care was not administered or documented on one of the scheduled days. Observations revealed that the resident's heel dressings were soiled, falling off, and dated two days prior, indicating that the dressings had not been changed for over 48 hours. Interviews with nursing staff confirmed that the wound care was not completed as scheduled over the weekend, with one nurse stating she was too busy and another agency nurse reporting that the task did not appear in the electronic medical record for her shift. The wound nurse and DON confirmed that the responsibility for wound care over the weekend was with the assigned nurse, and that the lapse in care was not acceptable, especially given the resident's ongoing wound infection. The wound care physician and medical director both confirmed that the resident was to receive daily wound care and that missing these treatments could impact healing and infection risk. The deficiency was identified through direct observation, record review, and staff interviews, all of which demonstrated that the facility failed to provide wound care according to physician orders for a resident with significant risk factors and ongoing infection.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors observed out of 25 opportunities, resulting in a 12% error rate. During a medication pass, a nurse administered Metoprolol 25 mg to a resident without first obtaining the resident's blood pressure, despite a physician's order to hold the medication if the systolic blood pressure was less than 110 mm/Hg. The nurse later confirmed she had overlooked this requirement and had not checked the blood pressure prior to administration. In another instance, a medication aide prepared and administered medications to a resident but initially omitted two prescribed medications, Losartan 25 mg and a multivitamin, from the medication cup. The aide realized the omission only after being questioned and subsequently added the missed medications before administration. Both incidents were confirmed through staff interviews and medication reconciliation, demonstrating a failure to follow physician orders and proper medication administration procedures.
Failure to Implement Occupational Therapy Order for Resident Needing Feeding Assistance
Penalty
Summary
A deficiency occurred when the facility failed to implement a written order for an occupational therapy (OT) evaluation for a resident with a history of diabetes, protein calorie malnutrition, gastrostomy, and bilateral upper and lower extremity impairments. The resident was cognitively intact, required assistance with personal care, and was on a mechanically altered and therapeutic diet, receiving a significant portion of nutrition and fluids via a feeding tube. The care plan included monitoring for dysphagia and providing adaptive feeding equipment, but the resident was observed using regular utensils and experiencing difficulty eating independently due to hand contractures. Despite a physician's order for OT evaluation and treatment, there was no documentation that the evaluation occurred as ordered. Multiple staff interviews revealed a lack of awareness of the OT order, and the process for communicating therapy orders relied on a 'Hey Therapy' form, which was not consistently used or understood by all staff. The Rehabilitation Director and Occupational Therapist were not aware of the order, and the order was not communicated effectively between nursing and therapy departments. The resident continued to have difficulty with self-feeding, and staff were not consistently providing the necessary assistance or adaptive equipment as outlined in the care plan. Observations showed the resident struggling to eat with regular utensils and requiring assistance to consume her meal. Staff interviews indicated inconsistent understanding of the resident's needs and the process for initiating therapy services. The OT eventually evaluated the resident after the deficiency was identified, confirming the need for therapy intervention due to fatigue and limited ability to self-feed. The failure to implement the OT order and provide appropriate assistance with feeding constituted the deficiency.
Failure to Accurately Document and Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately document and post daily nurse staffing information on four separate days within the review period. Specifically, the Daily Nursing Hours Report was left blank on two days, contained no data for the third shift on another day, and incorrectly documented eight hours of RN coverage on a day when no RN was present in the building. These deficiencies were confirmed through record review and staff interviews, including verification by the Human Resources Director who checked employee timecard punches and found no RN coverage on the day in question. The Administrator acknowledged the blank postings and explained that oversight of the daily postings had lapsed several months after the last recertification survey.
Failure to Provide Adequate RN Coverage
Penalty
Summary
The facility failed to provide 8 hours of Registered Nurse (RN) coverage on 28 of 45 days reviewed. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 1, 2024, and daily assignment schedules from October 1, 2023, through March 19, 2024, revealed multiple dates where RN coverage was not met. Specific dates without RN coverage included 10/08/23, 11/13/23, 11/14/23, 11/18/23, 11/29/23, 11/23/23, 12/03/23, 12/16/23, 12/20/23, 12/21/23, 12/22/23, 12/26/23, 12/30/23, 12/31/23, 01/13/24, 01/14/24, 01/27/24, 01/28/24, 02/10/24, 02/11/24, 02/14/24, 02/16/24, 02/15/24, 02/28/24, 03/04/24, 03/07/24, 03/29/24, and 03/10/24. Interviews with the facility Scheduler and the Payroll and Human Resources Coordinator confirmed the lack of RN coverage on these dates, attributing it to staff resignations and the facility's inability to use agency staffing. The facility had recently hired two RNs, one of whom had started, while the other was awaiting commencement of work. The Administrator acknowledged the deficiency, citing staff resignations and changes in employment status as contributing factors. Two RNs had switched to PRN (as needed) status, and several others had quit. Efforts to recruit new RNs included advertising on social media, distributing flyers in the community, using a state-based recruiting site, and attending job fairs. Despite these efforts, the facility experienced significant gaps in RN coverage, particularly on weekends, which were not adequately addressed by the current staffing strategies.
Improper Storage of Refrigerated Meat Items
Penalty
Summary
The facility failed to ensure refrigerated meat items stored in the walk-in refrigerator for resident sandwiches were dated and sealed. During an observation of the kitchen's walk-in refrigerator, two clear plastic bags of sliced sandwich ham were found not sealed or dated and were open to air. The Dietary Manager (DM) was unable to explain why the food was not properly stored. In an interview, the DM stated that she monitored the items in the refrigerators and freezers weekly when conducting inventory and acknowledged that the two bags of sliced ham should have been dated and sealed. The Administrator confirmed that it was his expectation for the kitchen staff to follow all regulatory guidelines for food and kitchen sanitation safety.
Repeat Deficiencies in QAA Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions following the recertification survey and an on-site revisit survey and complaint investigation. This resulted in three repeat deficiencies in the areas of Posted Nurse Staffing Information (F732), Residents Are Free of Significant Med Errors (F760), and Resident Records - Identifiable Information (F842). Specifically, the facility failed to accurately document the Daily Nursing Hours postings for 2 of 45 reports reviewed, did not follow physician orders for sliding scale insulin administration for two residents, and failed to accurately document the administration of narcotic pain medications and other prescribed medications in the electronic Medication Administration Record (eMAR). These deficiencies were noted during both the recertification survey and the revisit survey, indicating a pattern of the facility's inability to sustain an effective QAA program. In the case of medication errors, the facility did not administer sliding scale insulin as prescribed to two residents, resulting in missed doses. Additionally, the facility failed to follow physician orders for Zoloft and Novolog insulin administration, leading to missed and incorrect doses. The facility also did not accurately document the administration of medications in the eMAR, including scheduled and as-needed narcotic pain medications. These issues were compounded by staff turnover and a lack of monitoring by the facility Administrator, who acknowledged the failure to ensure accurate daily staff postings.
Failure to Document Narcotic Administration in eMAR
Penalty
Summary
The facility failed to accurately document the administration of prescribed as-needed narcotic pain medications in the electronic Medication Administration Record (eMAR) for two residents. For Resident #46, a dose of Percocet 10-325 mg was removed from the locked narcotic drawer by Nurse #1 on 03/19/24 at 6:49 PM, but it was not documented in the eMAR. Nurse #1 admitted to forgetting to sign off the medication in the eMAR due to being occupied with other medication passes at the time. Similarly, for Resident #177, multiple doses of Hydrocodone 10 mg-Acetaminophen 325 mg were removed from the locked narcotic drawer by Nurse #1 and Nurse #5 on 03/19/24 and 03/20/24, but these administrations were not documented in the eMAR. Nurse #1 stated she was unable to sign off the medication in the eMAR because it was locked, and she did not know how to unlock it. Nurse #5 admitted to forgetting to document the administration in the eMAR. Interviews with the Unit Manager and the Administrator revealed that there was an expectation for all medications to be accurately documented in both the narcotic record and the eMAR. The Unit Manager explained that if a nurse marked a medication as prepared but did not return to mark it as administered, the medication would lock in the eMAR, preventing further documentation. The Unit Manager was unsure who had the authority to unlock the medication in the eMAR since the departure of the previous Director of Nursing. The Administrator reiterated the expectation for accurate documentation of medication administration in both records.
Inaccurate Documentation of Daily Nursing Hours
Penalty
Summary
The facility failed to accurately document the Daily Nursing Hours postings for two specific dates. A review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 1, 2024, revealed that there was no Registered Nurse (RN) coverage on four dates, including 10/08/23 and 12/03/23. However, the facility's Daily Nursing Hours postings inaccurately reported 8 RN hours for these two dates. Further review of the daily assignment sheets confirmed that no RN was present in the building on these dates. Interviews with the Payroll/Human Resources Coordinator and the Administrator corroborated that no RN was scheduled or paid for those days, despite the incorrect postings. The Administrator acknowledged the discrepancy but could not explain why the postings were incorrect, noting that an RN had been scheduled but did not show up for work on one of the days.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
