Cabarrus Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Concord, North Carolina.
- Location
- 430 Brookwood Avenue Ne, Concord, North Carolina 28025
- CMS Provider Number
- 345183
- Inspections on file
- 29
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 32 (1 serious)
Citation history
Health deficiencies cited at Cabarrus Health And Rehabilitation Center during CMS and state inspections, most recent first.
A consultant pharmacist did not identify or report medication transcription errors for a resident with dementia and BPH. The resident received incorrect dosages of Finasteride and Melatonin due to discrepancies between the hospital discharge summary and facility orders, with no documentation of authorized changes. The pharmacist's monthly review did not detect these errors, and no notification was sent to the DON or medical staff.
A resident admitted with BPH was prescribed Finasteride 5 mg once daily, but due to a transcription error, was administered the medication twice daily for over two weeks. Staff interviews revealed that the error was not identified or corrected through the facility's cross-check process, and there was no documentation of physician notification or order clarification. The facility's intended checks and balances system for new admissions was not properly followed, resulting in the resident receiving unnecessary medication.
A resident with severe cognitive impairment and a history of stroke did not receive podiatrist-ordered daily moisturizing cream for chronic dry skin, as the order was not entered into the treatment record or communicated to staff. Multiple staff interviews confirmed unawareness of the order, and observation showed the resident's feet were very dry with thick, flakey skin.
A resident with a feeding tube was readmitted after hospitalization, but hospital discharge orders for tube feedings and free water flushes were not entered into the MAR. Nursing staff continued tube feedings and water flushes based on previous routines and verbal reports, without verifying or documenting current orders. The Unit Manager did not enter the necessary orders, and the Registered Dietician was not contacted for clarification. The physician confirmed that staff should not use nursing judgment for tube feeding flushes and should have obtained proper orders.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not specify particular residents or staff actions.
The facility did not provide or obtain x-rays or tests as ordered and failed to promptly notify the ordering practitioner of the results, resulting in a lapse in timely communication and follow-through on physician orders.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not specify particular staff actions or resident details.
The facility did not maintain frozen foods at or below 0°F, with several food items found above safe temperatures and soft to the touch. Additionally, a dietary staff member used a soiled towel to clean a thermometer probe before checking food temperatures, without documented training. These actions had the potential to affect the safety of food served to residents.
Staff failed to label and date insulin pens on two medication carts, with one insulin pen not labeled with a resident's name and another not dated when opened. An insulin pen was also found in use beyond the manufacturer's recommended discard date. Interviews revealed that staff were unaware of or did not notice the labeling and dating requirements, leading to improper medication storage.
Ants were repeatedly observed in two resident rooms, including on a bedside table and an enteral feeding syringe, despite no open food or debris being present. Staff and responsible parties had noticed and reported the ants inconsistently, and while extermination treatments for other pests had occurred, no specific action was taken for ants due to lack of proper reporting and communication among staff and administration.
Two residents, one with respiratory disease and moderate cognitive impairment and another with dementia and brain injury, were not afforded the opportunity to participate in their person-centered care plan process. Both the residents and their responsible parties reported not being invited to care plan meetings for several months, despite care plan revisions. Staff interviews confirmed that care plan meetings had not been held as required, and the administrator was unaware of the missed meetings until the survey.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal, and failed to establish or implement a grievance policy or make prompt efforts to resolve complaints.
A resident with documented decayed and missing teeth was inaccurately coded on the MDS as having no dental issues. The MDS nurse was unaware of the resident's dental problems, and the assessment did not reflect the actual dental status observed and documented in clinical notes.
A resident who required pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
A resident who was severely cognitively impaired and dependent on staff for all ADLs was not provided with regular nail care or facial shaving. Despite observations of long fingernails and a dense beard, nursing assistants had not performed these grooming tasks or consulted the family about preferences. The resident's representative reported making multiple requests for these services, but staff and administration were unaware of the unmet needs, resulting in the resident not maintaining a clean and neat appearance.
A resident with a suprapubic catheter did not receive a scheduled monthly catheter change as ordered by a urologist, due to the facility's failure to document and implement the correct order. Nursing staff were unaware of the monthly change requirement, and the order was entered as PRN only, resulting in the omission of the required catheter change.
A resident with a gastrostomy tube and severe cognitive impairment was found to have an enteral feeding syringe repeatedly stored with the plunger engaged and not properly cleaned or dried between uses. The same syringe was used for multiple medication administrations and flushes, and on several occasions, ants were observed in or around the syringe. Nursing staff interviews revealed inconsistent knowledge and practice regarding proper cleaning and storage procedures for enteral feeding syringes.
A resident with heart disease and anemia repeatedly requested peanut butter and mayonnaise sandwiches due to difficulty chewing meat and intolerance to spicy foods, but the facility failed to provide these sandwiches as documented in her food preference list. Despite staff awareness and documentation, the sandwiches were not included on her meal tray, and communication between dietary and nursing staff was insufficient to address the resident's needs.
The facility did not ensure accurate documentation of medication administration for two residents who received pain medication following falls. In both cases, nursing notes and controlled substance records indicated that medications were given, but the MARs lacked corresponding entries. Nursing staff acknowledged the omissions and the administrator confirmed that all medication administration should be properly recorded.
The facility did not transmit MDS assessments to the State within the required timeframe for four residents, with delays confirmed by submission reports and staff interviews. The late transmissions were attributed to staff turnover and delays by the previous MDS Coordinator.
A resident with dementia and osteoarthritis experienced an unwitnessed fall and later developed pain and swelling in her right leg. Nursing staff did not immediately notify the physician or responsible party when these symptoms appeared, instead waiting until the next shift. The delay in notification led to a late diagnosis of a femur fracture, with both the provider and responsible party confirming they were not informed promptly.
A resident with cognitive impairment and a history of fractures experienced an unwitnessed fall. Staff failed to promptly report the incident, complete required documentation, or notify the responsible party and physician. As a result, subsequent shifts were unaware of the fall, leading to delayed assessment and treatment despite the resident later exhibiting pain and swelling, which was ultimately found to be a new fracture.
A resident with a history of aggression was admitted to a facility without proper interventions in place, leading to an incident where he attacked another resident. The aggressive resident wandered into the room of a severely cognitively impaired resident and physically assaulted him, causing pain but no acute injuries. Staff interviews revealed a lack of communication and documentation regarding the aggressive resident's behavior, and the facility's admission process failed to address his behavioral history.
The facility failed to submit a 5-day investigative report to the State Agency on time for an incident where one resident attacked another, requiring police intervention. The Administrator mistakenly sent the 24-hour report twice and did not submit the investigation report within the required timeframe.
A resident with multiple health conditions, including being on blood thinners, fell out of bed during incontinence care due to improper assistance by a nursing assistant. The NA rolled the resident away from her, contrary to training, causing the resident to fall and sustain bruising and skin tears. The resident required hospital evaluation but returned without new orders. Observations confirmed the resident needed two-person assistance, highlighting a failure in following proper procedures.
A resident with severe cognitive impairment fell out of bed during incontinence care due to inadequate assistance from a nursing assistant who failed to check the Kardex for required assistance levels. The resident sustained a fractured left femur, requiring surgical repair. The incident highlighted a lapse in ensuring safe care practices during bed mobility.
A resident with a history of aggression struck another resident with a metal bar, causing injury, after a verbal altercation in the facility. Despite care plans requiring 1:1 supervision, the incident occurred due to inadequate supervision and management of resident behaviors. The facility reported the incident to authorities and conducted an investigation, but the deficiency in preventing the altercation remains evident.
The facility failed to report a resident-to-resident abuse incident within the required 2-hour timeframe. A resident struck another with a pipe, causing minor injuries. The Administrator, informed while out of town, instructed a staff member to report the incident, but did not verify its submission. The report was sent five days later, along with the investigation, indicating a deficiency in timely reporting.
A resident with major depression and psychotic symptoms did not receive prescribed quetiapine fumarate due to it not being available in the medication cart. The nurse responsible lacked access to the automated medication dispenser and did not follow protocol to obtain the medication. The facility's NP confirmed the medication order was active, and the UM and DON stated that all nurses should have access to the dispenser. The Administrator expected staff to know how to obtain medications, highlighting a procedural lapse.
A resident with major depression and psychotic symptoms did not receive three out of four doses of quetiapine fumarate as ordered. An agency nurse failed to administer the medication due to lack of access to the automated medication dispenser and miscommunication with the pharmacy. The facility's management indicated that the nurse should have had access and the medication was available.
The facility failed to provide appropriate dining utensils, specifically forks, to four residents capable of eating independently during a lunch meal. These residents, who were cognitively intact and had no significant swallowing issues, were served a meal but were only given spoons, leading to frustration and difficulty in eating. The issue was due to a shortage of forks and knives, as explained by the Dietary Manager, who noted that some knives were discarded due to rust and the stock of forks was low upon her arrival.
The facility failed to maintain safe temperatures for milk and thickened juice, with observed temperatures exceeding the safe range. The high-temperature dishwasher also did not meet the manufacturer's recommended wash cycle temperature. Additionally, PCAs were observed refilling residents' cups with ice and water in an unsanitary manner, allowing the ice scoop to touch the rims of the cups and water to flow back into the ice cooler. Hand hygiene was inconsistently performed between residents.
The facility's QAPI committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in maintaining a safe, clean environment and ensuring sanitary food practices. Issues included unclean furniture, improper food storage, and failure to maintain appropriate temperatures for food and dishwashing.
A staff member at the facility misappropriated money from several residents, failing to return the money or purchase the requested items. The issue was discovered after a resident complaint led to an investigation, revealing multiple affected residents. The staff member was terminated, and the residents were reimbursed.
The facility failed to ensure a resident's hair was not greasy for a resident dependent on staff for personal hygiene. The resident missed multiple scheduled showers, and staff interviews revealed a lack of awareness and inconsistency in providing care. The resident's care plan and facility policies were not adequately followed, resulting in unmet personal hygiene needs.
The facility failed to complete annual performance reviews for 4 of 5 nursing assistants reviewed. The issue was discovered in November 2023 when staff inquired about annual raises, and the DON has been working to address the backlog.
A facility failed to act on a pharmacy recommendation to reduce a resident's atorvastatin dose from 40 mg to 20 mg, despite the Medical Director's agreement. The order was not updated in the electronic medical records, leading to the resident receiving the incorrect dose for over two weeks.
A facility failed to change a resident's atorvastatin dose from 40 mg to 20 mg as ordered by the physician. Despite the Pharmacist's recommendation and the Medical Director's agreement, the nurses continued administering the higher dose for over two weeks. The Unit Coordinator indicated the order might have been misplaced, and the Director of Nursing confirmed the nursing staff's responsibility to enter the updated order.
The facility failed to date five medications that had been opened and stored in two medication carts. Staff acknowledged that the failure to date the bottles was due to human error, despite being aware of the requirement.
The facility failed to maintain consistent advance directive information for a resident, resulting in discrepancies between the electronic medical record and the paper medical record. Staff interviews revealed confusion about the resident's code status and decision-making authority.
A resident with renal failure and diabetes filed a grievance about not receiving meals for dialysis treatments. Despite assurances from the Dietary Manager, the issue persisted, and the resident was observed hungry and knocking on the kitchen door. Interviews revealed that the grievance should have been addressed by both nursing and dietary departments.
A resident with a new diagnosis of major depressive disorder was not referred for a Level II PASRR review. The Social Services Director was unaware of the new diagnosis and admitted to not being trained in PASRR. The Administrator confirmed the importance of the PASRR process and acknowledged the oversight.
A resident who required dialysis treatments three days a week was not provided with a meal before leaving for dialysis, despite having a care plan that included snacks and a therapeutic diet. The issue was highlighted by a grievance filed by the resident and confirmed through staff interviews and observations.
A resident's meal preferences were not honored when he was served a double portion of peas despite his documented dislike for them. Staff interviews revealed a lack of clarity and follow-through in addressing the resident's dietary needs, leading to frustration and unmet dietary requirements.
The facility failed to report allegations of misappropriation of property for two residents as required by their abuse policy and federal and state law. Both residents filed grievances indicating they gave money to an Activities Assistant to purchase items but never received their items or money back. The Administrator did not report these incidents to the State Agency.
The facility failed to notify the Ombudsman of resident transfers to the hospital. Two residents were transferred, but the Ombudsman did not receive the required discharge summaries. The Social Worker did not verify fax confirmations, and the Administrator did not check the fax confirmations either.
Consultant Pharmacist Failed to Identify and Report Medication Transcription Errors
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report medication transcription errors for a resident admitted with dementia and benign prostatic hyperplasia (BPH). Upon admission, the hospital discharge summary listed Finasteride 5 mg daily and Melatonin 30 mg at bedtime, but the facility's physician orders transcribed these as Finasteride 5 mg twice daily and Melatonin 10 mg at bedtime. There was no documentation of a verbal order authorizing these changes. The resident's Medication Administration Record (MAR) reflected administration of the incorrect dosages as per the facility's orders. During the monthly medication regimen review, the Consultant Pharmacist did not detect or report these discrepancies, stating during an interview that she had not noticed any dose errors and would have notified the Director of Nursing (DON) if she had. The DON confirmed that no notification was received regarding a discrepancy for this resident. The Medical Director, upon review, noted the high dose of Melatonin and expected staff and the Consultant Pharmacist to cross-check admission medication orders for accuracy. The Administrator also indicated that the Consultant Pharmacist would typically communicate any discrepancies, which did not occur in this case.
Medication Transcription Error Leads to Unnecessary Drug Administration
Penalty
Summary
A deficiency occurred when a resident was admitted with a diagnosis of benign prostatic hyperplasia (BPH) and a hospital discharge summary that prescribed Finasteride 5 mg once daily. Upon admission, the facility's physician order was incorrectly transcribed to administer Finasteride 5 mg twice daily, and this error persisted from 10/10/25 through 10/27/25. There was no documentation of a verbal order or any physician notification authorizing this change from the hospital's discharge instructions. Multiple staff interviews confirmed the error in transcription. The nurse responsible for entering the medication orders acknowledged the mistake after reviewing the hospital discharge summary and facility orders, stating she did not recall notifying the physician or nurse practitioner about the discrepancy. The Unit Managers described a cross-check process for admission medication orders, but could not recall the specific admission or confirm that the process was completed for this resident. The Consultant Pharmacist noted that the pharmacy had both the hospital and facility orders, and the medication card matched the hospital's order, but staff were instructed to follow the facility's order, which was incorrect. The Director of Nursing (DON) and Administrator both described a multi-level checks and balances system intended to ensure accuracy of admission medication orders, including an admission Audit Checklist. However, the DON could not provide the checklist for this resident, and acknowledged that the cross-checks likely were not completed. The Medical Director was unaware of the transcription error and stated he would expect nursing staff and the Consultant Pharmacist to verify admission medication orders for accuracy.
Failure to Provide Ordered Foot Care Treatment
Penalty
Summary
A deficiency occurred when the facility failed to provide foot care treatment as ordered by a podiatrist for a resident with a history of stroke and severe cognitive impairment. The podiatrist's note documented a chronic problem with dry skin (xerosis) and included an order for daily application of moisturizing cream to both feet, avoiding the area between the toes, for three months. However, this order was not transcribed into the resident's physician orders or treatment record, and no staff were aware of the order. Observations revealed the resident's feet were very dry with thick, flakey dead skin. Interviews with nursing staff, nursing assistants, the unit manager, and the DON confirmed that none were aware of the podiatrist's order, and the moisturizing cream had not been applied. The unit manager explained that consultant notes were typically reviewed for orders, but in this case, the podiatry note was sent directly to medical records for scanning and was not reviewed. The DON and administrator both stated that consultant notes should be reviewed for orders and entered into the electronic document system, but this process was not followed for the podiatrist's order.
Failure to Enter and Implement Tube Feeding and Free Water Orders After Hospital Readmission
Penalty
Summary
The facility failed to enter and implement hospital discharge orders for tube feedings and free water administration for a resident who was readmitted after hospitalization with a feeding tube. Upon return, the resident's previous tube feeding and free water flush orders were not entered into the medication administration record (MAR), despite staff administering tube feedings and water flushes based on prior routines and verbal reports. Multiple nurses reported continuing tube feedings and water flushes as before, without verifying that appropriate orders were present in the MAR. The Unit Manager acknowledged receiving the hospital discharge orders but did not enter the tube feeding formula, rate, or free water flushes into the electronic documentation system. The Registered Dietician was not contacted for clarification of dietary orders after the resident's return. Nursing staff administered tube feedings and water flushes without documented orders, relying on previous practices and nursing judgment rather than current, physician-authorized instructions. The physician confirmed that nursing staff should not use their own judgment for tube feeding water flushes and that the facility should have contacted him to clarify and obtain proper orders. The Director of Nursing stated that the hospital discharge orders were not reviewed during the morning meeting following the resident's readmission, and the Administrator expected all discharge orders to be clarified and entered into the system, which did not occur in this case.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Failure to Obtain and Communicate Ordered X-rays/Tests
Penalty
Summary
The facility failed to provide or obtain x-rays or tests when ordered and did not promptly inform the ordering practitioner of the results. This deficiency indicates that there was a lapse in following physician orders for diagnostic testing and in communicating the results to the practitioner in a timely manner. No additional details about the specific patient(s) involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their medical histories mentioned.
Failure to Maintain Proper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain frozen foods at or below 0 degrees Fahrenheit, as required by professional standards. During an observation of the walk-in freezer, the internal thermostat was found to be reading 32 degrees Fahrenheit, and multiple frozen food items were soft to the touch. Internal temperatures of various food items, including raw ground beef, chicken thighs, sausage patties, diced turkey, meatballs, fish squares, and hotdog franks, were all above the required freezing temperature, with some items reaching as high as 46 degrees Fahrenheit. The Dietary Manager noticed the malfunction upon arrival and reported it to the Maintenance Assistant and Administrator at different times that morning. Additionally, during a lunch meal tray line observation, a dietary staff member was seen using a soiled hand towel from a food preparation table to wipe a thermometer probe before checking the internal temperatures of food items. This staff member stated he had not received training from the Dietary Manager, who later indicated that orientation training had been provided but not documented. These practices had the potential to affect the safety of food served to residents.
Failure to Properly Label, Date, and Discard Insulin Pens
Penalty
Summary
Surveyors identified that staff failed to properly label and date insulin pens on two medication carts. On Medication Cart #3, a glargine insulin injection pen was found open and dated but not labeled with the resident's name. Additionally, an insulin lispro injection pen was found opened and dated over 30 days prior, contrary to manufacturer instructions that require discarding after 28 days. Medication Aide #2 was unaware of the required discard timeframe and could not explain why the glargine pen was not labeled. On Medication Cart #5, a degludec insulin pen was found without a date indicating when it was opened. Nurse #2 stated she typically dates insulin pens when opening them but had not noticed this pen was undated and had not used it. Interviews with the DON and Administrator confirmed that insulin pens should be labeled with the resident's name and the date opened, and that expired insulin should be discarded per manufacturer guidelines. The staff involved were either unaware of the labeling and dating requirements or had not noticed the deficiencies, resulting in improper storage and handling of insulin pens on the medication carts.
Failure to Maintain Effective Pest Control for Ants
Penalty
Summary
The facility failed to maintain effective pest control in two of thirteen rooms reviewed, as ants were observed in both rooms on multiple occasions. In one room, ants were seen on a resident's bedside table and floor, despite no open food or debris being present. The responsible party reported having killed ants in the room previously and notifying staff, though could not recall which staff members were informed. Staff interviews revealed that both nursing and housekeeping personnel had observed ants in the affected rooms at various times, but there was inconsistency in reporting these sightings to the appropriate personnel. Extermination invoices showed treatments for cockroaches and rodents, but not specifically for ants, and no pests were found during the most recent exterminator visit prior to the observations. In the second room, ants were observed crawling on an enteral feeding syringe and a towel on the bedside table. Nursing staff acknowledged ongoing issues with ants in resident rooms and stated that maintenance had been notified, but the problem persisted. The Director of Nursing was unaware of the ant issue in these rooms, and the Administrator confirmed that extermination for ants had not occurred because the problem had not been reported to her. The lack of a clear and effective communication process among staff contributed to the failure to address the ant infestation in a timely manner.
Failure to Involve Residents and Responsible Parties in Care Plan Process
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were given the opportunity to participate in the development and implementation of person-centered care plans for two out of three residents reviewed for quarterly care plan reviews. For one resident with respiratory disease and moderate cognitive impairment, there was no documentation of a care plan meeting invitation or evidence that the resident or responsible party participated in the care plan process. Both the resident and responsible party confirmed that no care plan meeting had occurred for several months, despite a recent care plan revision. Another resident, diagnosed with dementia and brain injury and assessed as severely cognitively impaired, also had no record of the responsible party being invited to care plan meetings for several months, even though the care plan had been revised multiple times. Interviews with current and former social workers revealed that care plan meetings had not been completed quarterly and were already behind schedule when they began their roles. The administrator confirmed that care plan meetings for these residents had not occurred since before the last recertification survey and was unaware of the lapse until the current survey.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or implement a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints.
Inaccurate MDS Coding for Dental Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of dental status. The resident, who was cognitively intact, had documented dental issues including malpositioned, decayed, and missing teeth as noted in a dental clinical note. However, the annual MDS assessment indicated that the resident had no obvious or likely cavities or broken teeth. Direct observation confirmed the presence of black/brown discolored and missing teeth. The MDS nurse responsible for the assessment was unaware of the resident's dental issues and did not code them on the MDS. The facility administrator acknowledged that the MDS should have accurately reflected the resident's dental condition.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency related to the facility's failure to provide necessary pain management interventions for a resident in need.
Failure to Provide Nail Care and Shaving for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and diabetes, who was severely cognitively impaired and dependent on staff for all activities of daily living (ADLs), was not provided with adequate nail care or facial shaving. Observations over several days revealed that the resident had a full, dense beard approximately 1/2 inch in length and fingernails extending more than 1/4 inch past the fingertips. Nursing assistants assigned to the resident reported that they checked nails during baths but had not noticed the long nails or provided shaving. Both nursing assistants interviewed stated they had not clipped the resident's nails or shaved his facial hair, nor had they consulted the resident's family regarding his grooming preferences. The resident's representative reported repeated requests for nail trimming and shaving, stating that the resident had previously been clean-shaven or had a closely clipped beard prior to his stroke and would not have wanted long nails or facial hair. Nursing and administrative staff confirmed that nail care and shaving should be performed as needed and during baths, but were unaware of the resident's current condition or the representative's requests. The lack of attention to the resident's grooming needs resulted in the resident not maintaining a clean, neat, and odor-free appearance as outlined in his care plan.
Failure to Follow Physician Orders for Suprapubic Catheter Changes
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders for the timely changing of a suprapubic catheter for a resident with a history of stroke and obstructive reflux uropathy. The resident was admitted and readmitted to the facility with orders from a urologist to have the suprapubic catheter changed monthly or as needed for clinical indications. However, review of the medical record showed that the monthly catheter change order was not documented or carried out in May, and the order was not properly entered into the treatment administration record. Staff interviews revealed that nurses were unaware of a standing monthly catheter change order and believed the resident either went to the urologist for changes or that the order was only as needed. The physician confirmed that the order should have included both monthly and as-needed changes, and the DON acknowledged that the order had been entered as PRN only, without clarification from the urologist. The administrator and DON both stated that unclear orders should be clarified by nursing staff, but this was not done. As a result, the resident did not receive a scheduled suprapubic catheter change in May, contrary to the urologist's and hospital discharge orders.
Improper Storage and Cleaning of Enteral Feeding Syringes
Penalty
Summary
Staff failed to properly store and maintain enteral feeding syringes for a resident with a gastrostomy tube and severe cognitive impairment. Observations revealed that the enteral feeding syringe was repeatedly left with the plunger engaged and contained clear liquid with white sediment, rather than being separated and allowed to air dry as required. The same syringe was used for multiple medication administrations and flushes without being replaced or properly cleaned. On one occasion, the syringe was found in a plastic bag with ants present, and on another, ants were observed crawling on and inside the syringe and plunger. Interviews with nursing staff indicated a lack of knowledge regarding the correct procedure for cleaning and storing enteral feeding syringes, with one nurse stating she was unaware that the plunger should be separated to prevent bacterial growth. The unit manager and Director of Nursing confirmed that the facility's procedure required syringes to be washed after each use and air dried with the plunger removed, but this was not consistently followed by staff.
Failure to Provide Resident's Requested Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's documented food preferences and dietary needs. The resident, who had heart disease and anemia, had a food preference list indicating a request for peanut butter and mayonnaise sandwiches at lunch and dinner due to difficulty chewing meat and intolerance to spicy foods. Despite this documented preference and repeated requests from both the resident and her responsible party, the sandwiches were not provided. Observations confirmed that the requested sandwich was not present on the resident's meal tray, and the meal ticket did not reflect her preference. Staff interviews revealed that dietary staff were aware of the request but did not fulfill it, and nursing staff were not informed when the dietary department failed to provide the requested food item. The Dietary Manager stated that resident preferences were updated quarterly and that a sign was placed in the kitchen to remind staff of the resident's request, but the sandwiches were still not provided as required. The Registered Dietitian was not made aware of the resident's inability to tolerate the regular menu items, and the Director of Nursing indicated that communication between dietary and nursing staff was lacking. The deficiency was identified through record review, observation, and interviews with the resident, responsible party, and staff.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain accurate and complete documentation of medication administration for two residents. For one resident, physician orders indicated acetaminophen was to be administered for pain following a fall. Nursing progress notes documented that the medication was given on multiple occasions, but the Medication Administration Record (MAR) did not reflect administration on all relevant dates. The nurse involved could not recall the specific days the medication was administered and acknowledged that the MAR should have been signed if the medication was given. For another resident, there was a physician order for tramadol to be administered as needed for pain. After a fall resulting in pain, the controlled substance count sheet showed that tramadol was administered, but the MAR did not document this administration. The nurse responsible confirmed that she gave the medication but could not recall the time and stated she must have forgotten to document it on the MAR. The administrator confirmed that medication administration should be accurately documented on the MAR.
Failure to Timely Transmit MDS Assessments
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the State within the required 14-day period for four out of five residents reviewed. Specifically, quarterly and significant change MDS assessments for several residents were not transmitted until well after the assessment reference dates, as evidenced by the MDS Submission Reports. For example, one resident's quarterly MDS assessment was not transmitted until nearly a month after the assessment reference date, and another resident's significant change assessment was transmitted 15 days after the assessment reference date. These delays were confirmed through record reviews and staff interviews. Interviews with facility staff revealed that the late transmissions were due to turnover in the MDS staff, with the previous MDS Coordinator not completing transmissions in a timely manner. The facility had recently hired a new MDS Coordinator, but the late transmissions occurred during the period of staff transition. The Administrator acknowledged that the assessments should have been transmitted within the required timeframe.
Failure to Immediately Notify Physician and Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify the physician and the responsible party of a resident's change in condition following an unwitnessed fall. The resident, who had a history of dementia, osteoarthritis, and a previous hip fracture, experienced a fall in her room. Although a physical assessment was completed at the time of the incident and no injury or pain was initially reported, the event was not communicated to the oncoming nurse, resulting in a lack of documentation and monitoring for changes related to the fall during the subsequent shift. During the night, the resident began to complain of pain and exhibited swelling and discoloration in her right leg, which was not typical for her. The assigned nurse provided routine pain medication but did not notify the physician or the responsible party of these new symptoms, instead reporting the change in condition only to the oncoming nurse at shift change. It was not until the following morning that the nurse practitioner was notified, who then ordered a stat x-ray and informed the responsible party. The x-ray revealed an intertrochanteric fracture of the right femur. Interviews with staff and the responsible party confirmed that neither the physician nor the responsible party was notified promptly when the resident first reported pain and swelling. The responsible party stated she would have wanted the resident sent to the hospital for evaluation had she been notified at the time. The medical director also indicated that provider notification should have occurred when pain and swelling were first observed.
Failure to Provide Timely Assessment and Notification After Resident Fall
Penalty
Summary
A resident with a history of dementia, osteoarthritis, and a previous left hip fracture experienced an unwitnessed fall in her room. The resident was found on the floor by a nurse aide, who then sought assistance from a nurse. The nurse assessed the resident, who denied pain and injury at the time, and assisted her back to bed using a mechanical lift. However, the incident was not reported to the assigned nurse, and no fall incident report was completed immediately. The responsible party and physician were not notified of the fall on the day it occurred. Due to the lack of communication, the assigned nurses on subsequent shifts were unaware of the fall and did not monitor or document the resident's condition in relation to the incident. Later that night, the resident began to complain of pain, which was initially attributed to a previous injury. Swelling and abnormal coloration of the right leg were observed, but the physician and responsible party were still not notified promptly. The delay in recognizing the significance of the symptoms and the lack of ongoing assessment contributed to a delay in appropriate treatment. The incident report and post-fall investigation were not completed until the following day, after the nursing supervisor became aware of the situation. The resident was eventually evaluated and diagnosed with a right hip and femur fracture, but only after a significant delay in assessment and intervention. The failure to provide thorough and ongoing assessments, timely communication, and prompt notification to the responsible party and physician resulted in a delay in treatment for the resident following the fall.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a serious incident. A resident with a history of aggression and anger outbursts, who had been receiving antipsychotic medications and required a net bed and sitter while hospitalized, was admitted to the facility. Upon admission, this resident began wandering into other residents' rooms, including the room of a severely cognitively impaired resident who was dependent on staff for all activities of daily living. Despite the resident's known history of aggressive behavior, no interventions were documented to address the wandering or potential aggression. On the night of the incident, the aggressive resident wandered into the room of the cognitively impaired resident and physically attacked him. The aggressive resident pulled the other resident from his bed and struck him in the throat and upper body. The attack was witnessed by nursing assistants who intervened to separate the residents. The cognitively impaired resident, who was unable to defend himself, sustained pain in his head, arm, back, throat, and leg, although subsequent medical evaluations showed no acute injuries. Interviews with staff revealed a lack of communication and documentation regarding the aggressive resident's behavior and the absence of appropriate interventions. The facility's admission process failed to adequately assess and address the aggressive resident's behavioral history, leading to the incident. Staff were not informed of the resident's aggressive tendencies, and no measures were put in place to prevent the resident from wandering or to manage his aggression effectively.
Removal Plan
- Facility failed to protect resident #2 from abuse after admitting resident #1.
- Resident #2 received a trauma screen assessment by Social Work staff.
- The last seven days of progress notes of all residents were reviewed for dementia behaviors including aggression, wandering, yelling, delusions, hallucinations, paranoia to ensure interventions are in place.
- Current resident MD notes, incident accidents reports for behaviors or any resident to resident incidents were reviewed for order of psychiatric consult, and referrals made if appropriate.
- Administrator, Director of Nursing, and/or the Unit Manager ensured training to all staff in all departments utilizing online learning education modules on dementia care to include wandering and managing aggressive behaviors.
- All staff in all departments were educated by Administrator or designee that when a resident exhibits aggressive behavior, they will stay with them to provide one-on-one supervision and immediately notify a supervisor.
- Social Work staff are responsible for the initiation of psychiatric services when a consultation is placed.
- Administrator provided training to current social work staff to ensure psychiatric services referral are initiated following dementia behaviors including aggression.
- The Administrator provided training to all current Social Work staff to ensure they will notify Medical Provider and Administrator when a resident or responsible party refuses psychiatric services.
- The Administrator provided education to all current Medical Providers that they will discuss on a case-by-case basis with the Administrator if services for psychiatry can be managed by the Medical Provider in house or if involuntary commitment is needed to provide psychiatric services.
- Director of Nursing will educate all staff on abuse and neglect related to what abuse is, the types of abuse to include resident to resident abuse and reporting.
- All Nurses are responsible for notifying Medical Providers of each instance of change in condition which includes dementia behaviors and aggression.
- In reviewing a resident for potential admission, the facility Admission staff reviews their history and physical and current hospital documentation including diagnosis and medication management.
- Administrator or designee educated social work staff that when admitting a resident that has behaviors such as delusions/paranoia they will interview potential resident responsible party for information regarding current triggers and history of behaviors.
- The Administrator educated The Director of Nursing that nursing will initiate interventions as appropriate at time of admission based on resident history related to aggressive behaviors and residents with signs of or history of wandering.
- Director of Nursing and/or Unit Managers will review current resident and new admissions progress notes for dementia behaviors including aggression and ensure interventions are in place on resident baseline care plan.
- Director of Nursing or designee will audit physician progress notes and ensure that any psychiatric referrals have been consented and sent to psychiatric services.
- The Activity Director or designee will monitor Resident #2 for changes in activity participation and will notify administrator of any changes for psychiatric intervention.
- Social Worker or designee will complete psychosocial visits on Resident #2 for changes in current psychosocial state such as depression and/or anxiety.
- The Quality Assurance Performance Improvement committee will review all monitoring tools monthly and make any necessary changes as needed immediately.
Failure to Timely Submit 5-Day Investigative Report for Resident-to-Resident Abuse
Penalty
Summary
The facility failed to submit a 5-day investigative report to the State Agency within the required time frame for an allegation of resident-to-resident abuse involving two residents. According to the facility's policy, the Administrator is required to thoroughly investigate and file a complete written report of the investigation to the State Agency within five working days of the incident. However, the Administrator mistakenly sent the 24-hour report twice and neglected to submit the investigation report within the specified time frame. The incident involved one resident pulling another resident from his bed while he was asleep and striking him in the throat. The situation escalated to the point where the police had to be called as staff could not control the behavior of the aggressive resident. Both residents were separated, assessed for injuries, and sent to the hospital for further evaluation. The aggressive resident was removed from the facility with the assistance of law enforcement. Despite these actions, the required 5-day investigative report was not submitted on time, leading to the deficiency.
Resident Falls Due to Improper Bed Mobility Assistance
Penalty
Summary
The facility failed to provide safe care when a resident fell out of bed during incontinence care. The incident involved a resident who was admitted with multiple diagnoses, including respiratory failure, heart failure, peripheral vascular disease, right above the knee amputation, and atrial fibrillation. The resident was on an antiplatelet medication, clopidogrel, which thins the blood. According to the Minimum Data Set (MDS) assessment, the resident required moderate one-person assistance with bed mobility. However, during incontinence care, a nursing assistant (NA) rolled the resident away from her, causing the resident to fall out of bed and sustain bruising to the face and skin tears to the arms. The incident report and interviews revealed that the NA had pulled a blanket under the resident while rolling him, which contributed to the fall. The resident reported hitting his head and experiencing bleeding, prompting emergency medical services to transport him to the hospital for evaluation. The resident underwent x-rays and a CT scan, which showed no broken bones or brain bleed, but he did have significant bruising and a hematoma on the forehead. The NA involved in the incident admitted to checking the Kardex for assistance requirements but believed the resident could move himself in bed, leading her to roll him away from her, contrary to her training. Observations and interviews with other staff members indicated that the resident was unable to roll side to side in bed without assistance and should have been rolled towards the caregiver to prevent falls. The facility's Unit Manager and other nursing staff confirmed that the resident required two-person assistance for bed mobility, contrary to the initial assessment. The physician expressed relief that the resident did not sustain more serious injuries, attributing the lack of brain bleeding to the antiplatelet medication. The incident highlighted a failure in following proper bed mobility procedures, which directly led to the resident's fall and subsequent injuries.
Resident Falls During Incontinence Care Due to Inadequate Assistance
Penalty
Summary
The facility failed to provide care in a safe manner when a resident fell out of bed during incontinence care. The incident involved a resident who was severely cognitively impaired and required extensive assistance for bed mobility and toileting. During the provision of incontinence care, a nursing assistant rolled the resident away from her, resulting in the resident falling out of bed. The resident sustained a fractured left femur and required surgical repair. The nursing assistant involved in the incident did not review the Kardex to determine whether the resident required one- or two-person assistance with bed mobility. As a result, the resident was turned on her side facing away from the nursing assistant, leading to the fall. The incident report noted that the resident complained of leg pain after the fall, and an x-ray later revealed an acute intertrochanteric femur fracture. The nursing staff, including the nurse supervisor and other nurses on duty, responded to the incident by providing pain medication and arranging for an x-ray. However, the x-ray was not conducted immediately as there was no obvious indication of a fracture at the time. The resident was eventually transferred to the hospital for evaluation after continued complaints of pain, where the fracture was confirmed, and surgical intervention was scheduled.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when another resident struck him with a metal bar, resulting in redness, swelling, and a skin tear on the left hand and wrist. The incident involved two residents with complex medical histories, including mental health diagnoses and cognitive impairments. Resident #7, who had a history of verbal aggression, struck Resident #8 after a verbal altercation in Resident #7's room. Resident #8, who also had a history of physical and verbal aggression, entered Resident #7's room, leading to the confrontation. The care plans for both residents included interventions to manage their aggressive behaviors, such as 1:1 supervision and medication administration. However, these interventions were not effectively implemented, as evidenced by the altercation. The facility's initial allegation report indicated that Resident #7 became upset when Resident #8 entered his room, leading to the physical altercation. Staff statements and interviews revealed that Resident #8 was not adequately supervised, allowing him to enter Resident #7's room and escalate the situation. The facility's response to the incident included notifying law enforcement and conducting an internal investigation. Interviews with staff and residents provided varying accounts of the events leading to the altercation. Despite the facility's actions following the incident, the failure to prevent the altercation and protect Resident #8 from abuse highlights a deficiency in the facility's ability to manage resident behaviors and ensure their safety.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to submit an initial report within the required 2-hour timeframe to the state regulatory agency for an allegation of resident-to-resident abuse. The incident involved a verbal argument between two residents, where one resident became upset and struck the other with a small black pipe, causing redness, swelling, and a skin tear on the victim's hand and wrist. The x-ray for the injured resident showed no further injury. The Administrator was informed of the incident while out of town and instructed a staff member to report it to the necessary entities, including the state regulatory agency. However, the Administrator did not verify whether the report was submitted, and the initial report was only sent to the state regulatory agency five days later, along with the investigation report. The Director of Nursing also believed the report had been faxed as required but later attached the initial report to the investigation report and sent them together. The delay in reporting the incident constitutes a deficiency in the facility's compliance with regulatory requirements for timely reporting of abuse allegations.
Failure to Administer Routine Medications Due to Access Issues
Penalty
Summary
The facility failed to provide routine medications as ordered by the physician for a resident diagnosed with major depression with psychotic symptoms. The resident was prescribed quetiapine fumarate, an antipsychotic medication, to be administered in the morning and at bedtime. However, the medication was not administered on two consecutive days due to it not being available in the medication cart. Nurse #1, who was responsible for administering the medication, did not have access to the automated medication dispenser and did not follow the protocol to obtain the medication from the pharmacy or a local pharmacy. The nurse reported that she was informed by the pharmacy that the medication had been discontinued and needed to be reordered, but she did not notify the physician about the unavailability of the medication. The facility's Nurse Practitioner confirmed that the medication order was active and should have been available. The Unit Manager and Director of Nursing stated that all nurses should have access to the automated medication dispenser and that Nurse #1 had been educated on the process during orientation. The Administrator expected the nursing staff to understand how to obtain medications, indicating a lapse in following established procedures.
Failure to Administer Antipsychotic Medication
Penalty
Summary
The facility failed to administer three out of four doses of quetiapine fumarate, an antipsychotic medication, as ordered by the physician for a resident diagnosed with major depression with psychotic symptoms. The resident was supposed to receive 50 mg in the morning and 200 mg at bedtime. However, the morning doses on two consecutive days and the bedtime dose on the second day were not administered. Nurse #1, who was responsible for administering the medication, reported that the medication was not available in the medication cart and that she did not have access to the automated medication dispenser. She was an agency nurse and had not received a code for the dispenser. Nurse #1 also mentioned that she contacted the pharmacy, but was informed that the medication had been discontinued and needed to be reordered. The facility's Unit Manager and Director of Nursing indicated that all nurses should have access to the automated medication dispenser and that Nurse #1 should have been able to obtain the medication. The pharmacist confirmed that the medication was available in the automated dispenser and that there was no record of Nurse #1 contacting the pharmacy. The Administrator expected the nursing staff to know how to obtain medications from the pharmacy and the automated dispenser. The Nurse Practitioner noted that missing the doses would not have caused an increase in the resident's behaviors.
Failure to Provide Appropriate Dining Utensils
Penalty
Summary
The facility failed to provide appropriate dining utensils, specifically forks, to four residents who were capable of eating independently during a lunch meal. These residents, who were cognitively intact and had no significant swallowing issues, were served a meal consisting of breaded chicken with barbeque sauce, cabbage, dressing, and cake, but were only given spoons. This oversight led to frustration among the residents, as they expressed difficulty and discomfort in eating their meals properly without forks. The issue was attributed to a shortage of forks and knives in the facility, as explained by the Dietary Manager, who had recently taken over the position. The manager noted that some knives were discarded due to rust, and the stock of forks was low upon her arrival. The Administrator was unaware of the shortage and stated that he would have addressed the issue immediately had he known. The lack of appropriate utensils was not an isolated incident, as residents reported similar occurrences in the past.
Failure to Maintain Safe Food and Dishwasher Temperatures and Proper Sanitary Practices
Penalty
Summary
The facility failed to ensure that milk and thickened juice for the lunch meal were within the safe temperature range of 41 degrees Fahrenheit or below. During an observation, the milk was found to be at 49 degrees F, thickened orange juice at 57 degrees F, and honey tea at 60 degrees F. The Senior Culinary Manager discarded the beverages and indicated that fresh cold beverages would be provided. Dietary Staff #1, who had a safe serve certification, admitted to not knowing the specific temperature requirements. Additionally, the high-temperature dishwasher was observed to have a wash cycle temperature that did not exceed 145 degrees F, below the manufacturer's recommended range of 155-160 degrees F. The Senior Culinary Manager confirmed that cold food should be at 41 degrees F or below, and the Administrator and Nurse Regional Consultant were not familiar with the required food and dishwasher temperatures. Furthermore, the facility failed to ensure that soiled cups did not come in contact with the clean ice scoop used to refill residents' water cups. PCAs were observed refilling residents' cups with ice and water in a manner that allowed the ice scoop to touch the rims of the cups, and water to flow back into the ice cooler. Hand hygiene was not consistently performed between residents. Interviews revealed that PCAs were trained by other PCAs and were not following proper sanitary and infection control practices. The DON and Administrator were not aware of the specific training processes for PCAs but confirmed that the PCAs were expected to follow sanitary practices taught during orientation.
Repeated Deficiencies in Environmental and Food Safety Standards
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions following recertification surveys and complaint investigation surveys. This resulted in repeated deficiencies in maintaining a safe, clean, comfortable, and homelike environment (F584) and ensuring food procurement, storage, preparation, and serving were sanitary (F812). Specifically, the facility failed to clean and keep furniture in good repair in various areas, including resident rooms, the front lobby, dining room, game room, and nursing station. Additionally, the facility did not ensure that milk and thickened juice were within safe temperature ranges, maintain the wash temperature of the high-temperature dishwasher, or prevent soiled cups from contacting the clean ice scoop used to refill residents' water cups. These practices had the potential to affect the food served to residents. Further observations revealed that the facility failed to clean plastic ceiling light covers, a microwave oven, oven knobs, and a fryer. Items in the dry storage room, walk-in refrigerator, and walk-in freezer were not labeled, and frozen food boxes were stored on the freezer floor. The facility also failed to wash dishes in the dish machine at the recommended temperature, store frozen foods at the appropriate temperature, and store canned goods and snacks off the floor. Additionally, expired food was found in the dry storage room, and opened food in the walk-in cooler was not dated and labeled. The Administrator acknowledged that the QAPI committee met monthly and discussed past tags and new areas of concern but attributed the repeat tags to the inability of department heads to maintain the corrective actions put in place.
Misappropriation of Resident Property by Staff Member
Penalty
Summary
The facility failed to protect residents from the misappropriation of their property by a staff member. The incident came to light when a resident complained about giving money to an Activities Assistant to purchase items, but neither the items nor the money was returned. Upon investigation, it was discovered that this was not an isolated event, as three other residents reported similar experiences with the same staff member. The staff member in question was subsequently terminated following the investigation. Resident interviews revealed that the affected residents were cognitively intact and had given varying amounts of money to the Activities Assistant for purchasing items. The residents did not receive the items or their money back initially, leading to feelings of betrayal and upset. However, all residents were eventually reimbursed by the facility, which helped alleviate their dissatisfaction to some extent. The Administrator confirmed that the facility conducted an investigation after the initial complaint and found multiple residents affected by the same issue. The Activities Assistant was suspended and later terminated for not following the facility's policy. The facility also conducted staff training on resident abuse and misappropriation to prevent future occurrences. Despite attempts, the alleged perpetrator could not be reached for comment.
Failure to Provide Scheduled Showers and Hair Washing
Penalty
Summary
The facility failed to ensure a resident's hair was not greasy for a resident who was dependent on staff for personal hygiene. Resident #44, who had a history of stroke, hemiplegia, and aphasia, was moderately cognitively impaired and dependent on staff for toileting and personal care. The resident's care plan indicated that all care needs would be met by staff due to decreased mobility. However, the facility's shower schedule and documentation revealed that Resident #44 did not receive showers on multiple scheduled dates, including 2/5/2024, 2/8/2024, 2/12/2024, 2/15/2024, 2/19/2024, 4/1/2024, 4/8/2024, and 4/15/2024. Interviews with the resident and responsible party confirmed that the resident's hair had not been washed for 3 to 4 weeks, and the resident indicated a desire for showers on missed dates. Staff interviews revealed a lack of awareness and inconsistency in providing scheduled showers and hair washing for Resident #44. Nurse Aide #9, who was assigned to the resident, was unaware of the shower schedule and the resident's need for hair washing. The Unit Manager acknowledged that a Nurse Aide call-out on one of the scheduled shower days resulted in the resident missing a shower, but was unaware of other missed showers. The Director of Nursing admitted difficulties in getting the resident to shower due to occasional refusals but noted that the resident was not care-planned for refusing care. The Administrator confirmed that residents should be showered and have their hair shampooed at least twice a week and whenever requested. The facility's documentation and staff interviews indicated a failure to consistently provide scheduled showers and hair washing for Resident #44, leading to the resident having greasy hair. The lack of proper documentation and communication among staff contributed to the deficiency, as staff were not consistently aware of the resident's shower schedule or the need for hair washing. The resident's care plan and the facility's policies were not adequately followed, resulting in unmet personal hygiene needs for the resident.
Failure to Complete Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete a performance review every 12 months for 4 of 5 nursing assistants (NAs) reviewed. Specifically, NA #4, NA #5, NA #6, and NA #7 did not have performance evaluations completed in the past 12 months. NA #4, who was hired on 2/12/2001, reported not recalling the last time she had a performance evaluation. NA #5, hired on 8/12/2014, and NA #6, hired on 8/21/2014, were not available for interviews, but their records also showed no recent performance evaluations. NA #7, hired on 4/18/1995, similarly had no performance evaluation in the past 12 months and was not available for an interview. The Staff Development Coordinator (SDC) stated that she provided education for the NA staff, while the Director of Nursing (DON) was responsible for the performance evaluations. The DON reported that it was discovered in November 2023 that performance evaluations had not been completed for any staff after a staff member inquired about annual raises. The DON has been working to complete 5 to 10 evaluations per week. The Administrator confirmed that the issue was identified in November 2023 and that the DON has been addressing the backlog of performance evaluations.
Failure to Update Medication Order
Penalty
Summary
The facility failed to act upon a pharmacy recommendation to change the dose of atorvastatin for a resident diagnosed with hyperlipidemia. The resident was admitted with a physician's order for atorvastatin 40 mg daily. On 3/19/24, the pharmacist recommended reducing the dose to 20 mg, which the Medical Director agreed to and signed on 4/1/24. However, the nurses continued to administer the 40 mg dose from 4/1/24 through 4/17/24, as the order was not updated in the electronic medical records. The Unit Coordinator did not recall receiving the pharmacy recommendation and suggested it might have been sent directly to medical records instead of nursing. Interviews revealed that the Medical Director handed the signed forms back to the Unit Coordinator, who was responsible for entering the orders into the electronic medical records. The Pharmacist stated that the facility should have followed the atorvastatin order, and the Director of Nursing confirmed that nursing staff were responsible for entering the signed pharmacy recommendations as physician orders. The failure to update the medication order resulted in the resident continuing to receive the incorrect dose of atorvastatin for over two weeks.
Failure to Update Medication Dosage as Ordered by Physician
Penalty
Summary
The facility failed to change the dose of atorvastatin from 40 mg to 20 mg as ordered by the physician for a resident diagnosed with hyperlipidemia. The resident was admitted with a diagnosis of hyperlipidemia, and the physician had ordered atorvastatin 40 mg daily at bedtime. On 3/19/24, the Pharmacist recommended decreasing the dose to 20 mg based on the resident's lipid levels, which were within the acceptable range. The Medical Director agreed with this recommendation and signed the form on 4/1/24. However, the nurses continued to administer the 40 mg dose from 4/1/24 through 4/17/24, as indicated by the medication administration record (MAR). The Unit Coordinator revealed that the order might have been misplaced and not entered into the electronic medical records. Interviews with the Pharmacist, Medical Director, and Director of Nursing confirmed that the facility did not follow the updated atorvastatin order. The Pharmacist stated that the recommendation forms were sent to the Administrator, DON, and Unit Coordinators, and the facility should have followed the new order. The Medical Director mentioned that continuing the 40 mg dose did not cause any harm to the resident. The Director of Nursing stated that the nursing staff were responsible for entering the order once the pharmacy recommendation was signed by the provider.
Failure to Date Opened Medications
Penalty
Summary
The facility failed to date five medications that had been opened and stored in two medication carts. During an observation of the 2-hall medication cart, Chlorhexidine gluconate oral rinse, Dextromethorphan/Guaifenesin, and Lactulose solution were found opened and undated. Nurse #1 acknowledged that several nurses work on the 2-hall medication cart and suggested that the failure to date the bottles was due to human error, despite the staff being aware of the requirement to date opened medications. Similarly, during an observation of the 3-hall cart, a therapeutic multi-vitamin supplement and Docusate Sodium capsules were found opened and undated. Medication Aide #1 admitted that sometimes the medication aides and nurses forget to date the bottles when they are opened. The Director of Nursing confirmed that the staff had been educated on the importance of dating medications when opened, and the Administrator reiterated that the nursing staff should date any medication bottles when opened.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to maintain accurate advance directive information for a resident, leading to discrepancies between the electronic medical record (EMR) and the paper medical record. The resident's EMR and care plan indicated a Do Not Resuscitate (DNR) status, while the paper medical record at the nurse's station showed a Medical Orders for Scope of Treatment (MOST) form indicating to attempt Cardiopulmonary Resuscitation (CPR) with limited additional interventions. This inconsistency was discovered during staff interviews and record reviews, revealing that the resident's code status was not consistently documented across different records. Interviews with various staff members, including a nurse, the Director of Nursing (DON), the Unit Manager, the Business Office Manager (BOM), and the Administrator, highlighted the confusion and lack of coordination regarding the resident's advance directives. The Unit Manager and BOM provided conflicting information about who had the authority to make decisions for the resident, with the Unit Manager believing the resident's husband was the decision-maker and the BOM indicating that the daughter initially filled out the paperwork. The Administrator acknowledged that the interdisciplinary team should have ensured that the advance directive information was updated and consistent across all records.
Failure to Resolve Resident Grievance Regarding Meals for Dialysis
Penalty
Summary
The facility failed to resolve a grievance for a resident who was admitted with renal failure requiring dialysis treatments and diabetes. The resident, who was cognitively intact, had previously filed a grievance on 2/13/2024 regarding not receiving a snack or meal when transported to dialysis treatments. Despite the Dietary Manager's assurance that a list of residents needing bagged meals for dialysis would be posted in the kitchen, the issue persisted. On 4/16/2024, the resident was observed knocking on the kitchen door, stating he was hungry because he had not received breakfast before his early dialysis appointment and had not eaten since the previous dinner. Interviews with the Director of Nursing and the Administrator revealed that the grievance should have been addressed by both the nursing and dietary departments to ensure a sustained resolution. The Director of Nursing acknowledged awareness of the grievance, and the Administrator confirmed that the issue should have been collaboratively resolved by both departments. The failure to effectively address and resolve the resident's grievance led to the deficiency noted in the report.
Failure to Refer Resident for Level II PASRR Review
Penalty
Summary
The facility failed to refer a resident with a new mental health diagnosis for a Level II Preadmission Screening and Resident Review (PASRR). Resident #52, who was admitted with diagnoses including end stage renal disease and stroke, received a new diagnosis of major depressive disorder. Despite this new diagnosis, no referral for a Level II PASRR review was made. The Social Services Director (SSD) admitted to not being trained in PASRR and was unaware of the new diagnosis. The SSD relied on morning meetings, emails, or telephone calls for updates on residents but was not informed about the change in Resident #52's condition. The Administrator confirmed the importance of the PASRR process and acknowledged that the SSD was responsible for tracking and referring residents for Level II PASRR assessments when needed.
Failure to Provide Meal for Dialysis Resident
Penalty
Summary
The facility failed to provide a meal for Resident #63, who required dialysis treatments three days a week. Resident #63, who was cognitively intact and required set-up assistance with meals, left for dialysis before breakfast was served and returned after breakfast. Despite having a care plan that included providing snacks and a therapeutic diet, the facility did not ensure that Resident #63 received a meal before leaving for dialysis. This issue was highlighted by a grievance filed by Resident #63 on 2/13/2024, stating that he was not provided with a snack and lunch bag for his dialysis treatments. On 4/16/2024, Resident #63 was observed at the facility's kitchen door, stating he was hungry as he had not eaten since the previous day's dinner. Interviews with various staff members, including a nurse aide, a nurse, the dietician, the assistant dietary manager, and the transportation driver, revealed a lack of coordination and communication regarding the provision of meals for Resident #63. The Director of Nursing and the Administrator acknowledged the issue, with the Director of Nursing noting that Resident #63 sometimes refused meals when transported to dialysis. However, the facility failed to ensure that a meal was consistently provided to Resident #63 before his dialysis treatments.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to honor a resident's meal preferences, specifically serving a double portion of peas to a resident who had explicitly requested not to be served peas. This incident involved a resident who was cognitively intact and had clear dietary preferences documented on his tray card. Despite these preferences being noted, the resident received a meal with a double portion of peas, which he had previously indicated he disliked. The resident expressed his dissatisfaction to the nursing assistant staff, but no alternative meal was provided, leading to frustration and unmet dietary needs. Interviews with various staff members, including nursing assistants, a registered dietitian, and the facility administrator, revealed a lack of clarity and follow-through in addressing the resident's dietary preferences. The dietary manager position was vacant at the time, and the responsibility for updating food preferences was not adequately managed. Staff members acknowledged the resident's frequent complaints about his meals but did not take appropriate action to rectify the situation. The administrator confirmed that the resident's preferences should have been honored and recognized the failure to do so in this instance.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement their abuse policy in the area of reporting for an allegation of misappropriation of property for two residents. According to the facility's policy, all allegations of abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property, must be reported immediately, but not later than 2 hours after the allegation is made if it involves abuse or results in serious bodily injury, or not later than 24 hours if it does not involve abuse and does not result in serious bodily injury. However, the facility did not report the allegations made by Resident #4 and Resident #86 to the State Agency as required by their policy and federal and state law. Both residents had filed grievances indicating that they gave money to an Activities Assistant to purchase items, but they never received their items or money back. The grievances were signed by the Administrator, but no reports were filed to the State Agency for these incidents. An interview with the Administrator revealed that he was not aware of the misappropriation of money for Resident #86 and did not complete a report for Resident #4. The Administrator explained that he had previously sent an initial report and investigative report to the State Agency for four other residents related to misappropriation of property and was not aware of Resident #4's situation until after the report was completed. This failure to report the allegations as required by the facility's policy and federal and state law constitutes a deficiency in the facility's implementation of their abuse policy.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide written notification to the Ombudsman for residents who were transferred to the hospital. Specifically, Resident #29 was sent to the hospital for fever and low oxygen saturation and was readmitted to the facility after nine days. Resident #145 was transferred to the hospital after a change in status and was documented as discharged to the hospital. Despite these transfers, the Ombudsman did not receive the required discharge summaries for these residents in a timely manner. The Social Worker (SW) responsible for communicating discharges to the Ombudsman reported that she attempted to fax the discharge summaries monthly but did not verify if the faxes were successfully sent. A review of the fax machine activity confirmed that no fax attempts were made to the Ombudsman’s fax number during the relevant period. The Ombudsman confirmed not receiving any discharge summaries since December 2023. The Administrator acknowledged that he had not verified the fax confirmations, relying solely on the SW's assurances.
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.
