Camellia Gardens Center For Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, North Carolina.
- Location
- 280 South Beckford Drive, Henderson, North Carolina 27536
- CMS Provider Number
- 345344
- Inspections on file
- 25
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Camellia Gardens Center For Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to submit accurate RN staffing data to CMS through PBJ over three consecutive quarters. On multiple dates, PBJ reports showed zero RN hours even though daily schedules documented an RN scheduled for at least 8 hours, often covered by salaried RNs such as a regional nurse consultant and an MDS nurse who did not clock in or out. Because these salaried hours required manual entry by the corporate office, and this process was inconsistently performed, the PBJ submissions did not accurately reflect actual RN coverage.
The facility failed to follow its own COVID-19 vaccination policy by not consistently assessing eligibility, educating, offering, or documenting COVID-19 vaccination for multiple residents and staff. Several residents with conditions such as diabetes, CKD, COPD, hypertension, vascular dementia, and OSA were coded on the MDS as not up to date on COVID-19 vaccination, yet their immunization records lacked evidence of recent offers, administrations, or refusals of the vaccine. Some cognitively intact residents could not recall being offered the vaccine, and the Unit Manager could not provide documentation of their vaccination status. The IP reported having offered vaccines but had no records or declination forms, while the DON acknowledged not focusing on COVID-19 vaccinations and confirmed vaccines had not been offered during her tenure. For staff, the facility could not produce any documentation of COVID-19 vaccination status, and leadership interviews revealed confusion over who was responsible for tracking and maintaining these records.
Surveyors found an opened multi-dose vial of Tuberculin Purified Diluted solution in a medication room refrigerator that was not dated when opened, despite manufacturer instructions requiring discard 30 days after opening. The DON stated the Unit Manager is responsible for checking for expired or undated medications and acknowledged the vial should have been discarded or returned to the pharmacy. The Unit Manager reported that she and staff nurses check for expired and undated medications but could not explain why the vial was not dated and could not recall when she last checked the medication room and refrigerator. The Administrator stated that all multi-dose vials are expected to be dated when opened.
The facility failed to provide and document required written transfer/discharge notices and bed-hold policy information for multiple residents sent to the hospital. A cognitively intact resident who was her own RR had two hospital transfers without documented written notice of the reason for transfer, and for one transfer there was no documented bed-hold policy; she reported not receiving either written notice or the policy. Another resident with moderately impaired cognition was transferred without documented written notice or bed-hold policy, and the RR confirmed not receiving them. A third cognitively intact resident was transferred for planned surgery; the RR reported receiving written transfer notice but not the bed-hold policy, and the DON acknowledged emailing about the surgery but not the policy. Staff interviews revealed confusion between the Social Worker, Business Office Manager, and Administrator regarding who was responsible for issuing written transfer/discharge notices and mailing the bed-hold policy, and the facility could not explain the missing notices and documentation.
A resident with chronic respiratory failure and COPD, requiring continuous oxygen therapy, repeatedly smoked in undesignated areas while using a portable oxygen tank, despite being assessed as unsafe to smoke without supervision. Staff observed and reported these incidents, but no effective interventions or increased monitoring were implemented, and the resident's care plan did not address his ongoing non-compliance. The resident eventually sustained a flash burn after his shirt caught fire while smoking with oxygen in use, highlighting failures in supervision, communication, and enforcement of the facility's smoking policy.
A resident with end-stage COPD, who was on oxygen therapy, sustained burns after smoking while on oxygen and required EMS transfer to the hospital. The incident and subsequent change in condition were not documented in the medical record, as confirmed by the nurse on duty and the facility administrator.
A resident assessed as safe to smoke independently and known to use tobacco did not have a care plan addressing smoking, despite being observed smoking in non-designated areas on multiple occasions. Staff interviews confirmed the absence of a smoking care plan until after direct observation by the MDS Coordinator, resulting in a deficiency for not developing a comprehensive, person-centered care plan.
A resident with severe cognitive impairment was subjected to inappropriate behavior by a nurse aide, who exposed herself and passed gas on the resident while other staff laughed. Another resident witnessed the incident and reported it. The facility's Administrator confirmed the incident, leading to the aide's termination, but expressed a desire to remove the resident due to his behavior.
The facility placed an industrial-sized heater in the hallway and space heaters in several resident rooms, creating tripping hazards and violating life safety codes. Residents had to navigate around unsecured cords, and the heaters were unapproved for safety. The heating system had been out for weeks, leading to these temporary measures.
The facility exceeded the acceptable medication error rate, reaching 16% during an observation. A resident did not receive prescribed eye drops due to their absence in the medication cart. Another resident received incorrect dosages of Sodium Bicarbonate, Calcium Acetate, and Hydroxyzine Pamoate due to a nurse's failure to verify medication orders against available medications. The DON confirmed the need for accurate medication administration.
The facility failed to follow infection control policies, including not donning gowns for wound care on a resident with MRSA, neglecting hand hygiene during medication administration, and handling medications with bare hands. These actions were observed among staff members, leading to deficiencies in infection prevention and control.
A resident experienced discomfort due to inadequate room heating, as the facility's heating system was broken and space heaters caused circuit breakers to trip. The resident reported being cold at night and faced privacy issues during self-catheterization. The facility's temperature log lacked specific details, and the Administrator was unaware of the nighttime issues with resetting the circuit breaker.
A resident with quadriplegia and mental health issues was involved in a verbal and physical altercation with the DON during a smoking break. The resident accused the DON of hitting her, supported by a bruise photo. Conflicting accounts from witnesses and staff, including the DON's admission to hitting the resident, complicated the investigation. The facility deemed the abuse unsubstantiated, but concerns about the investigation's thoroughness and potential retaliation were raised.
The facility failed to implement effective anti-retaliation policies, leading to staff fear of reporting abuse allegations. A resident reported being struck by the DON, but staff were reluctant to come forward due to fear of job loss. Despite assurances from the Administrator and Nurse Consultant, the investigation could not confirm the allegations due to staff's fear of retaliation.
A facility failed to conduct a thorough investigation after a resident alleged being struck by the DON. The resident claimed no assessment was done, and a photo showed a bruise on her face. The facility's report indicated the resident struck the DON, and the abuse was deemed unsubstantiated. No documentation of a skin assessment was found.
A resident with osteomyelitis did not receive scheduled doses of Vancomycin and Cefepime due to an error in entering orders into the electronic medical record. The orders were incorrectly categorized, preventing the pharmacy from receiving them, resulting in missed doses. Nursing staff confirmed the antibiotics were unavailable, and the issue was not resolved until after the scheduled administration times.
A resident admitted with diabetes and osteomyelitis did not receive prescribed antibiotics and insulin due to errors in medication orders and communication. The facility had the medications available, but staff failed to administer them due to misunderstandings and lack of coordination.
The facility did not ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, for 48 out of 180 days reviewed. This was identified through a review of staffing schedules, and attempts to contact the prior DON and Scheduler were unsuccessful. The Administrator acknowledged the responsibility of the DON and Scheduler in ensuring compliance with RN coverage requirements.
The facility failed to resolve and communicate efforts to address resident concerns from Resident Council meetings in late 2023 and early 2024. Issues included delayed responses to requests, problems with obtaining ice, lost clothing, and meal-related complaints. Staff interviews revealed a breakdown in the grievance resolution process, with department heads not returning resolutions to the Social Worker, who was responsible for logging and resolving grievances.
The facility failed to provide written advance directive information and opportunities to formulate advance directives for five residents with various medical conditions. Despite having physician orders for code status, there was no documentation of education or offers to formulate advance directives. Interviews revealed that the only resource available was the MOST form, and the Administrator acknowledged the lack of documentation.
The facility failed to notify the responsible parties and the Ombudsman in writing about the transfer of two residents to the hospital. The DON, Administrator, and Social Worker were unaware of their responsibilities regarding these notifications, leading to a lack of documentation and communication with the Ombudsman, who had previously requested such notifications.
Two residents in the facility experienced significant medication administration deficiencies. One resident, with breast cancer and vascular dementia, had inconsistent administration of letrozole, a cancer medication, due to confusion and lack of communication among staff. Another resident, admitted with osteomyelitis and a stump infection, missed several doses of an antibiotic due to unclear delivery and administration processes. The facility's staff, including the DON and Unit Manager, were unaware of these issues until later, highlighting lapses in communication and oversight.
The facility failed to maintain proper documentation for influenza and pneumococcal vaccinations for several residents. There were no signed consent or declination forms, nor records of education provided to residents or their responsible parties. Interviews with new staff members revealed they were unable to locate the required documentation, and the Administrator could not explain the absence of records.
The facility failed to notify physicians about missed medication doses for two residents. One resident did not receive letrozole for breast cancer on multiple occasions, and another missed doses of an antibiotic for a wound infection. Despite being aware of the unavailability of medications, staff did not inform the necessary medical personnel promptly.
A resident admitted with a PICC line for intravenous antibiotic therapy did not have physician orders for its management due to oversight by the Unit Manager. Despite the care plan addressing monitoring needs, the necessary orders were not entered, and nursing staff were unaware of the omission. The DON and Regional Nurse Consultant confirmed the orders should have been in place upon admission.
A resident with severe cognitive impairment was left unsupervised while smoking, contrary to the facility's policy requiring supervision and a smoking apron. The resident was observed smoking without staff present, and another resident provided and lit the cigarette. The responsible nurse aide admitted to leaving the resident unsupervised to retrieve smoking materials, acknowledging the error.
A newly admitted resident with osteomyelitis and a stump infection did not receive a scheduled dose of IV antibiotic due to a delay in medication delivery. The resident's medication orders were entered upon arrival, but the pharmacy's delivery schedule resulted in the antibiotic not being available for the 10:00 pm dose. The DON confirmed the medication was delivered later that night.
A facility failed to address recommendations from a Consultant Pharmacist regarding a resident's use of haloperidol, an antipsychotic medication. The resident, diagnosed with vascular dementia and schizophrenia, was prescribed haloperidol without an allowable diagnosis. Despite receiving the Consultant Pharmacist's report, the DON did not verify the correction of the physician order, leading to a deficiency in medication management.
The facility failed to maintain proper documentation for COVID-19 vaccinations for two residents, leading to a deficiency. A resident received a vaccine without a signed consent form or documented education, while another had no records of subsequent doses. Interviews with new staff revealed they were unaware of the missing documentation due to recent appointments.
A facility failed to document a thorough investigation into an abuse allegation by a resident with cognitive impairment. The resident accused a nurse aide of physical abuse, leading to the aide's suspension. The investigation report lacked evidence of completed resident interviews and assessments, and the files could not be found, indicating inadequate documentation.
The facility failed to deliver mail to residents on Saturdays, affecting all 65 residents. Interviews revealed that mail was only delivered Monday through Friday by the Activities Director, or on Saturdays if she was present. Staff members, including the Manager on Duty, were unaware of their responsibilities for mail delivery on Saturdays, leading to inconsistencies and confusion in the process.
Inaccurate PBJ Submission of RN Staffing Hours
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system, specifically related to RN hours for three consecutive quarters of Federal Fiscal Year 2025. For Quarter 2, the PBJ report showed no RN hours on several specific dates, while the daily staff schedules for those same dates showed an RN scheduled for at least 8 hours per day. Similar discrepancies were identified in Quarter 3 and Quarter 4, where the PBJ reports reflected no RN hours on multiple dates, yet the facility’s daily staffing schedules documented that an RN was scheduled for at least 8 hours on each of those dates. During interviews, the Regional Nurse Consultant stated that on each of the dates with zero RN hours reported in PBJ, the facility did in fact have RN coverage for a minimum of 8 consecutive hours, often provided by herself and the MDS nurse, both of whom are salaried RNs who do not clock in or out, resulting in no timecard record of their worked hours. She explained that the corporate office was responsible for manually adjusting and entering hours for salaried nursing staff who covered shifts. The Administrator reported that the corporate office was not always consistent in manually entering these hours, which led to multiple dates with inaccurate RN staffing data in the PBJ submissions for the three reviewed quarters. Attempts by surveyors to contact the Regional Business Office Manager by telephone were unsuccessful, and no return call was received.
Failure to Offer and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The deficiency involves the facility’s failure to assess residents for eligibility, educate them on COVID-19 vaccination, offer the vaccine, and document vaccination status as required by its own policies. The facility’s Infection Prevention and Control Program policy assigned oversight of infection prevention to the Infection Preventionist (IP), and the COVID-19 Vaccination policy required the facility to educate and offer the vaccine to residents, resident representatives, and staff, and to maintain documentation. Despite these policies, surveyors found that residents’ records lacked evidence that COVID-19 vaccines or additional doses had been offered, administered, or refused, and that staff vaccination status was not documented. For five residents reviewed for immunizations, records and interviews showed missing or incomplete COVID-19 vaccination documentation. One resident with diabetes, chronic kidney disease, and COPD had received a COVID-19 vaccine dose in the facility, but there was no documentation of any subsequent offer, administration, or refusal of additional doses, and the MDS coded the resident as not up to date. Another cognitively intact resident with diabetes and COPD had last refused the vaccine in 2023, with no documentation of any further offers or refusals. A resident with severe cognitive impairment and vascular dementia had last refused the vaccine in 2023, again with no record of additional offers or refusals. Two cognitively intact residents with COPD, hypertension, diabetes, chronic kidney disease, and obstructive sleep apnea had no documentation at all that the COVID-19 vaccine had been offered, given, or refused, and both reported they were unsure if the vaccine had been offered in the past year. The Unit Manager confirmed she could not provide any documentation of COVID-19 vaccination status for these residents. Interviews with facility leadership and staff further demonstrated a lack of clear responsibility and tracking for COVID-19 vaccination activities. The IP, in the role for about one and a half years, stated she had offered the COVID-19 vaccine to residents and believed none wanted it, but she was unable to locate any documentation of offers or signed declination forms. The DON, in the position for about four months, stated she had not focused on resident COVID-19 vaccinations and confirmed the facility had not offered the vaccine to residents during her tenure, with no documentation that residents were offered the vaccine in the prior year. Regarding staff, the facility was unable to provide any documentation of staff COVID-19 vaccination status. The IP stated she was not responsible for maintaining staff vaccination records and did not know who was; the DON similarly did not manage staff vaccination logs and was unsure who did. The Administrator stated that she and the nursing management team, including the IP, Unit Manager, and DON, were working together to track staff vaccinations and that information was sent to corporate, but she was unable to provide any documentation of staff COVID-19 vaccination status.
Undated Multi-Dose Tuberculin Vial Found in Medication Refrigerator
Penalty
Summary
Surveyors identified a deficiency in medication labeling and storage when, during an observation of Nurse's Station #1 medication room, they found an opened multi-dose vial of Tuberculin Purified Diluted solution stored in the medication refrigerator without a date indicating when it had been opened. The manufacturer's instructions on the vial specified that the medication should be discarded 30 days after opening, but there was no way to determine the open date from the vial. During interviews, the DON stated it was the Unit Manager's responsibility to check the medication room for expired or undated opened medications and acknowledged that the undated medication should have been discarded or returned to the pharmacy. The Unit Manager reported that she and the staff nurses are responsible for checking the medication room for expired and undated opened medications, but she could not explain why the vial had not been dated when opened and was unable to recall when she last checked the medication room and refrigerator for expired or undated medications. The Administrator stated that all multi-dose vials should be dated when opened. No residents or specific patient conditions were mentioned in relation to this deficiency, and the report focuses solely on the improper labeling and oversight of the multi-dose vial of Tuberculin solution in the medication storage area.
Failure to Provide Written Transfer/Discharge Notices and Bed-Hold Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notifications of transfer/discharge to the hospital and to provide or document provision of the bed-hold policy to residents and/or their Resident Representatives (RRs). For Resident #1, who was cognitively intact and her own RR, the medical record showed two hospital transfers. For the first transfer, there was no documentation that she received written notification of the reason for transfer/discharge or a copy of the bed-hold policy. For the second transfer, the record again lacked documentation of written notification of the reason for transfer/discharge, although the bed-hold policy was provided. In an interview, Resident #1 stated she had not received written notification of the bed-hold policy or the transfer/discharge notice when she was transferred to the hospital. For Resident #60, who had moderately impaired cognitive skills and could not complete the BIMS, the record showed a hospital transfer with no documentation that the resident or RR received written notification of the reason for transfer/discharge or a copy of the bed-hold policy. In an interview, the RR confirmed not receiving written notification of the transfer/discharge or the bed-hold policy. The Social Worker reported that the Business Office Manager was responsible for providing the bed-hold policy when a resident was transferred, and also stated she was not aware she was responsible for written transfer/discharge notifications. The Business Office Manager stated she typically followed up within 24 hours and sent a handwritten bed-hold policy the next day after transfer, but could not locate evidence that the bed-hold policy had been provided for this resident. For Resident #34, who was cognitively intact, the record showed a hospital transfer with no documentation that the resident or RR received a copy of the bed-hold policy. The RR stated she did not receive the bed-hold policy but did receive written notification of the transfer, and she had coordinated the surgery date with the DON, knowing the resident would return to the same bed. The DON stated that during the week of this transfer the Business Office Manager was out of the office, and the DON communicated with the RR by email about the upcoming surgery but did not email the bed-hold policy and was not aware it needed to be mailed. Throughout interviews, the Administrator stated that the Social Worker was responsible for written transfer/discharge notifications and the Business Office Manager was responsible for ensuring the bed-hold policy was completed and mailed, but was unable to explain why the required notices and policies were not sent or documented for these residents.
Failure to Supervise Unsafe Smoking Practices for Resident on Oxygen
Penalty
Summary
The facility failed to provide effective supervision and implement adequate interventions for a resident who was assessed as unsafe to smoke without supervision and had a known history of non-compliance with the facility's smoking policy. Despite being on continuous supplemental oxygen therapy for chronic respiratory failure and COPD, the resident was repeatedly observed by staff smoking in undesignated areas while using a portable oxygen tank via nasal cannula. These incidents were reported to facility leadership, but no new interventions or increased monitoring were implemented to prevent recurrence, and the resident's care plan did not document his non-compliance or address the ongoing risk. On multiple occasions, the resident exited the facility independently and smoked with his oxygen in use, both alone and in the presence of another resident. Staff removed the oxygen tank when they discovered these incidents, but no harm occurred until a later event when the resident's shirt caught fire while smoking with oxygen in use. The resident sustained a flash burn to his face and upper lip, requiring evaluation in the emergency department. Interviews with staff revealed inconsistent awareness of the resident's supervision requirements, lack of communication regarding his non-compliance, and failure to ensure that staff responsible for supervision were informed of which residents required monitoring during smoking times. The facility's smoking policy prohibited smoking in all but designated areas and specifically forbade oxygen use in those areas. However, the resident was able to obtain cigarettes from visitors and access exit doors with codes known to residents and visitors. Staff and leadership acknowledged breakdowns in the smoking supervision process, including lack of effective monitoring, failure to update care plans with non-compliance information, and inadequate enforcement of the smoking policy. The deficiency affected multiple residents reviewed for smoking, and immediate jeopardy was identified due to the facility's failure to implement effective interventions after repeated incidents.
Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain a complete and accurate medical record by not documenting a resident's change in condition that required Emergency Medical Services (EMS) intervention and subsequent hospitalization. The resident, who had chronic respiratory failure with hypoxia and end-stage COPD, was admitted to the facility on oxygen therapy. On the day of the incident, the resident was smoking a cigarette while receiving oxygen, resulting in a flash burn. The resident sustained burns to the upper left lip, singed nose hair, and a burn mark on the forehead, but did not report pain or breathing difficulties at the time. Despite the severity of the incident and the need for EMS transfer to a hospital, there was no documentation in the resident's electronic medical record regarding the change in condition or the events leading to the transfer. The nurse on duty confirmed that she did not document the incident, and the facility administrator verified that there were no nurse progress notes for the relevant shift. This lack of documentation constitutes a failure to maintain a complete and accurate medical record as required.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address smoking for one resident. The resident was admitted with a Safe Smoking screen indicating they were safe to smoke independently and was noted as cognitively intact, using tobacco, and able to ambulate and transfer independently. Despite these findings, there was no care plan in place related to smoking as of a specific observation date. The resident was observed smoking in areas outside the designated smoking area, including the employee parking lot and another location approximately 100 feet from the designated area. Staff interviews revealed that the resident had been seen smoking on multiple occasions prior to the initiation of a care plan, but this was not documented or addressed until after a direct observation by the MDS Coordinator. The MDS Coordinator and DON confirmed that a smoking care plan was not initiated until after the resident was observed smoking, despite prior assessments and staff observations indicating the resident's tobacco use. The DON stated that the resident had denied smoking when the smoking policy was reviewed with all residents who had Safe Smoking Screening Assessments. The lack of a timely and comprehensive care plan addressing the resident's smoking behavior constituted the deficiency identified during the survey.
Inappropriate Behavior and Lack of Dignity in Resident Care
Penalty
Summary
The facility failed to provide services with dignity and respect for two residents, leading to a deficiency in resident rights. Resident #3, who had severe cognitive impairment and a history of verbal aggression, was subjected to inappropriate behavior by a nurse aide. The aide exposed herself and passed gas on Resident #3 while other staff members laughed, failing to intervene or stop the behavior. This incident occurred despite Resident #3's repeated requests to be left alone and his refusal of care. Resident #1, who was cognitively intact, witnessed the incident and reported it during a therapy session the following day. The Rehabilitation Director confirmed the report and took steps to inform the Director of Nursing and other relevant personnel. Multiple staff members, including nurse aides, confirmed the inappropriate actions of the nurse aide and the laughter from the staff, although some were reluctant to intervene due to fear of workplace repercussions. The facility's Administrator acknowledged the incident, stating that the nurse aide involved was suspended and terminated. However, the Administrator also mentioned that there were no cameras in the facility to capture the event, contradicting a staff member's claim that the incident was recorded. The Administrator expressed a desire to remove Resident #3 from the facility due to his behavior, which included racial slurs and vulgar language towards staff.
Heaters Create Safety Hazards in Facility
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by placing an industrial-sized heater in the hallway and space heaters in several resident rooms, creating tripping hazards. During an initial tour, it was observed that the industrial heater's cord was not secured, causing residents in wheelchairs to navigate around it. Additionally, space heaters in rooms 102, 103, 104, 105, and 106 had cords that were not taped down, posing further tripping risks. Residents expressed concerns about the heaters, with one resident noting the inconvenience of navigating around them. The facility's heating system had been out for three weeks, prompting the use of these temporary heating solutions. Interviews with residents and staff revealed that the space heaters were unapproved for safety in the facility, and their use violated life safety codes due to fire risks. The Administrator explained that the heating system required a part that needed to be manufactured, leading to the temporary use of heaters. The Director of Plant Operations confirmed that the facility had been on fire watch since the heaters were installed. Despite these measures, the presence of the heaters and their cords in resident areas constituted a significant safety hazard, as confirmed by the Life Safety Engineering Supervisor.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 16% error rate during a medication administration observation. This deficiency was identified through observations, staff interviews, and record reviews involving two residents. For Resident #11, a medication aide did not administer prescribed eye drops due to their absence in the medication cart, despite the resident having a current order for Carboxymethylcellulose sodium PF ophthalmic solution for dry eyes. For Resident #12, a nurse administered incorrect dosages of three medications. The nurse gave a 325 mg tablet of Sodium Bicarbonate instead of the ordered 650 mg, only one 667 mg capsule of Calcium Acetate instead of two, and a 25 mg capsule of Hydroxyzine Pamoate instead of the ordered 50 mg. The nurse acknowledged the discrepancies upon review and admitted to not verifying the medication orders against the available medications. The Director of Nursing confirmed that medications should be administered as ordered and that the medication carts should match the orders.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during wound care for a resident with MRSA. Nurse #1 and a nurse aide entered the room of a resident on contact precautions without donning gowns, despite a sign indicating the requirement. Nurse #1 provided wound care to the resident's feet, which had tested positive for MRSA, without wearing a gown. The nurse later stated that the required PPE was not available outside the resident's door and expressed uncertainty about the necessity of wearing a gown for wound care. During a medication pass observation, Medication Aide #1 did not perform hand hygiene between residents, despite the facility's policy requiring hand hygiene before and after medication administration. The aide was observed administering medications to multiple residents, including those on contact precautions, without sanitizing her hands. When interviewed, the aide attributed her lapse in hand hygiene to nervousness, although she acknowledged the importance of hand hygiene, especially for residents on contact precautions. Nurse #3 was observed handling medications with bare hands during medication administration, contrary to the facility's policy that requires using gloves or avoiding direct contact with medications. The nurse admitted to using her hands to prevent losing or dropping pills. The Director of Nursing later clarified that medications should be handled with a gloved hand to prevent contamination and ensure safe administration practices.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to provide a comfortable room temperature for a resident, identified as Resident #16, who was cognitively intact. The resident reported that the facility had been without heat in certain rooms for three weeks, and space heaters were used as a temporary solution. However, when multiple space heaters were used simultaneously, the circuit breaker would trip, leaving the resident without heat. The resident expressed discomfort due to the cold temperatures at night, requiring multiple blankets and a thick hoodie to stay warm. The resident also faced privacy issues during self-catheterization due to the need to keep the door open for heat, which was not feasible. The facility's Administrator and Maintenance Director confirmed the heating issues, stating that a part needed to be manufactured to fix the heating unit. The Maintenance Director, who was new to the facility, used a digital thermometer to measure the room temperature, which read 73 degrees Fahrenheit, although it did not feel that warm. The facility maintained a temperature log, but it lacked specific details such as the time of day and who recorded the temperatures. The Administrator was unaware of the staff's inability to reset the circuit breaker at night, which contributed to the resident's discomfort.
Failure to Prevent Abuse and Conflicting Accounts of Incident
Penalty
Summary
The facility failed to prevent physical and verbal abuse involving a resident with a history of quadriplegia and mental health disorders. The incident occurred when the Director of Nursing (DON) and a Nurse Aide (NA) escorted three residents, including the involved resident, outside to smoke. An argument ensued between two residents, during which the DON allegedly told the resident to be quiet, leading to a verbal altercation. The resident accused the DON of hitting her, which was corroborated by a photograph showing a bruise on the resident's face. Multiple interviews provided conflicting accounts of the incident. The resident claimed the DON hit her, while the DON stated she only made contact to prevent herself from falling after being hit by the resident's wheelchair. Witnesses, including another resident and confidential sources, provided varying testimonies, with some indicating the DON pushed the resident and others denying any physical contact. The police report listed both the DON and the resident as suspects in a simple assault case, but no injuries were documented. The facility's investigation concluded that the abuse was unsubstantiated, with the Administrator stating that the resident had run her wheelchair into the DON. However, confidential sources reported that the DON admitted to hitting the resident, and there were concerns about potential retaliation against those who came forward. The lack of video evidence and the facility's decision to return the DON to work shortly after the incident raised further questions about the thoroughness of the investigation.
Failure to Implement Anti-Retaliation Policies in Abuse Reporting
Penalty
Summary
The facility failed to implement policies and procedures that promote a culture of safety and open communication, as well as prohibit potential retaliation for staff who report abuse allegations. This deficiency was highlighted by the case involving a resident who reported being struck by the Director of Nursing (DON). Despite the facility's policy stating that staff should be able to report concerns without fear of retribution, multiple confidential sources expressed fear of losing their jobs if they came forward with information about the incident. These sources included staff members who either witnessed the altercation or heard a confession from the DON admitting to hitting the resident. The incident in question involved a resident who allegedly struck the DON with an electric scooter and attempted to hit the DON with her arms and legs. The DON reportedly raised her arms to deflect the resident's attempts. However, confidential sources reported that the DON admitted to hitting the resident twice. The facility's investigation, led by the Administrator and a Nurse Consultant, was unable to confirm the allegations due to the reluctance of staff to come forward, despite assurances that they would not face retaliation. The Administrator acknowledged the challenge of convincing staff that they could report incidents without fear of losing their jobs.
Failure to Conduct Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an abuse allegation involving a resident and the Director of Nursing (DON). The incident occurred when the resident claimed to have been struck by the DON, who was subsequently suspended. However, the facility's investigation report indicated that the resident had struck the DON with her electric scooter and attempted to hit the DON, who then raised her arms to deflect the strikes. Despite the altercation, there was no documentation of a skin assessment or any assessment of the resident's injuries immediately following the incident. The resident later confirmed that no assessment was conducted, and a photograph taken by the resident showed a bruise on her face, which she claimed to have shown to the Administrator and the Social Worker. However, there was no documentation or statements from the Administrator or Social Worker regarding the photograph. The Administrator concluded that the abuse allegation was unsubstantiated, and the investigation results were submitted to the state agency. Despite interviews with the Administrator and a Nurse Consultant, it remained unclear whether a skin assessment was completed on the day of the incident.
Failure to Administer Antibiotics Due to Order Entry Error
Penalty
Summary
The facility failed to have an effective system in place for entering new admission orders into the electronic medical record, which resulted in missed doses of antibiotics for a resident. Resident #7, who was admitted from the hospital with a diagnosis of osteomyelitis, required intravenous Vancomycin and Cefepime. However, due to an error in entering the orders into the electronic system, the pharmacy did not receive the prescriptions, leading to missed doses. Upon admission, the orders for Vancomycin were incorrectly entered as 'Other Orders' instead of 'AHR Medication Orders,' which prevented the pharmacy from receiving the order. Additionally, there was no evidence that an order for Cefepime was entered at all. As a result, Resident #7 did not receive the scheduled doses of Cefepime and Vancomycin on the specified dates. The nursing staff, including Nurse #5 and Nurse #7, confirmed that the antibiotics were not available from the pharmacy, and attempts to rectify the situation were delayed. Interviews with the nursing staff and the pharmacist revealed that the pharmacy only received the orders for the antibiotics on a later date, with a start date that was after the resident's admission. The Director of Nursing acknowledged the issue and attempted to contact the hospital to send the antibiotics with the resident, but the resident was already en route. The Medical Doctor for the resident also acknowledged that the antibiotics should have been administered upon admission, but the facility was not prepared to do so due to the order entry error.
Failure to Administer Antibiotics and Insulin Upon Admission
Penalty
Summary
The facility failed to administer four doses of antibiotics and one dose of insulin to a resident upon admission, leading to significant medication errors. The resident, who was admitted from the hospital with diagnoses of diabetes and osteomyelitis, was prescribed intravenous Vancomycin and Cefepime for a six-week course to treat the infection, as well as Glargine insulin for diabetes management. However, due to a series of oversights and miscommunications, the resident did not receive the initial doses of these medications. Upon admission, Nurse #4 entered an order for Vancomycin into the electronic medical record but failed to enter the order for Cefepime. This omission, coupled with the lack of communication and verification of medication availability in the automated medication dispensing system, resulted in the resident missing doses of both antibiotics. Despite the facility having the antibiotics in stock, the staff did not access them due to a misunderstanding of the system's requirements and a lack of coordination among the nursing staff. Additionally, the order for Glargine insulin was discontinued prematurely by Nurse #4, leading to the resident missing a scheduled dose. The Director of Nursing and other staff members were unaware of the insulin's availability in the backup fridge kit, and there was no communication with the physician to address the discontinuation. These lapses in medication administration and communication highlight the facility's failure to ensure the resident received the necessary treatments upon admission.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to maintain compliance with the requirement of having a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, for 48 out of 180 days reviewed. This deficiency was identified through a review of the Nursing Staff Schedule and the Daily Staffing Form, which showed that an RN was not scheduled for the required hours on multiple specific dates between August 2023 and March 2024. Attempts to contact the prior Director of Nursing (DON) and Scheduler for clarification were unsuccessful, as calls and messages were not returned. During an interview, the Administrator acknowledged that it was the responsibility of the DON and the Scheduler to ensure compliance with the RN coverage requirement, and noted that staffing changes had occurred, suggesting improvements were made.
Failure to Resolve and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to effectively resolve and communicate efforts to address resident concerns voiced during Resident Council meetings held in October 2023, January 2024, and June 2024. During a Resident Council group interview, residents expressed ongoing issues with the resolution of concerns raised in these meetings. The review of Resident Council minutes revealed that there was no documentation of the facility's response to concerns raised in previous meetings, such as a resident not receiving requested money for three weeks, issues with obtaining ice, lost clothing, delays in being put to bed, cold food, lack of meal variety, and laundry being returned to the wrong residents. Interviews with facility staff, including the Activities Director, Administrator, and Social Worker (SW), highlighted a breakdown in the grievance resolution process. The Activities Director reported complaints to the Administrator, who delegated them to department heads. However, the SW, who was responsible for logging and resolving grievances, indicated that department heads often did not return resolutions, preventing her from creating resolution letters. The Administrator acknowledged that department heads were not returning grievance resolutions to the SW, and there was no thorough process in place to log grievances and check their status. The SW was not formally notified of her role as the Grievance Official, contributing to the lack of resolution and communication of resident concerns.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written advance directive information and an opportunity to formulate an advance directive for five residents. These residents were either admitted or readmitted with various medical conditions such as heart failure, diabetes, chronic obstructive pulmonary disorder, and seizures. Despite having physician orders for code status, there was no documentation in their medical records indicating that they were educated about or offered the opportunity to formulate advance directives. For instance, Resident #1, who was readmitted with heart failure and other conditions, had no record of advance directive education. Similarly, Resident #5's medical orders were signed by a Nurse Practitioner without the resident or their responsible party's signature, and the responsible party could not recall any discussion about advance directives during the admission process. Interviews with facility staff, including the Regional Nurse Consultant and the Administrator, revealed that the only available resource for advance directives was the Medical Orders for Scope of Treatment (MOST) form, which was stored in binders at the nurses' stations. The Administrator acknowledged that discussions and education about advance directives should have been documented for each resident and stated that residents should be reassessed for advance directives every three months or when there is a significant change in condition. However, this was not reflected in the documentation for the residents reviewed.
Failure to Notify Responsible Parties and Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification to the resident's responsible party and the Ombudsman regarding the transfer of residents to the hospital. Specifically, for one resident, there was no documentation that the resident, their responsible party, or the Ombudsman were notified of the reason for the transfer to the hospital. The Director of Nursing (DON) and the facility Administrator were unaware of the requirement to send written notifications, and the Social Worker was unaware of her responsibility to notify the Ombudsman. Additionally, for another resident, the facility did not notify the Ombudsman of the resident's transfer to the hospital. The DON and the facility Administrator confirmed the lack of notification, and the Social Worker stated she was unaware of her responsibility to notify the Ombudsman. The Ombudsman confirmed that she had not been notified of resident discharges and had previously requested such notifications from the facility Administrator.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to administer significant medications as ordered for two residents, leading to deficiencies in medication management. Resident #24, diagnosed with malignant neoplasm of the female breast and vascular dementia, had an active physician order for letrozole, a medication used to treat breast cancer. Despite the medication being delivered to the facility, it was inconsistently administered throughout August 2024. Several staff members, including medication aides and nurses, documented the medication as either administered or on order, indicating a lack of availability. Interviews with staff revealed confusion and lack of communication regarding the medication's whereabouts, and the Unit Manager and Director of Nursing were unaware of the missed doses until later notified. Resident #269, admitted with osteomyelitis and complications of a stump infection, had an active order for piperacillin sodium-tazobactam, an antibiotic to be administered intravenously every eight hours. The medication was not administered as scheduled on multiple occasions shortly after admission, with documentation indicating it was not available or not delivered. Interviews with nursing staff revealed a lack of clarity on the medication's delivery and administration, and the Nurse Practitioner was not informed of the missed doses. The Director of Nursing was also unaware of the issue until later, despite the medication being available at the facility for the scheduled administrations. The deficiencies in medication administration for both residents highlight significant lapses in communication, documentation, and oversight within the facility. The failure to ensure medications were administered as ordered, coupled with the lack of timely notification to medical providers, contributed to the deficiencies observed by surveyors. These issues underscore the need for improved processes and accountability in medication management to prevent similar occurrences in the future.
Deficiency in Vaccination Documentation
Penalty
Summary
The facility failed to maintain proper documentation for influenza and pneumococcal vaccinations for four out of five residents reviewed. Specifically, the facility did not have signed consent or declination forms, nor did it have records of education provided to the residents or their responsible parties regarding the vaccines. Resident #28 declined the pneumococcal vaccine, but the date of declination was not recorded, and there was no documentation of consent or education for the influenza vaccine administered. Resident #16 received the influenza vaccine, but there was no documentation of consent or education. Resident #29 declined the pneumococcal vaccine, but the date was unknown, and there was no documentation of consent or education for the influenza vaccine administered. Resident #10 received the influenza vaccine, but there was no documentation of consent or education. Interviews with the facility's staff, including the Regional Nurse Consultant, Infection Preventionist, and Director of Nursing, revealed that they were unable to locate the required documentation. The staff members were new to their positions and could not explain why the documentation was missing. The Administrator indicated that the Director of Nursing and the Infection Preventionist were responsible for maintaining the immunization documentation but could not provide an explanation for the absence of the records, as the administrative team was new to the facility.
Failure to Notify Physicians of Missed Medication Doses
Penalty
Summary
The facility failed to notify the physician about the non-administration of prescribed medications for two residents. Resident #24, diagnosed with malignant neoplasm of the female breast and vascular dementia, had a physician order for letrozole, a medication for breast cancer, which was not administered on multiple dates in August 2024. The Medication Administration Record (MAR) indicated the medication was on order, but there was no documentation that the Nurse Practitioner (NP) or Medical Director was informed of the missed doses. Interviews revealed that the medication was unavailable, and although the medication aide and nurse were aware, they did not notify the necessary medical personnel until much later. Similarly, Resident #269, with diagnoses including osteomyelitis and complications of stump infection, had an order for an antibiotic, piperacillin sodium-tazobactam, which was not administered on several occasions due to non-delivery. The MAR noted the missed doses, but there was no documentation of physician notification. Interviews with nursing staff and the NP confirmed that the missed doses were not communicated to the physician or the Director of Nursing (DON), highlighting a lapse in the facility's protocol for medication administration and notification.
Failure to Obtain Physician Orders for PICC Line Management
Penalty
Summary
The facility failed to obtain a physician order for the management of a peripherally inserted central catheter (PICC) for a resident who was admitted with osteomyelitis and complications of a stump infection. Upon admission, the resident had a PICC line in the right upper arm for intravenous antibiotic therapy. Although the care plan included monitoring for redness or drainage around the PICC and wound site, there were no physician orders for the PICC line's use and management. The Unit Manager, responsible for entering the physician orders, acknowledged forgetting to generate the required orders for the PICC line, despite being aware of its necessity for antibiotic therapy. Interviews with the nursing staff revealed a lack of awareness and oversight regarding the missing orders. Nurse #4, who completed the admission assessment, did not enter the physician orders, assuming the Unit Manager would do so. Nurse #2, responsible for administering the antibiotics, did not notice the absence of PICC line orders but followed facility policy by flushing the line before and after medication administration. The Director of Nursing and the Regional Nurse Consultant confirmed that the orders should have been entered upon admission, highlighting a lapse in the facility's process for ensuring all necessary physician orders are in place for new admissions.
Failure to Supervise Resident During Smoking
Penalty
Summary
The facility failed to provide adequate supervision and safety measures for a resident identified as a supervised smoker. Resident #9, who had severe cognitive impairment and was a tobacco user, was observed smoking unsupervised at the facility's smoking area. The resident was not wearing the required smoking apron, and there were no staff members present to supervise him. Another resident, who was a non-supervised smoker, provided Resident #9 with a cigarette and lit it for him. This incident occurred despite the facility's smoking policy and care plan, which required Resident #9 to be supervised and to wear a smoking apron while smoking. Nurse Aide #1, who was responsible for supervising Resident #9 during designated smoking times, admitted to leaving the resident unsupervised to retrieve his cigarettes and lighter. Upon returning, the aide found Resident #9 already smoking. The facility's administrator confirmed that staff were aware of the smoking protocol, which included obtaining cigarettes and smoking aprons for supervised smokers before they exited the building. The deficiency highlights a lapse in following established protocols for resident safety and supervision during smoking activities.
Failure to Administer Timely IV Antibiotic to New Admission
Penalty
Summary
The facility failed to ensure that intravenous antibiotic medication was available as ordered for a newly admitted resident with osteomyelitis and complications of a stump infection. The resident had a physician's order for piperacillin sodium-tazobactam to be administered every 8 hours, but the 10:00 pm dose was not given because the medication was not delivered on time. Nurse #5, who was responsible for the 3:00 pm to 11:00 pm shift, documented that the medication was not administered due to its unavailability, as the pharmacy typically delivered new admission medications around 2:00 am. The deficiency occurred despite the discharge summary, which included the resident's medication list, being provided to the Unit Manager before the resident's arrival. The Unit Manager entered the medication orders into the system upon the resident's admission. The Director of Nursing confirmed that medication orders were received before admission but were not entered until the resident arrived, leading to a delay in the delivery of the medication. The Consultant Pharmacist indicated that medication orders become active once the resident is admitted, and the orders are reviewed for contraindications before being sent to the facility.
Failure to Address Pharmacist Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) for a resident who was reviewed for unnecessary medications. The resident, who was admitted with diagnoses including vascular dementia and schizophrenia, was prescribed haloperidol, an antipsychotic medication, without an allowable diagnosis to support its use. Although the Consultant Pharmacist's report provided schizophrenia as an allowable diagnosis, the facility did not update the physician order accordingly. The Consultant Pharmacist completed the MRR and sent the reports to the Director of Nursing (DON), who was responsible for ensuring the recommendations were completed. However, the DON did not verify that the physician order was corrected, despite receiving the completed and signed recommendation report. The Administrator confirmed that the DON was responsible for ensuring the resident's diagnosis was updated for the haloperidol medication.
Deficiency in COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain proper documentation for COVID-19 vaccinations for two residents, leading to a deficiency in their immunization process. Resident #16 was administered the COVID-19 vaccine at the facility, but there was no documentation of a signed immunization consent form or evidence that vaccination education was provided to the resident or their Responsible Party (RP). The Regional Nurse Consultant confirmed the absence of these documents during an interview. Similarly, for Resident #29, the facility's records showed administration of the first dose of the COVID-19 vaccine, but there was no documentation of any subsequent doses being offered, administered, or declined. Interviews with the facility's new Infection Preventionist (IP) and Director of Nursing (DON) revealed that they were unable to provide information regarding the immunization records for Residents #16 and #29 due to their recent appointments. The Administrator also confirmed that the new administrative team was unaware of the reasons behind the missing documentation, as the previous DON could not be reached for clarification. This lack of documentation and continuity in the immunization process led to the identified deficiency.
Failure to Document Abuse Investigation
Penalty
Summary
The facility failed to maintain documented evidence of a thorough investigation into an allegation of staff-to-resident abuse involving a resident with a history of stroke and mild cognitive impairment. The resident accused a nurse aide of physical abuse, prompting the immediate suspension of the aide. The investigation report, completed by the previous Administrator, outlined plans to interview and assess all residents under the care of the accused aide. However, there was no evidence that these interviews and assessments were completed, and the allegation was ultimately not substantiated. Interviews with the President of Operations and the previous Administrator revealed that the investigation files could not be located, indicating a lack of proper documentation and follow-through on the investigation process.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, affecting all 65 residents. Interviews with the Resident Council revealed that mail was only delivered Monday through Friday by the Activities Director, or on Saturdays if she was present. The Activities Director confirmed that she was responsible for mail delivery during weekdays, and the Manager on Duty was supposed to handle it on Saturdays. However, interviews with staff members, including Medical Records/Central Supply and the Dietary Manager, indicated that they had never distributed mail on Saturdays when serving as Manager on Duty. Further interviews revealed confusion and inconsistency in mail delivery procedures. The Receptionist stated that she collected mail and placed it in the Activities Director's mailbox, as instructed by the Regional Business Office Manager (BOM). The Receptionist had never distributed mail to residents. The Regional BOM confirmed that the Receptionist was supposed to give the mail to the Activities Director, who worked most Saturdays. The Administrator acknowledged that prior to a specific date, mail was not delivered on Saturdays unless the Activities Director was present. Despite new instructions for Managers on Duty and the Receptionist to distribute mail on Saturdays, these procedures were not being followed.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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