Carolina Rehab Center Of Burke
Inspection history, citations, penalties and survey trends for this long-term care facility in Connelly Spring, North Carolina.
- Location
- 3647 Miller Bridge Road, Connelly Spring, North Carolina 28612
- CMS Provider Number
- 345526
- Inspections on file
- 23
- Latest survey
- August 25, 2025
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Carolina Rehab Center Of Burke during CMS and state inspections, most recent first.
A deficiency was cited when a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive was not honored by the facility. The facility did not ensure these rights were upheld as required.
Surveyors found expired influenza vaccine vials stored in a medication room refrigerator, an undated opened insulin pen, and a cup containing loose pills with a resident's name in a medication cart. The Infection Preventionist and DON confirmed that expired medications should have been removed during regular checks, and staff acknowledged that medications were not properly dated or stored according to policy.
The facility did not post required daily nurse staffing census information for nearly all days reviewed, as the responsible Scheduler was unaware of the requirement until recently informed by the DON. Both the DON and Administrator were also unaware that the census section had not been completed on the staffing sheets.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with pneumonia did not have their oxygen therapy reflected in the MDS, while another with a fractured arm was inaccurately shown as having no impairment. A resident on dialysis was not recorded as receiving it, and a diabetic resident's insulin administration was not reflected. Additionally, a resident receiving hospice care was not coded for a life expectancy of less than six months, and a resident with schizophrenia had an unrecorded PASRR Level II determination.
A facility failed to maintain emergency tracheostomy supplies at the bedside for a resident and did not post oxygen cautionary signs for residents receiving supplemental oxygen. Observations showed a lack of ambu bags and obturators in a resident's room, and interviews revealed staff were unaware of the need for these supplies. Additionally, oxygen cautionary signage was not posted on room doors, as the facility believed signage at the main entrance was sufficient.
A facility failed to ensure emergency tracheostomy supplies were available for a resident with respiratory issues. The resident lacked an ambu bag and obturator in their room, and staff were not adequately trained on emergency procedures. The DON believed storing an ambu bag on the crash cart was sufficient, but this did not meet the expectations of some staff. The last training on emergency tracheostomy care was over a year ago.
The facility was found to have deficiencies in food storage and cleanliness, including undated and spoiled food items in coolers and storage areas, and unclean refrigerators in nourishment rooms. The Dietary Manager and Administrator acknowledged the expectations for proper food handling and cleanliness, which were not met.
A facility failed to notify a resident's Responsible Party (RP) of a medication change involving Lorazepam, instead discussing it with the resident's private sitter, who was not authorized to make care decisions. The RP, who had requested weekly updates, was not informed until after the resident fell. Staff assumed the sitter would inform the RP, leading to a communication lapse acknowledged by the Director of Nursing and Administrator.
A facility failed to request a PASRR reevaluation for a resident with schizophrenia after a significant change in condition. The oversight occurred due to a change in Social Worker employment and the new Social Worker being in training. The Regional Social Worker confirmed the lapse, while the DON was not knowledgeable about the PASRR process. The Administrator expected the Social Worker to handle PASRR requests.
A resident with fractures requiring substantial assistance with ADLs did not have an individualized care plan. The care plan only included general therapy evaluations without specific interventions for the resident's needs. Facility staff acknowledged the oversight, and the Administrator confirmed that care plans should reflect residents' needs.
A facility failed to update a resident's advance directive care plan to reflect a DNR status, despite physician orders indicating DNR/DNI. The resident, who was severely cognitively impaired, had a care plan inaccurately showing a full code status. The MDS Coordinator acknowledged the oversight, and the Administrator expected accurate care plan updates.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, as required by regulations. Specific actions or omissions by facility staff led to this deficiency, but no further details about the residents involved or their medical conditions are provided in the report. The deficiency centers on the lack of adherence to protocols that protect resident autonomy in making decisions about their care and participation in research, as well as the formulation of advance directives.
Expired Vaccines, Undated Insulin, and Loose Pills Found During Medication Storage Audit
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals. In one medication room, five unopened and two opened vials of influenza vaccine were found in the refrigerator, all labeled with an expiration date that had already passed. These expired vials were still available for use. The Unit Manager acknowledged that the expired vials should have been returned to the pharmacy after expiration. The Infection Preventionist, who is responsible for weekly checks of medication rooms, stated she had recently checked the room but did not observe the expired vials. The Director of Nursing confirmed that the Infection Preventionist is tasked with removing expired medications during weekly checks and after resident discharges, and expressed surprise that the expired vials were present, as no flu shots had been administered since the end of the previous flu season. Additionally, in a medication cart, an opened insulin pen was found without a date indicating when it was opened, despite manufacturer instructions that the pen expires 28 days after opening. The nurse responsible for the cart admitted the pen should have been dated and was unaware of its status. In the same cart, a plastic cup containing 18 loose pills labeled with a resident's name was found in the narcotic drawer. The nurse stated she did not place the loose pills there and had not noticed them during narcotic counts. The Director of Nursing confirmed that loose pills should not be kept in medication carts and that daily checks are required.
Failure to Post Daily Nurse Staffing Census Information
Penalty
Summary
The facility failed to post required daily nurse staffing census information for 322 out of 323 days reviewed. Record review showed that from October 2024 through August 18, 2025, the daily nurse staffing sheets did not have census information entered. Observation on August 19, 2025, confirmed that the census was entered on that day's sheet, but not on previous days. During interviews, the Scheduler, who had been in the position for about two years, stated she was unaware that census information needed to be completed on the daily nurse staffing sheet until informed by the DON on August 19, 2025. The DON also stated she was not aware that the census had to be completed for all three shifts or that it had not been done since October 2024. The Administrator was similarly unaware that the census had not been entered and believed it was adjusted throughout the day as residents were admitted or discharged.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for six residents, leading to discrepancies in their medical records. Resident #23, who was admitted with pneumonia, had a physician's order for oxygen therapy, which was administered as per the Treatment Administration Record (TAR). However, the admission MDS did not reflect the oxygen therapy received during the assessment period, which was confirmed as an oversight by the MDS Coordinator. Similarly, Resident #71, admitted with a displaced fracture of the right humerus, had orders for a non-weight bearing status and a sling, but the MDS assessment inaccurately showed no impairment of the upper extremities. Resident #130, diagnosed with end-stage renal disease and dependent on dialysis, had orders for dialysis three times a week. The admission MDS inaccurately indicated that the resident did not receive dialysis while at the facility, which was acknowledged as an oversight by the MDS staff. Resident #74, with a diagnosis of diabetes, had multiple physician orders for insulin, which were administered as per the Medication Administration Record (MAR). However, the MDS assessment failed to reflect the administration of hypoglycemic medication during the look-back period. Resident #38, who began receiving hospice services, was not coded in the MDS as having a life expectancy of less than six months or as receiving hospice services, despite a significant change in status. This was identified as an oversight by the MDS Coordinator. Lastly, Resident #6, with a diagnosis of schizophrenia, had a PASRR Level II determination, but the MDS assessment did not reflect this status. The Regional Social Worker confirmed the oversight, and the Administrator expressed an expectation for accurate MDS assessments to reflect the residents' conditions accurately.
Deficiencies in Respiratory Care and Safety Signage
Penalty
Summary
The facility failed to maintain necessary emergency tracheostomy supplies at the bedside for a resident with a tracheostomy, which is crucial for immediate use in case of an unplanned extubation. Observations revealed that a resident with a tracheostomy was receiving oxygen therapy but did not have an ambu bag or obturator readily available in their room. The Infection Prevention (IP) Nurse later placed an ambu bag in the room, but initially, there was uncertainty about the availability of an obturator. Interviews with staff, including the IP Nurse and the Staff Development Coordinator (SDC) Nurse, indicated a lack of awareness and training regarding the necessity of having these emergency supplies accessible. Additionally, the facility did not post cautionary and safety signs indicating the use of oxygen for residents receiving supplemental oxygen therapy. Observations showed that several residents were receiving oxygen therapy without any signage on their room doors or doorframes to indicate oxygen use. Interviews with staff revealed that the facility had decided not to post these signs for dignity reasons and because it was a non-smoking facility. The Director of Nursing confirmed that the facility only posted oxygen cautionary signage at the main entrance and exit doors, based on the belief that this was sufficient. These deficiencies affected multiple residents who were reviewed for respiratory services, highlighting a systemic issue in the facility's approach to respiratory care and safety protocols. The lack of emergency tracheostomy supplies and appropriate signage for oxygen use could potentially compromise resident safety in emergency situations.
Deficiency in Emergency Tracheostomy Care Supplies
Penalty
Summary
The facility failed to ensure that emergency tracheostomy supplies were immediately available for a resident with a tracheostomy, leading to a deficiency in care. The resident, admitted with respiratory failure, hypoxia, and pneumonia, did not have an ambu bag or obturator in their room, which are critical for emergency tracheostomy care. Observations confirmed the absence of these supplies, and interviews with staff revealed a lack of education and awareness regarding the necessity of having these items readily available. The Staff Development Coordinator Nurse, responsible for educating nursing staff, admitted to not providing education on emergency tracheostomy procedures due to time constraints and reliance on respiratory therapy personnel, who had not conducted such training since the resident's admission. The Infection Preventionist Nurse and several other nurses also reported not receiving adequate training on emergency procedures for tracheostomy dislodgement, highlighting a gap in the facility's educational practices. The Director of Nursing acknowledged that every resident with a tracheostomy should have an obturator and ambu bag accessible, but considered storing an ambu bag on the crash cart as sufficient. However, this practice did not align with the expectations of some staff members, who were accustomed to having these supplies at the bedside. The deficiency was further compounded by the lack of recent training sessions on emergency tracheostomy care, as the last documented training occurred over a year prior.
Deficiencies in Food Storage and Cleanliness
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, as observed during a survey. In the walk-in cooler, a 3-pound bag of sliced ham was found undated and open to air, and a box of tomatoes showed signs of spoilage. The Dietary Manager confirmed that all opened food items should be dated and covered, and produce should be checked daily for spoilage. In the reach-in cooler, an opened and undated bottle of prune juice and nine thawed milkshakes without labels indicating their removal date from the freezer were found. The Dietary Manager stated that opened beverages should be dated, and milkshakes should be labeled with the date they were thawed, as they are only good for 14 days post-thawing. In the dry storage room, several expired boxes of honey thickened beverages and undated bags of rice and elbow noodles were discovered. The Dietary Manager acknowledged that staff should date items when opened and discard expired items. Additionally, an undated bin of sugar was found in the kitchen's food preparation area. The nourishment room refrigerators on three different halls were observed to have multiple dried stains, indicating a lack of cleanliness. The Dietary Manager stated that dietary staff should clean these refrigerators daily. The Administrator expected dietary staff to follow the facility's policies on food dating, storage, and cleanliness.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
The facility failed to immediately notify a resident's Responsible Party (RP) of a medication change for a resident with severe cognitive impairment. The resident, who was admitted with a diagnosis of dementia, had a medication change involving Lorazepam, which was altered from an as-needed basis every 8 hours to every 12 hours, and a scheduled dose was added. This change was discussed with the resident's private sitter, who was not authorized to make decisions regarding the resident's care, instead of the RP. The RP was not informed of the medication change until after the resident experienced a fall. Interviews revealed that the facility staff assumed the private sitter would inform the RP, as the sitter was actively involved in the resident's care and appeared to be communicating with the RP via text. However, the RP had previously requested weekly email updates from the facility regarding the resident's condition and any medication changes. The Director of Nursing and the Administrator acknowledged the communication lapse, noting that the staff should have directly informed the RP about the medication change rather than relying on the private sitter.
Failure to Request PASRR Reevaluation After Significant Change
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASRR) re-evaluation for a resident with a serious mental health diagnosis after a significant change in condition. Resident #6, diagnosed with schizophrenia, was admitted with a Level II PASRR determination that required reevaluation upon any change in condition. Despite a significant change in the resident's condition in April 2024, no PASRR reevaluation request was made. The Regional Social Worker confirmed the oversight, attributing it to a change in employment status of the previous Social Worker and the new Social Worker still being in training. The Director of Nursing stated that PASRR was the responsibility of the Social Worker, and she was not knowledgeable about the process. The Administrator expected PASRR requests to be completed by the Social Worker.
Failure to Develop Individualized ADL Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered Activities of Daily Living (ADL) care plan for a resident who required substantial to maximum assistance with various ADL tasks. The resident, who was admitted with a displaced fracture of the surgical neck of the right humerus and a displaced fracture of the base of the neck of the right femur, had intact cognition and needed significant assistance with toileting hygiene, personal hygiene, showering/bathing, dressing, footwear, bed mobility, and transfers. Despite these needs, the resident's comprehensive care plan only included a general intervention for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) to evaluate and treat as needed, without specific interventions tailored to the resident's care requirements. During interviews, both the MDS Assistant and the MDS Coordinator acknowledged that the care plan lacked specific interventions addressing the resident's care needs, attributing this to an oversight. The MDS Assistant noted that the care plan should have included details such as transfer status and the use of bed rails to guide staff in providing the appropriate level of care. The facility's Administrator also confirmed that care plans are expected to accurately reflect residents' needs, indicating a failure in the facility's process to ensure comprehensive and individualized care planning for the resident.
Failure to Update Advance Directive Care Plan
Penalty
Summary
The facility failed to revise the advance directive care plan for a resident who was severely cognitively impaired. The resident was admitted to the facility on 08/24/22, and a significant change in status Minimum Data Set (MDS) assessment indicated severe cognitive impairment. A Medical Orders for Scope of Treatment (MOST) form dated 06/18/24 showed that the resident had Do Not Resuscitate (DNR) physician orders. However, the resident's electronic medical record contained a physician order dated 06/19/24 for Do Not Resuscitate/Do Not Intubate (DNR/DNI). Despite these orders, the resident's advance directive care plan, last revised on 07/16/24, inaccurately reflected a full code status, which involves providing life-saving measures. The care plan included interventions to honor the resident's advance directive choices and to refer to the physician as needed for changes. An interview with the MDS Coordinator revealed that the care plan should have been updated on 06/18/24 to reflect the DNR status, but it was not revised. The Administrator confirmed the expectation for care plans to accurately reflect the resident's status.
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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