Carolina Rehab Center Of Cumberland
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, North Carolina.
- Location
- 4600 Cumberland Road, Fayetteville, North Carolina 28306
- CMS Provider Number
- 345505
- Inspections on file
- 31
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Carolina Rehab Center Of Cumberland during CMS and state inspections, most recent first.
Surveyors identified that the facility’s medication error rate exceeded 5% when an RN administered the wrong stool softener to a resident and an incorrect form of calcium supplement to another resident. In the first case, the RN gave docusate sodium capsules from stock instead of the ordered sennosides-docusate sodium combination. In the second case, the RN administered a Calcium 600 mg with Vitamin D tablet from stock instead of the ordered calcium citrate 950 mg (200) tablet, explaining that only one calcium product was stocked. The DON later confirmed the calcium citrate order had been continued from the hospital without prior verification against the facility’s available stock.
Expired food items, including chicken breast strips, green beans, prepacked sandwiches, and nutritional shakes, were found stored in three nourishment room refrigerators. The Dietary Manager, DON, and Administrator all confirmed that staff were expected to remove expired food, but these items were not discarded as required.
A resident with a surgical incision on the right heel was admitted to a facility without proper wound care orders. The facility failed to coordinate with the resident's podiatrist, resulting in delayed treatment and significant maceration of the wound. The resident's condition worsened, requiring hospitalization and additional surgeries. Interviews revealed a lack of communication and coordination in managing the resident's wound care.
A resident fell from a transport van due to the van driver's failure to level the lift platform with the van. The resident, who required assistance for mobility, was being transported to a physician's visit when the driver mistakenly lowered the lift to the ground. Despite encountering resistance, the driver continued to push the resident's wheelchair, resulting in both the resident and the driver falling out of the van. The resident was evaluated at the ER and found to have no acute injuries.
A resident's privacy was compromised when a Nurse Aide used a cell phone for a video call in the shower room while the resident was unclothed. The resident, who was dependent on staff for bathing, felt exposed as the phone was angled towards her. The incident occurred when the Nurse Aide received an emergency call and chose to remain in the room, despite the privacy curtain initially being in place.
A resident with a stage 4 pressure sore and osteomyelitis did not receive scheduled doses of the antibiotic Ertapenem on two consecutive days. The nurse responsible did not administer the medication, citing an inability to find it and a perceived pharmacy issue. However, the pharmacy confirmed delivery, and the DON later discovered the medication was in the facility. The resident's physician extended the treatment to account for the missed doses.
A resident with a left below-knee amputation was unable to use his prosthesis due to a missing liner, hindering his gait training. Despite notifying the DOR, the facility delayed ordering a replacement until after the resident called 911. The prosthetic company required a prescription, and further delays occurred due to payment issues, resulting in the liner being delivered only after payment was made.
A resident's medical record was inaccurately documented at a facility, leading to a misrepresentation of their condition. The resident, with a history of MRSA pneumonia, was incorrectly noted as having pneumonia again due to a nurse's error in associating an antibiotic order with the wrong ICD code. This resulted in an inaccurate care plan update, causing confusion for the resident's responsible party. The physician confirmed no pneumonia diagnosis was made during the resident's stay.
A resident with severe cognitive impairment and osteoporosis was not transferred according to her care plan, which required a mechanical lift and two staff members. Instead, a Nurse Aide manually lifted the resident, leading to a deficiency. The resident later showed signs of a fracture, though the exact cause was uncertain. Staff interviews confirmed the care plan was not followed.
A resident with severe cognitive impairment and dependency on staff for all ADLs sustained a facial fracture after hitting a bed side rail during care. The facility failed to remove the bed rails and did not assess the resident's need for them, leading to the injury.
The facility failed to complete bedrail assessments and maintain bedrails securely, resulting in a facial fracture for one resident and ongoing safety concerns for another. The residents' complaints and issues with bedrails were not adequately addressed, leading to significant safety risks.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in Supervision to Prevent Accidents (F689) and other areas. Incidents included a resident smoking with oxygen in use, a resident rolling off the bed during care, and a resident sustaining a leg fracture during an unsafe transfer. The facility also failed to post accurate RN staffing information and the resident census.
A resident was not administered prednisone as per the hospital discharge summary for 23 days due to a medication reconciliation error. The issue was discovered when the resident's family inquired about the medication, leading to the physician being notified and the medication being restarted. The physician confirmed that the missed doses did not cause harm, and the Director of Nursing acknowledged the oversight.
The facility failed to document that Pneumococcal and Influenza vaccines were offered and declined, and did not provide proof of education on the benefits and side effects of the vaccines for five residents. Interviews revealed inconsistencies and gaps in the documentation process.
The facility failed to ensure proper urinary catheter care for two residents, leading to deficiencies in maintaining the urine collection bag below the level of the bladder and preventing the urinary drainage bag from coming into contact with the floor. One resident was left with a leg bag for several days due to a reported shortage of drainage bags, while another resident's drainage bag frequently touched the floor due to improper securing and the need for a low bed. These lapses in care increased the risk of UTIs and other complications.
The facility failed to involve a resident's designated representatives in the Medicaid application process, despite the resident's cognitive impairment and inability to make decisions independently. The Business Office Manager misunderstood the resident's BIMS score and had the resident sign the forms without consulting the representatives, causing distress when they later discovered the application had been submitted without their consent.
The facility failed to obtain the responsible party's permission before opening a Resident Trust Fund account for a severely cognitively impaired resident, leading to unauthorized direct deposits of the resident's benefits. The Business Office Manager misunderstood the resident's cognitive abilities and did not involve the family in the decision-making process.
The facility failed to notify law enforcement and APS regarding an allegation of staff-to-resident abuse. The Administrator mistakenly believed she had five days to report and did not notify authorities because the resident retracted the allegation on the fifth day.
A nurse aide failed to follow proper peri-care procedures by using the same washcloth to clean both dirty and cleaner areas of a severely cognitively impaired resident, spreading feces in the process. The DON confirmed the correct procedure was not followed.
A cognitively impaired resident with a history of paranoia and aggression assaulted another resident, causing injuries and fear. Despite known behavioral issues, the facility's interventions were insufficient, and staff were occupied with other residents during the incident, highlighting a significant lapse in supervision and safety measures.
A resident with paraplegia and incomplete quadriplegia sustained a fractured leg when two nursing staff members used a sliding board for transfer, despite therapy's recommendation for a mechanical lift. The staff were not fully aware of the care plan instructions, and the resident's insistence on using the sliding board contributed to the unsafe transfer.
A facility failed to obtain a psychiatric referral for a resident with dementia who exhibited severe psychosis and aggressive behavior. Despite multiple physician recommendations and documented episodes of agitation and paranoia, the necessary psychiatric evaluation was not completed, leading to the resident's hospitalization after an altercation with another resident.
The facility's QAPI Committee failed to maintain procedures and monitor interventions, leading to repeated deficiencies in supervision and accident prevention. Incidents included a resident sustaining a fractured leg during an unsafe transfer, a resident found smoking with oxygen via nasal cannula, and another resident rolling off the bed during care, resulting in injuries and hospitalization.
Medication Error Rate Above 5% Due to Incorrect Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 38 medication administration opportunities, resulting in a 5.26% error rate. During a medication pass observation, a nurse prepared and administered two 100 mg capsules of docusate sodium from a stock bottle to a resident. Record review showed that this resident did not have an order for docusate sodium 100 mg, but instead had an active order, dated 5/29/25, for two tablets daily of a combination product containing sennosides and docusate sodium 8.6-50 mg. The nurse later stated she had not realized she had administered the wrong type of stool softener. In a separate observation with another resident, the same nurse removed and administered one tablet of Calcium 600 mg with Vitamin D 5 mcg from a stock bottle. Record review revealed that this resident had an order, dated 1/8/26, for calcium citrate 950 mg (200) one tablet daily, with the 200 indicating the amount of elemental calcium. The nurse reported that the facility had only one dosage of calcium stocked and that she administered what was available in stock rather than the specifically ordered calcium citrate. The DON later confirmed that the calcium citrate order originated from the hospital and was continued on admission, and that there had been no prior verification with the physician regarding the discrepancy between the ordered calcium supplement and what the facility had in stock.
Expired Food Items Found in Nourishment Room Refrigerators
Penalty
Summary
Surveyors observed that expired food items were stored in three out of four nourishment room refrigerators, specifically in Units 1, 2, and 3. During inspections with the Dietary Manager, an unopened pack of chicken breast strips and green beans with a use by date of 5/13/25 was found in Unit 1, a half-full box of prepacked sandwiches with a best if used by date of 4/27/25 was found in Unit 3, and two bottles of nutritional shake with an expiration date of 5/6/25 were found in Unit 2. The Dietary Manager discarded all expired items upon discovery. Interviews with the Dietary Manager, DON, and Administrator confirmed that both dietary and nursing staff were expected to routinely inspect and remove expired food from nourishment refrigerators, but this was not done, resulting in the presence of expired food items.
Failure to Coordinate Wound Care Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to obtain necessary orders to coordinate care with a resident's podiatrist, resulting in inadequate treatment of a surgical incision site on the resident's right heel. Upon admission, the resident had no orders regarding the care of the surgical incision or the soft cast, despite being discharged from the hospital with a severe heel fracture and subsequent surgery. The facility's wound care nurse practitioner did not remove the soft cast to inspect the incision, citing a lack of supplies and direction to do so, and defaulted to not removing it until the resident was seen by the podiatrist. This led to a significant delay in addressing the resident's wound care needs. The resident's condition deteriorated as the surgical dressing was not removed, and no treatment was provided until the resident's podiatrist visit, where significant maceration was noted. The podiatrist initiated treatment with oral antibiotics and dressing changes, but the resident's condition worsened, requiring further intervention. The facility's failure to communicate with the podiatrist and clarify wound care orders upon the resident's admission contributed to the delay in treatment and the subsequent infection that necessitated hospitalization and additional surgeries. Interviews with facility staff, including the wound care nurse practitioner, nurse, director of nursing, and medical director, revealed a lack of communication and coordination in managing the resident's wound care. The facility relied on the wound care nurse practitioner's orders, which did not include removing the soft cast or initiating dressing changes, and did not question the absence of specific treatment orders. The delay in the resident's podiatrist appointment, due to insurance issues, further exacerbated the situation, as the facility did not proactively seek clarification or orders for wound care, ultimately leading to the resident's hospitalization for infection management.
Resident Falls During Transport Due to Improper Lift Use
Penalty
Summary
The facility failed to ensure the safe transportation of a resident to a physician's visit, resulting in an accident. The incident involved a contracted transportation company's van driver who did not ensure the lift platform was level with the van before rolling the resident out. As a result, the resident fell backwards out of the transport van onto a lift platform that was approximately 3 feet below the level of the van. The resident, who was cognitively intact and used a wheelchair, required substantial to maximum assistance for mobility. The incident was captured on video, which showed the van driver lowering the lift platform all the way to the ground instead of keeping it level with the van. The driver then attempted to roll the resident backwards out of the van, encountering resistance due to the safety mechanisms. Despite this, the driver continued to push, resulting in both the resident and the driver falling out of the van. The resident landed on her back inside her wheelchair, and the driver fell on top of her. The resident was transported to the emergency room for evaluation, where no acute injuries were found. Interviews with the resident, staff, and the van transportation company confirmed the sequence of events. The van company's director acknowledged the driver's mistake and noted that there were no mechanical issues with the van or lift. The driver admitted in a statement that she had mistakenly lowered the lift platform to the ground and did not realize it until the accident occurred. The facility had previously used the transportation company without incident, and the driver had been trained on safety procedures, but failed to apply them correctly in this instance.
Removal Plan
- The Driver was suspended. The lift gate was damaged during the incident and therefore the van was removed from service until repaired.
- The driver was drug and alcohol tested with no findings.
- The driver was interviewed by the contract transport company and maintained that a flap on the van used to keep patients in place failed to drop as expected therefore causing her to trip.
- The transportation contract company owners came to the facility and brought the van that was part of the incident. The administrator, assistant administrator and owners discussed their findings. The owners stated the van was equipped with video camera that was on the dash and pointed toward the back. They reviewed the video footage however stated it was difficult to fully understand what was happening with the lift gate due to resident #7 and her chair being in the center. They stated they also reviewed footage of her earlier transportations for the day and noticed that the sides of the lift gate were not in visible sight as they had been on her earlier transports for the day. The owners maintain that those flaps only stay up if the lift gate is not level. The driver had received certification upon hire on safety as it relates to ensuring the lift gate is even with the van bumper prior to unrestraining a patient and proceeding with unloading.
- The owners had implemented a remediation plan of their own after reviewing the tapes. All transports that have a single driver must call dispatch prior to removing the patient from the van to confirm all safety techniques including having the lift gate level are in place prior to unloading a patient.
- The facility failed to ensure resident #7 was safe during the unloading process of transport resulting in fall from the van.
- Any residents receiving transports are affected by this practice. The transport company implemented that when working alone all drivers will be required to confirm the lift is floor level by walking on the lift and notifying their administration, prior to unloading all residents, that lift is level and safe.
- All drivers received education by the transport company owners on Passenger Assistance Safety which includes lift operating procedures and safety harnesses. This was supplied to the facility by the transport company. Any new driver will receive education by the transport company in orientation and will be sent to administrator as needed. The center contracts with no other transportation company and therefore no further education was required from other companies.
- The Quality Assurance Committee (Regional Director of Clinical Services, administrator, Director of Nursing, Assistant Director of Nursing) met to review the findings and initiated a plan.
- Unit secretary or designee will ride on transport for an audit of 2 transports weekly x 4 weeks, weekly x 8 weeks to ensure the lift gate is level prior to wheeling patient off the van and driver has made all safety checks prior to unloading a patient.
- The audits will be reported to Quality Assurance for further review quarterly x 2.
Privacy Breach During Resident Shower
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records when a Nurse Aide used a cell phone by video chat in the vicinity of an unclothed resident receiving a shower. The incident involved a resident who was cognitively intact but totally dependent on staff for bathing and showering. The resident reported that while being showered by one Nurse Aide, another Nurse Aide, who was supposed to be present as a precaution against false accusations, used her cell phone for a video call within the shower room. The resident felt exposed and believed that the individuals on the call could see her naked. The incident occurred when the Nurse Aide received an emergency call about a sick child and chose to remain in the shower room to take the call, rather than stepping out to maintain the resident's privacy. The privacy curtain was initially in place, but the Nurse Aide moved to a position where the phone was angled towards the resident, causing the resident to feel her privacy was compromised. The resident yelled at the Nurse Aide, who then left the room. The facility's investigation confirmed the incident, noting that the Nurse Aide was present as a second staff member due to the resident's history of making false accusations. The Director of Nursing and the Administrator acknowledged the Nurse Aide's actions were inappropriate, despite the emergency nature of the call, and recognized the need for privacy to be maintained at all times during resident care.
Failure to Administer Scheduled Antibiotic
Penalty
Summary
The facility failed to administer a daily intravenous antibiotic, Ertapenem, to a resident on two consecutive days. The resident, who was admitted with a stage 4 pressure sore and osteomyelitis, was scheduled to receive the antibiotic as part of a six-week treatment plan. The medication was not documented as administered on the resident's Medication Administration Record (MAR) for two days. Nurse #1 confirmed that she did not administer the antibiotic, citing an inability to locate it and a perceived issue with the pharmacy. However, the pharmacy confirmed that the medication had been delivered to the facility, and there were no processing issues reported. The Director of Nursing (DON) initially believed the missed doses were due to a pharmacy issue but later discovered the antibiotic was present in the facility. The pharmacist confirmed the delivery of the medication and reported no record of a call from the facility regarding the missing doses. The resident's physician was informed of the missed doses after the weekend and extended the treatment to compensate for the missed doses. The physician did not believe the missed doses adversely affected the resident.
Failure to Replace Lost Prosthetic Liner
Penalty
Summary
The facility failed to facilitate the replacement of a lost prosthetic liner for a resident with a left below-knee amputation, which hindered the resident's ability to use his prosthesis and walk. The resident, who was cognitively intact but had moderate vision impairment, was unable to continue gait training due to the missing liner. Physical therapy documentation indicated that the resident was unable to perform static standing or ambulate for several days because the gel sleeve for the prosthesis could not be located. Despite notifying the Director of Rehab (DOR) and requesting a replacement, the issue persisted, and the resident was discharged from therapy without meeting his ambulation goals. The resident reported the missing prosthetic liner to 911, prompting a facility service concern report. The report noted that the resident claimed the liner had been missing for 30 days, and the DOR contacted a prosthetic company to check the availability of a replacement. However, the facility did not place the order until after the resident's 911 call, and the prosthetic company required a prescription to proceed. The prescription was sent, but the liner was not in stock, causing further delays. The prosthetic company notified the facility when the liner arrived, but payment was not made until a month later, delaying delivery. Interviews with staff revealed that the DOR was aware of the missing liner after the resident's 911 call, but the Director of Nursing (DON) was not informed until the clinical meeting following the incident. The prosthetic company confirmed that the facility's first request for the liner was made the day after the 911 call, and the liner was delivered only after payment was received. The resident expressed frustration over the lack of assistance in obtaining a new liner, which prevented him from using his prosthesis and continuing therapy.
Inaccurate Medical Record Documentation for Resident Diagnosis
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident regarding their diagnoses. The resident, who had a history of MRSA pneumonia while hospitalized, was inaccurately documented as having pneumonia again while residing at the facility. This error occurred when Nurse #1 entered a verbal order for Ciprofloxacin, an antibiotic, to treat the resident's yellow/green tracheal secretions. Instead of documenting the order for the discolored sputum alone, Nurse #1 incorrectly associated the order with the ICD code for MRSA pneumonia, which was part of the resident's history upon admission. This mistake led to the resident's care plan being updated inaccurately to reflect that the resident had developed pneumonia and was receiving antibiotics for it, despite no diagnosis of pneumonia being made. The resident's responsible party expressed concern about the conflicting information regarding the resident's condition, as they were told both that the resident had and did not have pneumonia. The physician confirmed that the resident had not been diagnosed with pneumonia while at the facility, and the antibiotics were prescribed due to concerns about the color of the resident's mucous.
Failure to Follow Transfer Care Plan Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a Nurse Aide followed a resident's plan of care during a transfer, which resulted in a deficiency. Resident #2, who was severely cognitively impaired and totally dependent on staff for transfers, was supposed to be transferred using a mechanical lift with the assistance of two staff members, as per her care plan. However, on the evening of August 6, 2024, the assigned Nurse Aide, unable to find assistance, manually lifted the resident into bed without using the mechanical lift, contrary to the care plan instructions. Resident #2, who had Alzheimer's disease, contractures, and osteoporosis, was found to have a bluish, swollen foot on July 18, 2024, and later, on August 7, 2024, an x-ray revealed a mildly displaced fracture of the tibia and fibula. The Nurse Aide reported that she had previously lifted the resident manually due to her small size and weight, and other aides had done the same. The Nurse Aide did not believe that her actions caused the fracture, as she was careful during the transfer and the resident did not show signs of pain. Interviews with the facility's staff, including the Unit Manager and the rehabilitation director, confirmed that the Nurse Aide should have used the mechanical lift as per the care plan. The facility's medical director noted that due to the resident's osteoporosis, the fracture could have occurred from minimal trauma or even spontaneously. Despite the uncertainty about the exact cause of the fracture, the failure to follow the care plan was identified as a deficiency.
Failure to Ensure Safe Care Resulting in Resident Injury
Penalty
Summary
The facility failed to provide safe care to a dependent resident, resulting in a facial fracture. Resident #216, who had severe cognitive impairment and was dependent on staff for all activities of daily living, sustained a facial injury when her face hit the bed side rail during care. The incident occurred when Nursing Assistant #3 found the resident with her face against the bed side rail and later noticed blood coming from her mouth. The resident developed bruising on her chin and around her left eye, and a subsequent x-ray revealed a right zygomatic arch fracture. The resident was later hospitalized for shortness of breath, and the hospital confirmed the facial fracture. Interviews with staff and the physician indicated that the resident was nonverbal and could not turn or reposition herself independently, suggesting that the injury was likely caused by the bed side rail during care. The investigation revealed that the resident's bed had side rails that were not supposed to be in use. The Director of Nursing and Corporate Nurse Consultant confirmed that the bed rails were not removed when the resident was moved to a new room, which was a process breakdown. The Administrator acknowledged that the resident had not been assessed for bed rails, which contributed to the accident. The facility's failure to ensure the bed rails were removed and to assess the resident's need for them led to the resident's injury.
Failure to Complete Bedrail Assessments and Maintain Bedrails Securely
Penalty
Summary
The facility failed to ensure a bedrail device assessment was completed prior to the use of bedrails for two residents and failed to ensure bedrails were maintained securely for one resident. Resident #216, who had severe cognitive impairment and was dependent on staff for all activities of daily living, sustained a facial fracture after hitting her face on the bedrail during care. The facility's investigation revealed that no bedrail device assessment was completed for Resident #216, and the resident was not supposed to have bedrails on her bed. The incident occurred when the resident coughed and hit the bedrail with her face, leading to bruising and a subsequent facial fracture identified during a hospital visit for an unrelated condition. Interviews with staff confirmed that the resident was nonverbal and could not turn or reposition herself independently, and the bedrails were not assessed or intended for her use. Resident #66, who was cognitively intact and required partial assistance for mobility, had issues with a loose left siderail that was not securely maintained. Despite the resident's complaints and makeshift solution of bracing the siderail with a dresser, the facility failed to address the issue promptly. The resident's left siderail was observed to be loose and lacking a necessary latch, which prevented it from being securely locked in place. The Maintenance Director attempted to fix the siderail but did not succeed, and the issue persisted. Interviews with staff revealed that the resident had reported the problem to multiple staff members, but no effective action was taken to resolve it. The facility's failure to complete proper bedrail assessments and maintain bedrails securely resulted in significant safety risks for the residents. The lack of assessment and improper maintenance of bedrails led to injuries and ongoing safety concerns. The facility's processes for bedrail assessment and maintenance were found to be inadequate, contributing to the deficiencies observed during the survey.
Repeated Deficiencies in Supervision to Prevent Accidents and Staffing Information
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions, resulting in repeated deficiencies in the area of Supervision to Prevent Accidents (F689). During multiple surveys, including recertification and complaint investigations, the facility was cited for failing to prevent accidents that resulted in significant harm to residents. Specific incidents included a resident found smoking in their room with oxygen in use on three occasions, a resident rolling off the bed during care resulting in a right frontal hematoma and laceration, and a resident sustaining a leg fracture during an unsafe transfer. The facility also failed to ensure peri-care was postponed until the last phase of bathing for a resident and did not shave two dependent male residents as required. Additionally, the facility was cited for failing to post accurate Registered Nurse (RN) staffing information and the resident census on the daily nursing staffing sheets. Despite the QAA committee meeting monthly and attempting to identify areas of concern, the facility continued to show a pattern of inability to sustain an effective Quality Assurance Program. The Administrator revealed that the root cause of the repeat accidents was determined to be the lack of Nursing Assistant competency due to insufficient hands-on training during the Covid pandemic.
Failure to Administer Prednisone as Ordered
Penalty
Summary
The facility failed to administer prednisone as per the resident's hospital discharge summary for 23 days. Resident #166, who was admitted with multiple diagnoses including orthopedic aftercare following surgical amputation, peripheral vascular disease, asthma, pulmonary fibrosis, and interstitial pulmonary disease, was supposed to continue taking prednisone 5 milligrams daily. However, this medication was not ordered until 7/2/23, despite being listed on the discharge summary from the hospital dated 6/9/23. The error was discovered when the resident's family inquired about the medication, leading to the physician being notified and the medication being restarted. Interviews with the physician and the Director of Nursing revealed that the prednisone order was missed during the medication reconciliation process upon admission. The physician confirmed that the resident should have been on prednisone since admission and noted that the missed doses did not cause any harm or deterioration to the resident. The Director of Nursing acknowledged that the medication should have been continued as per the hospital's discharge summary but was not aware of the error until it was brought to their attention by the family in July 2023. The admitting nurse responsible for the oversight was unavailable for an interview.
Failure to Document Vaccine Consent and Education
Penalty
Summary
The facility failed to document that the Pneumococcal and Influenza vaccines were offered and declined, and the reasons for the refusals. Additionally, the facility did not document that residents or their representatives were provided education regarding the benefits and potential side effects of the vaccines. This deficiency was observed in five residents, all of whom had no documented proof of vaccine consent or refusal, nor any evidence of education provided about the vaccines. For instance, Resident #14, who was not cognitively intact, had no consent forms on file, and there was no documented proof of refusal or education provided. Similarly, Resident #55, who was cognitively intact, stated he was never offered the vaccines by the facility, despite his immunization record indicating refusals without documented proof or reasons for refusal and education provided. Other residents, including Resident #59, Resident #92, and Resident #96, also had similar issues with missing documentation and lack of proof of education regarding the vaccines. Interviews with the Infection Preventionist, Nurse Consultant, Director of Nursing, and the facility Administrator revealed inconsistencies and gaps in the documentation process for vaccine consent and refusal. The Infection Preventionist admitted to not having signed VIS consent/declination forms for the residents in question. The Nurse Consultant and Director of Nursing acknowledged that the facility's process for documenting vaccine refusals and education was not followed correctly. The facility Administrator stated that while the facility was not required to get a signed declination or consent, it should have been documented in the electronic medical record or elsewhere. The Nurse Practitioner emphasized the importance of offering vaccinations and educating residents on the risks and benefits, and that refusals should be documented in the medical record along with the reasons for refusal.
Improper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper urinary catheter care for two residents, leading to deficiencies in maintaining the urine collection bag below the level of the bladder and preventing the urinary drainage bag from coming into contact with the floor. Resident #267, who was admitted with a diagnosis of overactive bladder and had an indwelling urinary catheter, was observed with a leg bag attached to her catheter while lying in bed. Despite the availability of drainage bags, the resident was left with a leg bag for several days, including overnight, due to a reported shortage of drainage bags. This situation was confirmed by multiple staff members, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who acknowledged the risk of urinary tract infection (UTI) due to the improper use of the leg bag at night. Resident #98, who had obstructive and reflux uropathy and required an indwelling urinary catheter, was observed multiple times with his urinary catheter drainage bag touching or partially lying on the floor. Despite the facility's policy and manufacturer's guidelines stating that the drainage bag should not touch the floor, observations revealed that the bag was not properly secured and often came into contact with the floor. Interviews with the Infection Preventionist (IP) Nurse and other staff members confirmed that the improper positioning of the drainage bag increased the risk of UTIs. The IP Nurse and other staff members attempted to address the issue by adjusting the bed height and securing the bag, but the problem persisted due to the resident's need for a low bed to prevent falls. The facility's failure to maintain proper urinary catheter care for these residents was further highlighted by the lack of communication and coordination among staff members. The Central Supply Clerk and the ADON were aware of the drainage bag shortage but did not effectively resolve the issue in a timely manner. Additionally, the staff's inconsistent adherence to the facility's policies and procedures for catheter care contributed to the deficiencies observed. These lapses in care and oversight put the residents at increased risk for UTIs and other complications related to improper catheter management.
Failure to Involve Resident's Representatives in Medicaid Application
Penalty
Summary
The facility failed to allow a resident's designated representative to decide whether an application for Medicaid would be completed for the resident. This deficiency involved a resident who was admitted with a diagnosis of cerebral infarction and was cognitively impaired, as indicated by a BIMS score of 99. Despite the resident's inability to communicate effectively and the presence of designated representatives (RR#1 and RR#2) responsible for making decisions on his behalf, the Business Office Manager (BOM) proceeded to have the resident sign forms authorizing the facility to apply for Medicaid without consulting the representatives. The BOM, misunderstanding the significance of the BIMS score, believed that a score of 99 indicated the resident could understand and sign the paperwork. The BOM attempted to explain the Medicaid application process to the resident, who nodded but did not verbally respond, and then signed the forms. The BOM did not contact the resident's representatives before obtaining the resident's signature, despite their established role in managing his financial and healthcare decisions. This action caused distress to the resident's representatives when they later discovered the application had been submitted without their consent. Interviews with various staff members, including social workers, nurses, and the Assistant BOM, confirmed that the resident was not capable of making such decisions independently. The staff consistently reported that the resident's cognitive impairment prevented him from understanding complex financial matters. The facility's failure to involve the resident's designated representatives in the Medicaid application process constituted a significant oversight and breach of protocol, leading to the identified deficiency.
Unauthorized Opening of Resident Trust Fund Account
Penalty
Summary
The facility failed to obtain the permission of the responsible party (RP) before opening a Resident Trust Fund account for a resident who was severely cognitively impaired. The resident, who had a diagnosis of cerebral infarction and was unable to communicate, was admitted to the facility with the understanding that his RP and another family member would make decisions for him. Despite this, the Business Office Manager (BOM) had the resident sign the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form without involving the RP or obtaining their consent. The form was signed by the resident, who had a BIMS score of 99, indicating severe cognitive impairment, and lacked witness signatures as required for an illegible signature or mark (X). The BOM misunderstood the BIMS score and believed the resident could understand and sign the forms, leading to the unauthorized opening of the trust account and the direct deposit of the resident's benefits into it. Interviews with various staff members, including the Social Worker (SW), nurses, and the BOM, revealed that the resident was not capable of making financial decisions for himself. The BOM admitted to explaining the form to the resident and taking his nodding as an indication of understanding, despite his severe cognitive impairment. The BOM also acknowledged that she did not involve the RP or other family members in the process because she could not get them to come in and sign the forms. The resident's family members confirmed that they were not aware of the trust account and had not given permission for its creation. They only became aware of the direct deposit changes through an automated text message and were not informed by the facility. The facility's failure to involve the RP in the financial decision-making process for the resident, who was severely cognitively impaired, led to the unauthorized opening of a Resident Trust Fund account. The account was eventually closed when the resident's family decided to transfer him to a Veteran's Administration (VA) facility and privately pay for his care. The incident highlights a significant lapse in the facility's adherence to protocols for managing residents' financial affairs, particularly for those who are unable to make decisions for themselves.
Failure to Notify Authorities of Abuse Allegation
Penalty
Summary
The facility failed to notify law enforcement and Adult Protective Services (APS) regarding an allegation of staff-to-resident abuse involving one resident. The facility became aware of the abuse allegation on January 30, 2024, at 10:52 AM, when the resident reported that a nurse aide was rough with his legs during care. However, the Administrator did not contact law enforcement or APS, mistakenly believing she had five days to notify them and because the resident retracted his allegation on the fifth day. This failure to report was identified during a review of the initial report sent to the state regulatory agency and confirmed through an interview with the Administrator on May 1, 2024.
Improper Peri-Care Procedure
Penalty
Summary
The facility failed to ensure peri-care was postponed until the last phase of bathing for a resident who was severely cognitively impaired and required maximal assistance with bathing and toileting hygiene. During an observation, a nurse aide was seen using the same washcloth to clean both dirty and cleaner areas of the resident's body, spreading feces in the process. The nurse aide did not notice the feces on the washcloth and continued to clean the resident's back, buttocks, and hamstrings with it. The Director of Nursing confirmed that the nurse aide should have discarded the washcloth after cleaning the dirty area to prevent the spread of feces. The resident's care plan included specific instructions for toileting hygiene and brief changes, which were not followed correctly during the observed incident.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired and dependent resident from abuse by another cognitively impaired resident. Resident #2, who had a history of paranoia, delusions, and aggression, entered Resident #3's room and assaulted him while staff were attending to other residents during an evening meal. Resident #3 sustained a laceration near his eye, multiple areas of bruising, and expressed fear that the incident would occur again. This incident was observed and reported by multiple staff members and residents, highlighting a significant lapse in supervision and safety measures for vulnerable residents. Resident #2 had a documented history of severe cognitive impairment and behavioral issues, including paranoia, delusions, and aggression. Despite these known issues, the facility's interventions, such as medication adjustments and attempts at psychiatric referrals, were insufficient to prevent the assault. Staff interviews revealed that Resident #2 had exhibited aggressive and paranoid behaviors on multiple occasions, yet he was often easily redirected and had not previously harmed other residents. However, the facility failed to ensure that a psychiatric consult was completed, which may have provided additional insights and interventions to manage Resident #2's behaviors. On the evening of the incident, staff were occupied with other residents, leaving Resident #3 vulnerable to the attack. Multiple staff members, including nurses and nurse aides, responded to the scene after hearing screams and found Resident #3 on the floor with injuries. The facility's investigation revealed that Resident #2 had a history of confusion and agitation, often expressing paranoid delusions about being attacked. Despite these warning signs, the facility did not implement adequate safety measures to protect other residents from potential harm, resulting in the severe assault on Resident #3.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was transferred safely, resulting in Resident #1 sustaining a fractured leg. Resident #1, who had a diagnosis of paraplegia and incomplete quadriplegia, was documented by physical therapy as having impaired strength in all extremities and was totally dependent on staff for transfers. Despite therapy's determination that a sliding board was not appropriate for Resident #1 due to her limited mobility, two nursing staff members used a sliding board to transfer her, leading to the injury. The physical therapy evaluation and progress notes clearly indicated that Resident #1 required a mechanical lift for safe transfers, and this was documented in her care plan and Kardex. However, on the evening of the incident, a nurse and a nurse aide used a sliding board to transfer Resident #1, resulting in her right leg getting caught and subsequently fracturing her femur. The staff involved were not fully aware of the care plan instructions, and Resident #1's insistence on using the sliding board contributed to the unsafe transfer. Interviews with the staff revealed that they were trying to accommodate Resident #1's preferences, despite the established safety protocols. The incident highlights a significant lapse in following the prescribed care plan and ensuring resident safety during transfers.
Failure to Obtain Psychiatric Referral for Dementia Resident
Penalty
Summary
The facility failed to obtain a psychiatric referral as ordered for a resident diagnosed with dementia who exhibited signs of psychosis. The resident, who had a history of severe cognitive impairment and behavioral disturbances, was admitted to the facility following a hospitalization where he had been physically restrained and started on antipsychotic medication. Despite multiple instances of severe agitation, paranoia, and hallucinations, the facility did not ensure that the resident received the necessary psychiatric evaluation and services as ordered by the physician. The resident's medical records and physician notes indicated ongoing issues with agitation, paranoia, and psychotic episodes, including suicidal ideations and aggressive behavior towards staff and other residents. The facility's Director of Nursing noted the need for a psychiatric referral, but the referral was not completed due to the resident's initial refusal. Subsequent physician notes continued to document the resident's severe agitation and psychosis, yet no psychiatric consult was obtained. The resident's condition escalated, leading to multiple incidents of aggressive behavior, including an altercation with another resident. Despite the physician's repeated recommendations for a psychiatric referral, the facility failed to follow through, resulting in the resident being hospitalized after a severe episode of aggression. The facility's Social Services Director later confirmed that the psychiatric referral had been missed, and the resident was only referred for psychiatric services after the altercation occurred.
Repeated Deficiencies in Supervision and Accident Prevention
Penalty
Summary
The facility's Quality Assurance/Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put into place following previous surveys. This resulted in a repeat deficiency related to the failure to provide supervision to prevent accidents. During a complaint survey, it was found that two nursing staff members transferred a resident using a sliding board, despite therapy determining that the resident did not have the functional ability to use it safely. This led to the resident sustaining a fractured leg. Additionally, during a recertification and complaint survey, the facility failed to supervise a resident who was non-compliant with the smoking policy, resulting in the resident being found smoking in their room with oxygen via nasal cannula on three occasions. There were no systems or interventions in place to prevent recurrent noncompliance with the smoking policy by residents. In another incident during a complaint investigation, the facility failed to prevent a resident from rolling off the bed during care, which resulted in a right frontal hematoma, laceration, and right periorbital swelling, leading to hospitalization. These repeated deficiencies over three federal surveys indicate a pattern of the facility's inability to sustain an effective Quality Assurance/Performance Improvement program. Despite the administrator's belief that the QAPI program was effective and had prevented specific incidents from being repeated, the continued occurrence of accidents suggests otherwise.
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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