Cedar Hills Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Clemmons, North Carolina.
- Location
- 3905 Clemmons Road, Clemmons, North Carolina 27012
- CMS Provider Number
- 345131
- Inspections on file
- 29
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Cedar Hills Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that the dish machine was operating below the required 120°F wash temperature, with readings between 90°F and 100°F, while dietary staff continued to process dishware. The dietary staff member using the machine was unsure whether it was a high- or low-temperature unit, even though posted instructions specified the correct parameters, and reported that temperatures had been fluctuating for about a week. The DM incorrectly believed the unit was a high-temperature machine, claimed to have submitted a work order that maintenance never received, and could not provide documentation. A regional food service consultant later confirmed the unit was a low-temperature machine and had not been informed of the malfunction, while the Maintenance Director stated he only became aware of the issue after the surveyors’ tour and then discovered hot water was not reaching the machine.
Surveyors found that garbage and refuse were not properly contained or managed in the dumpster area. A large, open construction-type container was overflowing with trash bags, some of which were on the ground, and there was no covering over the container. Two shared dumpsters were observed with doors left open, trash visible inside, and the surrounding gated area littered with cardboard, used gloves, cup lids, paper, an office chair, and a large planter, along with a strong odor. Staff interviews showed uncertainty about who was responsible for keeping the dumpster doors closed and the area clean, and the report notes these conditions had the potential to attract pests and rodents.
The facility did not implement its antibiotic stewardship program as required by its own policy, despite pharmacy tracking sheets showing that multiple residents were on antibiotics over several consecutive months. The policy called for an Infection Preventionist to track antibiotic starts, monitor adherence to evidence-based criteria, and review resistance patterns, but the current DON, responsible for Infection Prevention and Control, could not locate prior infection monitoring or tracking information. The previous DON reported that no antibiotic stewardship program was in place during her tenure and that she received no guidance, while the Administrator stated she expected the program to be in place and that infections were discussed in QAPI meetings, without evidence of a formal stewardship process.
The facility failed to complete baseline care plans within 48 hours of admission for multiple newly admitted residents with complex conditions such as paraplegia, dementia, fractures, CHF, COPD, pneumonia, diabetes, malnutrition, chronic wounds, and chronic pain. Record reviews showed that baseline care plans were missing from the charts, and staff interviews revealed that UMs, the DON, and the Administrator were often unaware that these plans had not been completed. Nurses and UMs gave conflicting statements about who was responsible for the baseline care plans, with some nurses believing UMs would complete them, some UMs stating the admitting nurse was responsible, and one UM reporting she had not been trained. In at least one case, a nurse reported that the baseline care plan was not included on the list of required admission assessments, contributing to the omission.
Surveyors found that the facility failed to maintain documentation of influenza and pneumococcal vaccine consents or declinations and failed to document education on benefits and potential side effects for multiple residents. Several cognitively impaired residents had MDS assessments indicating vaccines were not offered, and their medical records lacked any evidence that vaccines were administered, offered, accepted, or declined, or that education was provided. One cognitively intact resident had a recorded declination of a pneumococcal vaccine without a date and no record of an influenza vaccine for the current season. Another resident had documentation of vaccines given outside the facility in prior periods but no record of being offered the current season influenza vaccine or receiving related education. Interviews with the DONs and the Administrator showed that immunization processes and documentation had not been established or monitored, and staff were unaware whether immunizations were being completed.
A cognitively intact resident was admitted without being informed in writing of the right to accept or refuse medical/surgical treatment or to formulate an advance directive, and no code status or advance directive was documented in the medical record. The resident reported not receiving any paperwork or education on advance directives and expressed a wish to be resuscitated. The SW acknowledged that information on advance directives was only given if residents requested it, and a nurse confirmed there was no code status order in the EMR or code status book. The DON and Administrator each described expectations that admitting nursing staff obtain code status orders and that the SW or other staff explain advance directive choices, but there was no clear process or documentation showing this occurred for the resident.
Surveyors found that the facility did not provide the required CMS SNF-ABN (form 10555) to two residents whose Medicare Part A skilled services were ending while they remained in the facility. Record review showed no documentation that either resident or their representatives received the correct Part A liability notice before skilled coverage ended. The Social Worker, who stated it was her responsibility to issue these notices, instead used an Advance Beneficiary Notice of Non-Coverage form intended for Medicare Part B items and services, and the Administrator reported being unaware that the wrong form was being used.
Surveyors identified that the facility did not develop complete, measurable care plans for two residents in key areas. One resident with cognitive impairment and dependence on staff for ADLs, who expressed that group activities were somewhat important, had no care plan addressing ADLs or activities, which staff attributed to MDS non-triggering and lack of care plan training. Another cognitively intact resident with polyarthritis and metabolic encephalopathy, who participated in discharge planning and had a goal to return to the community, had no discharge planning goals or interventions in the care plan, which the responsible Social Worker and leadership described as an oversight.
A resident with neurogenic bladder, paraplegia, and an indwelling catheter did not receive consistent catheter output monitoring and documentation as ordered, with multiple shifts lacking recorded output and reports from the resident that the catheter bag was sometimes not emptied unless she requested it. Staff and a PA reported seeing full catheter bags with urine backflow. The resident was also observed with dry stool on the buttocks and catheter near the meatus, and an NA applied a brief without cleaning the area despite an order for routine cleansing with soap and water. In addition, ordered daily UA and C&S specimens over three days were not obtained or documented, and a later specimen showed E. coli, while the PA described repeated problems with obtaining ordered urine specimens and needing to reorder tests.
Surveyors found multiple loose, unlabeled pills of various shapes, sizes, and colors in two medication carts on the same hall, stored directly in cart drawers rather than in properly labeled packaging. A nurse and a medication aide each confirmed the presence of these loose medications but could not explain why they lacked required identifying information such as resident name or prescribing details. The Unit Manager reported that staff are expected to audit carts during shift changes and notify her of loose medications, and the DON stated that carts are audited by Unit Managers and the pharmacist and that loose pills should be disposed of, yet neither could explain why loose tablets remained in the carts at the time of the survey.
A cognitively intact resident with fractures, muscle weakness, and anxiety, who required staff assistance with toileting and mobility and used a wheelchair, reported that CNAs delayed more than 30 minutes in responding to her call light for incontinence care and told her not to ring out, which made her upset and mad. A grievance documented that night-shift aides were not changing her in a timely manner and told her not to call for help. The DON and Administrator confirmed that two NAs on the night shift were delayed in providing care and admitted they told the resident not to call out, even if they claimed it was said jokingly, resulting in a failure to treat the resident with dignity and respect.
Two residents who were cognitively impaired and dependent for ADLs did not receive needed nail and facial hair care despite clear care needs and expressed or observed need for grooming. One resident with dementia had long, jagged fingernails with debris under them on repeated observations, even after a NA acknowledged the issue and stated care would be provided. Another resident with a stroke and a hand contracture was observed with long, unshaven facial hair, mild body odor, and long, jagged nails, including a very long thumb nail, after a bath in which the NA had not offered nail care; a family member confirmed the resident appeared unkempt and that nails and facial hair had not been addressed, and there were no documented refusals of care.
A resident with spina bifida, paraplegia, and a stage 4 sacral pressure ulcer did not consistently receive ordered Dakin’s solution and collagen-based wound treatments, as multiple dates on the TAR lacked documentation of completion. Nurses assigned to provide care could not explain missed treatments, and one RN acknowledged that weekend treatments were sometimes not done and simply left unsigned. The wound nurse reported the resident’s concerns about missed weekend care and found that some treatments she provided were not signed off. The cognitively intact resident, dependent on staff for toileting and repositioning, reported that wound care was sometimes not done on weekends and described a specific missed treatment. Wound notes showed periods of deterioration with increased undermining, and the PA and wound NP stated that ordered treatments are necessary and that failure to perform dressing changes can impede or worsen wound healing, while facility leadership was unaware that treatments were being missed.
A resident with a history of C. diff infection and multiple comorbidities developed abdominal tenderness and loose stools, prompting a provider to order stool testing for C. diff on three separate occasions. Despite documented loose stools on multiple days and the provider’s notes that testing was still pending, nursing staff did not obtain a stool specimen for C. diff until several days after the initial and subsequent orders. Laboratory records showed no C. diff result for extended periods following the first two orders, and the specimen was only collected after the third order, at which point the test returned positive. Interviews with the PA, nursing staff, DON, and Administrator confirmed that the facility’s expectation was for ordered C. diff stool samples to be collected promptly, which did not occur in this case.
Surveyors found that the facility failed to follow its enhanced barrier precautions policy for a resident with a sacral wound. The resident’s door lacked required signage and PPE was not available outside the room. An NA began incontinence care wearing only gloves and without a gown, and only donned full PPE after the surveyor intervened upon observing the sacral wound and dressing. In interviews, the NA reported she relied on door signage to know when to use PPE, while the ADON and Administrator confirmed the resident should have been on enhanced barrier precautions with appropriate signage and PPE in place before care.
Survey results were kept in an unlabeled binder mounted high on a lobby wall without any posted notice of its location, making it inaccessible to residents in wheelchairs and unclear to visitors. Reception staff working different shifts had not been educated on what the survey results were or where they were kept, with one believing they were in a wall rack and another thinking they were in a desk drawer. Several residents at a Resident Council meeting reported they did not know what survey results were or where to find them, and the Activity Director confirmed she had not discussed survey results or their location during council meetings and was unsure of their exact placement, while the Administrator knew the general area but was unaware of the lack of labeling, signage, and staff education.
A resident with Alzheimer's and other conditions fell from a waist-height bed during incontinence care, sustaining a head laceration requiring staples. The resident became combative, and the NA, attempting to calm her, inadvertently allowed her to roll off the bed. Staff acknowledged the resident's known behaviors and the need for careful supervision during care.
The facility failed to resolve grievances raised during Resident Council Meetings over several months, including issues with coffee service and laundry. Interviews with residents confirmed ongoing concerns, and the Activity Director and Administrator were unaware of the lack of resolution and documentation.
A resident's monthly weights were not documented as ordered by the physician, with no weights recorded from February to October except for one in October. Interviews revealed a lack of awareness and a system to ensure weights were consistently documented, leading to the deficiency.
A resident was improperly discharged from an LTC facility after returning late from a leave of absence due to car trouble. The facility failed to provide documentation for the discharge, which was directed by the Regional Office Manager, despite the facility being able to meet the resident's needs. The Interim Administrator acknowledged the miscommunication and confirmed the resident should have been allowed to stay.
A resident was discharged from an LTC facility without proper discharge planning after being delayed due to transportation issues. The resident, who was cognitively intact and independent, was not given discharge instructions or prescriptions, leading her to seek medication refills at a hospital. Facility staff were misdirected to discharge the resident due to her absence exceeding 24 hours, which was later acknowledged as an error.
A facility failed to consistently monitor a resident's weight as required by physician orders, leading to incomplete nutritional assessments. The resident's MDS assessments lacked weight data, and the care plan's goals for weight management were not supported by regular evaluations. Staff interviews revealed systemic issues in weight documentation and oversight, contributing to the deficiency.
A resident with hemiplegia and hemiparesis did not receive the recommended restorative range of motion program and splinting devices as advised by the occupational therapist. Observations showed the resident without the necessary splints, and staff interviews revealed a lack of documentation and awareness regarding the application of these devices. The Regional Nurse Consultant confirmed the absence of a physician's order for the splinting devices and exercise program.
A resident with end-stage renal disease did not have a documented physician's order for dialysis services or a specific care plan in place. The facility failed to monitor the resident's condition after dialysis treatments, as vital signs were not taken and the permacath site was not checked for bleeding. Interviews and observations revealed a lack of awareness and oversight in the facility's processes, leading to inadequate dialysis care.
The facility failed to monitor nurse aide registry expirations, allowing a nurse aide to work with an expired listing. The lapse occurred due to the absence of a Staff Development Coordinator and a tracking system, resulting in the aide performing resident care tasks without a valid registry listing.
Two residents in an LTC facility were not provided with adequate privacy, as they lacked privacy curtains and one had an uncovered catheter bag. Despite being reported, the absence of curtains persisted, leaving residents exposed during care. The facility's administration was unaware of these issues until the survey.
Two residents in a facility's 200-hall lacked privacy curtains, affecting their privacy during care. One resident, cognitively intact, had requested a curtain since admission, while the other, cognitively impaired, had been without one for months. Despite reports to the previous housekeeping director, the issue remained unresolved. The new Director of Housekeeping and the Administrator were unaware of the missing curtains.
The facility did not post required contact information for State agencies and advocacy groups, including the State Survey Agency and the Ombudsman program, during a four-day survey. Observations showed no signage in common areas or nursing units, and the Administrator was unsure why postings were missing.
Two residents in the facility did not receive critical medications upon admission, leading to significant medication errors. One resident, with a history of seizures, did not receive antiseizure medications due to delayed pharmacy delivery and lack of stat ordering by the nurse. Another resident, admitted after knee replacement surgery, did not receive prescribed pain medication as it was not available in the emergency backup supply and was not ordered stat. The facility's Administrator was unaware of these issues, and the Pharmacist noted that the lack of antiseizure medication contributed to seizures.
A resident with a urinary catheter experienced abdominal pain and catheter flushing issues, which were not reported to the NP. Additionally, a urinalysis was delayed in being sent to the lab, and the results indicating an infection were not communicated until the resident was hospitalized. Staff interviews revealed a lack of communication and procedure adherence.
A facility failed to report an alleged abuse incident involving a severely cognitively impaired resident with hemiplegia and epilepsy to Adult Protective Services within the required 24-hour timeframe. The resident's family member reported that a male nurse allegedly slapped the resident. The facility's Administrator was informed of the allegation but delayed reporting it to Adult Protective Services. The facility conducted an investigation, suspended the accused nurse, and notified the police, but the allegation was unsubstantiated.
A resident with a suprapubic catheter experienced a delay in urinalysis testing after reporting purple urine, indicating a potential infection. The sample was not sent to the lab promptly, and when tested, it was contaminated. Despite symptoms of pain and distention, the facility did not act on the lab's suggestion for a new sample. The resident was hospitalized with a urinary tract infection due to a clogged catheter.
A resident admitted with a knee replacement did not receive prescribed pain medication due to delays in processing orders and lack of communication. The resident reported a pain level of 6, but the medication was not available, and the emergency backup supply was not utilized. Staff interviews revealed a lack of awareness and action, leading to inadequate pain management.
A resident admitted with a knee replacement did not receive prescribed Oxycodone/Acetaminophen for pain management due to unavailability. The admitting nurse faxed the prescription to the pharmacy but did not receive the medication. The resident was given Acetaminophen instead, and the nurse lacked access to emergency backup medications. The DON and Administrator were not informed, and the prescribed pain management was not provided, resulting in a deficiency.
Failure to Maintain Required Dishwashing Temperatures and Communication Breakdowns
Penalty
Summary
The facility failed to ensure its low-temperature dishwasher maintained the required wash temperature of 120°F, as observed during a kitchen tour when three checks of the dish machine showed water temperatures ranging from 90°F to 100°F. During this time, dietary staff continued to send dishware through the machine despite the substandard temperatures. The dietary staff member operating the machine was unsure whether it was a high- or low-temperature unit and relied on the manufacturer’s instructions posted on the machine, which specified a 120°F wash temperature and 50 ppm chlorine during the rinse cycle. He reported that the machine’s water temperature had been fluctuating for approximately one week and stated he had informed the Dietary Manager when the temperature decreased, but he did not explain why he continued to wash dishware in the malfunctioning machine. The Dietary Manager stated in an interview that the dishwasher was a high-temperature machine and acknowledged awareness of the fluctuating water temperatures, claiming to have submitted an electronic work order to maintenance, though she did not provide a copy when requested. A Regional Food Service Consultant later confirmed that the dishwasher was in fact a low-temperature machine and reported she had not been aware that it was not operating correctly. The Maintenance Director stated he first learned of the temperature issue after the initial kitchen tour and reported that he had not received any verbal or electronic work order from dietary. Upon inspection, he found that hot water was not reaching the dish machine, and both hot water tanks were subsequently replaced. These events demonstrate that the dishwashing process did not meet required temperature standards for proper operation over at least several days prior to the surveyors’ observation.
Improper Trash Disposal and Unsanitary Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of garbage and refuse in the dumpster area. On multiple observations, a large, open-to-air construction-type container was found overflowing with bags of trash, with additional bags on the ground next to the building. There was no covering or tarp over this container or the trash bags. Over several days of observation, the condition of this construction-type container did not change, and it continued to be used as an uncovered trash receptacle. In addition, two trash dumpsters located in a gated, fenced area at the back of the parking lot were found with their side doors open and trash visible inside. The surrounding area was littered with cardboard pieces, used plastic gloves, plastic cup lids, paper, an office chair lying on its side, and an upside-down large planter on the ground. A pungent odor was noted within the gated dumpster area. Staff interviews revealed that the dumpsters were shared with a neighboring facility, and the Dietary Manager was unsure who was responsible for keeping the dumpster doors closed and the enclosed area clean. The report states these practices had the potential to attract pests and rodents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required by its own policy, which had the potential to affect all 87 residents. The written policy, effective 12/2025, stated that the Antibiotic Stewardship Program was intended to optimize the infection prevention program by guiding treatment of infections and reducing adverse events associated with antibiotic use. The policy specified that the Infection Preventionist would use expertise and data to track antibiotic starts, monitor adherence to evidence-based criteria for evaluation and management of infections, and review antibiotic resistance patterns in the facility. Pharmacy services produced antibiotic use tracking sheets showing that 25 residents were on antibiotics in November 2025, 37 in December 2025, and 40 in January 2026, but there was no evidence that these data were being used within a functioning stewardship program. During interviews, the current DON, who had been in the role since the end of December 2025 and was responsible for the Infection Prevention and Control program, stated she was in the process of getting the Antibiotic Stewardship Program in place but was unable to locate any information from prior months. When asked about monitoring and tracking infections, she reported she could not find any information for the prior months. The previous DON, who served from 9/2025 to 12/2025, confirmed by telephone that she did not have an antibiotic stewardship program in place and that no one had provided her with guidance or instructions. The Administrator stated she expected the antibiotic stewardship program to be in place per protocol and reported that infections were discussed during QAPI meetings, but there was no indication that a formal antibiotic stewardship program, as described in the facility policy, had been implemented.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop baseline care plans within 48 hours of admission for multiple residents. For nine of thirty sampled residents, there was no documented evidence that a baseline care plan had been completed, despite diagnoses and conditions that required coordinated care. These residents included individuals with paraplegia and neuromuscular bladder dysfunction, closed fracture, dementia, type 2 diabetes, hypothyroidism, hypertension, dementia with a history of falls, protein calorie malnutrition, chronic wounds, acute on chronic systolic congestive heart failure, acute respiratory failure, displaced femur fracture, chronic obstructive pulmonary disease (COPD), influenza, pneumonia, fractures of the hand and pelvis, diabetes, chronic pain syndrome, and other serious conditions. In each case, record review showed that the baseline care plan was either missing or had not been developed by the time of the surveyor’s review. Staff interviews revealed a lack of awareness and inconsistent understanding of responsibility for completing baseline care plans. Unit managers repeatedly stated they were not aware that baseline care plans had not been completed for specific residents and confirmed, after attempting to locate them, that they did not exist. The DON consistently stated that the admitting nurse was responsible for completing the baseline care plan, with the expectation that if the admitting nurse did not complete it, the oncoming nurse or unit manager would do so within the required timeframe. However, the DON also acknowledged not knowing why the baseline care plans had not been completed for several residents. In some interviews, unit managers stated that the baseline care plan was part of the admission process and should be completed at the time of admission, while in other interviews, staff indicated that the baseline care plan was not included in the list of required admission assessments. Additional interviews highlighted confusion and lack of training among nursing staff regarding who was responsible for baseline care plan completion. One nurse who admitted a resident with influenza, pneumonia, and COPD stated that the baseline care plan was not on the list of assessments to be completed for new admissions and believed the unit manager would complete it, even though she was aware of the 48-hour requirement. Another nurse assigned to a resident with multiple pelvic fractures and COPD did not complete the baseline care plan, believing the unit manager was responsible. The unit manager who assisted with that admission stated she did not complete the baseline care plan because she had not yet been trained and thought the admission nurse was responsible. Administrators interviewed were not aware that baseline care plans had not been completed for the affected residents, though they stated they expected baseline care plans to be completed within the regulatory timeframe. Across all nine residents cited, the common factors leading to the deficiency were the absence of completed baseline care plans in the medical records within 48 hours of admission and inconsistent or incorrect assumptions among staff about who was responsible for completing them. The surveyors’ findings were based on record reviews that failed to show any baseline care plans and on staff interviews that confirmed the plans had not been developed, despite staff acknowledging that such plans should be completed within 24–48 hours of admission to address residents’ immediate needs.
Failure to Document Flu and Pneumonia Vaccine Consents, Declinations, and Education
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of influenza and pneumococcal vaccination consents or declinations, as well as failure to document education on the benefits and potential side effects of these vaccines, for all five residents reviewed. For a cognitively intact resident admitted on a specified date, the MDS showed she was not offered the influenza vaccine and had declined the pneumococcal vaccine, but her medical record did not contain the date of declination, any documentation of an influenza vaccine for the current season, or any record that the vaccines were offered, accepted, or declined, or that education was provided. During interview, this resident could not recall whether she had been offered either vaccine, and the facility could not produce supporting documentation. For a severely cognitively impaired resident, the MDS indicated the resident was not offered influenza or pneumococcal vaccines, while the medical record stated the resident declined both vaccines without including dates of declination. The facility was unable to provide documentation that either vaccine was offered, that the resident or responsible party had the opportunity to accept or decline, or that education on benefits and potential side effects was provided. Another severely cognitively impaired resident had no documentation in the medical record for either influenza or pneumococcal vaccination, and the MDS also indicated the resident was not offered these vaccines. The facility again could not provide evidence that the vaccines were offered, that a decision was made by the resident or responsible party, or that any vaccine education occurred. A further severely cognitively impaired resident had documentation that a pneumococcal vaccine and a prior season influenza vaccine were administered outside the facility, but there was no documentation of an influenza vaccine for the current season. The MDS indicated this resident was not offered the influenza vaccine, and the facility could not provide documentation that the current season influenza vaccine was offered, that the resident or responsible party had the opportunity to accept or decline, or that education was provided. Another resident with moderate cognitive impairment had no documentation in the medical record for either influenza or pneumococcal vaccines, and the MDS indicated these vaccines were not offered. Interviews with the current DON, the previous DON, and the Administrator revealed that the current DON had not yet started gathering immunization information, the previous DON had not received guidance on resident immunizations and did not know if they were being done, and the Administrator was unaware that immunizations had not been completed or offered, despite expecting that residents would receive education and consent per protocol.
Failure to Inform Resident of Treatment Rights and Advance Directive Options
Penalty
Summary
The facility failed to inform and provide written information to a cognitively intact resident regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. The resident was admitted on a specified date, and the nursing admission assessment documented that the resident was cognitively intact. However, there was no documentation in the medical record that the resident had been informed of the right to accept or decline medical or surgical treatment prior to making an advance directive decision, nor was there any advance directive or code status documented. During interview, the resident reported not receiving any paperwork or education on advance directives and stated a desire to be resuscitated if the heart stopped. Staff interviews confirmed the lack of required information and documentation. The Social Worker acknowledged that the facility had not informed the resident of the right to accept or decline treatment or to formulate an advance directive and explained that her practice was to provide advance directive information only if residents requested it. A nurse verified there was no code status order in the physician orders or in the code status book and was unsure why an order was missing. The DON stated she expected the admitting nurse to obtain code status and a physician order, and the Social Worker to provide advance directive education, while the Administrator stated an expectation that staff explain advance directive choices and that a code status order be in place, but was unaware that written documentation needed to be provided or who was responsible for providing it.
Failure to Provide Required SNF-ABN Notice for Ending Medicare Part A Coverage
Penalty
Summary
The facility failed to provide the required CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 to residents whose Medicare Part A skilled services were ending while they remained in the facility. For one resident admitted to Medicare Part A skilled services on 11/6/25, Part A coverage ended on 11/28/25, but record review showed no documentation that the resident or responsible party received the SNF-ABN prior to discharge from Part A services. Instead, the Social Worker reported that on 11/26/25 she issued an Advance Beneficiary Notice of Non-Coverage form intended for Medicare Part B items and services, meaning the resident did not receive the correct Part A liability notice required by CMS. A second resident was admitted to Medicare Part A skilled services on 11/28/25, with Part A coverage ending on 12/17/25, and this resident also remained in the facility after skilled services ended. Record review again showed no documentation that the resident or responsible party received the SNF-ABN form 10555 prior to discharge from Part A services. The Social Worker stated it was her responsibility to issue the SNF-ABN and acknowledged that on 12/15/25 she provided the same incorrect Advance Beneficiary Notice of Non-Coverage form used for Medicare Part B instead of the required SNF-ABN. In an interview, the Administrator stated she was not aware that the Social Worker had been using the wrong form and confirmed that both residents should have received the CMS SNF-ABN form 10555 as required by federal guidelines.
Failure to Develop Comprehensive Care Plans for ADLs, Activities, and Discharge Goals
Penalty
Summary
Surveyors found that the facility failed to develop comprehensive care plans for activities of daily living (ADLs) and activities for one resident, and for discharge planning for another resident. One resident with neurocognitive disorder with Lewy bodies and muscle weakness had a significant change MDS assessment indicating cognitive impairment and dependence on staff for personal hygiene, bathing, and toileting, and that it was somewhat important to participate in group activities. However, review of the comprehensive care plan showed no care plan for ADLs or activities. The MDS Coordinator stated that the resident was dependent on staff for ADLs per the MDS but was not care planned because the care area did not trigger on the MDS. The Assistant Activities Director, who completed the significant change MDS and coded the resident as finding group activities somewhat important, acknowledged that she did not create an activities care plan because she had not yet been trained on how to complete a care plan and agreed one should have been developed. The Administrator confirmed that care plans for ADLs and activities should have been developed and was unsure why these areas were omitted. For another resident admitted with polyarthritis and metabolic encephalopathy who later discharged home, the admission MDS showed the resident was cognitively intact, participated in discharge planning, and had a goal to return to the community. Despite this, the comprehensive care plan contained no goals or interventions related to discharge planning. The Social Worker, who reported being responsible for discharge planning and related care plans, stated she was aware of the resident's goal to return to the community but had not developed a discharge care plan and characterized this as an oversight. The DON and Administrator both indicated that the Social Worker should have created a discharge care plan and also described the omission as an oversight.
Failure to Provide Ordered Catheter Care, Output Monitoring, and Timely Urine Testing
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered catheter care, monitoring, and timely diagnostic testing for a resident with complex urologic conditions. The resident had spina bifida with hydrocephalus, paraplegia, neuromuscular dysfunction of the bladder, and a history of UTI, and was admitted with an indwelling urinary catheter related to neurogenic bladder. The care plan and physician orders required monitoring and documenting catheter output on day and night shifts, and monitoring for signs and symptoms of UTI. Review of the Treatment Administration Records showed multiple days across December, January, and February when catheter output was not documented on both day and night shifts. The resident reported that on some days the catheter bag was not emptied at all and that she had to ask staff to empty it. Staff interviews revealed that NAs sometimes emptied catheter bags and reported amounts to nurses, while a nurse and the PA both stated they had observed full catheter bags with urine backflow toward the resident. The facility also failed to provide appropriate catheter hygiene and perineal care as ordered. A physician order directed cleansing with soap and water every day and night shift. During an observation, dry brown stool was seen on the resident’s lower buttocks and on the urinary catheter from the meatus to the middle of the catheter. An NA was observed applying an adult brief over the area without cleaning the stool from the catheter. In a subsequent interview, the NA acknowledged that the stool had been present before she applied the brief and stated it should have been removed before the brief was applied, noting that the resident was not on her assignment. The PA stated that if stool remained on a urinary catheter and was not cleaned properly, it could cause a UTI. The DON and ADON both stated they would expect catheter care to be provided when needed, regardless of staff assignment. Additionally, the facility failed to obtain ordered urine analysis and culture and sensitivity specimens within the ordered timeframe. A physician ordered a UA and C&S once daily for three days, but the TAR showed no documentation that these specimens were obtained on the ordered dates. A later UA and C&S obtained on a subsequent date showed the resident was positive for E. coli. The PA reported there had been ongoing issues with specimens not being obtained, requiring him to reorder UAs multiple times and sometimes change antibiotics after results were finally received. Nursing leadership stated they expected licensed staff to collect specimens when ordered and to notify the provider if a specimen could not be obtained, and the Administrator stated that if a specimen could not be obtained, the PA should be called and the specimen should be obtained within 24 hours.
Loose, Unlabeled Medications Found in Two Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications when multiple loose, unlabeled pills were found in two of four medication carts observed on Hall 300. During an observation of Medication Cart #2 with a nurse present, surveyors noted several loose tablets of various shapes, sizes, and colors in multiple drawers of the cart, including pink, yellow, brown, white, and orange tablets, some marked and some unmarked. These pills were not in original packaging and lacked required identifying information such as the resident’s name or prescribing information. When questioned, the nurse confirmed the presence of the loose tablets and was unable to explain why medications were stored without the minimum required labeling information. A similar observation of Medication Cart #1 on the same hall, conducted with a medication aide present, revealed additional loose, unlabeled tablets and a capsule of various colors and sizes in several drawers of that cart. The medication aide confirmed the presence of these loose medications and likewise could not explain why they were stored without required identifying information. In subsequent interviews, the Unit Manager stated that staff were expected to audit medication carts during shift change and report any loose medications, but could not explain why loose pills were present in both carts. The DON reported that medication carts were audited by Unit Managers and the pharmacist and stated that all loose pills should be disposed of, but was also unable to explain why loose tablets were found in the two medication carts during the survey.
Delayed Call-Light Response and Disrespectful Communication Undermine Resident Dignity
Penalty
Summary
The facility failed to honor a resident's right to be treated with dignity and respect when staff delayed responding to her call light and told her not to call for help. The resident, who had been admitted with fractures of the left hand and left radius, muscle weakness, and anxiety, was cognitively intact and required staff assistance with toileting, bed mobility, and transfers, and used a wheelchair for mobility. According to a grievance initiated by the Social Worker, the resident reported that CNAs were not changing her in a timely manner and that night-shift aides were not coming in promptly; when they did respond, they told her not to ring out. In an interview, the resident stated that nursing assistants made her wait over 30 minutes for incontinence care after she used her call light and told her not to call for help, which made her upset and mad. She could not recall the exact date of the incident but confirmed that a grievance had been submitted. The DON and Administrator later indicated that their investigation showed that two nurse aides assigned to the resident’s hall during the night shift were delayed in providing care and admitted to telling the resident not to call out for assistance, stating they did so in a joking manner. The DON acknowledged that these staff did not treat the resident with respect.
Failure to Provide Dependent Residents with Nail and Facial Hair Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically nail care and facial hair care, to dependent residents. One resident with non-Alzheimer’s dementia, moderate cognitive impairment, and dependence for bathing, dressing, and personal care had a care plan identifying a self-care deficit and the need for assistance with clean and trimmed nails. On observation, this resident’s ten fingernails were approximately half an inch long, jagged, and had brown debris underneath. The resident expressed a desire for nail care and held up her hands. The assigned nurse aide acknowledged the nails were long and stated she would provide care, but a subsequent observation days later showed the nails remained untrimmed with debris still present, and the resident again held up her hands while the assigned aide admitted nail care had not been offered that morning. Another resident with a history of stroke, severely impaired cognition, a right-hand contracture, and dependence for all ADLs had care plans and physician/psychiatry notes indicating stability, no reported refusals, and a need for assistance with bathing, dressing, and nail care on bath days. Facial hair care was not addressed in the care plan. On observation, this resident had mild body odor, long facial hair on the upper lip, chin, and lower cheeks, and long nails, including a right thumb nail about an inch long and jagged. The resident indicated wanting a shave. The assigned nurse aide reported not having offered nail care during the bath and stated she would provide nail and facial hair care, but a later observation showed the resident’s nails and facial hair unchanged. A family member visiting at the time confirmed the facial hair was the longest he had seen, described the resident as looking ragged and needing a shave, and noted dirty nails needing trimming, particularly the sharp right thumb nail, and stated he had not been informed of any refusals of care.
Failure to Consistently Provide and Document Ordered Stage 4 Pressure Ulcer Treatments
Penalty
Summary
Failure to provide ordered pressure ulcer care occurred when nursing staff did not consistently complete or document prescribed sacral wound treatments for a resident with a stage 4 pressure ulcer. The resident, who had spina bifida with hydrocephalus, paraplegia, and impaired mobility, was care planned for a stage 4 sacral pressure ulcer with goals for healing and prevention of infection. Physician orders included Dakin’s solution dressings and later collagen powder with Dakin’s-moistened rolled gauze packing and a silicone super absorbent dressing, to be applied daily and as needed. The Treatment Administration Records (TARs) for December, January, and February showed multiple dates on which these treatments were not documented as administered. Record review identified missing treatment documentation on several specific dates in December, January, and February. Nurses assigned to provide the wound care on some of those dates, including Nurse #4 and Nurse #1, were unable to explain why the treatments were not completed, with Nurse #1 acknowledging that on weekends she could not always administer treatments and would simply not sign the TAR. The wound care nurse reported that the resident had voiced concerns that wound treatments were not being done on some weekends and confirmed that, although she had provided wound care on certain dates, those treatments were not signed off on the TAR. Attempts to interview another nurse responsible for a missed treatment date were unsuccessful. The resident, who was cognitively intact and dependent on staff for toileting, personal hygiene, and rolling, reported that wound treatments were sometimes not administered on weekends and specifically identified a recent date when treatment was not done. Nurse aides stated that when residents asked about wound care, they would notify the nurse and then inform the resident that the nurse was aware. Wound progress notes documented that the stage 4 sacral ulcer initially showed granulation tissue and later periods of deterioration with increased undermining. The physician assistant and wound nurse practitioner both stated that wound treatments are ordered for a reason and that failure to provide dressing changes as ordered could cause the wound to not progress or worsen. The DON and Administrator were not aware that wound treatments were not being administered on some weekend days and stated their expectation that treatments be provided according to physician orders.
Failure to Timely Obtain Ordered C. diff Stool Testing
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely ordered Clostridium difficile (C. diff) stool test for a resident with a history of C. diff infection who was experiencing abdominal tenderness and loose stools. The resident was admitted from a hospital with multiple diagnoses including declining functional status, pulmonary embolism, prior vaginal and rectal bleeding secondary to anticoagulant use, past C. diff infection, right hip osteoarthritis, depression, anxiety, obstructive sleep apnea, and generalized weakness. On 12/29/25, a provider documented abdominal tenderness on exam and ordered stool testing for C. diff. Bowel and bladder records showed a loose stool on 12/31/25, but there was no documented collection or result of a C. diff stool test following this order. In early January, the resident continued to have loose stools. A 1/2/26 provider note referenced multiple recent loose stools and indicated that the resident’s abdominal pain had resolved, with notation that stool testing for C. diff was still pending. Bowel and bladder records documented loose stools on 1/4/26 and 1/6/26, on days when Nurse #4 was assigned to the resident; however, Nurse #4 later reported being unable to recall the resident or why a stool sample was not collected on those dates. Laboratory records from 12/31/25 through 1/7/26 showed no C. diff stool result. A second order for C. diff stool testing was placed on 1/7/26, but again, no stool result was documented between 1/7/26 and 1/14/26. A third order for C. diff stool testing was placed on 1/11/26. On 1/8/26, the provider documented occasional loose stools, a history of diarrhea controlled with loperamide, and noted that the ordered C. diff stool had not yet been collected, despite having spoken with nursing staff and verbally requested collection. On 1/15/26, the provider documented that the resident appeared uncomfortable, reported stomach pain prior to bowel movements that was sometimes relieved afterward, and continued to have loose stools, with physical exam showing dull, nonspecific abdominal tenderness and active bowel sounds. The stool specimen was finally collected on 1/15/26, and on 1/16/26 the result was positive for C. diff. Interviews with nursing staff, the Physician Assistant, the DON, the Regional Nurse Consultant, and the Administrator confirmed that the expectation was for stool samples ordered for C. diff testing to be collected as soon as possible, but in this case the ordered testing was not obtained until after multiple orders and ongoing loose stools.
Failure to Implement Enhanced Barrier Precautions for Resident With Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies for enhanced barrier precautions for a resident with a sacral wound. The facility’s policy, last revised in December 2025, required enhanced barrier precautions to prevent transmission of multidrug-resistant organisms. On two separate observations of the resident’s room and the hallway outside, there was no enhanced barrier precaution signage on the door and no PPE available outside the room, despite the resident having a sacral wound. During an observation of incontinence care, the nurse aide initially entered the room and began care wearing only gloves, without a gown, and turned the resident before the surveyor intervened upon noticing the sacral wound and foam dressing. After being stopped, the nurse aide removed her gloves, performed hand hygiene, exited the room, and then reentered wearing a surgical mask and gown and donned gloves before continuing care. In an interview, the nurse aide stated she would have donned PPE before providing care if enhanced barrier precaution signage had been posted, explaining she had been trained to put on PPE when a sign was present. The ADON confirmed that the resident had a wound, should have had an enhanced barrier precautions sign on the door, and that the nurse aide should have donned PPE prior to providing care. The Administrator also stated that her expectation was that residents requiring enhanced barrier precautions would have signage and accessible PPE prior to care.
Failure to Provide Accessible and Clearly Identified Survey Results
Penalty
Summary
The facility failed to make survey results readily accessible and known to residents and visitors. On one survey day, the survey results binder was observed in the lobby in an unlabeled binder placed about five feet off the ground in a wall-mounted wire rack, with no posting or indication of what it was or where survey results were located. This placement made it impossible for residents in wheelchairs to reach the binder without assistance. A facility-wide observation also revealed there was no posted notice anywhere in the building indicating the location of the survey results. Interviews with staff and residents showed a lack of awareness and education regarding survey results and their location. One receptionist, who worked weekdays, did not know where the survey results were, had not been educated about them, and only guessed that an unlabeled binder might contain them. Another receptionist, who worked afternoons and evenings, believed the survey results were in a drawer at the front desk and also reported no education on what they were or where they were kept. Multiple residents attending a Resident Council meeting stated they did not know what survey results were or where they were located, and the Activity Director acknowledged she had not reviewed this information during Resident Council meetings and was unsure of the exact location of the survey results. The Administrator reported knowing the binder was in the lobby near the front door but was unaware there was no posted notice, that the binder was not labeled, and that the receptionists had not been educated on the survey results’ location.
Resident Falls from Bed During Care, Sustains Head Injury
Penalty
Summary
The facility failed to provide care in a safe manner when a resident rolled off a bed raised to waist height, resulting in a laceration to the left side of her head that required five staples. The incident involved a resident with Alzheimer's dementia, osteoarthritis, and other conditions such as severe protein-calorie malnutrition and cognitive communication deficit. The resident was known to have repeated falls and required extensive assistance with bed mobility and other activities of daily living. Despite these needs, the care plan only included reporting falls to a physician and referring to physical therapy as needed. On the day of the incident, the resident became combative during incontinence care provided by a nursing assistant (NA). The NA, aware of the resident's behaviors during care, attempted to calm the resident by moving her hand off the resident, which led to the resident rolling off the bed and hitting her head on the wall. The bed was elevated to waist height, and the resident's behavior during care was known to include hitting and yelling. The nursing assistant did not maintain control of the resident during the care process, which contributed to the fall. Interviews with staff revealed that the resident was known to be calm when not touched and had behaviors related to her dementia. The staff, including the nurse assigned to the resident, acknowledged that the resident could not roll herself out of bed and that the accident could have been avoided by not letting go of the resident while on her side. The corporate nurse later suggested that the resident's pain might have contributed to her behavior during care, which was not initially considered by the facility's administration.
Failure to Resolve Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised during Resident Council Meetings over a period of five months. Concerns were consistently raised about coffee not being served before breakfast and clothes not being returned from the laundry. These issues were documented in the Resident Council Meeting Minutes for the months of May, June, July, August, and September 2024. However, the Resident Council Follow-Up forms attached to these minutes did not demonstrate any response or resolution from the facility regarding these grievances. Interviews with several residents during a Resident Council Meeting in November 2024 confirmed that the issues remained unresolved. The Activity Director, who assumed the role in May 2024, was unaware that grievances needed to be documented and resolved. She mentioned addressing concerns in meetings with department heads but lacked documentation to show resolution. The facility's Administrator was also unaware that grievances from Resident Council meetings were not being completed and resolved, although he expected concerns to be addressed and documented.
Failure to Document Monthly Weights as Ordered
Penalty
Summary
The facility failed to follow physician orders to obtain a monthly weight for a resident who was admitted with diagnoses including hypertension, depression, and fractures. The physician's order specified that the resident's weight should be monitored every Monday. However, the resident's quarterly Minimum Data Set (MDS) assessments left the weight section blank, and there was no assessment of weight loss or gain. A review of the resident's electronic weight record showed no monthly weights were documented from February 2024 through October 2024, except for a single weight recorded in October. Interviews with facility staff revealed a lack of awareness and a system to ensure weights were consistently documented. The Corporate Nurse Consultant acknowledged the absence of a system for obtaining weights, and the Director of Nursing was unaware that the weights were not being taken as ordered. The Medical Director confirmed that weights should be documented monthly as per the physician's order, and the Interim Administrator stated that any issues with obtaining weights should be reported to the clinician and physician. The deficiency was identified when the facility realized weights were not being obtained, prompting the documentation of weights in October.
Improper Discharge Due to Miscommunication
Penalty
Summary
The facility failed to allow a resident to remain in the facility and initiated her discharge after she returned later than expected from a leave of absence. The resident, who was cognitively intact and independent with activities of daily living, had been away from the facility for over 24 hours due to car trouble. Upon her return, she was informed by staff that she could not stay because her absence exceeded 24 hours, which allegedly ended her insurance coverage. The facility did not provide written documentation stating the reason they could not meet her needs, and no discharge planning or notice of transfer was issued. Interviews with facility staff revealed that the directive to discharge the resident came from the Regional Office Manager, despite the facility being able to meet her needs. The Interim Administrator later confirmed that the staff received incorrect guidance regarding the discharge and acknowledged that the resident should have been allowed to stay. Attempts to interview the resident, her physician, emergency contact, and the Regional Office Manager were unsuccessful.
Failure to Provide Safe and Orderly Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was reviewed for discharge. The resident, who was cognitively intact and independent with activities of daily living, signed out of the facility on a leave of absence with an expected return time. However, due to transportation issues, the resident was unable to return as planned and was informed upon arrival that she had been discharged and could not remain in the facility. The resident was not provided with discharge instructions or prescriptions, and the discharge location was not verified, leading her to seek medication refills at a hospital. The facility's social worker and office manager indicated that they were instructed by the regional office manager to discharge the resident due to her absence exceeding 24 hours, which allegedly ended her insurance coverage. The social worker did not conduct any discharge planning, believing the discharge was against medical advice. The resident explained her delay was due to car trouble and attempted to contact the facility without success. The facility's interim administrator later acknowledged that the internal staff received misdirection regarding the discharge, and the resident should have been allowed to remain in the facility.
Failure to Monitor Resident's Weight Consistently
Penalty
Summary
The facility failed to comprehensively assess a resident's weight as part of their nutritional monitoring. The resident, who was cognitively intact, had a physician's order for monthly weight monitoring, but the facility did not consistently record these weights from February 2024 through September 2024. The resident's quarterly Minimum Data Set (MDS) assessments left the weight section blank, and there was no assessment of weight loss or gain. The care plan indicated a goal for gradual weight loss and maintaining adequate nutritional status, but the interventions, including dietician evaluations, were not effectively implemented due to missing weight records. Interviews with facility staff revealed systemic issues in obtaining and documenting weights. The Corporate Nurse Consultant acknowledged the lack of a system for consistent weight monitoring, and the MDS Coordinator noted that the absence of documented weights affected the MDS assessments. The Dietician had not completed a dietary assessment since the resident's admission because the resident had not been flagged for weight loss, and the Director of Nursing was unaware of the failure to take monthly weights. This lack of coordination and oversight led to the deficiency in monitoring the resident's nutritional status.
Failure to Provide Restorative ROM and Splinting for Resident
Penalty
Summary
The facility failed to provide restorative range of motion and the application of splinting devices as recommended by the occupational therapist for a resident with limited range of motion. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, had impairments in the range of motion on one side of her body. The occupational therapy discharge summary recommended a restorative ROM program and the use of a T-splint for up to 6-7 hours a day to prevent further contracture. However, observations and interviews revealed that the resident did not receive follow-up exercises and was unable to apply the splints herself. During observations, the resident was seen without the recommended splinting devices, and interviews with staff indicated a lack of awareness and documentation regarding the application of these devices. The Regional Nurse Consultant confirmed the absence of a physician's order for the splinting devices and exercise program, which should have been completed based on the therapist's recommendations. The occupational therapist noted that if the resident remained in the facility, it was the nursing staff's responsibility to obtain the necessary physician's order and ensure the application of the splints and exercises.
Failure to Provide Adequate Dialysis Care
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident with end-stage renal disease who required dialysis services. The resident, who was admitted with a permacath for dialysis, did not have a physician's order for dialysis services documented in their medical record. Additionally, the resident's care plan lacked specific information regarding dialysis care, and there was no documentation of monitoring the resident's condition after dialysis treatments. Interviews with the resident and nursing staff revealed that vital signs were not taken when the resident returned from dialysis, and the permacath site was not checked for bleeding. The nursing staff was observed assisting the resident back to bed and restarting tube feeding without performing necessary post-dialysis assessments. The MDS nurse and Unit Manager confirmed the absence of a dialysis care plan and physician's order, indicating a lack of awareness and oversight in the facility's processes. The Director of Nursing and Medical Director acknowledged the facility's policies and procedures for dialysis care, which were not followed in this case. The admitting nurse was responsible for obtaining dialysis orders from the hospital discharge summary, and the MDS nurse was to create a care plan. However, these steps were not completed, resulting in inadequate monitoring and documentation of the resident's dialysis care.
Failure to Monitor Nurse Aide Registry Expirations
Penalty
Summary
The facility administration failed to maintain effective systems to monitor the expiration of nurse aide registry listings, resulting in a deficiency. Specifically, a nurse aide, identified as NA #4, continued to work at the facility for three days after her registry listing with the North Carolina Nurse Aide Registry had expired. NA #4 was responsible for various resident care tasks, including passing breakfast trays, providing bed baths, incontinence care, assisting with meals, and grooming. The lapse in monitoring allowed NA #4 to work on multiple days with an expired registry listing, as confirmed by the NC Nurse Aide Registry representative. Interviews with facility staff revealed that the previous Staff Development Coordinator (SDC) was responsible for verifying registry listings during pre-employment screening, but the position was currently vacant. The Director of Nursing (DON) and the Administrator acknowledged the absence of a tracking system to monitor registry expirations. The Administrator noted that a tickler file or tracking system should be in place to alert staff about upcoming expirations, and the DON should communicate with employees about their license status. However, due to the vacant SDC position, this function was not being effectively managed, leading to the oversight with NA #4's expired registry listing.
Failure to Provide Privacy for Residents
Penalty
Summary
The facility failed to provide personal privacy for two residents, leading to a deficiency in maintaining the dignity and confidentiality of their care. Resident #14, who was cognitively intact and dependent on toilet use, was observed without a privacy curtain in his room, allowing his catheter to be visible from the hallway. Despite expressing his desire for a privacy curtain to the nursing staff, none was provided since his admission. Staff interviews revealed that the absence of privacy curtains had been reported multiple times to the previous housekeeping director, but no action was taken. Additionally, Resident #14's catheter bag lacked a privacy cover, which was known to the staff but not addressed. Resident #55, who was severely cognitively impaired and incontinent, also lacked a privacy curtain in a shared room, compromising privacy during care. The absence of a curtain had persisted for two to three months, and staff had reported this issue to the previous housekeeping director without resolution. The new Director of Housekeeping and the Administrator were unaware of the missing curtains until the survey, indicating a lapse in communication and oversight. Both residents were left without adequate privacy, which was expected by the facility's administration.
Privacy Curtain Deficiency in Two Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains for two rooms on the 200-hall, affecting two residents. Resident #14, who was cognitively intact, did not have a privacy curtain since admission, which prevented him from having privacy from the hallway during care. Despite expressing his need for a curtain to the nursing staff, the issue remained unresolved. Nurse Aide #8 confirmed the absence of the curtain and reported the issue multiple times to the previous housekeeping director, but no action was taken. The housekeeping aide, who regularly worked on the 200 Hall, was unaware of the missing curtain and indicated that the prior housekeeping director was responsible for handling and hanging curtains. Resident #55, who was cognitively impaired, also lacked a privacy curtain for two to three months. Similar to Resident #14, Nurse Aide #8 reported the missing curtain to the previous housekeeping director without resolution. The housekeeping aide admitted to missing the absence of the curtain during routine checks. Interviews with the Administrator and the new Director of Housekeeping revealed that they were unaware of the missing curtains and expected all residents to have them. The new Director of Housekeeping had just started in the role, and the previous director was unavailable for comment.
Failure to Post Required Contact Information for State Agencies and Advocacy Groups
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the State Survey Agency, adult protective services, the Office of the State Long-Term Care Ombudsman program, and the protection and advocacy network. This deficiency was observed during a four-day onsite recertification survey. Observations conducted on multiple days revealed that there was no signage or posting in the facility's common areas, upper and lower nursing units that included the required contact information. During a walking tour of the facility with the Administrator, it was confirmed that the required postings were absent, except for the local Ombudsman posting. In an interview, the Administrator expressed uncertainty about why the postings were not in place and acknowledged their importance, indicating an oversight in maintaining compliance with posting requirements.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility failed to administer necessary medications to two residents, leading to significant medication errors. Resident #8, who was admitted with a diagnosis of malignant neoplasm to the brain resulting in seizures, did not receive her prescribed antiseizure medications, Lamotrigine and Levetiracetam, on the evening of her admission and the following morning. The medications were not delivered to the facility until the day after her admission. Nurse #1, who was responsible for Resident #8 during the night shift, did not call the pharmacy for a stat order or notify the Nurse Practitioner about the unavailability of the medications. The Director of Nursing (DON) confirmed that the medications should have been ordered stat to prevent missed doses. Resident #9, admitted with a left knee replacement, kidney disease, and heart disease, did not receive his prescribed pain medication, Oxycodone/Acetaminophen, upon admission. The medication was not available in the facility's emergency backup supply and was not delivered until the day after his admission. Nurse #7, who was on duty during Resident #9's admission, did not report the unavailability of the medication to the DON or order it stat from the pharmacy. The DON stated that the nurse should have checked the emergency backup and notified the physician if the medication was unavailable. Interviews with the facility's Administrator revealed that she was not informed about the medication issues for both residents. The Administrator acknowledged that the medications should have been ordered immediately upon admission to ensure timely delivery. The Pharmacist confirmed that the lack of antiseizure medication contributed to Resident #8 experiencing seizures, highlighting the critical nature of timely medication administration.
Failure to Report Urinary Catheter and Urinalysis Issues
Penalty
Summary
The facility failed to promptly report critical medical information regarding a resident's urinary catheter care and urinalysis results to the appropriate medical personnel. The resident, who was cognitively intact and had a urinary catheter due to conditions such as end-stage renal disease and neuropathic bladder, experienced issues with catheter flushing on a specific date. Despite the resident's report of abdominal pain and distention, and the failure of the catheter flush to return fluid, this information was not communicated to the Nurse Practitioner (NP) on the same day. Additionally, a urinalysis ordered due to discolored urine was not sent to the laboratory until three days later, and the results indicating a urinary infection were not reported to the NP until the resident was sent to the hospital several days after the test was conducted. Interviews with facility staff revealed a breakdown in communication and procedure adherence. Nurse #2, who was responsible for the resident during the day shift, did not report the catheter flushing issue or the delay in sending the urinalysis to the NP. Furthermore, the laboratory results were not followed up on or communicated to the NP in a timely manner, leading to a delay in addressing the resident's infection. The Director of Nursing and the Administrator were also not informed of these lapses, indicating a systemic issue in the facility's reporting and communication processes.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to Adult Protective Services within the required timeframe for a resident who was severely cognitively impaired and required total assistance with bed mobility and transfers. The resident, diagnosed with hemiplegia and epilepsy, was allegedly slapped in the face by a male nurse, as reported by a family member. The incident occurred on 7/25/2024 and was reported to the facility's Administrator on 7/26/2024. However, the Administrator did not notify Adult Protective Services until 8/1/2024, which was beyond the 24-hour reporting requirement stated in the facility's Abuse, Neglect and Exploitation Policy. The facility conducted an investigation, suspended the accused staff member, and notified the police, but ultimately unsubstantiated the allegation.
Delayed Urinalysis and Inadequate Catheter Care
Penalty
Summary
The facility failed to ensure timely and appropriate testing of a urinalysis with culture for a resident with a suprapubic catheter. The resident, who had a history of end-stage renal disease, neurogenic bladder, and Parkinson's disease, reported purple urine to a nurse practitioner on August 5, 2024. A urinalysis with culture was ordered to rule out infection. However, the sample was not sent to the laboratory on the same day as ordered, and the results were delayed until August 8, 2024. The laboratory indicated the sample was contaminated and suggested a new sample, but the facility did not follow through with this recommendation. The resident experienced symptoms such as lower abdominal pain and distention, which were reported by the resident and a family member. Despite these symptoms, the facility did not act promptly to address the potential blockage of the catheter or the possibility of infection. The resident was eventually sent to the hospital on August 12, 2024, after experiencing decreased urine output and pain. The hospital admission note confirmed a urinary tract infection due to a clogged catheter, and the resident was treated with intravenous antibiotics. Interviews with facility staff revealed a lack of communication and follow-up regarding the urinalysis with culture. Nurse #2 admitted to placing the urine sample in the refrigerator but failed to ensure it was picked up by the laboratory in a timely manner. The Director of Nursing and the Administrator were not aware of the delays in testing and reporting the results. The nurse practitioner was also not informed of the results until the resident was hospitalized, indicating a breakdown in the facility's processes for managing and communicating critical health information.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident who was admitted with a left knee replacement. The resident was supposed to receive Oxycodone/Acetaminophen for pain rated at 4 or more on a scale of 1 to 10. However, the medication was not available when the resident reported a pain level of 6. The resident's pain medication was delivered to the facility after a delay, and the emergency backup supply was not utilized in a timely manner. Nurse #6 admitted the resident and did not fax the admission orders to the pharmacy until later in the evening, resulting in the medication not being available when needed. The resident's pain was not adequately managed due to a series of communication and procedural failures. Nurse #7 documented the resident's pain but did not ensure the medication was administered. The Director of Nursing and the Administrator were not informed of the issue, and the necessary steps to obtain the medication from the emergency backup or through a stat order were not taken. Interviews with staff revealed a lack of awareness and action regarding the resident's pain management needs, contributing to the deficiency.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide pain medication as ordered for a resident who was admitted with a left knee replacement. The resident was prescribed Oxycodone/Acetaminophen for pain rated at 4 or more on a scale of 1 to 10. However, the medication was not available on the night of admission. Nurse #6, who admitted the resident, faxed the prescription to the pharmacy but did not receive the medication that night. Instead, the resident was given Acetaminophen per standing orders, and Nurse #6 did not have access to the electronic emergency backup medications. Nurse #7, who worked later, noted the unavailability of the pain medication but did not document notifying the Nurse Practitioner about the issue. The Director of Nursing (DON) #2 and the Administrator were not informed of the medication unavailability at the time. DON #2 stated that the emergency backup should have been checked, and if the medication was not available, the physician or nurse practitioner should have been contacted for an alternative. The Administrator confirmed that the pain medication should have been provided from the emergency backup supply, and a stat order should have been sent to the pharmacy if necessary. The failure to provide the prescribed pain medication was not addressed promptly, leading to a deficiency in pain management for the resident.
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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