Charlotte Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 1735 Toddville Road, Charlotte, North Carolina 28214
- CMS Provider Number
- 345405
- Inspections on file
- 27
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Charlotte Health & Rehabilitation Center during CMS and state inspections, most recent first.
A dependent, cognitively intact resident with hemiplegia, care planned for 2-person assistance with a mechanical lift for all transfers, fell and sustained a nondisplaced greater trochanteric femur fracture during an unsafe transfer. The resident was in a wheelchair on a urine-soaked lift pad when a NA, working alone, attempted to reposition the pad; the resident then slid to the floor. EMS and ED documentation, as well as the resident’s own account, indicated that the fall occurred while being lifted with a mechanical lift when a sling strap broke, while facility staff interviews described a slide from the wheelchair during pad repositioning. The DON later acknowledged that the NA should not have repositioned the sling without a second staff member, and the resident’s labeled lift pad involved in the incident was not subsequently located by staff.
Surveyors identified multiple failures in dietary services, including dirty and poorly maintained cooking equipment, standing water on damaged kitchen flooring, and improper food storage and labeling. Open food items in reach-in coolers and dry storage were not consistently labeled with use-by dates, and at least one item was stored past its documented use-by date. A foam cup was used as a scoop and left in direct contact with cornmeal, and dented canned goods were stored on a rotation rack for use. A steamer appliance was leaking water onto the floor from a misdirected pipe, creating a large puddle, but no electronic maintenance requests had been submitted, and facility leadership reported they were unaware of the issue despite verbal reports from dietary staff.
The facility failed to maintain an effective pest control program and sanitary conditions in the main kitchen and a nourishment room, as evidenced by long‑standing broken, loose, and missing floor tiles, poor drainage, dirty floor drains, and persistent standing water that created pest harborage sites. Monthly pest control reports over an extended period repeatedly documented these structural and sanitation issues and identified them as breeding sites for roaches and small black flies, yet no related work orders were entered into the electronic maintenance system. Surveyors observed small black flies in the kitchen and nourishment room, standing water under equipment and loose tiles, and a trash can with food debris that released numerous flies near a food preparation and handwashing area. The Pest Control Technician reported documenting these problems for about a year and a half, while the Maintenance Director stated he was unaware of the tile and water issues and had received no formal requests, and the Dietary Manager reported she had only communicated concerns via text messages rather than the maintenance request system.
The facility failed to submit a required 5‑day written investigation report to the State Survey Agency after an allegation that a resident, who was severely cognitively impaired and intermittently agitated, reported being beaten by a staff member. An initial allegation report was timely faxed, law enforcement was notified, and a head‑to‑toe assessment showed no injuries. Internally, the Administrator completed a written investigation summary within several days, including body audits and interviews on the hallway, but this document lacked identification of the reporting staff member and contained no witness statements. DHSR later notified the facility that the 5‑day report had not been received, and both the Administrator and DON acknowledged they had no record of faxing the 5‑day investigation and could not recall who initially reported the allegation, resulting in failure to comply with the facility’s own abuse reporting policy and state reporting requirements.
A resident with BPH, urinary obstruction requiring self-catheterization, homelessness, and cognitive impairment was discharged after skilled services ended without an effective discharge plan. The SW knew the resident was homeless and that returning to the community was not feasible, and the RR requested Medicaid assistance and long-term placement, but there was no follow-up on a Medicaid application, no confirmed housing, and no arranged home health despite therapy’s recommendation. The facility documented discharge to a homeless shelter without verifying shelter availability or obtaining an address, and discharge instructions incorrectly indicated no devices/treatments and no education or medical supplies were provided, even though the resident needed catheter supplies. The discharge was labeled AMA, an APS report was expected but never filed, and the RR reported she was not informed of appeal rights and received only medications and a medication list at discharge.
Surveyors found that MDS assessments were inaccurately coded for two residents, one with a documented Stage 4 pressure ulcer and another receiving daily insulin for type 2 DM with hyperglycemia. For the first resident, clinical records, care plans, wound care notes, physician orders, and the TAR all showed an ongoing Stage 4 coccyx pressure ulcer with daily treatment, but the quarterly MDS did not code any pressure ulcer diagnosis, unhealed ulcer, Stage 4 ulcer, or pressure ulcer care. For the second resident, admission orders, the MAR, and the care plan documented daily subcutaneous insulin glargine and management of diabetes, yet the admission MDS failed to code insulin injections or hypoglycemic medication use. The MDS Coordinator acknowledged that both residents’ MDS assessments were completed incorrectly and that these key clinical conditions and treatments were overlooked.
Surveyors found that one resident admitted with a history of BPH, urinary obstruction, and hospital orders to continue intermittent self-catheterization did not have self-catheterization orders entered into the EMR, was not care planned for intermittent catheterization, and did not receive catheter supplies from the facility despite documentation by the Medical Director that self-catheterization was required and repeated requests from the resident. The resident’s representative reported obtaining catheters from a urologist because the facility was not providing them. In a separate case, another resident with an indwelling urinary catheter and a care plan to prevent catheter-related complications was repeatedly observed in bed with the bedside drainage bag attached below bladder level but resting on the floor over multiple days, even though NAs, nurses, the IP, and a corporate nurse consultant all acknowledged that catheter drainage bags and valves should be kept off the floor to prevent contamination and UTI.
Staff failed to follow the facility’s Enhanced Barrier Precautions policy requiring gown and glove use during high-contact device care. One nurse performed gastric tube care for a resident on EBP wearing only gloves despite clear signage and available PPE, later stating she thought gowns were only needed for contact precautions. In a separate instance, a nurse aide provided trach care to another resident on EBP wearing gloves but no gown, acknowledging awareness of the requirement but citing the brief duration of the task. The Infection Preventionist reported that staff are trained on PPE use and that precaution signage and PPE availability are monitored, and the DON stated she expects staff to follow the posted PPE requirements.
A cognitively intact but severely physically impaired resident, fully incontinent of bowel and bladder and care planned for q2h incontinence rounding with assistance from two staff, was transferred to a wheelchair in the afternoon and not checked again for incontinence for approximately six hours. During this time, including through the evening meal, the resident’s brief, clothing, wheelchair seat, and lift pad became saturated with urine, which was discovered only after the resident eventually called out for help. The assigned NA acknowledged not performing routine incontinence checks because she believed the resident could request assistance, while another NA and nursing staff confirmed the resident’s dependence on staff for incontinence care and that facility expectations required q2h incontinence care to maintain dignity and comfort.
A resident with chronic pain, mobility impairment, and an order for Tramadol had been reporting increased left hip pain to PT, but on the day of discharge nursing documentation reflected a pain score of 0 and no pain medication given. During a mechanical-lift transfer from bed to wheelchair for transport to another SNF, the resident yelled out that the left leg was hurting; the NA performing the transfer focused on quickly lowering the resident into the wheelchair and did not notify the nurse or anyone else of this pain complaint. The resident was then transported by a driver who, per video review, did not remove the resident from the wheelchair and reported no pain complaints. After arrival at the receiving SNF, the resident complained of pain and was sent to the hospital, where imaging showed an acute impacted left femoral neck fracture. The deficiency involves the NA’s failure to report the resident’s pain during transfer, which resulted in no nursing assessment or communication of pain concerns at discharge.
Two residents were affected by environmental deficiencies when one resident’s room and bathroom were not adequately cleaned and had plaster debris on the floor and baseboards pulling away from the wall, while another resident’s room had a window screen with a large vertical tear that went unreported and unrepaired. Despite routine housekeeping and maintenance expectations, debris under a bed remained over multiple days, baseboards stayed in disrepair, and the torn window screen persisted without a work order, indicating that staff did not identify or report these issues through the facility’s maintenance process.
A facility failed to provide a resident with necessary durable medical equipment upon discharge, including a hospital bed and oxygen supplies, due to inadequate discharge planning and communication. The resident, with conditions such as GERD and sleep apnea, did not receive the required equipment, leading to health complications. The discharge summary omitted the need for oxygen, and the DME company did not receive proper documentation to fulfill the order.
A resident with severe cognitive impairment was subjected to inappropriate touching by another resident, who had a history of such behaviors. Despite previous recommendations for increased supervision, the facility staff were unaware of the perpetrator's past behaviors until after the incident. The victim was found with disheveled clothing and exposed, leading to a hospital evaluation. This highlights a deficiency in the facility's ability to protect residents from abuse.
A facility failed to provide a complete transfer/discharge notice, omitting the appeal rights page for a resident discharged to a hospital due to inappropriate behaviors. The notice incorrectly listed a local adult care home as the discharge location and lacked the necessary Nursing Home Hearing Request form. The Ombudsman identified the omission, but the notice was not reissued, and the adult care home had no record of the resident.
A facility failed to readmit a resident after hospitalization, citing inappropriate sexual behavior as the reason. The resident, who was cognitively intact and had hemiplegia and hypertension, was sent to the hospital for evaluation. Despite the hospital's case management contacting the facility for readmission, the facility refused, based on the Psychiatric Nurse Practitioner's assessment. The resident's representative was informed of a 30-day discharge notice but could not secure placement elsewhere.
A resident with COPD and respiratory failure showed signs of distress, including restlessness and difficulty breathing, but the facility failed to notify the on-call provider. Despite multiple reports from nurse aides, the nurses did not take appropriate action, and one nurse administered Ativan, a medication the resident was allergic to. The resident was later found unresponsive and pronounced deceased after EMS arrived.
A resident experienced a significant change in condition, including difficulty breathing, which was not promptly addressed by the facility. Additionally, a medication error occurred when Ativan was administered despite a documented allergy, leading to the resident being found unresponsive and later pronounced deceased. The facility failed to consult medical staff or perform thorough assessments, resulting in neglect.
A resident with COPD and respiratory failure experienced a significant change in condition, expressing difficulty breathing and showing signs of distress. Despite these symptoms, the nursing staff failed to conduct thorough assessments or notify a physician. The resident was administered Ativan, despite a documented allergy, leading to her death. The staff bypassed allergy alerts and did not verify her allergy status, contributing to the incident.
A facility failed to provide effective training and orientation for new hires, resulting in a fatal medication error. A resident with a documented allergy to Ativan was administered the medication by a nurse under the direction of an inadequately trained Unit Manager. The resident was found unresponsive and later pronounced deceased. The facility's lack of proper training and oversight put all residents at risk for serious adverse outcomes.
A resident with COPD and respiratory failure was administered Ativan despite a documented allergy, resulting in their death. The error occurred when a nurse bypassed an allergy alert in the electronic health record, and the medication was administered by another nurse without verifying allergies. The resident became unresponsive and was pronounced deceased by EMS.
A resident in a LTC facility, who was cognitively intact and required extensive assistance with toileting, reported feeling disrespected after a NA ignored her request for incontinence care and left her in a soiled brief. The NA displayed negative body language and did not provide care when the resident activated the call light. The resident remained in a soiled brief until another NA and a nurse provided care over an hour later, finding the resident's clothing soaked with urine.
A resident with chronic conditions did not receive meals as per the planned menu, with missing items like protein sources. Staff interviews revealed inconsistent food deliveries and budget-related order changes. The Dietary Manager made substitutions without updating meal tickets, and residents were not informed of changes unless they checked the menu outside the dining room.
The facility was found deficient in food storage and handling practices, with several food items in the reach-in coolers and walk-in freezer not labeled with use-by dates, and some stored past their best-by dates. Additionally, 51 serving trays were wet-nested due to limited space. The Dietary Manager was unaware of these issues, and the Administrator expected adherence to policies.
The facility failed to maintain the food steamer in the kitchen, resulting in a water leak onto the floor. Despite multiple verbal reports from kitchen staff to Maintenance, the issue persisted. The Dietary Manager, Maintenance Assistant, and Administrator were unaware of the problem, highlighting a breakdown in communication and maintenance procedures.
A resident with severe cognitive impairment did not receive full visual privacy during tracheostomy care as two nurses left the door open to the hallway. The room lacked a privacy curtain, allowing the hallway to be visible from the bedside. Both nurses admitted to forgetting to close the door, and the DON and Administrator confirmed the expectation for doors to be closed during care.
A facility failed to accurately code the MDS for a resident with respiratory needs. The resident, admitted with respiratory failure and a tracheostomy, was noted in the MDS as receiving invasive mechanical ventilation, but the care plan and physician orders did not reflect this. An observation confirmed the absence of invasive mechanical ventilation, and a nurse confirmed the resident was weaned off it before admission.
A nurse failed to use sterile gloves during tracheostomy care for a resident, and the facility lacked physician orders for the resident's continuous oxygen use. The nurse did not follow proper hand hygiene and glove protocols, and the resident was observed receiving oxygen without corresponding orders. The Director of Nursing and Administrator acknowledged the oversight in reviewing new admission orders.
The facility failed to properly dispose of garbage and refuse around two outdoor trash receptacles behind the kitchen. Observations revealed loose garbage, including used gloves and a sandwich bag with food debris, scattered on the ground. An open garbage bag with debris and spaghetti noodles was found on the sidewalk, and one trash receptacle had its door open with the lid caved in. The Maintenance Assistant stated that housekeeping and maintenance were responsible for cleaning the area each morning, and the Administrator expected adherence to facility policies.
Failure to Provide Safe Mechanical-Lift Transfer and Supervision Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe transfer and adequate supervision for a dependent resident who required a mechanical lift for all transfers. The resident had a history of cerebral infarction with left hemiplegia and hemiparesis, was cognitively intact, used a manual wheelchair, and was care planned as dependent on staff with a requirement for 2-person assistance and a mechanical lift for all transfers. On the evening of the incident, the resident was in a wheelchair with a lift pad underneath and was incontinent of urine, leaving both the pad and pants soaked. Nurse Aide (NA) #1 reported that she was repositioning the lift pad while standing beside the wheelchair when the resident and the pad slid from the wheelchair to the floor. Nurse #1, who was down the hall administering medications, heard the resident yelling for help and found the resident on the floor in front of the wheelchair with NA #1 present. Nurse #1 observed that the lift pad remained in the wheelchair and was soaked with urine, and the resident complained of severe left hip pain and had an abrasion on the left lower leg. Unsure if it was safe to use the mechanical lift to move the resident from the floor to the bed, Nurse #1 and three staff members manually lifted the resident into bed. Pain medication was administered but was ineffective, and the on-call provider was notified, after which the resident was sent to the ED for further evaluation. There were conflicting accounts regarding how the fall occurred. NA #1 stated that the lift pad was not yet attached to the mechanical lift and that the lift itself was in the doorway, while she repositioned the pad under the resident in the wheelchair. She denied that a lift strap broke and stated she typically hooked the sling to the lift before obtaining a second staff member when performing mechanical lift transfers. The EMS prehospital report, however, documented that facility staff reported a witnessed fall from a mechanical lift when a strap on the lift pad broke, and the resident confirmed to EMS that he fell from the lift, striking his head on the lift mast and his left leg on the bed before landing on the floor. ED records also documented that the resident was being transferred with a mechanical lift when a strap on the lift pad broke, resulting in a fall of approximately two feet and a nondisplaced greater trochanteric fracture of the left femur. In a subsequent interview, the resident stated that after calling for assistance with incontinence care, NA #1 was lifting him from the wheelchair with the mechanical lift when he heard fabric ripping and the left front strap of the lift pad broke, causing him to fall about two feet to the floor, hitting his head on the lift and his left leg on the bed before landing on his left side. He reported severe hip and tailbone pain following the fall. The resident also stated that the lift pad that broke was labeled with his name in black marker and that he had not seen it since the incident. Other staff, including another NA and the laundry aide, confirmed that the resident had a lift pad labeled with his name but reported they had not seen it in the room or laundry that week. The DON later stated that NA #1 should not have attempted to reposition the lift sling under the resident without a second person present to ensure safety, and the Administrator acknowledged that NA #1 was attempting to reposition the soaked lift pad when the resident slid from the wheelchair to the floor.
Food Storage, Sanitation, and Maintenance Failures in Dietary Services
Penalty
Summary
The deficiency involves failure to procure, store, prepare, and maintain food and kitchen areas according to professional standards. During an initial kitchen tour, surveyors observed visible dirt and grime buildup on a wall-mounted knife holder containing seven knives, black buildup and food particles on the cooking range, and a large white stain extending from the gas stove onto the adjacent floor. Black buildup was also present on oven door seals and window areas. Broken and missing floor tiles were noted under the right side of the oven and near the floor drain under the steamer, with the missing areas filled with standing water. A foam drinking cup was being used as a scoop and was left in direct contact with cornmeal in a bin. In reach-in coolers, multiple open food items were not labeled with use-by dates, including cans of whipped cream and a bag of provolone cheese, and one container of olives was open, dated, and stored past its use-by date. In the dry storage area, open and resealed items such as a bag of dry yellow cake mix and a bag of crisped rice cereal were not labeled with use-by dates, and other open items, including cocoa powder and strawberry gelatin, lacked any open or use-by dates. On a subsequent kitchen tour, surveyors again observed the previously identified concerns and additionally found two large cans of sliced beets with significant dents along the rims stored on a rotation rack for use. The Dietary Manager reported she had been in her role for about four months and stated that kitchen staff were not consistently following procedures for labeling perishable foods with use-by dates. She also indicated that the main cook, who typically oversaw kitchen cleaning, was on medical leave and that cleaning responsibilities had been assumed by other staff, resulting in cleaning tasks falling behind. Separate observations showed a large puddle of water under a food steamer, with water dripping and later pouring from a plastic pipe on the back of the appliance that was not positioned over the floor drain, causing water to accumulate on the kitchen floor. The Dietary Manager stated she had verbally reported the leaking steamer to Maintenance multiple times, but a review of the electronic maintenance request system showed no work orders for the kitchen area, and the Maintenance Director and Administrator both reported they were not aware of the leak and expected staff to report repair concerns through established procedures.
Failure to Maintain Effective Pest Control and Sanitary Flooring in Kitchen and Nourishment Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program and a pest‑free environment in the main kitchen and one nourishment room. Monthly pest control service reports over many months documented repeated findings of broken, loose, or missing floor tiles and baseboards in the kitchen, missing grout, excess and standing water, drainage issues, and dirty floor drains, all identified as potential pest harborage and breeding sites. These reports, some signed by the Maintenance Director, repeatedly noted that the kitchen floor and drains needed cleaning, repair, resealing, or replacement, and stated that the kitchen could never be pest free as long as these major issues existed. Despite these documented concerns, there were no corresponding work orders in the facility’s electronic maintenance request system for broken or missing tiles or pest control treatment requests for the kitchen or nourishment rooms during the review period. During surveyor observations of the main kitchen, small black flies were seen near the handwashing sink and standing water was observed in areas of missing floor tile under the steamer. Later the same day, a large trash can with food debris was observed next to the handwashing sink in the food service area, and when trash was thrown in, an estimated 20–30 small black flies flew out into the air near the food preparation area and handwashing sink. In the 100‑hall nourishment room, surveyors observed small black flies, standing water under the ice cooler, and several loose or detached floor tiles with water on and under them. On a subsequent tour, small black flies were still visible in both the kitchen and the nourishment room, and standing water remained under loose tiles in the nourishment room and in broken and missing tile areas in the kitchen. Interviews further described the conditions leading to the deficiency. The Pest Control Technician stated he had documented broken and missing floor tiles and related pooling water in the kitchen for about a year and a half, and that these conditions attracted pests such as roaches, maggots, and small black flies. He reported that the facility’s pest control coverage did not originally include fly treatment and that he had repeatedly encouraged the Maintenance Director to add this service. The Maintenance Director, employed at the facility for a couple of years, stated he was not aware of the broken and missing floor tiles in the kitchen or the loose tiles in the nourishment room and reported that no maintenance requests had been entered or verbally reported to him for these issues. The Dietary Manager, in her role since September 2025, stated she had not been aware of the online maintenance request system and had not entered any requests, but had sent many text messages to the Maintenance Director about broken floor tiles and small flies in the kitchen. The Administrator stated she expected Maintenance and Kitchen staff to follow policies to eliminate pests and to submit maintenance requests for broken items such as floor tiles.
Failure to Submit Required 5‑Day Abuse Investigation Report to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to submit a complete 5‑day written investigation report to the State Survey Agency (DHSR) within 5 working days following an allegation of employee‑to‑resident abuse, as required by facility policy. The facility’s abuse/neglect/misappropriation/crime reporting policy required the Administrator to thoroughly investigate and file a complete written report to the State Agency within 5 working days, including specific details such as the date of occurrence, names of the resident and staff involved, description and location of any injury, description of the occurrence, immediate protective actions, prevention mechanisms, and documentation of reports to outside agencies. Despite this policy, the 5‑day investigation report associated with an allegation of employee‑to‑resident abuse for one resident was not received by DHSR. The incident began when a resident, identified as severely cognitively impaired and disoriented, reported that he had been “beat up” by a staff member the previous evening. The initial allegation report submitted to DHSR documented that the resident could not identify the staff member involved, that a head‑to‑toe skin assessment revealed no signs of injury, and that there were no details of physical or mental injury or harm. The facility became aware of the allegation the following day, submitted the initial allegation report to DHSR within hours, and notified law enforcement. The resident’s EMR included a Medical Director note indicating the resident reported being beaten, had baseline intermittent confusion and agitation toward staff, and that nursing staff reported he liked to roll out of bed and scream for help. Subsequently, DHSR sent an email to the Administrator and DON stating that the 5‑day investigation report had not been received and requesting that it be faxed as soon as possible. The Administrator later stated she could not locate this email, had no records of fax transmittals for the 5‑day report, and acknowledged the report was not sent to DHSR. A 5‑day investigation summary dated within the required timeframe was found in the facility’s internal folder, documenting that the allegation could not be substantiated, that body audits and interviews were conducted on the hallway, and that no issues were noted. However, this internal summary did not identify the staff member who reported the allegation and did not include any witness statements. Both the Administrator and DON were unable to recall who initially reported the allegation, and the DON acknowledged that submission of the 5‑day report to DHSR may have been missed, resulting in noncompliance with the facility’s own reporting requirements and state reporting expectations.
Failure to Ensure Safe and Coordinated Discharge for Homeless Resident Requiring Self-Catheterization
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective discharge planning process for a resident with benign prostatic hyperplasia causing urinary obstruction, homelessness, substance abuse, and cognitive communication deficits. The resident had been admitted from a hospital where he was treated for a urinary tract infection related to his enlarged prostate and was instructed to continue self-catheterization until a scheduled surgery. At admission, the resident was documented as moderately cognitively impaired and unable to make his own decisions, with a resident representative (RR) designated as decision maker. The RR informed the social worker (SW) that the resident had recently been evicted, was homeless, and that returning to the community was not feasible. The RR requested assistance with a Medicaid application and long-term placement closer to her, and the SW documented that discharge planning was ongoing and that the stay was expected to be short term. Despite this, the admission MDS coded the resident as participating in discharge planning with an active plan for return to the community, and a key MDS question about discussing community discharge was skipped. The SW stated she notified the Business Office Manager that the RR requested Medicaid assistance but did not follow up to confirm that an application was submitted, and the Business Office Manager later reported no record of such a request or application. The SW also reported that a follow-up BIMS showed the resident cognitively intact but could not identify who completed it or when. During daily clinical meetings, therapy notified the SW that the resident’s skilled services were ending, and the SW then issued a CMS-10123 NOMNC letter explaining that Medicare Part A coverage would end. The SW stated she explained the appeal process and that the resident said he would not remain and would go to a homeless shelter, but the RR reported she was not informed of the right to appeal and was only told that the resident would be responsible for payment if he stayed. The discharge planning notes documented that the resident would be discharged to a homeless shelter and that therapy recommended home health services for safety awareness, medication, and household management, but these services were not arranged because the discharge location and address were unknown. The SW did not contact the shelters the resident named to verify availability, and no safe discharge location was confirmed. The discharge instructions, completed by the SW and a nurse, indicated the resident had no devices or treatments and that no education or medical supplies were provided, even though the resident required self-catheterization and had a history of reusing catheters. The RR reported that at discharge she was only given medications and a medication list, with no catheter supplies or instructions, and that she later had to obtain catheter supplies from the urology office. The facility documented the discharge as against medical advice (AMA), completed an AMA form that the resident refused to sign, and the SW stated that an APS report was to be filed, but APS had no record of any report. The Medical Director and Administrator both stated that discharging the resident without arranged housing and needed medical supplies was not a safe discharge, and the Medical Director specifically noted that discharging the resident without housing and catheter supplies was not safe given his homelessness, variable cognition, and need for self-catheterization. The SW indicated she did not know the resident was performing self-catheterization and believed nursing was responsible for reviewing discharge instructions and medications, but the assigned nurse could not recall whether instructions or supplies were provided. The SW also did not follow up with the RR or the resident after discharge and was unaware of his status. The RR stated that she had clearly informed the SW that local shelters were full and that the resident had no housing options, and that the SW offered no placement assistance other than stating the resident could remain at the facility only if he paid a daily rate. The RR further stated she was unaware that the discharge was labeled AMA and believed the facility initiated the discharge due to therapy ending. The Medical Director and Administrator were aware only that the discharge was categorized as AMA and did not recall details of the decision-making process. Collectively, these actions and omissions resulted in the resident being discharged without a verified safe destination, without coordination of recommended home health services, and without necessary medical supplies for his ongoing catheter care. The facility’s documentation and interviews show multiple breakdowns in communication and follow-through related to discharge planning. The SW did not ensure that the RR’s request for Medicaid assistance and long-term placement was acted upon, did not verify shelter availability, and did not coordinate home health services due to lack of an address. The MDS documentation conflicted with earlier determinations that the resident could not safely return to the community, and a key discharge planning question was skipped. Nursing staff did not document or recall providing catheter supplies or education, and the discharge paperwork inaccurately indicated that the resident had no devices or treatments. The facility labeled the discharge as AMA and expected an APS report to be filed, but APS had no record of a report, and the SW did not verify that the report was made. These documented failures led to a discharge that did not ensure the resident’s needs were met, did not coordinate necessary services, did not identify a safe discharge location, and did not provide required medical supplies.
Inaccurate MDS Coding for Wounds and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the MDS assessments for wounds and medications for two residents. One resident was admitted with a diagnosed Stage 4 pressure ulcer of the sacral/coccyx area, documented in the care plan as a chronic Stage 4 wound with interventions such as an alternating air mattress, regular skin assessments, turning and repositioning, and enhanced barrier precautions. Wound care provider notes, physician orders, and the Treatment Administration Record all documented a Stage 4 pressure ulcer with daily wound care and weekly wound care provider visits. However, the quarterly MDS dated 01/05/26 did not reflect any diagnosis of a pressure ulcer, did not code an unhealed pressure ulcer or a Stage 4 pressure ulcer, and did not indicate that pressure ulcer care was provided. The Wound Nurse confirmed the presence of the Stage 4 coccyx wound present on admission and ongoing daily treatment, and the MDS Coordinator acknowledged that the pressure ulcer was overlooked and the MDS was completed incorrectly. The second resident was admitted with type 2 diabetes mellitus with hyperglycemia and had a physician order for daily evening subcutaneous insulin glargine injections, which were documented as administered on the Medication Administration Record. A care plan was initiated for diabetes mellitus with interventions including administering medications as ordered, monitoring for hyperglycemia and hypoglycemia, providing a therapeutic diet, and obtaining labs as ordered. Despite this, the admission MDS dated 12/21/25 did not indicate that the resident received insulin injections or hypoglycemic medications. The MDS Coordinator confirmed that the resident received daily insulin and stated that the MDS assessment should have included both insulin injections and the use of hypoglycemic medication, acknowledging that these were overlooked and the MDS was coded incorrectly.
Failure to Follow Self-Catheterization Orders and Maintain Proper Catheter Bag Positioning
Penalty
Summary
The deficiency involves the facility’s failure to follow hospital discharge orders for a resident who required intermittent self-catheterization and failure to maintain proper positioning of an indwelling urinary catheter drainage bag for another resident. One resident was discharged from the hospital with a diagnosis of benign prostatic hyperplasia with urinary obstruction and hospital discharge orders to continue self-catheterization. On admission, a nurse documented that the resident required self-catheterization due to urinary obstruction and reported being informed by the hospital nurse that the resident was self-catheterizing. The nurse stated she notified the DON that the resident needed physician orders and catheter supplies, but there were no physician orders entered in the EMR for self-catheterization, and the DON later reported she did not recall being informed. The Medical Director documented that the resident required self-catheterization and had received education on catheter hygiene, but the admission MDS did not code intermittent catheterization, and the care plan described the resident as usually continent and independent with toileting without reference to self-catheterization. Subsequently, another nurse documented that the resident became increasingly belligerent and repeatedly requested to self-catheterize due to pain with urination, reporting that he had been self-catheterizing prior to admission. That nurse observed the resident urinating into the toilet and educated him that self-catheterization was not required because he was able to void, and she obtained an order for a urinalysis, which later returned negative. She reported she was unaware the resident required self-catheterization and saw no orders or supplies indicating such a need. The resident’s representative stated the resident had been self-catheterizing for approximately two years due to a urinary blockage requiring surgery, had been hospitalized for a UTI related to reusing catheters, and reported to her about a week after admission that the facility was not providing catheter supplies. The representative obtained approximately 15 catheters from the resident’s urologist and brought them to the resident, and also reported that no catheter supplies were provided to the resident at discharge from the facility. The deficiency also includes improper management of an indwelling urinary catheter drainage bag for another resident with neuromuscular dysfunction of the bladder and an indwelling catheter order. The resident’s care plan included goals to remain free from complications related to the catheter and interventions such as catheter care every shift and monitoring for UTI. On multiple observations over three consecutive days, the resident was seen in bed with the indwelling catheter connected to a bedside drainage bag that was attached to the bed frame below bladder level, but the bottom of the drainage bag was touching the floor. Nursing assistants and nurses assigned to the resident on those days stated they provided catheter care and were aware that catheter bags should not touch the floor to prevent infection, yet each reported they did not notice the bag in contact with the floor during their shifts. The Infection Preventionist/Staff Development Coordinator and the Corporate Nurse Consultant both stated that urinary catheter drainage bags and valves should be kept off the floor and hung on the bed frame below bladder level to avoid contamination and potential urinary tract infection, confirming that the observed positioning of the drainage bag was inconsistent with expected practice. The DON later explained that, at the time of the first resident’s admission, the admission nurse position was vacant and the nurse assigned to the resident was responsible for reviewing hospital orders and entering them into the EMR. She stated that when residents are admitted with self-catheterization orders, the usual process is to enter orders into the EMR for the Medical Director to sign, assess the resident’s ability to self-catheterize safely, and provide catheter supplies, but she was unsure why the orders for this resident were overlooked and did not recall being informed by the admitting nurse about the need for self-catheterization and supplies. The Medical Director stated the resident was performing self-catheterization upon admission and acknowledged documenting the need for self-catheterization, but he did not recall whether he signed related orders in the EMR and was not aware of concerns that staff did not know the resident was self-catheterizing or that supplies were not being provided. These combined actions and inactions resulted in the facility not implementing the hospital’s self-catheterization orders for one resident and not maintaining proper catheter drainage bag positioning for another resident, as observed by surveyors.
Failure to Follow Enhanced Barrier Precautions for Device Care
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring use of gowns and gloves during high-contact resident care activities involving medical devices. The facility’s EBP policy, revised on 3/26/2024, specified that gowns and gloves must be used for high-contact activities such as device care, including feeding tubes and tracheostomy care, when residents are on EBP. For one resident with a feeding tube, an EBP sign and PPE bin were posted outside the room. A nurse entered the room without a gown, performed gastric tube care by stopping the feeding pump, flushing the feeding tube with a syringe, and later reconnecting the tube to the pump, wearing only gloves. The nurse acknowledged awareness that the resident was on EBP but stated she believed a gown was only required for residents on contact precautions. In a separate incident, a nurse aide provided tracheostomy care to another resident who also had an EBP sign posted outside the room instructing staff to wear a gown and gloves, with PPE available in a bin outside the door. The nurse aide was observed cleaning around the resident’s trach using gloves and gauze but did not wear a gown. When interviewed immediately afterward, the nurse aide stated she knew she should have worn a gown while providing trach care but did not plan to be in the room long. The Infection Preventionist reported that appropriate precaution signs and PPE availability were monitored daily and that staff received training on PPE use during orientation and monthly staff meetings, and the DON stated she expected staff to use PPE according to posted precaution signs.
Failure to Provide Timely Incontinence Rounding Resulting in Prolonged Urine Saturation
Penalty
Summary
A cognitively intact resident with hemiplegia, hemiparesis, acute kidney failure, and severe physical impairment was care planned and assessed as always incontinent of bowel and bladder, dependent on two staff for toileting, hygiene, and incontinence care, with an expectation of two-hour incontinence rounding to keep the resident clean and dry. On the date in question, a nurse aide assigned to the resident from 7:00 AM to 11:00 PM transferred the resident to a wheelchair between 2:00 PM and 3:00 PM and did not check the resident’s incontinence status again until approximately 8:00 PM, despite the resident’s care plan and facility expectations for two-hour checks. During this period, the resident remained in the wheelchair, including through the supper meal, and later reported that his brief and pants were soaked with urine and that he felt bad having to sit in wet pants. The resident stated he did not inform staff he had urinated because he did not want to bother them. When the nurse aide finally responded around 8:00 PM after the resident activated his call light, she found the resident’s brief, pants, wheelchair seat, and lift pad saturated with urine. Another nurse, who began her shift at 7:00 PM and had not checked on the resident prior to responding to the resident yelling for help at approximately 8:00 PM, also observed that the resident’s pants, wheelchair seat, and lift pad were saturated to the extent that a mechanical lift could not be safely used, requiring four staff to assist the resident back to bed. A second nurse aide, who had left at 3:00 PM, confirmed that the assigned aide was responsible for two-hour incontinence rounding and stated the resident was not consistently able to notify staff when he needed to be changed and was dependent on staff for incontinence rounding. The DON and Administrator both stated that residents were to receive incontinence care every two hours and should not be left sitting in incontinence, confirming that the resident should have received incontinence care between 2:00 PM and 8:00 PM.
Failure to Report Resident’s Pain During Transfer Prior to Discharge
Penalty
Summary
A resident with chronic pain, morbid obesity, muscle weakness, gait and mobility abnormalities, and bilateral lower extremity range of motion impairment was admitted and used a manual wheelchair and walker for mobility. The admission MDS indicated the resident was cognitively intact, had no reported pain in the five days prior to the assessment, and no prior falls. A physician order was in place for Tramadol 50 mg every 12 hours as needed, and pain assessments were documented twice daily. In July, the resident’s last documented pain score was 7/10 on day shift on 7/28, and the last documented Tramadol administration was on the morning of 7/30; no pain medication was documented on 7/31, the day of discharge. The PT reported that the resident could not complete the initial PT assessment on admission due to pain and fatigue, that therapy was limited to bed mobility and stretching because the resident could not tolerate getting out of bed due to pain, and that the resident began complaining of increased left hip pain on 7/23, which was reported to the Medical Director, who asked PT to continue to monitor. On the day of discharge, the nurse documented a pain score of 0 and noted in a progress note that the resident was discharged to another SNF with all belongings via a transport company, with report given that there were no concerns or issues at the time of discharge. However, NA #8 later reported that while she and another NA were transferring the resident from bed to a manual wheelchair using a mechanical lift, the resident yelled out that her left leg was hurting as she was being raised in the lift. NA #8 stated that she and the other NA quickly lowered the resident into the wheelchair to ease the pain, and that the resident stopped complaining of pain once seated. NA #8 acknowledged that she did not inform the nurse or anyone else of the resident’s complaint of pain during the transfer, explaining that the resident often complained of pain with positioning but did not usually yell or scream, and that she focused on expediting the transfer rather than notifying the nurse. After the transfer to the wheelchair, the transportation driver took the resident to the van; the NAs did not escort them. The transportation company’s Operations Manager reported that video review showed the driver rolling the resident into the van on a hydraulic lift, locking the wheelchair in place, and never removing the resident from the wheelchair, with no observed fall or impact and no pain complaints reported to the driver. Subsequently, the receiving SNF reported that the resident complained of pain on arrival, and an x-ray obtained at the hospital revealed an acute impacted fracture through the left femoral neck. The Medical Director stated that he had not issued new orders earlier because staff had not reported a fall, impact, or significant change, and later opined that the fracture could have occurred prior to admission, during transfer, or at the new SNF. The deficiency centers on NA #8’s failure to report the resident’s acute complaint of left leg pain during the lift transfer to the nurse, resulting in no nursing assessment being completed prior to discharge and no pain or condition concerns being communicated to the receiving facility.
Failure to Maintain Cleanliness and Environmental Repairs in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a clean, safe, and well‑repaired environment in a resident room and bathroom, and to maintain an intact window screen in another resident room. One resident reported that her room and bathroom had not been swept or mopped for some time and could not recall when they were last thoroughly cleaned. She pointed out debris on the floor at the head of her bed, which she stated resulted from the bed hitting the wall when the head of the bed was adjusted, and reported that she had told housekeeping about the issue, though she could not recall when or to whom. Surveyor observations of this resident’s room and bathroom showed approximately a half cup of white plaster‑like debris, ranging from dime‑sized pieces to powder, on the floor at the head of the bed, with two visible plaster patches on the wall where repairs had been made. In the resident’s bathroom, sections of baseboard along the left wall, under the sink, and under the PTAC unit had pulled away from the wall by about one inch. These conditions were repeatedly observed on multiple subsequent dates, with the debris remaining untouched and the baseboards still in disrepair. The assigned housekeeper stated she swept and mopped resident rooms and bathrooms twice daily and rechecked rooms before the end of her shift, reported that the bed was too heavy to move alone, and indicated she had not noticed the debris and had not been informed of it by the resident. The work order log contained no entries about the bed striking the wall or baseboards pulling away. A separate deficiency was identified in another resident’s room, where a window screen had a large vertical tear approximately 12 inches long on one window panel. On initial observation, the window was not latched; on later observations, the window was closed and latched, but the torn screen remained unchanged. The Maintenance Director stated he conducted weekly random room checks and expected staff to submit maintenance requests for needed repairs but had not checked this room, was unaware of the torn screen, and did not recall any work orders for it. Review of the maintenance work order log showed no concerns documented regarding this window screen. The DON and Administrator both stated they expected staff to report and request repairs for environmental issues in resident spaces, including damaged screens and general maintenance concerns.
Failure in Discharge Planning and Equipment Provision
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident, resulting in the resident not receiving necessary durable medical equipment (DME) upon discharge. The resident, who was admitted with diagnoses including GERD, sleep apnea, and rhabdomyolysis, required oxygen therapy and a hospital bed with specific accessories to manage her conditions. Despite having physician orders for these items, the discharge summary did not include the need for oxygen supplies, and the necessary equipment was not delivered to the resident's home. Interviews with facility staff revealed a lack of communication and coordination in the discharge process. Nurse #1, who was responsible for the discharge, did not ensure that the resident's need for oxygen was included in the discharge summary. The Social Worker (SW) was responsible for ordering the DME but was not aware of the resident's need for oxygen therapy. The SW relied on information from morning meetings and did not follow up with the resident after discharge. The DME company did not receive the necessary documentation to fulfill the order, resulting in the resident not receiving the required equipment. The resident's family made multiple attempts to contact the DME company to resolve the issue, but the lack of proper documentation from the facility delayed the process. The resident experienced health complications due to the absence of the necessary equipment, such as sleeping in a recliner due to the lack of a hospital bed, which exacerbated her GERD symptoms and caused edema in her ankles. The facility's failure to ensure the resident's needs were met upon discharge highlights significant deficiencies in their discharge planning process.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically resident-to-resident abuse. In January 2025, a resident with severe cognitive impairment and under hospice care was subjected to inappropriate touching by another resident. This incident was observed by a housekeeper who reported it to the nursing staff. Despite this, the resident who committed the act continued to exhibit inappropriate behaviors, including staring at the victim and touching her inappropriately on another occasion. The resident who committed the abuse was cognitively intact and had a history of inappropriate sexual behaviors, as noted by a Psychiatric Mental Health Nurse Practitioner. However, his care plan did not reflect any behavioral issues, and the facility staff, including the Administrator, were not aware of his past behaviors until after the incident. The Psychiatric Mental Health Nurse Practitioner had previously suggested increased supervision and medication adjustments for the resident, but these recommendations were not effectively implemented. The incident on February 1, 2025, was reported by a Nurse Aide who found the victim with her clothing disheveled and exposed. The resident was immediately sent to the hospital for evaluation, and the perpetrator was placed under one-to-one supervision. However, the lack of prior intervention and awareness of the resident's behavioral issues contributed to the failure to prevent the abuse, highlighting a significant deficiency in the facility's ability to protect its residents from harm.
Incomplete Transfer/Discharge Notice Lacking Appeal Rights
Penalty
Summary
The facility failed to provide a complete written notice of transfer/discharge, including a statement of the resident's appeal rights, for a resident reviewed for discharge. The resident was admitted to the facility and was cognitively intact according to the admission Minimum Data Set. On a specified date, the resident was discharged to the hospital due to inappropriate behaviors and did not return to the facility. The notice of transfer/discharge form completed by the Administrator incorrectly listed a local adult care home as the discharge location instead of the hospital and was issued without the second page, which included the Nursing Home Hearing Request form necessary for the resident to appeal the discharge. The Ombudsman identified the missing second page and informed the Social Worker that both pages were required for the resident to appeal the discharge. Despite this, the notice was not reissued to the resident. The Social Worker was unaware of the need to include the second page until informed by the Ombudsman. Additionally, the adult care home listed as the discharge location had no record of the resident as a potential resident, and the facility's Administrator was unaware that the second page was not provided to the resident.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, citing inappropriate sexual behavior as the reason for refusal. The resident, who was cognitively intact and had diagnoses including hemiplegia and hypertension, was sent to the hospital for evaluation following an incident of inappropriate sexual behavior. The Psychiatric Mental Health Nurse Practitioner recommended the resident be discharged to the hospital for psychological evaluation, stating the resident was a threat to female peers and staff. Despite the hospital's case management contacting the facility for the resident's readmission, the facility refused, citing the resident's behavior as inappropriate for their setting. The facility's Social Worker delivered a notice of transfer/discharge to the resident at the hospital, and the facility's Admission Liaison confirmed the refusal to readmit the resident based on the Psychiatric Nurse Practitioner's assessment. The resident's representative was informed of a 30-day discharge notice but was unable to secure placement in another facility. The facility's Administrator did not directly communicate with the hospital case managers but understood that alternative placement was being sought. The survey team later informed the Administrator of the expectation to readmit the resident with appropriate supervision.
Failure to Notify On-Call Provider and Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to immediately consult with the on-call Nurse Practitioner when a resident experienced a significant change in condition. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and respiratory failure, showed signs of restlessness, agitation, and expressed difficulty breathing. Despite these symptoms, the staff did not notify the on-call provider, and the resident was later found unresponsive with seriously abnormal vital signs. Interviews with staff revealed that the resident was anxious, restless, and repeatedly expressed difficulty breathing throughout the night. Multiple nurse aides reported the resident's condition to the nurses on duty, but the nurses did not take appropriate action. One nurse assumed that the resident's condition was baseline and did not notify the physician, while another nurse administered Ativan, a medication to which the resident had a documented allergy. The resident's condition deteriorated, and she was found unresponsive with low oxygen saturation levels. Emergency Medical Services were called, but the resident was pronounced deceased shortly after their arrival. The facility's failure to notify the on-call provider and administer a medication despite a known allergy contributed to the resident's death.
Removal Plan
- The facility failed to notify the on-call medical provider that Resident #1 had experienced a change of condition.
- An audit was completed by the Director of Nursing and designee to review nursing notes to ensure any noted changes in residents' condition were noted and the physician had been notified.
- Education started by the Director of Nursing for the change in condition and physician notification related to change in condition to include providing comprehensive assessments, that required medical attention, obtain vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues.
- Any licensed nurse and medication aides not receiving this education will not be able to work until receiving the education.
- New licensed nurses and medication aides will receive education during the orientation process.
- Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift.
- Director of nursing reeducated all certified nursing assistants on verbally reporting any noted change in condition such as altered mental status, abnormal behaviors, abnormal vital signs, etc. to the nurse for assessment.
- All nursing note reviews, and reports reviews were completed by the Director of Nursing or designee to ensure noted changes in condition were addressed, vitals taken and physician notified.
- Nursing note reviews will be completed by the Director of Nursing or Designee on residents.
- New changes in conditions will be reviewed by the nursing clinical team during clinical meetings for any noted change in condition and physician notification.
- New changes in condition from the weekend will be reviewed by the nursing clinical team during the clinical meeting.
- The nursing team was notified of this responsibility by the facility administrator.
- The results of the monitoring will be reviewed by the Administrator or Director of Nursing in the Risk meeting and during the Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT).
- Changes will be made to the plan as necessary to maintain compliance with resident safety.
Neglect and Medication Error Lead to Resident's Death
Penalty
Summary
The facility failed to protect a resident's right to be free of neglect, resulting in a series of critical oversights. The resident experienced a significant change in condition, including restlessness, agitation, and difficulty breathing, which was not immediately addressed by consulting the on-call Nurse Practitioner. Despite the resident's verbal expressions of distress, the facility staff did not perform ongoing thorough assessments or recognize the urgent need for medical attention. Additionally, the facility committed a significant medication error by administering Ativan to the resident, who had a documented allergy to the medication. The electronic medical record system flagged the allergy, but the alert was deliberately bypassed by a nurse, leading to the administration of the medication. The facility also failed to notify the physician about the administration of Ativan to a resident with a known allergy. The resident was found unresponsive in her room with seriously abnormal vital signs, including a low oxygen saturation level, and was pronounced deceased shortly after by Emergency Medical Services. This series of failures affected one of the three sampled residents reviewed for neglect, highlighting a critical lapse in the facility's duty to provide adequate care and prevent neglect.
Removal Plan
- The facility neglected to act upon the system alert for Resident #1's allergy to Ativan when ordering a one-time dose.
- Nurses involved in the incident were suspended pending investigation.
- Nurse #1 and Nurse #3 were terminated and reported to the Board of Nursing.
- Nurse #2 turned in a resignation letter.
- The Unit Manager was initially terminated, appealed the termination, was brought back into the training program, and then resigned.
- The Medical Director was notified of Resident #1's change in condition and medication allergy.
- An audit of medication allergy alerts, change in condition, and physician notification in the electronic medical records was completed.
- Education started by the Director of Nursing for the process for medication order entry in regard to alerts related to allergies and acknowledgement of alerts.
- Education included physician notification of known allergies.
- Education started for the change in condition and included providing comprehensive assessments that require medical attention, obtaining vital signs, signs of restlessness, agitation, oxygen saturations, and any breathing issues.
- Education addressed failure to follow above processes results in neglect which is a form of abuse.
- Director of Nursing educated all certified nursing assistants on reporting any noted change in condition to the nurse verbally for assessment.
- Any licensed nurse and medication aides not receiving this education will not be able to work until receiving the education.
- New licensed nurses will receive education during the orientation process by the Director of Nursing until a Staff Development Coordinator is hired.
- Medication Observations on current licensed nurses and medication aides will be completed by the Director of Nursing or designee to ensure no medications are given related to a resident allergy.
- Med pass observations will be completed by Director of Nursing or Designee on 5 licensed nurses and/or medication aides.
- New medication alerts will be reviewed by the director of nursing and the clinical team during morning clinical meetings.
- All nursing notes and 24-hour reports will be reviewed by the nursing clinical team during morning clinical meetings for any noted changes in condition.
- Nursing note reviews will be completed by the Director of Nursing or Designee on 5 residents.
- The Director of nursing or designee will interview 5 nurse aides to ensure they are reporting any change in condition to their charge nurse verbally.
- Until a Staff Development Coordinator is hired, the Director of Nursing will complete monthly training on abuse and neglect and then quarterly ongoing.
- The results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT).
Failure to Address Change in Condition and Medication Error
Penalty
Summary
The facility failed to recognize and appropriately respond to a significant change in condition for a resident with a history of chronic obstructive pulmonary disease (COPD) and respiratory failure. The resident, who was cognitively intact, expressed difficulty breathing and exhibited signs of restlessness and agitation during the evening and night shifts. Despite these clear indicators of distress, the nursing staff did not conduct thorough assessments or notify a physician of the resident's condition. The resident's vital signs were not consistently monitored, and the staff failed to recognize the urgency of the situation. Throughout the night, the resident repeatedly expressed that she could not breathe and was observed moving from the bed to the floor, indicating severe discomfort and distress. Multiple nurse aides reported the resident's condition to the nurses on duty, but the nurses dismissed the symptoms as anxiety without conducting further assessments or seeking medical intervention. The resident's condition deteriorated, and she was found unresponsive with critically low oxygen saturation levels the following morning. Compounding the issue, the resident was administered Ativan, a medication to which she had a documented allergy, without proper verification of her allergy status. The administration of this medication was based on standing orders for agitation, but the nurses involved bypassed allergy alerts in the electronic medical record system. The failure to assess the resident's condition accurately, notify medical personnel, and adhere to medication administration protocols contributed to the resident's death.
Removal Plan
- The facility failed to provide comprehensive assessments, failed to identify a significant change in condition that required medical attention, failed to obtain vital signs and ongoing oxygen saturations.
- Nurse #2 failed to properly assess the resident.
- Current residents are at risk of this occurring.
- An audit was completed by the Director of Nursing and designee to review nursing notes, 24-hour reports, and vital sign logs in the electronic healthcare record to ensure any noted changes in residents' condition were noted and the physician notified.
- The audit also included a review to ensure that residents' vital signs were taken and noted in the electronic record.
- Education started by the Director of Nursing for the change in condition and included providing comprehensive assessments that require medical attention, obtaining vital signs, signs of change in condition, and notifying the physician.
Inadequate Training Leads to Fatal Medication Error
Penalty
Summary
The facility failed to provide effective training and orientation for new hires, including preceptorship, skills validations, and specific training related to pharmacy services and resident allergies in the electronic medical record (EMR) system alerts. This deficiency was highlighted when Unit Manager #1, who had not received a complete orientation, was scheduled to precept Nurse #2. Under Unit Manager #1's direction, Nurse #2 administered Ativan to a resident who had a documented allergy to Ativan. The resident was found unresponsive with seriously abnormal vital signs and was pronounced deceased shortly after by Emergency Medical Services (EMS). The investigation revealed that Unit Manager #1 had not received training on facility equipment, supervising Nurse Aides, clinical processes, pharmacy services, EMR documentation, or clinical skills competencies. She had not completed nursing competencies under the heading of Unit Manager Responsibilities. Despite being scheduled to precept Nurse #2, Unit Manager #1 had not been placed with a preceptor herself and had not received further training after an initial three-day classroom orientation. The facility's failure to ensure that Unit Manager #1 was adequately trained and oriented put all residents at risk for serious adverse outcomes. Additionally, the facility failed to prevent a significant medication error when a nurse bypassed an allergy alert in the EMR system and entered an order for Ativan, which was then administered to the resident. The facility had a period without a Staff Development Coordinator, and the Former Director of Nursing was responsible for overseeing newly hired staff. However, the orientation process was incomplete, and the nurses involved in the incident did not receive adequate training on verifying resident allergies or acknowledging system alerts, contributing to the medication error and subsequent resident death.
Removal Plan
- Identified employees return for a corrected orientation, onboarding, and training process.
- Licensed Nurses completed Medication Pass Observations with the Director of Nursing.
- Skills Validations were started for Licensed Nurses by the Director of Nursing or designee.
- Nurses involved in the incident were suspended pending investigation.
- Nurse #1 and Nurse #3 were terminated and reported to the Board of Nursing.
- Nurse #2 turned in a resignation letter.
- Unit Manager was initially terminated, appealed, brought back, and then resigned.
- Training program held by the Administrator, Director of Nursing, and Human Resources Director.
- Training included validation of successful completion of Skills Validation Record, Medication Pass Observation, and Treatment Observation.
- Director of Clinical Education and Regional Director of Clinical Services provided detailed training on company expectations.
- Administrator, Director of Nursing, or designee, and Human Resources Director will ensure implementation of company expectations for orientation, onboarding, and training.
- Classroom orientation followed by on-the-floor 1:1 onboarding and training with a clinical preceptor.
- HR will interview new hire employees to ensure proper orientation and comfort with training.
- Medication pass observations will be completed by the Director of Nursing or Designee on licensed nurses.
- Results of monitoring will be discussed by the Administrator during the QAPI meeting with the Interdisciplinary Team.
Medication Error Leads to Resident's Death
Penalty
Summary
The facility failed to prevent a significant medication error when a resident with a documented allergy to Ativan was administered the medication, resulting in the resident's death. The error occurred when Nurse #3 entered an order for Ativan into the electronic health record, bypassing an allergy alert. The medication was then pulled from the automated system for medication management by Nurse #3 and Unit Manager #1, and subsequently administered by Nurse #2, who was still in orientation and did not verify the resident's allergies. The resident, who had been readmitted to the facility with diagnoses of chronic obstructive pulmonary disease (COPD) and respiratory failure, exhibited signs of restlessness and agitation. Despite the allergy alert in the electronic medical record, the standing order for Ativan was used to address the resident's behavior. The medication was administered without checking the resident's allergy list, leading to the resident becoming unresponsive shortly after administration and being pronounced deceased by Emergency Medical Services (EMS). Interviews with the involved staff revealed a lack of adherence to protocol, as none of the nurses verified the resident's allergies before administering the medication. Nurse #3 admitted to bypassing the allergy alert, and Nurse #2, under the supervision of Unit Manager #1, administered the medication without reviewing the resident's allergy list. The facility's standing orders and the failure to follow proper procedures contributed to the medication error and the resident's subsequent death.
Removal Plan
- The facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan 0.5 milligram as a one-time dose. Resident #1 had a documented allergy to Ativan.
- All licensed nurses were given access to the automated system for medication management by the Director of Nursing.
- An audit of current resident's allergy listing and current medication list was completed by the Director of Nursing and designee to ensure that medications were not ordered or given with the listed allergies.
- Education started by the Director of Nursing for all licensed nurses and medication aides on alerts in the electronic health record order entry in the MAR.
- Education was also conducted for pulling medications from the automated system for medication management to ensure there is order in place and allergies are checked prior to withdrawing medication.
- All flagged notifications will be reviewed when flagged as an alert when entering the order in the electronic health record by the nurse, and the nurse will notify the physician for direction.
- Any licensed nurse not receiving this education will not be able to work until receiving the education.
- New licensed nurses will receive education during the orientation process.
- Director of Nursing ensured all licensed nurses and medication aides were educated prior to working their next scheduled shift.
- Medication observations on current licensed nurses and medication aides will be completed by the Director of Nursing or designee to ensure residents are not receiving medication with listed allergies on their EMAR.
- Medication pass observations will be completed by the Director of Nursing or Designee on 5 licensed nurses weekly to ensure residents do not receive medications with listed allergies on the EMAR.
- Education was provided to all licensed nurses that before activating a standing order, allergies must be reviewed to ensure the resident does not have a listed allergy for the medication by the Director of Nursing.
- All new orders are reviewed during the morning clinical meeting by the nursing clinical team to ensure no new medications are ordered that residents have an allergy to.
- Regional Clinical Nurse or designee will review medication allergy alerts in the electronic health record by reviewing the progress notes for allergy alerts weekly to ensure no allergy alerts were bypassed.
- The results of the monitoring will be reviewed by the Administrator or Director of Nursing in the weekly Risk meeting and during the monthly Quality Assurance Performance Improvement (QAPI) meeting with the Interdisciplinary Team (IDT).
- Changes will be made to the plan as necessary to maintain compliance with resident safety.
Failure to Provide Dignified Incontinence Care
Penalty
Summary
The facility failed to treat a resident with dignity during incontinence care and did not respond effectively to a call light. The resident, who was cognitively intact and required extensive assistance with toileting, reported feeling disrespected and upset after being ignored and left in a soiled brief. The resident had requested not to use soap for urinary incontinence due to recurring urinary tract infections, but the nursing assistant (NA) seemed frustrated and displayed negative body language, such as rolling her eyes and slamming the bathroom door. The incident occurred when the resident placed a call light for incontinence care, and the NA entered the room, turned off the call light, and left without providing care or speaking to the resident. The resident remained in a soiled brief until another NA and a nurse provided care over an hour later. The resident's clothing was soaked with urine, and she expressed concern about her skin condition, which was being treated with barrier cream. Interviews with staff revealed that the NA had not routinely checked on the resident, assuming the resident would call when assistance was needed. The nurse on duty was informed of the situation and took steps to prevent the NA from returning to the resident's room. The facility's administrator acknowledged that the NA should have provided care when requested and that the resident should not have felt disrespected or had to wait for the next shift for incontinence care.
Failure to Follow Planned Menus and Inform Residents of Changes
Penalty
Summary
The facility failed to adhere to its planned menus, impacting the nutritional needs of residents, as evidenced by the case of a resident with end-stage renal disease and other chronic conditions. Despite having a dietary order for a renal diet with regular texture and thin liquids, the resident frequently did not receive meals as per the menu or meal tickets. Observations showed discrepancies between what was served and what was listed on meal tickets, such as missing items like sausage patties and milk. The resident expressed concerns about not receiving enough protein and not being given choices regarding the menu. Interviews with staff revealed that food deliveries were inconsistent, and budget constraints led to changes in orders. The Dietary Manager made substitutions without updating meal tickets, and residents were not informed of these changes unless they checked the menu outside the dining room. The Registered Dietician confirmed that substitutions were made post-factum and were supposed to be posted, but the kitchen lacked alternatives for certain items. The Administrator expected residents to be informed of menu changes, but this was not consistently happening.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to proper food storage and handling practices, as observed during an initial tour of the main kitchen. Several food items in the reach-in coolers were found open and not labeled with a use-by date, including cut watermelon, sweet pickle relish, blue cheese dressing, sour cream, and whipped cream. Additionally, a bag of leftover frozen French fries in the walk-in freezer was not dated. In the dry storage room, three bags of hamburger buns were found with a manufacturer's best-by date that had already passed. Furthermore, four disposable bowls of vanilla pudding were observed uncovered and undated in the reach-in cooler. The facility also failed to maintain cleanliness and orderliness in the food storage area, as evidenced by 51 clean serving trays being wet-nested in the dishwashing area. An aide revealed that the trays were stacked wet due to limited space. The Dietary Manager, who had been in the role for about a month, was unaware of these issues, including the wet-nested trays, unlabeled items, and items stored past their use-by date. The Administrator expressed an expectation that kitchen staff and managers would follow established policies and procedures.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain the food steamer in the main kitchen in safe operating condition, as it was observed leaking water onto the floor. On the specified date, a large puddle of water was seen under the food steamer, with water dripping from a plastic pipe at the back of the appliance. The pipe was not positioned above the floor drain, resulting in water accumulation on the kitchen floor. Kitchen staff had verbally reported the issue to Maintenance staff multiple times in previous weeks, but the leak persisted. The Dietary Manager and Maintenance Assistant were both unaware of the leaking pipe. The Maintenance Assistant mentioned that the facility used an online maintenance tracking system, and staff were expected to enter concerns into the system for Maintenance staff to address. He also stated that urgent issues should be verbally reported for immediate response. The Administrator was also unaware of the issue and expected kitchen staff and managers to follow policies and procedures for equipment maintenance and reporting concerns to Maintenance staff.
Failure to Maintain Resident Privacy During Tracheostomy Care
Penalty
Summary
The facility failed to maintain a resident's privacy during tracheostomy care for a resident with severe cognitive impairment. The incident involved two nurses who left the door to the resident's private room open while performing tracheostomy care, including cleaning the site, suctioning, and changing the tracheostomy cannula. This lack of privacy was observed during a continuous observation session, where it was noted that the hallway was easily visible from the resident's bedside, and there was no privacy curtain in the room to obstruct the view. Interviews with the involved staff revealed that both nurses acknowledged the oversight, with Nurse #1 admitting she forgot to close the door and Nurse #2 failing to remind her. The Director of Nursing confirmed that there were no privacy curtains in the private room and expressed the expectation that doors should be closed during care to ensure privacy. The Administrator also stated that staff were expected to close doors when providing care to maintain resident privacy.
Inaccurate MDS Coding for Resident with Respiratory Needs
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident reviewed for special services. The resident was admitted with diagnoses including respiratory failure with hypoxia, pneumonia, and tracheostomy status. The admission MDS indicated severe cognitive impairment, aphasia, and respiratory failure, and noted the resident was receiving oxygen, required tracheostomy care, and was on invasive mechanical ventilation. However, the care plan did not include a plan for invasive mechanical ventilation, and physician orders from 10/7/2024 to 10/20/2024 did not include orders for invasive mechanical ventilation. An observation on 10/20/2024 showed the resident with a tracheostomy and oxygen but no evidence of invasive mechanical ventilation. An interview with a nurse revealed that the resident had been weaned off invasive mechanical ventilation before admission to the facility.
Deficiencies in Tracheostomy Care and Oxygen Orders
Penalty
Summary
Nurse #1 failed to adhere to the facility's procedure for tracheostomy care by not using sterile gloves from the sterile tracheostomy kit when cleaning the tracheostomy site and changing the inner cannula for Resident #187. During the procedure, Nurse #1 did not remove gloves, perform hand hygiene, or apply new gloves after retrieving a new tracheostomy cleaning kit when an item fell to the floor. This breach in protocol was observed during a continuous observation of tracheostomy care, and Nurse #1 acknowledged the mistake during an interview, stating that sterile gloves should have been applied and changed when the sterile field was broken. Additionally, the facility failed to have a physician order for continuous oxygen for Resident #187, who was admitted with diagnoses including respiratory failure with hypoxia, pneumonia, and tracheostomy status. Observations showed that Resident #187 was receiving oxygen at 3 liters per minute, but there were no corresponding physician orders for oxygen use in the resident's records. Interviews with Nurse #3, the 200 Hall Unit Manager, and the Director of Nursing confirmed the absence of orders for oxygen flow rate, which should have been in place. The Director of Nursing and the Administrator both expressed that there should have been orders for the oxygen flow rate and that new admission orders are typically reviewed by several members of the nursing team. However, the orders for Resident #187's oxygen were missed, indicating a lapse in the review process for new admissions. The Administrator emphasized the expectation for all orders for newly admitted residents to be discussed during clinical meetings and for any discrepancies to be addressed with the physician.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed around two outdoor trash receptacles located behind the kitchen. During an inspection, surveyors noted loose garbage, including eight sets of used disposable gloves and a used sandwich bag with food debris, scattered on the ground outside the receptacles. Additionally, a garbage bag was found open on the sidewalk leading to the trash area, with debris and spaghetti noodles spilling out. One of the trash receptacles had its door open, and the lid was caved in due to the weight of garbage bags. Interviews with the Maintenance Assistant revealed that the housekeeping and maintenance departments were responsible for maintaining the cleanliness of the trash area, which was supposed to be cleaned each morning. The Administrator confirmed that the trash area should be maintained according to the facility's policies and procedures.
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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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