Clayton Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Clayton, North Carolina.
- Location
- 204 Dairy Road, Clayton, North Carolina 27520
- CMS Provider Number
- 345317
- Inspections on file
- 23
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 24 (1 serious)
Citation history
Health deficiencies cited at Clayton Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified failures in kitchen sanitation and food labeling, including an uncleaned puddle of spilled milk on the walk-in refrigerator floor that remained for several hours despite expectations that spills be cleaned promptly. Opened dry goods such as brown sugar and cereal were stored in clear packaging without original boxes, labels, or dates, contrary to facility expectations that all opened items be dated and checked at least daily. In a nourishment room refrigerator used for residents, three cups of apple juice were found without dates after a nurse aide placed them there and became distracted, while dietary staff reported they were responsible for daily checks of refrigerator temperatures and contents.
The facility failed to accurately code an MDS assessment for a resident receiving routine quetiapine for agitation associated with schizoaffective disorder, depression, and anxiety. Although a mental health provider documented that a gradual dose reduction (GDR) of the antipsychotic was clinically contraindicated due to the resident’s history of agitation and underlying diagnosis, this contraindication was not captured on the quarterly MDS. The MDS nurse reported not seeing the contraindication when coding the assessment, and the Administrator later acknowledged the MDS should have reflected the documented GDR contraindication.
A resident with bipolar disorder, schizoaffective disorder, depression, ESRD on dialysis, orthostatic hypotension, and muscle weakness had medication orders in which Midodrine was linked to hypokalemia and Lamotrigine was linked to generalized muscle weakness, despite these drugs being used for blood pressure management and bipolar disorder/epilepsy. Consultant pharmacists repeatedly documented in MRRs that diagnoses on the MAR for Midodrine, Lamotrigine, and other medications required review and updating, but the NP either disagreed with recommendations or acknowledged them without correcting the diagnosis links. The NP later admitted the diagnoses were incorrect and had not been updated due to workload. The Medical Director confirmed there was no facility policy specifying timeframes for implementing MRR recommendations and expected NPs to act on them, with pharmacist escalation to him if not corrected, while pharmacists reported uncertainty about expectations and did not escalate the incorrect diagnoses.
Surveyors found that a medication refrigerator in a medication room was reading 66°F while storing 52 refrigerated medications, including multiple insulin products, Ozempic, Procrit, ophthalmic solutions, Formoterol Fumarate, and Alteplase, which are required by USP standards to be maintained between 36°F and 46°F. The temperature log on the refrigerator showed a prior reading of 38°F without a documented time. The DON reported that these were overflow and stock medications and that a medication had become stuck in the door, preventing it from closing properly, and also noted that corrective action was needed for temperatures above 41°F, though the exact time of the earlier temperature check was unknown.
Two residents experienced cardiac arrest and did not receive effective basic life support from facility staff. In both cases, chest compressions were performed without a hard surface or backboard, and there were delays and confusion in using an AMBU bag for ventilation. Staff were unfamiliar with the process for announcing a Code Blue and had difficulty locating code status information, leading to further delays in resuscitation efforts. Emergency responders found that necessary equipment was not in use upon arrival, and both residents expired despite resuscitation attempts.
Multiple residents with pressure ulcers did not receive timely or appropriate wound care due to unclear physician orders, lack of staff follow-through, and poor communication. In one case, a resident's request for a dressing change was denied, resulting in maggots being found in the wound. Other residents experienced delays in treatment initiation and inconsistent documentation, with staff often unaware of their wound care responsibilities.
The facility did not have effective systems in place for the prompt return of controlled medications to the pharmacy, resulting in numerous discontinued or expired controlled substance cards remaining on medication carts. Staff were required to count these medications each shift, and documentation was incomplete or missing for some items. Leadership gaps and unclear procedures contributed to the failure to properly secure and return controlled substances, as confirmed by interviews with nursing staff, the consultant pharmacist, and the Regional Clinical Director.
Two residents with non-pressure wounds did not receive appropriate wound care due to lack of coordination between providers, unclear or outdated orders, and staff not being aware of or able to access the wound physician’s plan of care. One resident with post-cancer surgery wounds received incorrect treatments and missed topical antibiotics, while another with diabetic ulcers experienced delays and missed wound care due to unclear staff responsibilities.
The facility did not ensure that nurses had validated competencies in essential skills and procedures, as evidenced by missing competency checklists and inadequate orientation. A resident with complex medical needs was cared for by nurses who reported difficulty accessing orders and lacked training on secure communication and emergency procedures. Another nurse was unable to use the intercom system during a code event, and staff had trouble locating emergency equipment, highlighting gaps in training and competency validation.
Meal trays were not delivered at regular, scheduled times to two halls because of a broken oven, resulting in late meal service and resident complaints. Cognitively intact residents reported receiving meals, including dinner, significantly later than scheduled, and staff confirmed the ongoing kitchen equipment issue was the cause.
Nursing staff failed to accurately document wound dressing changes for three residents, including instances where nurses signed for treatments they did not perform and a case where a dressing change was completed but not recorded. Interviews confirmed discrepancies between documentation and actual care provided.
A nurse, lacking training on secure communication protocols and without access to a HIPAA-compliant messaging system, used a personal phone to text a resident's name and medical details to the NP after the resident experienced bleeding from a gastrostomy tube site. This resulted in a breach of privacy and confidentiality of the resident's medical records.
Nursing staff failed to properly reconcile and administer medications for a newly admitted resident with complex medical needs, resulting in missed doses and lack of required blood sugar checks. Additionally, another resident with Parkinson's disease missed a scheduled dose of carbidopa-levodopa, leading to increased tremors and confusion. Communication lapses and lack of access to medical records contributed to these deficiencies.
A resident with a gastrostomy tube and severe dysphagia did not receive prescribed enteral feedings for two consecutive days due to failures in communication, documentation, and order entry. Staff were unaware of their responsibilities, could not access necessary orders, and only partial feedings were documented, resulting in the resident not receiving nutrition as ordered.
A resident with a pressure wound infection did not receive four doses of a prescribed antibiotic as ordered by the physician. Although the MAR showed all doses as administered, a review of the medication package revealed fewer tablets had been given than documented. Staff interviews and medication counts confirmed the discrepancy, and the facility could not account for the missing doses.
A resident with moderate cognitive impairment was served a piece of toast that was mostly burnt during breakfast. The burnt toast was observed by staff and the resident's roommate, and it was acknowledged by facility leadership that it should not have been served. Dietary staff cited new personnel and equipment problems as contributing factors.
A resident with dementia, malnutrition, and significant communication impairments was repeatedly served a peanut butter and jelly sandwich as her main entree instead of being offered available menu alternatives like chicken or egg salad. The facility's dietary system defaulted to this option due to a list of beef dislikes, and staff did not attempt to communicate with the resident to clarify her preferences, despite her ability to use sign language and writing. This resulted in the resident not receiving meals that matched her documented preferences and needs.
A resident with advanced dementia and a wound infection experienced severe pain during dressing changes, but facility staff were unable to reach hospice for timely evaluation and stronger pain medication. Despite multiple attempts by nursing staff to contact hospice, no hospice nurse responded for several days, resulting in delayed pain management until a hospice nurse eventually visited and ordered appropriate medications.
A kitchen oven remained out of service for over a month due to delayed maintenance response, miscommunication, and vendor scheduling issues. As a result, staff had to prepare meals using only one oven, causing late meal trays and affecting timely meal delivery to residents.
Three residents experienced significant lapses in medication management, including missed doses of essential medications due to lack of access to emergency supplies, delayed pharmacy deliveries, and failure to obtain required prescriptions. One resident did not receive multiple ordered medications for several days after admission, another missed doses of blood pressure medication and antibiotics after readmission due to order reconciliation failures, and a third resident's home-supplied medication was neither administered nor properly returned, resulting in a medication mix-up at discharge.
Two residents experienced significant medication errors due to missed or delayed administration of critical medications, including an anticoagulant, insulin, pregabalin, and an antibiotic. One resident did not receive multiple doses of her prescribed medications after admission because staff lacked access to the back-up supply and a required prescription was not provided, resulting in several missed doses over consecutive days. Another resident missed several doses of a prescribed antibiotic after readmission because new orders were not reconciled, and pharmacy delays further postponed administration.
Two residents were unable to access clean linens for bathing, with one resident having to use a wet wipe before an outside appointment due to a recurring linen shortage. Multiple nurse aides confirmed the lack of linens was a frequent problem, and the facility's laundry process resulted in clean linens not being available during morning care. The Housekeeping Director and administrator acknowledged gaps in the linen supply system.
A resident experienced ongoing pest issues due to unsealed gaps and holes in her room and common areas, despite repeated pest control treatments. Facility staff and pest control logs confirmed repeated sightings of ants and roaches, and inspections revealed missing caulk, holes around pipes, and worn weather stripping on exit doors. Maintenance staff acknowledged the need for repairs but had not completed them, and communication gaps prevented all necessary actions from being taken.
The facility failed to label and date leftover food items in the walk-in refrigerator, as observed during a survey. Containers with various food items were found without labels or dates. The Assistant Dietary Manager confirmed the issue, stating it was the cooks' responsibility. Interviews revealed a breakdown in communication and responsibility between the cooks, leading to the deficiency.
The facility inaccurately coded the MDS assessments for two residents, failing to reflect the administration of aspirin and furosemide during the look-back periods. The MDS Nurse acknowledged the errors, and both the DON and Administrator emphasized the need for accurate medication documentation.
The facility failed to invite three cognitively intact residents to care plan meetings, despite having initiated and revised their care plans. A resident with stroke, anemia, and hypertension was not invited to any meetings until a scheduled one, while another with hypertension and Alzheimer's disease was not included in meetings despite their representative attending one via phone. A third resident with stroke, diabetes, and hypertension did not recall being invited to any meetings. The Social Worker confirmed meetings were held without resident participation, contrary to expectations for quarterly meetings.
A nurse failed to prime an insulin pen and administered an incorrect dosage of Acetaminophen, resulting in an 8% medication error rate. The nurse misunderstood the priming process for the insulin pen and did not verify the physician's order for Acetaminophen, leading to errors in medication administration for a resident with diabetes and neuropathy.
A NA failed to perform hand hygiene during meal delivery, handling a resident's bed and linens without sanitizing hands afterward, despite available hand sanitizing dispensers. This was against the facility's infection control policy, which emphasizes hand hygiene to prevent infection spread.
A resident admitted for short-term rehab expressed dissatisfaction and a desire to return home, but the facility failed to address her discharge planning. Despite being cognitively intact and having a history of spinal stenosis and stroke, her requests were not acted upon, leading her to leave with a friend's help without formal discharge. The facility was unaware of her departure until the next day, highlighting a breakdown in communication and responsibility among staff.
A facility failed to timely identify and treat arterial wounds on a resident's feet, leading to delayed medical intervention. Another resident experienced a critical drop in hemoglobin levels, which was not promptly addressed due to communication failures and delayed lab follow-up. These deficiencies highlight lapses in the facility's processes for monitoring and responding to residents' medical needs.
A resident with a history of falls and cognitive intactness left a facility unnoticed after expressing a desire to go home. Despite informing the ADON, no discharge arrangements were made. Miscommunication among staff during shift changes led to the resident's absence going unnoticed until the next day. The facility's investigation revealed inconsistencies in staff accounts and a lack of clarity on the resident's departure time.
A resident admitted with insomnia and hyperthyroidism did not receive Methimazole and Temazepam on time due to delayed transmission of medication orders to the pharmacy and a delivery error by a third-party courier. The facility lacked these medications in their emergency supply, and there was no record of follow-up with the pharmacy.
A resident with a history of anemia experienced a delay in receiving critical lab results due to communication failures between the LTC facility and the lab company. Despite multiple attempts to notify the facility of critically low hemoglobin levels, the lab's messages were not effectively communicated, leading to a delay in redrawing the blood sample. The resident was eventually hospitalized for severe anemia and treated before returning to the facility.
A resident left the facility against medical advice without signing any paperwork, and the facility failed to accurately document this event. The resident, who was cognitively intact, left with a friend after staff did not assist her, and she was not questioned or asked to sign any documents. The facility contacted her the next day to check on her well-being, but the form in her medical record was not correctly filled out to reflect the situation.
A facility failed to control an ant infestation, resulting in ants being found on residents and in their rooms. A resident with cognitive and visual impairments had ants on his foot dressing during dialysis, and another resident experienced ants crawling on him in bed. Despite regular pest control services, the facility did not take immediate measures to prevent ants from reaching residents, leading to multiple incidents.
A resident with basal cell carcinoma experienced a delay in receiving a dermatology consultation due to the facility's failure to schedule an appointment in a timely manner. Despite the Wound Physician's repeated recommendations for a dermatology referral, the appointment was not made until months later, leading to a lapse in care. The delay was attributed to a breakdown in communication and responsibility within the facility.
A facility failed to accurately account for the delivery and receipt of 15 Oxycodone tablets for a resident. The pharmacy reported the medication as delivered, but the facility could not confirm its receipt. Discrepancies arose due to illegible signatures and rushed courier procedures, leading to an investigation that could not locate the missing medication.
Failure to Maintain Kitchen Sanitation and Proper Food Labeling
Penalty
Summary
The deficiency involves failure to maintain proper sanitation and food labeling practices in the main kitchen and nourishment areas. Surveyors observed a puddle of milk from two busted 8-ounce milk cartons on the floor under storage racks in the walk-in refrigerator during the initial kitchen tour with the Dietary Manager. Although the Dietary Manager stated the walk-in refrigerator floor was swept multiple times a day and had been swept the previous night, the same puddle of milk remained uncleaned several hours later during a follow-up observation. The Dietary Manager stated he planned to clean the floor after lunch and that his expectation was for staff to check the condition of the walk-in refrigerator between meals and clean spills as soon as they saw them. A dietary aide later stated the walk-in refrigerator should be checked and cleaned daily and that he cleaned spills right away when assigned those tasks, but he was not assigned those tasks on the day in question. The Administrator stated his expectation was that nothing should be on the floor in kitchen areas and that all spills should be cleaned up as soon as possible. Additional deficiencies were identified in food labeling and dating practices. In the dry goods pantry, surveyors observed two opened non-perishable food items (brown sugar and cereal) stored in their original clear packaging, without the original box containing the expiration date, and not labeled or dated. The Dietary Manager stated he expected staff to date all food items once opened and that he checked the pantry each morning, but he could not explain why these items lacked open dates. Another Dietary Manager stated the walk-in refrigerator, freezer, and dry pantry were supposed to be checked at least once a day, usually by the manager, though other staff could be delegated. In a nourishment room refrigerator, surveyors observed three plastic cups of apple juice with plastic lids that were not dated. The second Dietary Manager reported seeing a nurse aide place the cups in the refrigerator and stated that nourishment refrigerators were for resident use only and that kitchen staff were responsible for checking temperatures and contents daily. The nurse aide confirmed placing the juice cups in the refrigerator, acknowledged they should have been dated, and stated he normally dated items but became distracted and did not do so. The Administrator stated his expectation that anything placed in nourishment refrigerators must be labeled and dated.
Failure to Accurately Code MDS for Antipsychotic GDR Contraindication
Penalty
Summary
The facility failed to accurately code the MDS assessment for one resident by omitting physician-documented information that a gradual dose reduction (GDR) of an antipsychotic medication was clinically contraindicated. The resident had diagnoses including depression, anxiety, and schizoaffective disorder, and had a physician’s order for quetiapine 25 mg three times daily for agitation. A mental health progress note documented that a GDR of the antipsychotic was contraindicated due to the resident’s history of agitation and underlying schizoaffective disorder, and the Medication Administration Record showed the resident received quetiapine routinely over a specified period. However, the quarterly MDS assessment, while indicating that the resident received antipsychotic medication on a routine basis, did not include the physician-documented contraindication to GDR. During an interview, the MDS nurse stated she did not see the contraindication when coding the MDS, and the Administrator acknowledged that the MDS should have been coded to reflect the contraindication to gradual dose reduction of the antipsychotic medication.
Failure to Act on Pharmacist Medication Regimen Review Diagnosis Irregularities
Penalty
Summary
The deficiency involves the facility’s failure to ensure that identified medication regimen irregularities were acted upon following monthly drug regimen reviews. Resident #5 was admitted with multiple diagnoses, including bipolar disorder, schizoaffective disorder, depression, end stage renal disease with dialysis dependence, orthostatic hypotension, and muscle weakness, and was cognitively intact per the admission MDS. Physician orders showed Midodrine 15 mg by mouth four times daily with an associated diagnosis of hypokalemia, and Lamotrigine 200 mg daily with an associated diagnosis of generalized muscle weakness, despite Midodrine being used for low blood pressure and Lamotrigine for epilepsy and bipolar disorder. The admission MDS documented active conditions including orthostatic hypotension, end stage renal disease/dialysis dependence, bipolar disorder, depression, psychotic disorder, and muscle weakness, and indicated the resident received antipsychotic, antidepressant, anticoagulant, opioid, and anticonvulsant medications during the assessment period. A new admission Drug Regimen Review dated 10/23/2025 by the consultant pharmacist recommended reviewing and updating diagnoses on the MAR for Simethicone, Lamotrigine, and PRN Loperamide; the NP signed the form and circled “Disagree” for all three drugs. Subsequent MRR summaries dated 11/30/2025 and 12/31/2025 documented that Midodrine and Lamotrigine, among other medications, required diagnosis review and MAR updates, and noted that “muscle weakness” was not a sufficient diagnosis for Lamotrigine; these forms were acknowledged by the NP, but the diagnoses were not corrected. In interviews, the NP acknowledged that hypokalemia was not the correct diagnosis for Midodrine, and that Lamotrigine was prescribed for bipolar disorder and should not have been linked to generalized muscle weakness, stating she had many patients and had not gotten around to updating the diagnoses. The Medical Director stated there was no facility policy establishing a timeframe for implementing MRR recommendations and that his expectation was that NPs would make necessary adjustments, with escalation to him if recommendations were not corrected. The consultant pharmacists indicated they sent monthly reports with recommendations to the DON, did not know the expectations for escalation, and one pharmacist stated the incorrect diagnoses would not have affected the resident’s medication or care and were not something she would have escalated to the Medical Director.
Improper Refrigerated Medication Storage Due to Elevated Refrigerator Temperature
Penalty
Summary
Surveyors identified a deficiency in medication storage when a medication refrigerator in one medication room was observed with an internal temperature gauge reading 66°F, despite the attached temperature log indicating 38°F earlier that day with no time documented. At the time of observation, 52 refrigerated medications were stored in this refrigerator, including multiple types and brands of insulin pens and vials (such as Humalog, Lantus, Toujeo, Basaglar, Novolog, Humulin, Novolin, Levemir, Tresiba), Ozempic, Procrit, ophthalmic solutions (Lumigan and Latanoprost), Formoterol Fumarate, and Alteplase with diluent. United States Pharmacopeia standards require these medications to be stored at controlled refrigerated temperatures between 36°F and 46°F prior to use. During interviews, the DON reported that the medications in this refrigerator were overflow and stock medications and that one medication had become stuck in the door, preventing the refrigerator from closing properly. The DON also stated that corrective action was considered necessary any time the refrigerator temperature exceeded 41°F and that the refrigerator temperature had been checked earlier that morning and documented as 38°F, though the exact time of that check was unknown. The Administrator stated that the refrigerator temperature should be checked multiple times throughout the day and that staff should be more careful when removing medications from the refrigerator.
Failure to Provide Effective Basic Life Support and CPR
Penalty
Summary
Facility staff failed to provide effective basic life support, including CPR, to two residents who experienced cardiac arrest on weekends. In both cases, staff did not ensure that chest compressions were performed on a hard surface, as required by American Heart Association guidelines, and did not consistently use an AMBU bag for ventilation. For one resident, there was a delay in locating the AMBU bag, and staff were unable to find the resident's code status promptly in the electronic medical record, leading to further delays in initiating appropriate resuscitation efforts. Additionally, staff did not know how to use the intercom system to announce a Code Blue, which hindered the ability to quickly summon additional help. The first resident had a history of heart failure, chronic atrial fibrillation, diabetes, chronic obstructive pulmonary disease, and prior respiratory failure. This resident was found unresponsive with no pulse or breathing, and although staff attempted CPR, they did not use a backboard or hard surface, and there was confusion and delay in using the AMBU bag for ventilation. Emergency responders reported that when they arrived, staff were either about to start or had just started CPR, but no crash carts or AMBU bag were in use, and no backboard was present. The resident was a full code, but the code status was not immediately accessible in the electronic record, and staff were unfamiliar with the process for overhead Code Blue announcements. The second resident, who had multiple chronic conditions and was a full code, was found unresponsive and without vital signs. Staff initiated chest compressions but did not move the resident to a hard surface or use a rigid backboard. An AMBU bag was eventually connected for ventilation, but only after additional staff arrived with the crash cart. There was no overhead Code Blue announcement, and communication among staff was disorganized, with delays in calling 911 and confirming code status. In both cases, EMS arrived and took over resuscitation efforts, but both residents expired. Observations after the incidents confirmed that crash carts were equipped with necessary equipment, including backboards and AMBU bags, but these were not utilized effectively during the emergencies.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident with chronic wounds and multiple comorbidities, the Wound Physician's orders for pressure sore treatment were unclear regarding the frequency of dressing changes, and staff did not seek clarification. Documentation showed inconsistencies and contradictions in the treatment administration records, with some staff signing off on dressing changes they did not perform and others unaware of their responsibilities. The resident experienced significant wound drainage, odor, and pain, and despite requests for a dressing change, the request was denied. Subsequently, maggots were found in the resident's pressure sore, which was attributed by a diagnostic entomologist to wound drainage attracting flies. The event was distressing for the resident and was witnessed by multiple staff members. Another resident was admitted with a hospital-acquired sacral pressure sore, but the facility failed to obtain and initiate treatment orders upon admission. Nursing staff were unclear about their responsibilities for wound care, with some nurses unaware they were assigned to the resident or unable to access the necessary information to perform dressing changes. Documentation of dressing changes was missing for several days, and interviews revealed that some staff did not perform or document wound care, assuming it was the responsibility of a treatment nurse who was not present. The responsible party for the resident reported that there were days when the resident's pressure sores were not changed. A third resident developed new unstageable pressure sores, and although a physician assistant verbally instructed staff to keep the resident off the affected area and to consult the wound nurse, the instructions were not recalled or documented by the assigned nurse. There was a lack of clarity and follow-through regarding wound care orders and interventions for this resident as well. Across these cases, the facility failed to ensure clear communication of wound care orders, timely and appropriate dressing changes, and staff awareness of their responsibilities for pressure ulcer care.
Failure to Timely Return and Account for Controlled Medications
Penalty
Summary
The facility failed to maintain effective systems for the timely return of controlled medications to the pharmacy across all four medication carts. Documentation revealed that numerous cards and containers of controlled substances, including those belonging to discharged residents, remained on the medication carts instead of being promptly returned. Inventory count sheets showed that large numbers of controlled medication cards were removed from the carts on specific shifts, but some empty cards were not properly documented, and there was a lack of clarity regarding which residents and medications were involved. Staff interviews confirmed that nurses were required to count excessive numbers of controlled medications each shift, many of which should have already been returned, increasing the risk of errors in accounting for these substances. Further interviews indicated that the former DON was unable to manage the return of controlled medications due to overwhelming job responsibilities, and the facility had been without effective nursing leadership. The consultant pharmacist was not aware of the facility's exact procedures for handling discontinued or expired controlled medications, but stated that such medications should be removed from carts, double-locked, and returned to the pharmacy at the next available opportunity. The Regional Clinical Director confirmed that the expected process was not being followed, as discontinued controlled medications were left on the carts rather than secured and returned, and inventory count sheets were not consistently or accurately completed and verified by two nurses.
Failure to Coordinate and Implement Wound Care Orders for Residents with Non-Pressure Wounds
Penalty
Summary
The facility failed to ensure that wound care was provided according to physician orders and residents’ needs for two residents with non-pressure wounds. For one resident with a history of squamous and basal cell carcinoma, there was a lack of coordination and communication between the facility, the wound physician, and the dermatologist. The plan of care for post-surgical wounds was not clarified when two different providers were involved, resulting in conflicting or unclear orders. The wound nurse was not aware of how to access the wound physician’s notes and did not receive direct communication regarding changes in the treatment plan. As a result, outdated wound care orders, such as the continued use of Dakin’s solution, remained in effect beyond the period recommended by the wound physician, and topical antibiotics recommended by the dermatologist were not implemented in a timely manner. Additionally, the facility failed to ensure that nurses responsible for wound care could access and implement the wound physician’s plan of care. The wound nurse reported difficulty obtaining records from the dermatologist and was unaware of the wound physician’s updated recommendations. The interim Director of Nursing was also not aware of the ongoing use of outdated wound care orders. This lack of communication and access to care plans led to inconsistencies in wound care delivery, including the use of incorrect treatments and missed opportunities to follow specialist recommendations. For another resident with diabetic ulcers, there was a delay in initiating wound care treatment orders. Although the wounds were identified upon admission, no treatment orders were entered for several days, and documentation of wound care was missing for multiple dates. Interviews with nursing staff revealed confusion about responsibility for wound care, with several nurses stating they were not trained or informed that it was their duty to perform treatments. This resulted in missed wound care treatments and incomplete documentation for the resident’s diabetic ulcers.
Failure to Validate and Document Nurse Competencies
Penalty
Summary
The facility failed to ensure a working system to evaluate and validate the competencies of nurses in skills, facility procedures, and knowledge, as evidenced by the lack of completed competency checklists and inadequate orientation for newly hired nurses. Three nurses were reviewed for competency validation, and it was found that two of them did not have completed competency checklists on file. The Staff Development Coordinator (SDC) reported that the process relied heavily on self-evaluation and verbal confirmation of skills, rather than direct observation or demonstration, and there was confusion about who was responsible for validating competencies when the SDC was working part-time. One resident was admitted with multiple complex medical conditions, including a history of stroke, congestive heart failure, diabetes, and a gastrostomy tube. The nurse assigned to this resident reported difficulty accessing the resident's electronic medical record, was unaware of the resident's orders, and had not received adequate training on facility procedures or the location of necessary supplies. The nurse also communicated protected health information via personal text message to a nurse practitioner, stating he had not been trained on secure communication protocols. Another newly hired nurse also reported being unable to access orders or the hospital discharge summary in the electronic record and was unsure about the procedures for medication and enteral feeding administration. In a separate incident, another newly hired nurse was unable to use the intercom system to call for help during a medical emergency and had difficulty locating emergency equipment, such as an AMBU bag. Other staff members also reported uncertainty about emergency procedures and the use of the intercom system. The SDC confirmed that while there was a process for orientation and competency validation, it was inconsistently applied, and documentation was missing for some nurses. Interviews with administrative staff revealed a lack of clarity regarding who was responsible for ensuring competency validation, and no completed competency checklists could be found for two of the nurses involved.
Delayed Meal Service Due to Kitchen Equipment Failure
Penalty
Summary
The facility failed to deliver meal trays at regular, consistent, and scheduled times to residents on two of three halls due to a prolonged issue with a broken oven in the kitchen. The 400 Hall, which was scheduled to receive the latest meal carts, experienced repeated delays, with residents sometimes receiving their evening meal after 7:00 PM. Observations confirmed that meal trays arrived late on multiple occasions, and interviews with residents indicated dissatisfaction with the timing of meal deliveries. The 200 Hall also experienced inconsistent meal delivery times, with some residents reporting that dinner was served as late as 7:00 PM. The Dietary Manager and Regional Corporate Dietary Manager confirmed that only one oven was operational for over a month, significantly impacting their ability to prepare and deliver meals on schedule, especially when multiple menu items required baking. Residents involved in the findings were cognitively intact and able to report their experiences. The deficiency was directly linked to the kitchen's inability to meet scheduled meal times due to equipment failure, resulting in late meal service and resident complaints.
Inaccurate and Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to ensure the accuracy and completeness of medical records regarding wound dressing changes for three residents with wounds requiring dressings. For one resident with multiple pressure sores and venous wounds, the Treatment Administration Record (TAR) was signed by a nurse for dressing changes that he did not perform, as confirmed during an interview. The nurse stated he had not changed the dressings as documented and believed another nurse had performed the care. The administrator confirmed that nurses should not sign for treatments they did not complete. Another resident, who had undergone surgery for skin cancer and required daily wound care, had a blank entry on the TAR for a day when the dressing change was performed but not documented. The nurse responsible admitted to completing the dressing change but failing to record it. For a third resident with a stage 3 pressure wound, the TAR indicated that two nurses had completed dressing changes on a specific date, but both nurses confirmed in interviews that they had not performed the care, and the treatment nurse stated the dressing had not been changed since two days prior. The administrator acknowledged that staff should not sign for care not provided.
Failure to Protect Resident Health Information During Communication
Penalty
Summary
A deficiency occurred when a nurse used a personal, non-secure phone to text a resident's name and medical information to the Nurse Practitioner, rather than using a secure and private communication method. The nurse was not aware that this was a violation of privacy protocols, as he had not received training on secure communication or been informed of any secure messaging application available for use. The interim Director of Nursing confirmed that the facility did not have a HIPAA-compliant secure messaging system in place and that staff were expected to call and verbally communicate with the Nurse Practitioner when necessary. The incident involved a resident who had recently been admitted after hospitalization and had a gastrostomy tube placed. The nurse became involved when the resident experienced bleeding from the gastrostomy tube site and, unable to find medical history or orders in the electronic record, attempted to contact the former DON without success. Out of concern for the resident and a lack of guidance on secure communication, the nurse texted the resident's information to the Nurse Practitioner. This action resulted in a failure to protect the privacy and confidentiality of the resident's medical records.
Failure to Ensure Professional Standards in Medication Administration and Resident Admission
Penalty
Summary
The facility failed to ensure that nursing staff met professional standards of quality in the care of newly admitted residents and in the administration of medications. In one instance, a nurse was not informed that he was responsible for a newly admitted resident with multiple complex medical conditions, including diabetes, congestive heart failure, and a gastrostomy tube. As a result, the nurse did not reconcile or administer the resident's medications as ordered, nor did he check the resident's blood sugar or review the resident's medical history upon admission. The nurse only became aware of the resident's presence and his responsibility for the resident after being called to address bleeding at the gastrostomy site later in the evening. The electronic medical record did not provide access to the necessary orders or hospital discharge summary, further impeding care. The resident did not receive several scheduled medications, including Atorvastatin, Alprazolam, Gabapentin, and Carvedilol, and there was no documentation of required blood sugar checks on the night of admission. Additionally, the facility failed to ensure that nurses were knowledgeable about a newly admitted resident's medical history and could access this information when assigned to the resident. Both the evening and night shift nurses reported being unable to view the resident's orders or hospital discharge summary in the electronic system, resulting in incomplete care and lack of medication administration. The nurse practitioner confirmed that the lack of a blood sugar check the night before did not directly impact the resident's blood sugar control the following day, but the documentation and communication failures were evident. In a separate incident, another resident with Parkinson's disease did not receive a scheduled dose of carbidopa-levodopa, a medication ordered to be administered every four hours. The medication administration record showed that one dose was missed, and the resident reported experiencing increased tremors and some confusion as a result. The nurse aide was informed by the resident about the missed dose but did not communicate this to the nurse, assuming the nurse would administer the medication. The nurse later stated that the medication was given late due to unfamiliarity with the hall and the resident's room location. The director of nursing and administrator were unaware of the missed dose until after the fact.
Failure to Administer Enteral Feedings as Ordered for Tube-Fed Resident
Penalty
Summary
A diabetic resident with severe dysphagia, recurrent pneumonia, and a newly placed gastrostomy tube was admitted to the facility following hospitalization for multiple acute conditions. Upon admission, medical orders were entered for enteral feedings via PEG tube at specific intervals, with corresponding water flushes before and after each feeding. However, documentation on the Medication Administration Record (MAR) showed that none of the scheduled enteral feedings were administered on the day of admission, and there was no indication that the resident received any nutrition as ordered. Interviews with staff revealed significant communication and documentation failures. The interim DON, who was the Unit Manager at the time, stated that orders were entered and that a nurse was assigned responsibility for the resident. However, the assigned nurse reported he was not informed about the resident's admission or his responsibility for the resident, and only became aware of the situation when called to address bleeding at the gastrostomy tube site. He was unable to locate the resident's orders or discharge summary in the electronic record and did not administer the enteral feeding. The nurse on the following shift also could not access the necessary orders or discharge summary and did not provide the enteral feeding, though she did perform tube flushes as prompted by the MAR. On the day after admission, a new order for enteral feeding was entered with revised administration times. The MAR indicated that only two feedings were documented as given that day, rather than the four scheduled. The medication aide confirmed that she only called the covering nurse to administer the enteral feeding twice, as those were the only times flagged on the MAR. There was no documentation of hypoglycemic episodes during this period, but the resident did not receive enteral feedings as ordered for two consecutive days.
Failure to Administer Prescribed Antibiotic Doses as Ordered
Penalty
Summary
A deficiency occurred when staff failed to administer four doses of a prescribed antibiotic, Amoxicillin-Potassium Clavulanate 875 mg, as ordered by the physician for a resident with a bacterial infection of a pressure wound. The resident, who was cognitively impaired and dependent on staff for all activities of daily living, had a care plan in place to prevent infection and required medications to be administered as ordered. The physician had performed a debridement on the resident's right hip pressure wound and ordered the antibiotic to be given every 12 hours. The Medication Administration Record (MAR) indicated that all scheduled doses were documented as administered, but a review of the medication package revealed discrepancies between the number of tablets remaining and the number of doses signed off as given. Interviews with staff and review of the medication supply confirmed that the number of antibiotics on hand did not reconcile with the MAR documentation. The facility was unable to identify any other source from which the medication could have been obtained, and there were no other residents receiving the same antibiotic at the time. The expectation was that the number of tablets administered should match the number removed from the resident's supply, but this was not the case, indicating that four doses were not administered as ordered.
Burnt Toast Served to Resident Due to Dietary Department Issues
Penalty
Summary
A deficiency occurred when a resident, who was moderately cognitively impaired and on a regular diet, was served a piece of toast that was approximately 75% blackened and burnt. The resident was observed with the burnt toast on her plate during breakfast, and although she considered eating it, her roommate intervened, suggesting she should not eat it. The issue was brought to the attention of the Administrator, who confirmed the toast should not have been served. The Dietary Manager and Regional Corporate Dietary Manager explained that new staff and a broken oven had contributed to challenges in meal preparation and timely service, which led to the burnt toast being served to the resident.
Failure to Accommodate Non-Verbal Resident's Dietary Preferences Due to System and Communication Issues
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with dementia, protein calorie malnutrition, moderate cognitive impairment, highly impaired hearing, and non-verbal status received meals that accommodated her preferences and needs. The resident communicated through writing, sign language, and a communication board, but staff did not attempt to communicate with her to offer menu options. On multiple occasions, the resident was served a peanut butter and jelly sandwich as her main entree, while other residents received meat-based entrees such as hamburger steak, chicken fried steak, or lasagna. Although alternate entrees like thyme chicken and egg salad sandwich were available and listed on the menu, these were not offered to the resident. The facility's dietary electronic system was programmed to track likes and dislikes, but due to a long list of beef dislikes for the resident, the system defaulted to providing a peanut butter and jelly sandwich as an alternative when beef was served. The system did not indicate that other available entrees should be offered, and the peanut butter and jelly sandwich, intended as a supplement, was incorrectly served as the main entree. The resident's responsible party confirmed ongoing issues with staff communication regarding food choices and clarified that the sandwich was meant to supplement, not replace, the main entree. Staff interviews confirmed the system's limitations and the lack of direct communication with the resident regarding her meal preferences.
Failure to Coordinate Timely Hospice Pain Management for Resident with Wound Infection
Penalty
Summary
The facility failed to ensure effective communication and coordination of care with the hospice provider for a resident with advanced dementia, cerebral infarction, malnutrition, and immunodeficiency who was receiving hospice services. The resident developed a wound infection, and the wound physician performed an incision and drainage, recommending pain medication stronger than acetaminophen. However, the wound physician did not prescribe additional pain medication, citing the resident's hospice status, and deferred to hospice for pain management. Nursing staff attempted to contact the hospice provider's on-call services on two consecutive days to request an evaluation for stronger PRN pain medication, but no hospice nurse responded or visited the facility during that period. Documentation from the hospice provider indicated no record of calls from the facility during the relevant dates. The resident continued to receive only acetaminophen for pain, despite documented severe pain during dressing changes, as assessed by nursing staff using a behavioral pain scale. It was not until several days later that a hospice nurse visited, assessed the resident, and ordered morphine and Ativan for pain and anxiety management. The lack of timely communication and coordination between facility staff and the hospice provider resulted in a delay in appropriate pain management for the resident, contrary to the care plan interventions and the facility's agreement with the hospice provider.
Failure to Maintain Kitchen Oven Delays Meal Delivery
Penalty
Summary
The facility failed to maintain essential kitchen equipment in working order, specifically one of two kitchen ovens, which resulted in difficulties with timely meal delivery. The issue with the oven began in early September and persisted for over a month, during which time only one oven was operational. The Dietary Manager reported that a work order was believed to have been submitted, but maintenance coverage was inconsistent, and the first documented work order was not entered until mid-September. Maintenance staff confirmed that the oven was not functioning due to a power issue and a non-operational fan, and that troubleshooting was delayed by staff schedules and corporate holidays. During this period, dietary staff had to use a single oven to prepare multiple items, leading to complaints about late meal trays, particularly on the last hall to receive trays. Attempts to repair the oven involved purchasing supplies and seeking assistance from vendors, but miscommunication and scheduling issues with vendors further delayed repairs. The first vendor was unable to service the specific oven model, and subsequent appointments with a second vendor were repeatedly rescheduled. When the vendor was finally able to assess the oven, it was determined that the cost of repair was not justified compared to replacement. Throughout this time, the facility struggled to maintain scheduled meal delivery due to the lack of a fully functional kitchen oven.
Failure to Ensure Timely Acquisition, Administration, and Accounting of Resident Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of residents by not ensuring the timely acquisition, dispensing, and administration of medications for three residents. For one resident, multiple essential medications, including those for hyperlipidemia, atrial fibrillation, diabetes, neuropathy, and pain, were not administered upon admission and for several days thereafter. The missed doses were due to a combination of factors: the admitting nurse did not have access to the emergency medication supply, pharmacy cut-off times delayed delivery, and a required prescription for a controlled substance was not obtained until several days after admission. Documentation on the Medication Administration Record (MAR) showed repeated missed doses, and interviews with staff revealed confusion about procedures for accessing backup medications and obtaining necessary prescriptions. Another resident was readmitted to the facility from another rehabilitation center and did not receive newly ordered medications, including a blood pressure medication and an antibiotic, for several days after readmission. The nurse on duty did not reconcile the new transfer orders with existing orders in the electronic system, resulting in a failure to order and administer the required medications. The pharmacy also delayed dispensing an antibiotic due to a potential drug interaction and the need for staff consultation, further contributing to missed doses. Documentation and interviews confirmed that the resident missed several scheduled doses of both the blood pressure medication and the antibiotic before they were finally administered. A third resident supplied her own medication from home, but the facility failed to maintain an effective system for accounting for this medication. The resident's home-supplied medication was not administered during her stay, and upon discharge, she was given another resident's medication in error. The resident reported the issue to facility management, but her medication was not returned, and she remained in possession of another resident's medication. Staff interviews confirmed a lack of documentation and tracking for medications brought in by residents, and the Director of Nursing acknowledged that procedures for handling such medications were not followed.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, both of whom experienced missed or delayed administration of critical medications. One resident, with diagnoses including chronic atrial fibrillation, diabetes, and neuropathy, was admitted in the late afternoon and did not receive her scheduled doses of apixaban (an anticoagulant), Lantus insulin, and pregabalin (for neuropathy) on the evening of admission. The nurse on duty did not have access to the facility’s back-up medication supply and was waiting for pharmacy delivery, which did not arrive that night. The resident’s blood sugar was elevated the following morning, and she reported not receiving her neuropathy medication for several days, which was confirmed by multiple missed doses documented in the MAR over the next four days. The pregabalin was not administered until a new prescription was obtained several days after admission, as the pharmacy required a prescription for this controlled substance and none was provided at admission. Multiple staff interviews revealed that nurses were unable to access the emergency medication supply due to lack of a prescription and that communication lapses occurred between nursing staff, the pharmacy, and the prescribing providers. The facility’s pharmacy had a cutoff time for medication orders, and the initial orders for the resident’s medications were received after this cutoff, resulting in further delay. The facility’s NP and physician confirmed that the prescription for pregabalin was not written until several days after admission, and the pharmacy did not receive the necessary order to dispense the medication until then. The resident missed a total of eight doses of pregabalin before it was finally administered. A second resident was readmitted to the facility after a hospital and short-term rehabilitation stay, with transfer paperwork indicating an active order for the antibiotic linezolid to treat a urinary tract infection. Upon readmission, the nurse on duty did not reconcile the new orders and continued administering medications from the resident’s previous stay, missing the new antibiotic order. The antibiotic was not ordered at the facility until the following day, and further delays occurred due to a pharmacy backorder and the need to resolve a potential drug interaction. As a result, the resident missed three scheduled doses of linezolid before receiving the first dose. Staff interviews confirmed that the missed doses were due to lack of order reconciliation, pharmacy delays, and communication issues.
Failure to Provide Consistent Access to Clean Linens for Resident Care
Penalty
Summary
The facility failed to ensure a consistent supply of clean linens for residents, resulting in two cognitively intact residents experiencing a lack of necessary linens for bathing. On the morning in question, one resident was unable to bathe before leaving for an outside appointment due to the absence of washcloths and towels, and instead had to use a wet incontinent wipe. Multiple nurse aides confirmed that the shortage of linens was a recurring issue, occurring as frequently as once to three times per week, and that on the day in question, there were no linens available from approximately 7:00 AM to 9:30 AM. The aides also reported checking with the laundry department, which was unable to provide additional linens during this period. The Housekeeping Director described the facility's laundry process, which involved leaving wet linens in the washing machines overnight due to the absence of staff after 7:00 PM, resulting in linens not being dried and available for use until after 7:00 AM the next day. Nurse aides were responsible for retrieving linens for their carts after 8:30 AM, but there was an expectation that leftover linens from the previous day would suffice until then. However, both staff and residents reported that linen shortages were common, and the Housekeeping Director acknowledged that hoarding of linens by staff and residents sometimes contributed to the problem. The facility administrator was unaware of the specifics of the linen distribution process and the timing issues that led to the deficiency.
Failure to Seal Entry Points and Maintain Effective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program by not repairing and sealing holes and gaps that allowed pests to enter a resident's room and common areas. A cognitively intact resident reported ongoing issues with roaches in her room, despite repeated pest control treatments. Observations confirmed a visible gap under the heating and air unit in her room, missing caulk, and a hole in the bathroom drywall around a water pipe, all of which were unsealed and provided entry points for pests. Facility records and pest control logs documented multiple instances of ants and roaches found in the resident's room over several months. Staff interviews corroborated the presence of live and dead roaches in the room and bathroom, with reports that the resident often left open snacks, which could attract pests. The Maintenance Director acknowledged being aware of the pest issues and the need to seal entry points but cited being too busy to complete all necessary repairs, as he was responsible for all maintenance with only part-time assistance. Further inspection revealed that several common area exit doors also had visible gaps due to worn or missing weather stripping, allowing light and potentially pests to enter from outside. The pest control technician confirmed that effective pest management required sealing these gaps and had communicated the need for repairs to the Maintenance Director. However, not all areas identified as needing sealing were addressed, and the Administrator was not fully informed of all required repairs, contributing to the ongoing pest problem.
Failure to Label and Date Leftover Food in Walk-In Refrigerator
Penalty
Summary
The facility failed to label and date leftover food items stored in the walk-in refrigerator, which was observed during a survey. The observation revealed several containers with various food items, including corn, rice, marinara sauce, biscuit gravy, tuna salad, cooked ham, fruit cocktail, and sliced peaches, all without labels or dates. The Assistant Dietary Manager confirmed the lack of labeling and dating, stating it was the cooks' responsibility to ensure all leftover food items were properly labeled and dated when placed in the refrigerator. Interviews with the staff revealed a breakdown in communication and responsibility. The cook on duty on 11/23/24, from 5:30 AM to 1:00 PM, acknowledged it was her responsibility to label and date the food but left the task to the afternoon cook, who did not complete it. The afternoon cook, who worked from 1:00 PM to 7:30 PM, admitted he did not check the refrigerator for labeling and dating due to being occupied with cooking and cleaning. The Dietary Manager and the Administrator both confirmed that all leftover food should be labeled and dated, and any unlabeled food should be discarded, indicating a failure in following established procedures.
Inaccurate MDS Coding for Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the area of medication. Resident #2 was administered aspirin, an antiplatelet medication, during the look-back period of her quarterly MDS assessment. However, the MDS did not reflect this medication use. The MDS Nurse acknowledged the error, attributing it to a possible interruption during the coding process. Both the Director of Nursing and the Administrator confirmed that MDS assessments should accurately reflect the medications residents are receiving. Similarly, Resident #17's quarterly MDS assessment failed to include the use of furosemide, a diuretic medication, which was administered during the look-back period. The MDS Nurse admitted to not noticing the administration of furosemide, resulting in an inaccurate coding of the medication section. The Director of Nursing and the Administrator reiterated the importance of accurate MDS assessments in reflecting the medications administered to residents.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility failed to invite residents to care plan meetings, as evidenced by the cases of three residents who were cognitively intact and not included in their care planning process. Resident #40, admitted with diagnoses including stroke, anemia, and hypertension, had a care plan initiated and revised but was not invited to any care planning meetings until a scheduled meeting on 11/26/24. The Social Worker confirmed the absence of previous meetings and stated that care planning meetings should occur quarterly. Similarly, Resident #16, with diagnoses of hypertension and Alzheimer's disease, was not invited to care planning meetings despite being cognitively intact. The resident's representative confirmed attending only one meeting via telephone, and the Social Worker noted that meetings were held without the resident's participation. Resident #79, diagnosed with stroke, diabetes, and hypertension, also did not recall being invited to any care planning meetings. The Social Worker confirmed that meetings were held without the resident or their representative, contrary to the facility's expectations for quarterly meetings and inclusive attendance.
Medication Administration Errors Lead to 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate of less than 5%, resulting in an 8% error rate during a medication pass observation. This deficiency involved a nurse who did not prime an insulin pen before administering a dose to a resident with diabetes mellitus. The manufacturer's instructions for the Humalog insulin pen require priming to ensure proper function, but the nurse misunderstood this process, believing it was only necessary to set the dose. This misunderstanding led to the incorrect administration of insulin to the resident. Additionally, the same nurse administered an incorrect dosage of Acetaminophen to the resident, who had idiopathic peripheral autonomic neuropathy. The resident requested two tablets for pain, contradicting the physician's order of one 500 mg tablet every six hours as needed. The nurse complied with the resident's request without verifying the order with the physician, resulting in a medication error. The Director of Nursing confirmed that staff are expected to follow physician orders and should have clarified any discrepancies with the physician.
Failure to Perform Hand Hygiene During Meal Delivery
Penalty
Summary
The facility failed to adhere to its infection control policy when a Nurse Aide (NA) did not perform hand hygiene during meal delivery and setup. Specifically, NA #1 was observed sanitizing her hands before removing a meal tray from the delivery cart but failed to perform hand hygiene after entering a resident's room, adjusting the bed, and handling bed linens. This lapse occurred despite the presence of hand sanitizing dispensers on the hall and the facility's policy emphasizing hand hygiene as the primary means to prevent infection spread. The incident was observed during a lunch meal tray delivery service on the 100 Hall, where NA #1 was seen handling multiple items in a resident's room without sanitizing her hands afterward. This action was contrary to the facility's hand hygiene policy, which requires hand hygiene after contact with objects in the vicinity of a resident. Interviews with the NA, the facility's Infection Preventionist, and the Director of Nursing confirmed that the NA was aware of the hand hygiene requirements but failed to comply due to moving too quickly and forgetting.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to provide adequate discharge planning for a cognitively intact resident who was admitted for short-term rehabilitation with the goal of returning to her previous residence in the community. The resident, who had spinal stenosis and a history of stroke, was admitted following a hospital discharge with recommendations for rehabilitation therapy. Despite her initial agreement to the rehabilitation plan, the resident expressed dissatisfaction with the facility and a preference to receive therapy at home. However, her requests to return home were not addressed, and no discharge plan was documented in her care plan. The resident's dissatisfaction was known to the therapy department, but there was a lack of communication and coordination among the staff to facilitate her discharge. The social worker, who was absent due to illness during the resident's admission, did not engage with the resident upon her return. The Assistant Director of Nursing was informed of the resident's desire to leave but did not perceive any urgency. Consequently, the resident left the facility with the assistance of a friend without any formal discharge orders or documentation, and the facility was unaware of her departure until the following day. Interviews with staff revealed a breakdown in communication and responsibility for discharge planning. The social worker assumed the resident was content after being moved to a private room, and the Director of Rehabilitation believed the resident was safe to return home. The new Administrator was not informed of any issues with the resident. The facility's failure to address the resident's discharge needs resulted in her leaving against medical advice, which was later reported to the Department of Social Services, causing distress to the resident.
Failure to Timely Address Wounds and Critical Lab Results
Penalty
Summary
The facility failed to identify and treat arterial wounds on a resident's feet in a timely manner. The resident, who had a history of dementia, peripheral vascular disease, and other chronic conditions, was admitted after hip surgery. Despite a care plan directive for weekly skin checks, the resident's arterial wounds were not identified until the responsible party (RP) reported blackened toes to a medication aide, who failed to communicate this to the appropriate nursing staff. The wounds were only assessed and treated after the RP directly contacted the wound care nurse the following day. The delay in identifying the wounds led to a late consultation with a wound physician, who recommended urgent follow-up with a vascular surgeon, which did not occur before the resident's discharge. Another resident with a history of stroke, vascular dementia, and anemia experienced a critical drop in hemoglobin levels, which was not promptly addressed by the facility. A CBC ordered by the physician revealed a critical hemoglobin level, but the facility failed to follow up on the lab's attempts to communicate this result. Although a redraw was ordered, it was not completed until nine days later, during which time the resident's hemoglobin levels dropped further. The resident was eventually sent to the hospital, where he was treated for severe anemia and discharged back to the facility. The facility's failure to promptly identify and address these medical issues resulted in deficiencies in providing care according to professional standards. The lack of communication and follow-up on critical lab results and the delay in wound assessment and treatment contributed to these deficiencies. Interviews with staff and review of records highlighted gaps in the facility's processes for monitoring and responding to residents' medical needs.
Resident Leaves Facility Unnoticed Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a resident, resulting in the resident leaving the facility without staff knowledge. The resident, who was cognitively intact and had a history of spinal stenosis, lower extremity weakness, and recurrent falls, expressed a desire to return home. Despite communicating this to the Assistant Director of Nursing, no arrangements were made, and the resident left the facility with a friend's assistance. The resident's departure went unnoticed until the following day. On the evening of the resident's departure, there was a lack of communication and coordination among the staff. Nurse #2, who was responsible for the resident during the 3:00 to 11:00 PM shift, reported that the resident was present at the end of her shift. However, Nurse #5, who took over at 11:00 PM, was under the impression that the resident had been sent to the hospital. This misunderstanding was compounded by the fact that Nurse #5 did not conduct walking rounds with Nurse #2 during the shift change, which could have confirmed the resident's presence. The facility's investigation into the incident revealed inconsistencies in staff accounts and a lack of clarity regarding the resident's exact time of departure. The front door of the facility was supposed to be locked at 9:00 PM, requiring staff assistance for entry or exit, yet the resident was able to leave without being stopped. The Administrator noted that some staff members were not being honest about the events, making it difficult to determine the precise circumstances that allowed the resident to leave unnoticed.
Medication Administration Delay for New Resident
Penalty
Summary
The facility failed to ensure that a resident's medications were available for administration upon admission. Resident #9, who was admitted with diagnoses of insomnia and hyperthyroidism, did not receive her prescribed medications, Methimazole and Temazepam, on time. The Methimazole was not administered on the first day it was due, and the Temazepam was not available for the resident's first two nights at the facility. The delay in medication administration was due to several factors. The pharmacy did not receive the resident's medication orders until the day after her admission, which delayed the initial delivery. Additionally, a third-party courier attempted to deliver the medications to the wrong facility, and the error was not communicated back to the pharmacy, further delaying the delivery. The facility did not have these medications in their emergency supply, and there was no record of the facility contacting the pharmacy to inquire about the missing medications. Interviews with staff revealed that the admitting nurse did not transmit the medication orders to the pharmacy upon the resident's arrival, which contributed to the delay. The pharmacist confirmed that the facility did not keep Methimazole in their emergency supply, and the physician noted that missing one dose of Methimazole would not significantly impact the resident's condition. However, the resident expressed dissatisfaction with the facility's system for obtaining her medications promptly.
Communication Breakdown Delays Critical Lab Results
Penalty
Summary
The facility failed to ensure effective communication with the lab company, resulting in a significant delay in obtaining a critical lab result for a resident. The resident, who had a history of stroke, vascular dementia, and anemia, was ordered to have a CBC test. The initial test revealed critically low hemoglobin and hematocrit levels, but the lab's attempts to notify the facility of these results were unsuccessful due to communication issues. Subsequent attempts to redraw the blood sample were also problematic. The lab company reported that the blood sample collected was cloudy and needed to be recollected. Despite the lab's internal processes to alert the facility and schedule a redraw, there was a delay in obtaining a usable sample. The facility's records indicated that the phlebotomist had marked the sample as drawn, but there was no communication from the lab about the need for a redraw until several days later. The resident's condition was stable, and the physician was aware of the low hemoglobin levels, but the delay in obtaining a successful lab result led to the resident being sent to the hospital for severe anemia. The hospital discharge summary confirmed the diagnosis, and the resident was treated and returned to the facility. Interviews with facility staff and lab employees highlighted the communication breakdowns that contributed to the delay in addressing the resident's critical lab results.
Failure to Accurately Document Resident's Departure Against Medical Advice
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected the resident's signature on a form indicating that the resident left the facility against medical advice. This deficiency was identified for a resident who was cognitively intact and had no discharge orders. The form in question, titled 'Statement of Resident Releasing Facility from Liability Upon Leaving Facility Against Medical Advice,' contained a signature that was not clearly legible and appeared to be the resident's. However, the resident reported leaving the facility without signing any paperwork and without staff intervention. The resident stated that she left the facility with a friend after staff did not assist her in going home, and she was not questioned or asked to sign any documents upon departure. The facility did not contact her until the following day to inquire about her whereabouts. An interview with a corporate Nurse Consultant revealed that the former DON and Assistant Director of Nursing had called the resident to check on her well-being the day after she left. The Nurse Consultant acknowledged that the form should have been correctly filled out to reflect the discharge against medical advice, verified by a phone call to the resident.
Ant Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in ants being found on residents and in their rooms. Resident #1, who was cognitively impaired and visually impaired, was found with ants on his foot dressing during a dialysis session. The facility staff were aware of the ant issue but did not take immediate action to prevent ants from reaching the resident. The ants were suspected to be attracted by food spills due to the resident's blindness. Despite the facility's awareness of the problem, the ants were not found in the resident's room when checked by staff, indicating a lack of thorough inspection and monitoring. Another resident, Resident #15, who was also cognitively and visually impaired, experienced ants crawling on him while in bed. The ants were reported by a nurse aide, who noted that the resident could feel them crawling on his arm. The resident's room was cleaned and treated, but the presence of ants persisted. Additionally, Resident #16 reported ants in his room and bed, which the facility was attempting to address. The resident noted that the ants crawled up the bedspread, suggesting inadequate measures to prevent ants from accessing the bed. The facility's pest control records indicated that the pest control technician had been servicing the facility regularly, but the ant problem persisted. The technician suspected that ant colonies were located under the building's slab and were traveling to different rooms. The technician's approach involved baiting the ants to eradicate the colonies, but this method required time to be effective. Despite ongoing pest control efforts, the facility failed to implement immediate measures to prevent ants from reaching residents, leading to multiple incidents of ants being found on residents and in their rooms.
Failure to Timely Refer Resident with Basal Cell Carcinoma to Dermatologist
Penalty
Summary
The facility failed to follow through with a referral to a dermatologist for a resident diagnosed with basal cell carcinoma. The resident, who was cognitively intact, had been under the care of a Wound Physician who identified the carcinoma and recommended treatment with 5% 5-fluorouracil cream. Despite the initial response to the treatment, the Wound Physician repeatedly noted the need for a dermatology consultation, which was not arranged in a timely manner. The resident's lesion was initially mistaken for a pressure sore, and it was only after a biopsy confirmed basal cell carcinoma that the appropriate treatment was initiated. Over several months, the Wound Physician documented the lesion's progress and consistently advised that a dermatology appointment was necessary. However, the appointment was not scheduled until months later, leading to a delay in specialized care. Interviews with facility staff revealed a breakdown in communication and responsibility for scheduling the dermatology appointment. The Administrator and Wound Physician acknowledged the oversight, with the Wound Physician expressing a desire for a second opinion from a dermatologist. The delay in arranging the appointment was attributed to a failure in passing the necessary information to the person responsible for scheduling, resulting in a significant lapse in the resident's care.
Failure to Account for Oxycodone Delivery
Penalty
Summary
The facility failed to ensure accurate accounting for the dispensing and receipt of 15 tablets of Oxycodone for a resident. The resident was admitted to the facility and had an order for Oxycodone 5 mg every four hours as needed for pain. The medication was reported by the pharmacy as delivered, but the facility could not definitively confirm its receipt. Nurse #7, who was on duty during the initial delivery attempt, reported that the Oxycodone was not delivered during the routine delivery and had to be ordered for special early delivery. However, the medication was still not available the following day, prompting further investigation. The investigation revealed discrepancies in the delivery and receipt process. A packing slip from the pharmacy indicated that 15 tablets of Oxycodone were delivered and signed for by Nurse #4, but the signature was illegible and Nurse #4 denied receiving or signing for the medication. Nurse #5, who was present during the delivery, signed for a package that did not specify its contents and later forgot about it. The facility's investigation could not locate the missing Oxycodone, and the pharmacy's records showed that the medication was delivered, but the facility's records did not match. Interviews with the pharmacy director and the facility's DON highlighted issues with the courier service used for medication delivery. The courier service's process involved obtaining a nurse's name from their badge and rushing them to sign electronically, which may have contributed to the discrepancy. The facility identified a problem with their system for recording the receipt and disposition of controlled drugs, which led to the inability to reconcile narcotic records with pharmacy records.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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