Crown Haven Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 620 Tom Hunter Road, Charlotte, North Carolina 28213
- CMS Provider Number
- 345388
- Inspections on file
- 26
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Crown Haven Health And Rehabilitation during CMS and state inspections, most recent first.
A resident was not properly assessed or prepared for transfer or discharge, and the facility did not ensure that the process met the resident's needs and preferences, resulting in a deficiency in care planning and transition.
A resident with a history of alcohol dependence and other mental health diagnoses was prescribed Chlordiazepoxide HCl for alcohol withdrawal, but the facility did not obtain or document written informed consent for this medication. Although staff and the Medical Director discussed the treatment plan and side effects with the resident and a family member, no signed consent form was found in the medical record, and the resident did not recall agreeing to the treatment.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care.
A resident with end stage renal disease, encephalopathy, and diabetes, requiring dialysis and insulin, did not have a comprehensive care plan addressing dialysis, ADL functioning, or insulin use. The omission occurred due to an oversight during a transition in MDS nursing staff, resulting in the resident's needs not being fully addressed in the care plan.
Surveyors identified deficiencies in medication management, including failure to transcribe a hospital discharge order for lorazepam gel for a resident with anxiety, improper administration practices when a nurse prepared to give Metoprolol to a resident with a low heart rate without provider notification, and failure to remove a lidocaine patch as ordered for a resident with chronic pain. These lapses involved multiple staff and resulted in noncompliance with professional standards of care.
Two residents who were assessed as safe smokers routinely kept their smoking materials and lighters in their rooms and personal belongings, despite the facility's policy requiring these items to be secured in assigned lockers. Staff and smoking monitors reported ongoing non-compliance and difficulty enforcing the policy, with residents refusing to use the lockers and staff reluctant to confront them. Facility leadership and staff were aware of the persistent issue, which was confirmed through observations and interviews.
A resident reported a suspected sexual assault, but the facility failed to conduct a thorough investigation as per its abuse policy. The investigation lacked signed statements, resident interviews, and skin assessments. No staff members were suspended during the investigation, despite a male nurse aide being on duty during the alleged incident.
A facility failed to ensure staff donned appropriate PPE before entering a resident's room under transmission-based precautions. A nurse aide entered a resident's room, who was under Enhanced Barrier Precautions for a feeding tube and CRE, without wearing a gown, although gloves were worn. The aide admitted to forgetting the gown due to a busy morning, despite knowing the requirement. The DON confirmed staff awareness of PPE requirements.
A resident reported being slapped multiple times by another resident, who had a history of verbal aggression. Despite the incident, the facility did not implement a protection plan, and the aggressor was allowed to return after a hospital evaluation. The incident was reported to law enforcement, but no charges were pressed.
A cognitively intact resident reported being slapped and having her hair pulled by another resident, but the facility failed to report the incident to the state or APS, conduct an investigation, or implement protective measures. The former Administrator did not report the incident, believing it was not reportable since no physical harm occurred. The current Administrator acknowledged the incident should have been reported and investigated per policy.
A resident in a LTC facility experienced a delay in receiving incontinence care, causing her to miss a favorite activity and become emotionally distressed. Despite activating her call light and requesting assistance, the resident waited over an hour and a half before receiving care. The delay was due to the nurse aide's inability to find necessary equipment and being occupied with other tasks. The MDS Nurse eventually provided the care, but the resident was upset and crying due to the prolonged wait.
A facility failed to maintain a clean environment in a resident's room, where dried tube feeding formula was observed on the feeding tube pole and floor. Despite multiple observations, the issue was not reported or addressed by housekeeping staff. Interviews revealed that staff were instructed to report such issues to the Housekeeping Director, but this protocol was not followed.
A resident with a history of incontinence and other medical conditions waited over an hour and a half for incontinence care after activating her call light. Despite the Activity Director's attempt to locate the responsible nurse aide, the resident remained in a soiled brief until the MDS Nurse provided care. The delay prevented the resident from attending a bingo activity, highlighting a deficiency in the facility's care provision.
A resident dependent on tube feeding was not administered the prescribed continuous feeding due to an oversight by a nurse. The resident's feeding tube was not restarted after a replacement, leaving the resident without necessary nutrition for most of the day. The Medical Director and Registered Dietitian confirmed the importance of continuous feeding for the resident's condition.
A resident with a PICC line did not have their dressing changed as ordered by the physician, despite documentation indicating otherwise. Observations showed the dressing had not been changed since its insertion, and the responsible nurse admitted to not performing the task. The DON confirmed the oversight, and the Medical Director highlighted the risk of infection due to this failure.
A resident with a tracheostomy in an LTC facility did not receive oxygen at the prescribed rate, and the oxygen concentrator was found dirty with a dusty filter. Staff interviews revealed confusion over cleaning responsibilities, with the nurse unaware of who should clean the equipment. The DON confirmed no cleaning schedule existed, and the resident could not adjust the oxygen settings, indicating a lapse in care.
A facility failed to maintain accurate medical records when a nurse documented changing a PICC line dressing for a resident, despite observations showing the dressing had not been changed as ordered. The nurse admitted to not performing the dressing change and assumed it had been done based on the date on the dressing. The DON confirmed the discrepancy and expressed disappointment in the inaccurate documentation.
Failure to Ensure Safe and Individualized Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not followed, resulting in a deficiency related to resident care planning and transition.
Lack of Documented Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to document that a resident was informed in advance of the risks and benefits associated with the use of Chlordiazepoxide HCl, a psychotropic medication prescribed for alcohol withdrawal. The resident, who had diagnoses including anxiety, depression, and alcohol dependence, was cognitively intact and had a history of leaving the facility to consume alcohol. Following an incident where the resident left to drink alcohol, the Medical Director, along with the DON and a family member via phone, discussed a treatment plan involving Chlordiazepoxide HCl. The medication was ordered in a tapered dose over five days, and monitoring for alcohol withdrawal symptoms was implemented per physician's orders. Despite evidence of verbal education and discussion about the medication's side effects and treatment plan, there was no written consent form for Chlordiazepoxide HCl in the resident's electronic medical record. Consent forms for other psychotropic medications were present and signed, but not for Chlordiazepoxide HCl. Interviews with the resident, Medical Director, DON, and Administrator confirmed that the resident did not sign any documentation agreeing to the treatment, and the resident did not recall consenting to the medication. This lack of documented informed consent constituted the deficiency identified during the survey.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan for a resident with multiple complex medical needs, including end stage renal disease, encephalopathy, and diabetes. The resident required supervision to total assistance with activities of daily living (ADLs), was receiving dialysis three times a week, and had physician orders for insulin administration before meals and at bedtime. Despite these needs being identified in the Minimum Data Set (MDS) and Care Area Assessment (CAA), a review of the resident's electronic medical record and care plan revealed that there were no care plan interventions in place for insulin use, behaviors, dialysis, or ADL functioning as of the review date. Interviews with facility staff indicated that the initial baseline care plan was completed by staff nurses, while the comprehensive care plan was the responsibility of the MDS nurses. Due to a transition in MDS nursing staff, the comprehensive care plan for this resident was overlooked and not completed within the required timeframe. Both the MDS nurse and the Director of Nursing acknowledged that the comprehensive care plan should have addressed all of the resident's needs and been completed appropriately.
Failure to Adhere to Professional Standards in Medication Management
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in three separate cases involving medication management and adherence to physician orders. In the first case, a resident with end stage renal disease, depression, and diabetes was admitted with a hospital discharge summary that included an order for lorazepam gel to be applied topically every 24 hours as needed for anxiety. Despite this, the lorazepam gel was not transcribed into the electronic medical record (EMR) or the medication administration record (MAR) from the time of admission until over two months later. Interviews revealed that both the admitting nurse and the Director of Nursing expected the medication to be processed and clarified with the provider if there were questions, but this did not occur, resulting in the omission of the medication from the resident's regimen. In the second case, a resident with hypertension and a history of cerebral infarction had an active order for Metoprolol, a medication that lowers heart rate and blood pressure. During medication administration, a nurse prepared to give Metoprolol to the resident despite a recorded heart rate of 46 beats per minute, which is below the normal range. The nurse did not have parameters to hold the medication and was unaware that Metoprolol should not be administered with a low heart rate unless directed by a provider. The nurse practitioner intervened before administration, instructed the nurse to hold the medication, and subsequently wrote an order to clarify the parameters for holding Metoprolol. In the third case, a resident with severe pain and a left knee contracture had a physician's order for a lidocaine patch to be applied in the morning and removed at bedtime. Observation revealed that the patch was not removed at bedtime as ordered, and the nurse responsible had documented its removal without actually performing the task. The nurse later could not recall if the patch had been removed, and the Director of Nursing confirmed that the order was not followed. These incidents demonstrate failures in medication transcription, administration, and adherence to physician orders for multiple residents.
Failure to Enforce Smoking Materials Storage Policy
Penalty
Summary
The facility failed to implement its smoking policy regarding the storage of smoking supplies for two residents who were assessed as safe smokers. The facility's policy required that all smoking materials and incendiary devices, such as lighters and cigarettes, be secured by the facility and not stored in residents' rooms. Despite this, both residents kept their smoking supplies in their personal spaces, such as bedside drawers and backpacks, and routinely carried them into and out of the facility without staff intervention. One resident, who was cognitively intact and independent in most activities of daily living, was observed keeping his cigarettes and lighter in his shirt pocket and bedside dresser, contrary to the facility's policy. Staff interviews revealed that although the resident was aware of the smoking agreement, he had never been told he could not keep supplies in his room. The staff responsible for monitoring smoking compliance reported difficulty enforcing the policy, as residents resisted using the assigned lockers for their smoking materials and staff were reluctant to confront them due to fear of negative reactions. Another resident, who had incomplete paraplegia and required maximum assistance with most activities of daily living, also kept his cigars and lighter in his room and in his backpack attached to his power wheelchair. Multiple staff members confirmed that this resident did not comply with the policy and managed his own smoking supplies. The facility had attempted to enforce the policy but was unsuccessful, as the resident refused to relinquish his smoking materials and declined to sign the smoking agreement. Facility leadership and staff acknowledged ongoing non-compliance with the smoking policy among residents, with several interviews indicating that the issue was persistent and difficult to manage.
Failure to Implement Abuse Policy Following Allegation
Penalty
Summary
The facility failed to implement its abuse policy effectively following an allegation of sexual assault involving a resident. The policy required a thorough investigation and protective measures, including interviewing all potential witnesses, securing physical evidence, and providing emotional support to the resident. However, the investigation was incomplete, lacking signed statements from staff, resident interviews, and skin assessments. The facility did not suspend any suspect staff members during the investigation, as required by their policy. The incident involved a resident who was cognitively intact and reported feeling pain in her lower abdomen and upper thigh area, suspecting sexual assault while she was asleep. The resident mentioned the incident during a pre-operation appointment, leading to her being sent to the emergency room for a sexual assault exam. The facility was informed of the allegation by the hospital staff, not by the resident directly, and began their investigation afterward. Interviews with staff, including the Unit Manager, Social Worker, and Director of Nursing, revealed inconsistencies and a lack of documentation in the investigation process. The staff did not recall specific details of the investigation, and no male staff members were suspended, despite the presence of a male nurse aide on duty during the alleged incident. The investigation folder lacked comprehensive documentation, and the facility's response did not align with their established abuse policy.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that appropriate Personal Protective Equipment (PPE) was donned by staff before entering a resident's room under transmission-based precautions. Specifically, Nurse Aide #1 entered the room of a resident who was under Enhanced Barrier Precautions (EBP) due to a feeding tube and carbapenem-resistant enterobacterales (CRE) without wearing a gown, although gloves were worn. The facility's policy required both gown and glove use during high resident care activities, which were not adhered to in this instance. During an interview, Nurse Aide #1 acknowledged the requirement to wear a gown and gloves under EBP but admitted to forgetting to don a gown due to a busy morning. The Director of Nursing (DON) confirmed that all staff were aware of the precautions and PPE requirements posted on residents' doors, despite the recent departure of the Assistant Director of Nursing who previously oversaw infection control education.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, as evidenced by an incident involving two residents. Resident #8, who was cognitively intact and required assistance for daily activities, reported being slapped multiple times by Resident #7, who also exhibited verbal aggression. Resident #7, diagnosed with schizophrenia and diabetes, had a history of verbal behavioral symptoms. The incident occurred when Resident #7 exited the smoking courtyard and encountered Resident #8, leading to physical aggression. Following the incident, Resident #8 reported the assault to Nurse #1, who noted that Resident #8 was in stable condition with no injuries. The Unit Manager was informed, and law enforcement was called, although Resident #8 declined to press charges. Resident #7 was sent to the hospital for evaluation and returned the same night. Despite the incident, the former Administrator did not consider it a reportable event or one requiring a protection plan, as no physical harm was observed. Interviews with staff, including the Social Worker and Activity Director, confirmed that Resident #8 was upset but did not wish to press charges. Attempts to interview Resident #7 and the Director of Nursing were unsuccessful. The facility's response to the incident, including the lack of a protection plan and the decision to allow Resident #7 to return, highlights the deficiency in safeguarding residents from abuse.
Failure to Implement Abuse Policy Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to implement its abuse policy in the areas of reporting, investigating, and protection following an allegation of resident-to-resident abuse. The incident involved a cognitively intact resident who reported being slapped and having her hair pulled by another resident. Despite the report, the facility did not notify the state agency or Adult Protective Services (APS), and no investigation was conducted. The facility's policy required the Abuse Coordinator or designee to investigate all allegations, take statements, secure evidence, and prepare a detailed report, none of which were completed in this case. Additionally, the facility did not implement any protective measures to prevent further potential abuse. The resident who reported the abuse was not injured, and the perpetrator was temporarily removed for a hospital evaluation but returned the same day. Staff interviews revealed a lack of communication and action from management, with no instructions given for increased supervision or protection. The former Administrator did not report the incident, believing it did not qualify as reportable since no physical harm occurred. The current Administrator, unaware of the incident, acknowledged that it should have been reported and investigated per the facility's policy.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, resulting in the resident missing a favorite activity and experiencing emotional distress. The resident, who was admitted to the facility in 2015, had a care plan indicating bowel and bladder incontinence and depressive episodes. On the day of the incident, the resident activated the call light at 1:47 PM, requesting assistance from a nurse aide for incontinence care before attending a bingo activity scheduled for 2 PM. However, the nurse aide did not return to provide the necessary care, leaving the resident in a soiled and wet brief. The Activity Director, upon noticing the resident's call light, attempted to locate the nurse aide but was unsuccessful. The Director of Nursing was informed of the situation, but the resident continued to wait for over an hour and a half before receiving care from the MDS Nurse. During this time, the resident remained in her room, missing the bingo activity and becoming upset and crying due to the delay in care. The resident expressed frustration over the inability to care for herself and the necessity of relying on staff for assistance. Interviews with staff revealed that the nurse aide was unable to find the necessary equipment to assist the resident and was occupied with other call lights. The nurse aide later apologized to the resident for the delay. The MDS Nurse confirmed that the resident's call light was on when she arrived and provided the needed incontinence care. The facility's Director of Nursing acknowledged that the delay in care was not dignified and that the resident's call light had been on for an extended period, causing distress to the resident.
Failure to Maintain Clean Environment in Resident Room
Penalty
Summary
The facility failed to maintain a clean and homelike environment in one of the resident rooms, specifically room [ROOM NUMBER], where tube feeding formula was observed dried on the feeding tube pole and the floor. Observations were made at multiple times throughout the day, revealing that the dried formula covered the pole, the base of the pole, and the floor beneath it. Despite the presence of the dried formula, it was not reported or cleaned by the housekeeping staff, leading to a deficiency in maintaining a clean environment for the resident. Interviews with the Housekeeping Director and Housekeeper #1 revealed that the housekeeping staff were instructed to report such issues to the Housekeeping Director, who would then clean the area using a specific method involving a cleaner and a scraper. However, Housekeeper #1, who was responsible for cleaning the room, stated that she did not notice any dirt during her cleaning shift and did not return to the room afterward. The Director of Nursing and the Administrator both indicated that staff members were expected to either clean such spills or report them to someone who could, but this protocol was not followed in this instance.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, leading to a deficiency in the care provided. The resident, who had a history of major depressive disorder, anxiety disorder, overactive bladder, urgency of urination, and urgency incontinence, was admitted to the facility in 2015. The resident required substantial to maximum assistance with toileting hygiene and was frequently incontinent of bladder and always incontinent of bowel. On the day of the incident, the resident turned on her call light at 1:47 PM, requesting assistance from a nurse aide for incontinence care before attending a bingo activity. Despite the resident's request, the nurse aide did not provide the necessary care in a timely manner. The Activity Director, who was informed of the resident's need, attempted to locate the nurse aide but was unsuccessful. The Director of Nursing was informed of the situation, but the resident remained in a soiled and wet brief until the MDS Nurse, who was not responsible for direct care, provided the necessary incontinence care much later. The resident expressed dissatisfaction with the delay, stating that she had to wait approximately an hour and a half for assistance, which prevented her from attending the bingo activity she enjoyed. Interviews with staff revealed that the nurse aide responsible for the resident's care was unable to find the mechanical lift needed for assistance and was occupied with other residents' needs. The nurse aide left the facility at the end of her shift without providing care to the resident, assuming the next shift would address the issue. The MDS Nurse confirmed that the resident's brief was soiled with feces and moderately wet with urine when she finally provided care. The facility acknowledged that it was unreasonable for a resident to wait over an hour and a half for incontinence care.
Failure to Administer Continuous Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feedings as ordered by the physician for a resident with a gastrostomy tube. The resident, who was dependent on tube feeding to meet nutritional needs due to a tracheostomy and other medical conditions, was observed multiple times throughout the day without the prescribed continuous tube feeding formula being administered. The feeding tube pump was present, but the formula was not hung, and an unopened bottle of formula was noted in the resident's room. Nurse #1 acknowledged the oversight, stating that the tube feeding was mistakenly not restarted after replacing a leaking gastrostomy tube earlier in the shift. Interviews with the Medical Director, Director of Nursing, and Registered Dietitian confirmed that the resident's tube feeding should have been immediately restarted once the tube was replaced and functioning. The Medical Director and Registered Dietitian emphasized the importance of continuous feeding for the resident's specific medical needs, highlighting that the resident was 100% dependent on the feeding tube for nutrition. The oversight resulted in the resident going without the necessary tube feeding for the majority of the day, contrary to the physician's orders.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to change the dressing on a peripherally inserted central catheter (PICC) line for a resident as ordered by the physician. The resident, who was admitted with osteomyelitis of a pressure ulcer and an abscess, had a PICC line inserted at the hospital prior to admission. The physician's order required the PICC line dressing to be inspected, cleaned, and changed every Thursday during the day shift. However, observations on July 1st revealed that the dressing had not been changed since June 13th, despite documentation on the Medication Administration Record (MAR) indicating that it had been changed on June 20th and June 27th. Nurse #2, who was responsible for the dressing changes, admitted during an interview that she had not changed the dressing in the last month and could not explain the discrepancy in the MAR. The Director of Nursing confirmed the oversight and acknowledged that the facility had limited experience with PICC lines. The Medical Director expressed concern about the increased risk of infection due to the failure to change the dressing as scheduled.
Deficiency in Respiratory Care for Tracheostomy Resident
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not delivering oxygen at the prescribed rate and not maintaining the cleanliness of the oxygen concentrator and its filter. The resident, who was severely cognitively impaired and dependent on a tracheostomy for oxygen, was observed multiple times with the oxygen concentrator set to 3.5 liters instead of the prescribed 4 liters. Additionally, the oxygen concentrator was found to be dirty with dried substances and dust on the filter. Interviews with staff revealed a lack of clarity regarding responsibilities for cleaning the oxygen concentrator and its filter. Nurse #1, who was responsible for the resident, confirmed the incorrect oxygen setting and acknowledged the need for cleaning the concentrator and filter. However, she was unaware of who was tasked with this cleaning duty. The Housekeeping Director and Housekeeper #1 also provided conflicting information about the cleaning responsibilities, with the Housekeeping Director stating that both nursing and housekeeping were responsible, while Housekeeper #1 indicated she was not supposed to clean the concentrator unless it was a quick wipe down. The Director of Nursing (DON) further confirmed the absence of a cleaning schedule for the oxygen concentrator and filters, and stated that night shift staff were responsible for changing the tubing. The DON also emphasized that the resident could not change the oxygen settings themselves, indicating a lapse in monitoring and maintenance of the equipment. This deficiency highlights a breakdown in communication and responsibility assignment among the staff, leading to inadequate respiratory care for the resident.
Inaccurate Documentation of PICC Line Dressing Change
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident requiring intravenous medications. Nurse #2 documented on the Medication Administration Record (MAR) that she had changed the peripherally inserted central catheter (PICC) line dressing on two occasions, as per the physician's order, which required the dressing to be changed every Thursday on the day shift. However, observations made on July 1, 2024, revealed that the dressing had not been changed since June 13, 2024, as it was noted to be rolled up at the edges with dirt particles, indicating it had not been replaced as documented. During an interview, Nurse #2 admitted that she had not changed the dressing in the last month and could not explain why she documented otherwise on the MAR. She mentioned that she assumed the dressing had been changed because it was dated for the same day she checked it. The Director of Nursing confirmed the discrepancy and expressed disappointment that Nurse #2 documented an action that was not performed, acknowledging that the dressing should have been changed according to the physician's order.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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