Dahlia Gardens Center For Nursing And Rehabilitati
Inspection history, citations, penalties and survey trends for this long-term care facility in Aberdeen, North Carolina.
- Location
- 915 Pee Dee Road, Aberdeen, North Carolina 28315
- CMS Provider Number
- 345509
- Inspections on file
- 27
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Dahlia Gardens Center For Nursing And Rehabilitati during CMS and state inspections, most recent first.
A resident with a new diagnosis of bipolar disorder and new psychotropic medication orders did not receive a required Level II PASRR evaluation. Staff interviews revealed that the MDS nurse, DON, and administrator each missed or misunderstood their roles in identifying and submitting the necessary PASRR request after the resident's mental health status changed.
A used, stained urine collection hat was found on the floor under a bathroom sink in a memory care resident's room, unlabeled and not stored in a bag. Staff were unaware of its presence and confirmed that such devices should be discarded after use or, if kept, properly cleaned, labeled, and bagged. This failure resulted in an environment that was not safe, clean, or homelike for the resident.
A resident with chronic pain and diabetes was prescribed methadone, but a card of the medication and its count sheet went missing. The issue was discovered when a refill request was denied for being too early, leading to an investigation that revealed the loss had been masked by missing documentation. The resident reported receiving all doses as ordered, and the incident was reported to law enforcement.
A resident with severe cognitive and physical impairments, fully dependent on staff for ADLs, was observed over several days with long, jagged fingernails and debris under one nail. Despite care plans requiring regular nail care and no documented refusals, staff failed to notice or address the resident's nail care needs, resulting in a deficiency.
The facility did not accurately post daily nurse staffing information, with incomplete and incorrect data regarding actual hours worked and staff numbers for both licensed and unlicensed personnel. Staff responsible for posting lacked access to necessary information and were unaware of requirements to include certain roles, resulting in discrepancies between posted and actual staffing levels.
A resident with moderately impaired cognition and a history of behavioral issues refused medications and care on several occasions, as documented in the MAR. However, the MDS assessment was not coded to reflect these refusals because the staff member responsible for this section only reviewed nurses' notes and was unsure where to find all relevant information in the medical record.
A resident with hemiplegia and other medical conditions was found to have their call light on the floor and out of reach, preventing them from requesting assistance. The resident expressed that this was a frequent issue, and a nursing assistant admitted to forgetting to check the call light's placement. The facility's administration confirmed that the call light should always be within reach.
A resident with a history of verbal aggression slapped his roommate, who was talking to himself, in a LTC facility. The incident was witnessed by a nursing assistant, who intervened and reported it to a nurse. The facility failed to protect the resident from abuse, as the altercation occurred despite existing care plans and interventions.
A nurse failed to report an incident where one resident slapped another, as she was unaware of the facility's abuse policy. The facility also delayed notifying APS due to the Administrator's unfamiliarity with local reporting requirements.
A resident with severe cognitive impairment and multiple health issues experienced significant decline, including a stage 3 pressure ulcer and notable weight loss. Despite these changes, the facility failed to complete a significant change MDS, as the MDS Nurse mistakenly completed a quarterly MDS instead. The DON and MD acknowledged the oversight and the resident's continuous decline.
An agency nurse at a LTC facility failed to report a resident-to-resident abuse incident due to a lack of prior abuse training. The nurse, who was on duty when one resident slapped another, did not notify administration as she was unaware of the facility's abuse policy. The nurse received orientation training, including the abuse policy, only after the incident occurred.
The facility failed to complete quarterly MDS assessments on time for five residents. The MDS nurse cited a high volume of admissions and discharges as the reason for the delay. The facility's Administrator and DON expected timely completion of these assessments.
The facility failed to maintain resident rooms in good repair, with observations revealing exposed sheetrock putty and a missing plank panel in some rooms. The Maintenance Director confirmed these issues but could not provide a timeline for repairs. The Administrator acknowledged the importance of a well-repaired environment and indicated that the Maintenance Director was responsible for addressing these concerns.
A facility failed to transmit an annual MDS assessment on time for a resident. The MDS nurse admitted to being behind due to a high volume of admissions and discharges, resulting in the assessment not being transmitted as required. The Administrator and DON confirmed the need for timely transmission.
A facility failed to complete a discharge MDS assessment within the required time frame for a resident. The MDS nurse admitted the delay was due to a high volume of admissions and discharges. The Administrator and DON confirmed the assessment should have been completed on time.
Two residents' MDS assessments were inaccurately coded, one for urinary status and another for upper extremity range of motion. A resident with a urinary catheter was incorrectly marked as incontinent, while another resident was mistakenly coded for limited range of motion based on a misinterpreted MD note. Staff interviews confirmed the inaccuracies.
Failure to Submit Level II PASRR Evaluation for Resident with New Serious Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was newly diagnosed with a serious mental illness. The resident was admitted with diagnoses of generalized anxiety disorder and unspecified depression, and a Level I PASRR was completed prior to admission. Subsequently, the resident was diagnosed with bipolar disorder by a psychiatrist, and new psychotropic medications were ordered and adjusted to address behaviors related to psychosis. Despite these changes, there was no evidence in the electronic medical record that a Level II PASRR screening was requested for the resident. Interviews with facility staff revealed gaps in communication and process oversight. The MDS nurse acknowledged noticing the new diagnosis and medication orders but did not recognize the need to notify the administrator for a Level II PASRR evaluation. The social worker did not have access to the state's PASRR submission system and indicated that the administrator was responsible for submitting requests. The DON believed the resident already had a Level II PASRR determination and maintained a list of residents needing screenings. The administrator confirmed she had not submitted a request for a Level II PASRR for this resident and relied on notifications from the DON and MDS nurse regarding changes in residents' conditions.
Improper Disposal and Storage of Used Urine Collection Device
Penalty
Summary
Surveyors observed a yellow-stained urine collection hat with a tissue inside lying on the floor underneath the sink in a resident's bathroom on two separate occasions. The device was not labeled with a resident's name nor stored in a bag. The resident, who resided in the memory care unit and was present in the room during both observations, was unable to confirm if the device belonged to him. Staff interviews revealed that nurse aides were unaware of the device's presence and stated that urine collection hats should be cleaned, labeled, and stored properly if intended for reuse, or disposed of after use. The unit manager and DON both confirmed that urine collection hats used for obtaining samples should be discarded after use and not left in resident bathrooms. The deficiency was identified as a failure to maintain a safe, clean, and comfortable environment for the resident by not properly disposing of or storing a used urine collection hat. The improper handling and storage of the device were attributed to staff inaction and lack of awareness, as well as a failure to follow established protocols for the disposal or storage of such items after use.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of narcotic medication, specifically methadone prescribed for pain management. The resident, who was cognitively intact and had a history of diabetes with polyneuropathy and chronic pain, was admitted with an order for methadone 10 mg three times daily. During a leave of absence, the facility sent a supply of methadone with the responsible party, and medication counts were maintained on count sheets. However, upon reconciliation of medications after the resident's discharge, it was discovered that one card of methadone and its corresponding count sheet were missing. The discrepancy was identified when a refill request for methadone was denied by the pharmacy for being too soon, prompting the nurse practitioner to notify the DON of possible drug diversion. Investigation revealed that after the last documented administration from one card, the next card and its count sheet were missing, and staff had begun using a subsequent card. The end-of-shift narcotic count appeared correct because both the medication card and count sheet were absent, masking the loss. The nurse who last handled the medication stopped coming to work once the investigation began and was subsequently terminated. Interviews with the resident confirmed she received her medication as ordered and did not experience uncontrolled pain. The pharmacy and pharmacy supervisor confirmed the facility attempted to refill the medication prematurely and that no methadone had been returned. The incident was reported to law enforcement, and the facility initiated an internal investigation. The deficiency centers on the facility's failure to prevent the misappropriation of a resident's narcotic medication, as required by policy and regulation.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
A resident with severe cognitive impairment, neurological disorder, contracture of the left arm, and vascular dementia was dependent on staff for all activities of daily living, including personal hygiene and nail care. The resident's care plan required staff to check, trim, and clean nails on bath days and as necessary, with no documented refusals of care. Despite this, multiple observations over several days revealed the resident's fingernails were long, jagged, and had a brown substance under one nail. The resident indicated a need for nail care, but there was no evidence that staff addressed this need. Interviews with direct care staff, including a nursing assistant, the DON, and a medication aide, confirmed that the resident's nails were in poor condition and that nail care was expected to be performed on shower days and as needed. Staff acknowledged they had not noticed or addressed the resident's nail care needs, and there were no documented refusals or reasons for the lack of care. The deficiency resulted from the facility's failure to provide necessary assistance with nail care for a resident who was fully dependent on staff.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information for a period of 32 consecutive days. Record review and staff interviews revealed that the posted staffing sheets were incomplete and inaccurate when compared to the actual daily staff schedules. Specifically, the total actual hours worked for each shift by Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides were left blank. Additionally, the total number of licensed and unlicensed staff listed on the postings did not match the actual number of staff working on multiple dates and shifts. The discrepancies included both underreporting and omission of staff such as wound nurses, nurse supervisors, and medication aides from the posted totals. Interviews with facility staff indicated a lack of understanding and oversight regarding the completion of the staffing sheets. The receptionist responsible for posting the information stated she did not have access to the new time clock system to calculate total hours and was unaware of the requirement to include certain staff roles in the totals. The Director of Nursing (DON) confirmed the inaccuracies and incomplete postings, acknowledging that the sheets did not reflect actual hours or correct staff numbers. The Administrator was also unaware of the deficiencies, as the DON was responsible for overseeing the task.
Inaccurate MDS Coding for Rejection of Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of rejection of care. The resident, who had a diagnosis including anxiety disorder and moderately impaired cognition, was admitted with a care plan that addressed behavior problems such as noncompliance with tube feedings and ordered oral diet. Review of the medical record and Medication Administration Record (MAR) showed that the resident refused medications and care on multiple occasions within the seven-day look-back period for the MDS assessment. Despite these documented refusals, the MDS assessment was not coded to reflect any rejection of care. Interviews with facility staff revealed that the Social Worker (SW), who was responsible for completing the rejection of care section on the MDS, only reviewed nurses' notes and did not check the MAR for refusals. The SW admitted to being unsure where to find information about rejection of care in the medical records and confirmed that the resident's refusals should have been coded on the MDS. The administrator stated an expectation for accurate MDS coding.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is necessary for the resident to request staff assistance. This deficiency was identified during an observation of a resident who was admitted with diagnoses including hemiplegia affecting the left side, requiring assistance with personal care, and type 2 diabetes mellitus. The resident was cognitively intact but dependent on staff for various activities of daily living, including toileting hygiene, transfers, and dressing. The resident's care plan specifically included interventions for staff to ensure the call light was within reach due to the resident's risk of falls and need for prompt assistance. During a continuous observation, it was noted that the resident's call bell was on the floor and out of reach while the resident was in bed. The resident expressed that the call bell often falls to the floor and staff frequently forget to place it within reach, causing him to feel uneasy. A nursing assistant confirmed that the call bell was on the floor and admitted to forgetting to check its placement after assisting the resident with lunch. The facility's administrator and director of nursing acknowledged that the call bell should always be within the resident's reach.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident where one resident slapped another resident on the side of the head. The resident who committed the act had a history of verbal aggression and poor impulse control, as noted in his care plan. Despite interventions in place to manage his agitation, the resident became agitated and struck his roommate, who was talking to himself. The incident was witnessed by a nursing assistant, who intervened and reported the event to a nurse. The resident who was slapped had a history of cerebral palsy, depression, and bipolar disorder, and his care plan noted episodes of agitation and unclear speech. The facility's response included separating the residents and initiating an investigation. However, the report indicates that the facility did not adequately protect the resident from abuse, as the altercation occurred despite the existing care plans and interventions. The administrator acknowledged the incident and noted that the residents had been considered a good match for roommates prior to the event.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy when a nurse did not report an incident where one resident slapped another. Nurse #2, who was on duty at the time, was informed by a nurse aide that Resident #19 slapped Resident #9 on the right hand/forearm. Despite separating the residents and ensuring Resident #9 was safe, Nurse #2 did not report the incident to the Administrator or other required agencies, as she was unaware of the facility's policy. The orientation training, which included the abuse policy, was signed by Nurse #2 after the incident occurred. Additionally, the facility did not notify Adult Protective Services (APS) in a timely manner regarding the abuse allegation. The Administrator submitted an initial report to the state regulatory agency but delayed notifying APS because she was unaware of the requirement to do so, having recently moved from a state with different reporting requirements. This oversight contributed to the facility's failure to adhere to its abuse policy and reporting procedures.
Failure to Complete Significant Change MDS for Resident with Decline
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) for a resident who experienced two areas of significant decline. The resident, who was admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and dementia, developed a stage 3 pressure ulcer and experienced a 9.36% weight loss over three months. Despite these changes, the MDS Nurse only completed a quarterly MDS instead of a significant change MDS, which was an oversight on her part. Interviews with the Medical Director and the Director of Nursing confirmed the resident's continuous decline and the expectation that a significant change MDS should have been completed. The Medical Director noted the resident's overall physical decline and the family's decision to opt for comfort care. The Director of Nursing acknowledged that the significant change MDS was expected due to the resident's condition, which had already been addressed in the care plan revisions.
Failure to Provide Abuse Training to Agency Nurse
Penalty
Summary
The facility failed to provide abuse training to an agency nurse, Nurse #2, before she began working at the facility. This deficiency was identified during a review of records and staff interviews. Nurse #2 was on duty during an incident of resident-to-resident abuse, where one resident slapped another. The Director of Nursing (DON) stated that Nurse #2 did not report the incident to the administration because she did not recognize it as abuse. The orientation training, which included the abuse policy, was signed by Nurse #2 after the incident occurred, indicating that she had not received the necessary training before starting her shift. Nurse #2 confirmed in a phone interview that she was unaware of the facility's abuse policy at the time of the incident. She had worked her first shift at the facility on the night of the incident and received orientation training, including the abuse policy, only after the incident had occurred. The Administrator also confirmed that Nurse #2 did not report the incident because she did not perceive it as abuse. The facility's goal was for agency staff to receive orientation before their first shift, but this was not achieved in Nurse #2's case.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required time frame for five residents. The residents involved were admitted to the facility on unspecified dates, and their most recent MDS assessments were dated in July 2024. However, these assessments were still in progress and had not been completed by the time of the survey. The residents affected by this deficiency were identified as Residents #17, #81, #24, #42, and #19. During an interview, the MDS nurse acknowledged that the quarterly MDS assessments for these residents had not been completed as required. She attributed the delay to a high volume of admissions and discharges, which caused her to fall behind in her duties. The facility's Administrator and Director of Nursing were also interviewed and expressed their expectation that MDS assessments should be completed within the required time frame.
Deficiency in Room Maintenance and Repair
Penalty
Summary
The facility failed to ensure that resident rooms were maintained in good repair, compromising the residents' right to a safe, clean, comfortable, and homelike environment. During an initial tour, it was observed that rooms had multiple areas of sheetrock putty exposed on the walls, indicating they were in preparation for painting. Additionally, one room had a missing plank panel on the wall behind the headboard, exposing a dried clear substance that appeared to be glue. These deficiencies were confirmed during a round with the Maintenance Director, who acknowledged the issues but could not provide a specific date or timeframe for when the repairs would be completed. The Administrator, who had been working at the facility since April, acknowledged the importance of maintaining a well-repaired environment and indicated that the Maintenance Director was responsible for addressing these concerns.
Failure to Transmit Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete an annual Minimum Data Set (MDS) assessment within the required time frame for one resident. Resident #9 was admitted to the facility, and a review of their most recent MDS assessment revealed it was dated as an annual assessment but had not been transmitted. The MDS nurse acknowledged that the assessments had not been transmitted as required, citing a high volume of admissions and discharges as the reason for falling behind. The Administrator and Director of Nursing confirmed that the MDS assessments should be transmitted within the required time frame.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a discharge Minimum Data Set (MDS) assessment within the required time frame for one of the residents reviewed. Resident #61 was admitted to the facility, and their most recent MDS assessment was dated as a discharge assessment. However, the assessment was still in progress and had not been transmitted to the State within the required 7-day period. During an interview, the MDS nurse acknowledged that the discharge MDS assessment for Resident #61 had not been completed as required, citing a high volume of admissions and discharges as the reason for the delay. The Administrator and Director of Nursing confirmed that the MDS assessment should have been completed within the required time frame.
Inaccurate MDS Coding for Urinary Status and Range of Motion
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of urinary status and upper extremity range of motion. For one resident, who was admitted with neuromuscular dysfunction of the bladder, the MDS assessment incorrectly indicated that the resident was always incontinent of bladder despite having an indwelling urinary catheter during the assessment's 7-day look-back period. This error was acknowledged by the MDS Nurse as an oversight. The facility's Administrator and Director of Nursing expected the MDS to be coded accurately. For another resident with a diagnosis of dementia and severe behavioral disturbance, the MDS assessment inaccurately coded a limited range of motion in the upper extremities. Observations and interviews with staff, including a Nursing Assistant and the Medical Director, revealed no evidence of a hand contracture or range of motion impairment. The MDS Nurse based her coding on a Medical Director's progress note, which was later clarified as a misinterpretation during a video visit. The Director of Nursing expected the MDS Nurse to question the MD's documentation if it appeared inaccurate.
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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