Davidson Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lexington, North Carolina.
- Location
- 4748 Old Salisbury Road, Lexington, North Carolina 27295
- CMS Provider Number
- 345066
- Inspections on file
- 22
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Davidson Health & Rehab Center during CMS and state inspections, most recent first.
A resident with a history of subdural hemorrhage, rib fractures, DM II, weakness, and unsteadiness fell after using the call light for bathroom assistance that was not answered, then attempted to ambulate alone and fell, reporting immediate severe right leg pain. Night-shift staff later lifted the resident from the floor, assisted with toileting, and returned the resident to bed without performing an assessment, documenting the fall, or notifying the MD, NP, or responsible party, despite the resident’s pain and verbal complaint. The oncoming nurse was not given a report of the fall. The next morning, a NA and a medication aide noted the resident’s significant pain and change in appearance, and the UM’s assessment found right leg pain, inability to bear weight, and limited ROM. Pain scores remained elevated throughout the day. Only after the UM’s involvement were the provider and family notified, imaging ordered, and a right hip fracture identified, demonstrating a failure to immediately notify the physician and responsible party of a change in condition following a fall.
A resident with a history of subdural hemorrhage, prior fractures, diabetes, and gait instability fell after using the call light for toileting assistance that was not answered, then attempted to ambulate alone and fell. Night-shift staff found the resident on the floor, noted a pain response when moving the leg, but did not complete or document a post-fall assessment or notify the provider, and the fall was not properly reported to the next shift. On the following shift, nursing staff did not perform or document a comprehensive assessment despite repeated reports of severe right hip pain (up to 10/10) from the resident, CNAs, a med aide, and therapy staff, and vital signs entries showing high pain scores. The UM eventually assessed the resident, obtained a verbal stat order for a right hip x-ray, but called the mobile imaging provider instead of entering the order into the required electronic system, causing delay in imaging. When imaging was finally completed and the provider notified, the resident was sent to the hospital, where a comminuted, displaced, impacted right hip fracture was confirmed and surgical repair was performed at a secondary hospital.
A resident with a history of falls and multiple comorbidities experienced an unwitnessed fall after using the call light for bathroom assistance and not receiving help, then reported severe right hip pain. Night-shift staff assisted the resident from the floor without documenting the fall, performing a pain assessment, or administering analgesics. On the following shift, multiple staff observed the resident in obvious distress, with repeated self-reported pain scores of 8–10/10 and significant pain on movement, yet nursing interventions were limited to intermittent PRN acetaminophen, with delayed and incomplete pain reassessments and no documented additional pharmacologic or non-pharmacologic measures. Despite ongoing high pain levels outside the resident’s acceptable range and repeated reports of severe discomfort, there was inadequate escalation or adjustment of pain management, and subsequent hospital imaging confirmed a comminuted, displaced, impacted right hip fracture.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled substances, were not stored in locked or separately locked compartments as required.
Surveyors found that food items in the walk-in refrigerator and freezer were not properly labeled, dated, or sealed, with some items left open and exposed to air. The Dietary Manager confirmed that required procedures for labeling and storing food were not followed due to absence and competing duties. The Administrator also acknowledged the expectation for correct food labeling and storage.
A resident with severe cognitive impairment and a care plan requiring meal cueing was left unattended with an untouched meal tray during lunch, while NAs assisted other residents. Staff were unaware of the resident's specific cueing needs, resulting in a delay before assistance was provided.
Two residents' room was found with unrepaired wall damage, peeling paint, strong urine odor, and unsanitary conditions including trash and food debris. The issues persisted over several days due to lack of maintenance reporting and significant housekeeping staff shortages, with management unaware of missed cleaning.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A medication cart was left unattended in a hallway with its computer screen displaying confidential resident information, including names, diagnoses, medications, dates of birth, and room numbers. The responsible nurse admitted to not locking the screen before leaving to administer medications, and staff members walked past the cart without securing the information. The DON confirmed that screens should be locked when unattended to protect resident privacy.
The facility did not provide written grievance response summaries to residents' representatives for grievances filed on behalf of three residents. In each case, the resolution was communicated verbally by staff, but no written documentation was given, despite regulatory requirements. Interviews confirmed that staff were unaware of the need for written responses, and the Administrator was not aware that this step was being missed.
A resident with a history of bipolar disorder and anxiety experienced increased behavioral symptoms and medication changes, but the facility did not notify the State Mental Health Authority or initiate a Level II PASRR evaluation as required. Staff interviews confirmed the oversight in referral and the need for timely PASRR determinations.
A resident admitted with multiple medical conditions, including pelvic fractures, glaucoma, and anxiety, did not have a comprehensive, person-centered care plan developed as required. Although the Care Area Assessment identified eight areas needing care planning, only four care plans were present in the record. The MDS nurse acknowledged forgetting to complete the necessary care plans, and the DON confirmed that these should be completed on time.
A resident admitted after a total knee replacement did not have hospital discharge orders for surgical wound care transcribed into the facility's records. The Aquacel and Zipline dressings were not removed according to the specified postoperative timeline, and the resident reported repeatedly asking staff about the dressings without response. The required wound care was not documented or communicated at discharge, and facility leadership confirmed the omission of these orders.
A resident with severe cognitive impairment and a feeding tube did not receive enteral nutrition according to the physician's prescribed schedule, as tube feeding continued past the ordered stop time due to staff unfamiliarity with the charting system and miscommunication during shift change. Additionally, a syringe used for tube feeding was improperly stored with the plunger inside the barrel and liquid present, contrary to infection control protocols.
Two residents with physician orders for oxygen therapy did not receive oxygen at the prescribed rates, with staff administering higher flow rates than ordered and failing to check or document the settings as required. Additionally, required 'oxygen in use' signage was not posted on a resident's door while oxygen was in use. Staff interviews confirmed a lack of awareness and adherence to orders and facility protocols.
A resident with a history of pain and cognitive impairment continued to receive scheduled acetaminophen after a new order for Hydrocodone-acetaminophen was initiated, due to a nurse's oversight in not discontinuing the previous order. The error was discovered after a family member raised concerns, and review of the MAR confirmed the resident received both medications concurrently for several days.
Two residents did not receive supplemental oxygen as ordered, with staff documenting administration and verification on the MAR without actually confirming the correct flow rate. Observations revealed one resident's oxygen was set higher than prescribed, and staff admitted to not checking the concentrator as required. The DON confirmed that nurses are responsible for verifying and documenting accurate oxygen administration.
Two residents were not properly educated or offered pneumococcal and influenza immunizations upon admission, and the facility failed to maintain required documentation of immunization status, refusals, and related education. The ADON confirmed missing records and was unable to account for the lapses.
A resident was not educated or offered the COVID-19 vaccine upon admission, and there was no documentation in the medical record regarding vaccine education, offer, administration, refusal, or previous vaccination history. Staff confirmed that required forms and information were missing from the resident's chart.
Feeding tubes were utilized for a resident without documented medical justification or resident consent, and proper care for a resident with a feeding tube was not provided.
A resident with Alzheimer's dementia was found with a handprint on her hip after an altercation with a nurse aide. The incident was witnessed by the resident's roommate, who reported hearing a verbal exchange followed by a smack. The nurse aide was removed from the facility, and the incident was reported to authorities.
A resident with morbid obesity and a history of falls experienced two incidents of falling from a regular-sized bed while receiving care, resulting in injuries. The facility failed to provide a bariatric bed in a timely manner, contributing to the unsafe conditions. Despite being cognitively intact, the resident could not prevent the falls due to inadequate space on the bed.
A facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medication, catheter use, and dental status records. A resident was incorrectly coded as receiving antipsychotic medication, another had inaccurate insulin injection records, a third was wrongly marked as incontinent despite having a catheter, and a fourth had dental issues unrecorded. The MDS nurse, working with remote assistance, verified these errors, which may have been influenced by recent changes in ownership and computer systems.
The facility failed to update care plans for residents after MDS assessments and did not notify residents or their representatives of care plan meetings. This deficiency affected residents with various medical needs, including those on medications and with feeding tubes. Staffing challenges and a transition to a new EMR system contributed to the oversight.
The facility failed to date leftover food items and improperly stored raw meat above fresh produce in the walk-in refrigerator. Unlabeled containers with leftover food and a thawed pork loin stored above fresh blueberries were found during an inspection. The Dietary Manager acknowledged the errors, attributing them to being short-staffed and overwhelmed. The Regional Dietary Manager confirmed the facility's policy on labeling and storage, and a follow-up inspection revealed no further issues.
The facility experienced a deficiency in dietary staffing, resulting in nursing staff preparing meals and significant delays in meal delivery. The dietary manager was left alone in the kitchen due to staff absences, and residents reported late meals. The administrator was not informed until the survey team arrived, and the situation was compounded by the resignation of the DON.
Four residents in an LTC facility reported receiving unpalatable and unappealing meals, with observations confirming the food was often dry and overcooked. A test tray tasting by the RD and surveyor found the baked ham dry and sweet potatoes overly seasoned, indicating the cook did not follow the corporate recipe.
The facility experienced significant delays in serving lunch meals, with trays arriving over two hours late in the main dining room and on three halls. Residents expressed dissatisfaction, and the delay was attributed to insufficient kitchen staffing, which was not promptly communicated to management.
A facility failed to develop a comprehensive care plan for a resident with a right hand contracture, despite the resident's severe cognitive impairment and dependency on staff. The oversight was linked to staffing changes and a transition to a new EMR system, which required manual transfer of care plans. The MDS Nurse acknowledged the omission, and the administrator confirmed the contracture should have been care planned.
A resident with a history of CVA and right-sided hemiplegia was using a right resting hand splint and a pommel cushion without Physician orders. Staff interviews revealed confusion between nursing and therapy regarding responsibility for obtaining these orders. The Medical Director confirmed that orders should have been in place.
A resident with a stage 4 pressure ulcer had their air mattress incorrectly set at 450 pounds instead of their actual weight of 136.6 pounds. The Wound Nurse, who was responsible for monitoring the settings, was unaware of the discrepancy and the absence of a daily check order in the treatment records. The Wound Physician Assistant confirmed the importance of setting the mattress to the resident's weight for effective wound healing.
A resident with hypertension received Metoprolol despite physician orders to hold the medication if the heart rate was below 60. The July MAR showed the medication was administered on four occasions when the heart rate was between 52 and 59. A medication aide acknowledged the oversight, and the facility's Administrator and Medical Director expected adherence to the physician's orders.
A resident with severely impaired cognition and frequent incontinence was left in urine-soaked clothing, compromising their dignity. The resident was observed in this state at the nurses' station, and it was confirmed by a nurse that the resident should not have been left in such a condition. The nursing assistant responsible for the resident admitted to not checking on them after an initial round, contrary to the facility's expectations for resident care.
A resident was discharged from an LTC facility without the necessary standard wheelchair documented in the discharge summary. The Occupational Therapist did not recall any indication for a standard wheelchair, and the Social Worker was unaware of a new DME company process requiring a discharge summary, delaying the order. The Medical Director amended the order, but the wheelchair was delivered after discharge. The Administrator acknowledged the expectation for necessary equipment at discharge.
Two residents experienced deficiencies in care at the facility. One resident, with dementia and Alzheimer's, was left in urine-soaked clothing due to inadequate incontinence care, despite a care plan requiring frequent checks. Another resident, with severe cognitive impairment, had neglected nail care, resulting in long, jagged fingernails pressing into her palm. The responsible NA admitted to not paying attention to the resident's nails, and the Nurse Manager acknowledged the oversight.
A resident with diabetes and peripheral vascular disease had a healed venous stasis ulcer, but the facility failed to update the treatment orders. The Wound NP's progress note indicated the wound was resolved, requiring a new order for skin prep. However, the original wound care order continued without change. The Wound Care nurse acknowledged the oversight, and the NP confirmed no harm occurred, but emphasized the need for updated care instructions.
The facility failed to display State Agency and advocacy group information in an accessible location. Residents in wheelchairs could not view the bulletin board, which was placed outside the kitchen near the main dining room. Observations and interviews confirmed the board was not at eye level for wheelchair users. The Maintenance Director and Administrator acknowledged the issue.
The facility failed to post accurate and complete nurse staffing information for several days, with discrepancies between scheduled and actual staffing levels. Additionally, the daily nurse staffing sheets were not updated for several days, leading to outdated information being displayed. Interviews revealed a lack of clarity and responsibility among staff regarding the posting of these sheets.
A facility failed to update a resident's medical records accurately after a wound on the resident's heel resolved. Despite a new order to apply skin prep and leave the area open to air, the outdated order for calcium alginate application remained in the MAR. The Wound Care nurse acknowledged the oversight, and an observation confirmed the wound had healed.
Failure to Report Fall and Notify Provider/Family Resulting in Delayed Hip Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the responsible party and physician after a cognitively intact resident experienced a fall with significant pain, resulting in delayed diagnostics and treatment for a fractured hip. The resident had been admitted with traumatic subdural hemorrhage, fractured ribs, type II diabetes, muscle weakness, and unsteadiness on her feet, and had a history of a fall with fracture prior to admission. On the night in question, the resident activated her call light to request assistance to the bathroom, but no one responded, so she attempted to ambulate independently, lost her balance, and fell. She reported that two female staff later found her, picked her up from the floor, placed her in a wheelchair, assisted her to the bathroom, and then back to bed, without performing an examination. The resident stated her right leg hurt after the fall and rated her pain as 10/10. Nurse #1, who was on duty from the evening through the morning shift, stated she was informed by NA #1 around 5:30 AM that the resident had fallen. Nurse #1 and NA #1 assisted the resident off the floor into a wheelchair, asked what happened, but Nurse #1 did not complete an assessment. Nurse #1 observed the resident wince and say “Oh my leg” when being helped up but believed the resident was not hurt because she appeared to have full range of motion. Nurse #1 had the NA take the resident to the bathroom and then back to bed, and later looked in on the resident, who “looked fine,” and then left the room. Nurse #1 did not notify the physician, NP, or responsible party of the fall or the resident’s pain and did not document the fall in the medical record or report it to the oncoming nurse. The DON later confirmed that Nurse #1 failed to report the fall and that there was no corresponding documentation despite a time notation of 5:45 on the 24-hour report. On the following day shift, NA #2 discovered before breakfast that the resident was in pain, saying “ouch” during care and reporting she had fallen during the night. NA #2 relayed this to the Medication Aide, who had not been informed of any fall. The Medication Aide then observed the resident and noted she appeared different than the previous day, with a look of agony and self-reported pain of 10/10. The Unit Manager, who had just arrived, was informed and went to assess the resident, finding her alert, oriented, emotional, and complaining of right leg pain, with inability to bear weight on the right leg, limited range of motion, and increased pain with movement. Vital sign entries throughout the late morning and afternoon documented persistent elevated pain scores (8/10 and then 5/10 and 10/10) with limited or no listed interventions. The Unit Manager learned that neither the Medication Aide nor Nurse #2 had received any report of a fall from the night shift. After reviewing camera footage showing Nurse #1 and NA #1 entering the resident’s room at 5:45 AM, the Unit Manager confronted Nurse #1, who then admitted the fall had occurred and that she had “messed up” by not reporting it. The physician and responsible party were not notified until later that afternoon, after the Unit Manager’s assessment and subsequent orders for imaging, at which point a right hip fracture was identified and the resident was sent to the hospital for evaluation and treatment.
Failure to Assess and Respond to Post-Fall Pain and Delay in Diagnostic Imaging
Penalty
Summary
The deficiency involves the facility’s failure to recognize and appropriately assess the seriousness of an unwitnessed fall and associated pain, and to complete and document comprehensive nursing assessments to determine the need for transfer to a higher level of care. The resident involved had a history of traumatic subdural hemorrhage, fractured ribs, type II diabetes, muscle weakness, unsteadiness, and a prior fall with fracture before admission, and was cognitively intact and required supervision with toilet transfers and toileting hygiene. During a night shift, the resident activated the call light for assistance to the bathroom, but no one responded, and the resident attempted to get up independently, lost balance, and fell. A nursing assistant later found the resident on the floor; the resident was unsure if she was injured. The NA notified the nurse, and together they assisted the resident from the floor into a wheelchair and then into bed. During this transfer, the resident winced and said, “Oh my leg,” but the nurse did not complete a full assessment, relying instead on an impression that range of motion appeared intact. No post-fall assessment or documentation of the fall or the resident’s condition was entered in the nursing progress notes for that shift. On the following day shift, the oncoming nurse received verbal report that the resident had an unwitnessed fall but did not complete an assessment, stating her day was too busy. She visually checked on the resident at some point and believed the resident appeared comfortable, but did not document an assessment. Vital signs later recorded in the electronic record showed the resident reporting pain levels of 8/10 in the morning and higher levels later in the day, with acetaminophen administered but no documented comprehensive assessment of the fall-related condition. A nursing assistant on the day shift, who had not been informed of the fall, reported that while changing the resident’s brief the resident repeatedly said “ouch” and stated she had fallen during the night. This NA relayed the information to a medication aide, who also had not been told of the fall, and then to the Unit Manager. The medication aide, upon seeing the resident, observed that the resident appeared to be in agony and reported a pain level of 10/10. Therapy staff who saw the resident that morning and midday documented extreme right hip pain, tenderness to palpation, and significant pain with passive range of motion, and reported these concerns to nursing and management. The Unit Manager assessed the resident after being informed of the fall and pain complaints and documented that the resident reported attempting to walk to the bathroom without assistance, slipping and falling, and being helped off the floor and back to bed by two female staff. The Unit Manager’s note indicated the resident complained of right hip pain, was unable to bear weight on the right lower extremity, and had limited range of motion with increased pain on movement. However, the progress note did not include a pain scale rating, vital signs, or descriptive details such as redness, swelling, bruising, or external rotation of the leg. The Unit Manager obtained a verbal order for a stat right hip x-ray and post-fall monitoring, but instead of entering the order into the computerized system required by the mobile imaging provider, she phoned the order directly to the provider, who later reported they did not accept verbal orders and required electronic entry. The mobile imaging provider’s records showed receipt of the electronic order later that morning, with dispatch occurring thereafter. The delay in proper ordering contributed to a delay in imaging and subsequent transfer. When the x-ray was finally obtained, therapy staff visually noted what appeared to be a fracture, and the physician then ordered transfer to the emergency department for evaluation and treatment. Hospital imaging confirmed a comminuted, displaced, and impacted right hip fracture, and the resident was admitted and then transferred to another hospital for surgical repair. Throughout the period from the fall discovery until transfer, there were no comprehensive, timely nursing assessments documented that correlated the resident’s persistent high pain levels and functional limitations with the need for urgent evaluation at a higher level of care. The Director of Nursing later stated that Nurse #1 did not report the fall to the physician or to the oncoming shift and was not in the resident’s room long enough to have completed a post-fall assessment. The DON also stated that Nurse #2, a new nurse, failed to document the resident’s condition on the day shift, and that she found no documentation of a completed assessment. The Nurse Practitioner reported that she was notified by the Unit Manager that the resident had fallen and gave an order for a right hip x-ray due to reported pain, and further stated that if she had been informed of the severity of the resident’s pain, she might have given different treatment orders. The facility submitted a plan of correction for past non-compliance, but this plan was later determined to be incomplete and lacking necessary information.
Failure to Provide Effective Pain Management After Unwitnessed Fall and Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide effective pain management to a cognitively intact resident who experienced an unwitnessed fall and subsequently reported severe right hip pain. The resident had a history of traumatic subdural hemorrhage, fractured ribs, diabetes, muscle weakness, and unsteadiness on her feet, and had a PRN order for acetaminophen 500 mg, two tablets every six hours as needed for pain. During the night/early morning, the resident activated her call light for assistance to the bathroom, but no one responded, and she attempted to ambulate independently, lost her balance, and fell. A nursing assistant later found her on the floor around 5:30 AM; the resident reported she had tried to go to the bathroom and fell and was unsure if she was injured. The NA notified the nurse, and together they assisted the resident from the floor into a wheelchair and then to bed. The nurse recalled the resident wincing and saying, "Oh my leg," when being lifted but did not complete a pain assessment, did not document the fall, and did not administer any pain medication at that time. On the following day shift, another NA reported that when she was changing the resident before breakfast, the resident repeatedly said "ouch" with repositioning, stated she had fallen during the night, and complained of right leg pain. This NA reported the fall and pain complaint to the Unit Manager, who said she would check on the resident. A medication aide, upon being informed of the reported fall, entered the room between 8:00 and 9:00 AM and observed that the resident’s appearance had significantly changed from the prior day, with an expression consistent with severe discomfort and a self-reported pain level of 10/10. Around the same time, the Unit Manager assessed the resident, who was alert, oriented, very emotional, and complaining of right leg pain, with limited range of motion and increased pain on movement; the resident was unable to bear weight on the right lower extremity. The Unit Manager instructed that acetaminophen be given and obtained an order for a right hip x-ray, but the nursing progress note documenting this assessment did not include a numerical pain scale. Vital sign documentation at 8:58 AM showed the resident reporting pain at 8/10, outside her documented acceptable pain range of 0–4/10, and acetaminophen was administered at 8:59 AM. However, the nurse did not reassess the resident’s pain until 12:20 PM, when the resident reported pain at 5/10, still above the acceptable range, and no additional interventions were documented. A therapy note between 8:50 and 9:10 AM recorded the resident stating she was in extreme right hip pain rated 10/10, and a physical therapist evaluating the resident between 11:01 AM and 12:10 PM documented right hip pain rated 7/10, significant pain with passive range of motion, and tenderness to palpation; the therapist reported these concerns to nursing. Despite these repeated high pain scores and reports, there was no documented escalation of pain management beyond PRN acetaminophen, no documented timely reassessment after administration consistent with facility expectations, and no additional non-pharmacologic interventions such as positioning or ice documented. Later that day, further vital sign entries showed the resident continuing to report pain levels of 5/10 and then 10/10, with acetaminophen again administered at 2:13 PM and a final documented pain score of 10/10 at 3:00 PM without listed interventions. The resident reported to multiple staff and to her responsible party that she had told several people throughout the day that she was in a lot of pain and that she was not offered anything beyond acetaminophen or other measures for pain relief. Emergency medical services were called, and upon arrival they documented right hip pain with tenderness to touch. At the hospital, imaging revealed a comminuted, displaced, and impacted right hip fracture. Interviews with the DON and Nurse Practitioner confirmed that the initial fall was not reported or documented by the night nurse, that the day nurse was new and failed to adequately document the resident’s condition and pain, and that the provider was not fully informed of the severity of the resident’s pain, which affected the treatment orders given. These actions and omissions resulted in the facility’s failure to provide safe, appropriate, and effective pain management for a resident with acute severe pain following a fall and hip fracture.
Failure to Properly Label and Secure Medications
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in a failure to meet regulatory requirements for the labeling and secure storage of medications and biologicals within the facility.
Failure to Properly Label, Date, and Store Food Items
Penalty
Summary
Surveyors observed that the facility failed to properly label, date, and seal food items stored in both the walk-in refrigerator and freezer. Specifically, an open and partially used box of turkey sausage and a package of Danishes were found in the refrigerator without labels, dates, or proper wrapping, leaving the contents exposed to air. In the walk-in freezer, a large plastic zippered bag containing uncooked ground meat was found with a date of 7/7/25 but without a label indicating its contents. During interviews, the Dietary Manager confirmed that food should be wrapped, labeled, and dated once opened, and used or discarded within seven days, but acknowledged that these procedures were not followed due to his absence over the weekend and other work priorities. The Administrator also confirmed that foods should be labeled and stored correctly.
Failure to Provide Meal Cueing Assistance as Specified in Care Plan
Penalty
Summary
The facility failed to provide cueing assistance during a meal as specified in the care plan for a resident with Alzheimer's disease, dementia, dysphagia, and memory deficit. The resident was assessed as severely cognitively impaired and required set-up or clean-up assistance with eating, with her care plan specifically stating she needed set-up and cueing assistance at meals. During two separate lunch observations, the resident was seated alone with her meal tray untouched, while other residents nearby were eating. No staff were observed providing her with the required cueing or assistance during these periods. Interviews with nurse aides revealed that they believed the resident only occasionally needed assistance and were unaware that her care plan specified cueing was required. The aides were assisting other residents and did not approach the resident in question until after a significant delay. The Director of Nursing confirmed that residents needing cues to eat should be placed closer to staff and should not have to wait for assistance while others are being helped.
Failure to Maintain Resident Room in Good Repair and Sanitary Condition
Penalty
Summary
Surveyors observed that a resident room was not maintained in good repair and was not kept clean or sanitary. Specifically, there was a large hole in the wall near a resident's headboard with exposed sheetrock, and peeling paint above the PTAC unit extending the length of the unit. These issues were not reported to the Maintenance Director, who stated he was unaware of the damage and explained that staff are expected to submit maintenance slips for such repairs. The room remained in disrepair during multiple observations before repairs were eventually made. Additionally, the same room was found to have a strong odor of urine, an empty urinal on the floor, personal items and trash under the bed, a sticky substance and food crumbs on the bedside table, and food crumbs scattered on the floor. These unsanitary conditions persisted over several days. The housekeeper responsible for cleaning the room could not recall if she had cleaned it, and the Environmental Services Director reported significant staffing shortages due to call-outs and resignations, resulting in only one person being available to clean resident rooms. The Environmental Services Director did not notify management or corporate for assistance, and the Administrator was unaware that rooms had been missed during cleaning.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Unattended Medication Cart Exposes Resident Information
Penalty
Summary
A deficiency occurred when a medication cart in the upper 100-hall was left unattended in the hallway with its computer screen displaying confidential resident information, including names, diagnoses, medications, dates of birth, and room numbers. The cart remained unattended for five minutes, during which time staff members walked past without securing the information. The nurse responsible for the cart confirmed that she did not lock the computer screen before leaving to administer medications and acknowledged that this was not her usual practice. The DON confirmed that all computer screens should be locked when unattended to protect resident privacy.
Failure to Provide Written Grievance Response Summaries
Penalty
Summary
The facility failed to provide written grievance response summaries to residents' representatives (RRs) for grievances filed on behalf of three residents. According to the facility's grievance policy, the Grievance Official is required to inform the resident of the results of the investigation and provide a written grievance decision upon request. However, the policy did not specify procedures for handling grievances filed by individuals other than the resident, such as RRs. Review of the grievance logs and concern forms revealed that, in each case, the resolution of the grievance was communicated verbally, either by phone or in person, but no written summary was provided to the RRs. For one resident, who was cognitively intact, the RR filed a grievance regarding negative staff interaction. The concern form indicated that the Social Worker notified the RR by phone, but no written response was given. The RR confirmed during an interview that she had never received or been offered a written resolution, only verbal communication. Similar patterns were observed for two other residents: one with moderately impaired cognition and another who was cognitively intact. Their RRs initiated multiple grievances related to staff concerns, laundry, care, and cleanliness, but in each instance, the resolution was communicated verbally, and no written summary was provided. Interviews with the Social Worker, who maintained the grievance log, revealed a lack of awareness that a written response was required for grievances. The Administrator acknowledged awareness of the requirement for written grievance responses but was not aware that this was not being consistently offered or provided to RRs. The deficiency was identified through record review, interviews with RRs, and staff interviews, all confirming the absence of written grievance response summaries as required by regulatory guidelines.
Failure to Notify State Mental Health Authority After Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the State Mental Health Authority after a resident with a diagnosis of bipolar disorder and generalized anxiety disorder experienced a significant change in condition. The resident had a Level I PASRR that indicated no further screening was required unless there was a significant change in mental health status or treatment needs. On review, it was found that the resident's Depakote dosage was increased and Lexapro was restarted due to increasing anxiety and behavioral changes, including refusing showers and yelling out. Interviews with facility staff revealed that the Social Worker, who was responsible for initiating Level II PASRR referrals, did not submit a request for further evaluation following the resident's change in treatment. The Social Worker acknowledged that a Level II PASRR screening should have been requested at the time of the medication changes but admitted to overlooking this responsibility. The DON and Administrator both confirmed the requirement for timely completion of PASRR determinations for residents with mental illness.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for one resident who was admitted with multiple medical conditions, including multiple pelvic fractures, glaucoma, and anxiety. The resident was found to be cognitively intact upon admission, and the Care Area Assessment (CAA) Summary identified eight areas of concern that required care planning: Visual Function, Activities of Daily Living Function, Urinary Incontinence, Falls, Dental Care, Pressure Ulcer, Psychotropic Drug Use, and Pain. However, only four care plans were present in the resident's record, covering Social Services discharge planning, Advanced Directives, Activities, and Nutritional Status. During interviews, the MDS nurse responsible for the resident's assessments and care plans admitted to forgetting to complete the required care plans, and the Director of Nursing confirmed that comprehensive care plans should be completed on time.
Failure to Transcribe and Implement Surgical Wound Care Orders on Admission
Penalty
Summary
The facility failed to initiate and transcribe physician orders for the care of a surgical wound upon admission for a resident who had recently undergone a total left knee replacement. Hospital discharge instructions specified that the Aquacel dressing should remain in place for seven days post-surgery, after which it should be removed and replaced with a dry dressing if needed, and that a Zipline dressing should be removed fourteen days postoperatively. Upon admission, the resident's skin assessment noted the presence of the Aquacel dressing but did not specify the presence of surgical clips or a Zipline dressing. There were no corresponding physician orders on the August MAR/TAR for the removal of either dressing as outlined in the hospital discharge summary. Interviews and record reviews confirmed that the required wound care orders were not present or transcribed into the facility's records. The resident reported repeatedly asking nursing staff about the removal of the dressings but did not receive a response. The outer Aquacel dressing was reportedly removed on the seventh postoperative day, but the Zipline dressing was not removed during the resident's stay and was only removed after discharge by a home health therapist. The discharge nursing note and instructions also failed to document or communicate any ongoing surgical wound care needs. Facility leadership, including the DON and Medical Director, confirmed that the hospital discharge summary contained clear instructions for wound management, which were not transcribed into the facility's orders or care records. The admitting nurse did not ensure the surgical wound orders were carried over, and there was no evidence that the physician or nurse practitioner reviewed or approved the discharge summary prior to admission. The lack of proper transcription and follow-through resulted in the omission of necessary wound care interventions during the resident's stay.
Failure to Follow Enteral Feeding Orders and Proper Syringe Storage
Penalty
Summary
The facility failed to ensure that enteral tube feeding was administered according to the active physician's order for a resident with severe cognitive impairment and multiple diagnoses, including cerebral infarction, type 2 diabetes, and dysphagia. The physician's order specified that the tube feeding should be administered continuously at 50 ml/hr from 2:00 PM to 10:00 AM, allowing for activities of daily living. However, observations revealed that the tube feeding was still infusing at 50 ml/hr after the designated stop time of 10:00 AM. Interviews with staff indicated that a nurse, who was new to the facility and unfamiliar with the charting system, was unaware of the specific timing of the order. The Assistant Director of Nursing had assisted by hanging the feeding bag earlier in the day, and the nurse did not realize the feeding should have been stopped, resulting in the feeding continuing outside the prescribed hours. Additionally, the facility did not properly store a plastic enteral feeding syringe used for administering medications and water flushes. The syringe was observed with the plunger inside the barrel and droplets of clear liquid present, which could lead to bacterial growth and contamination. Staff interviews confirmed awareness of the correct storage procedure, which was not followed in this instance. The Director of Nursing acknowledged that the plunger should have been removed from the barrel and stored separately, and that the medication aide typically administered medications but was not responsible for tube feedings.
Failure to Administer Oxygen as Ordered and Lack of Required Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not adhering to physician orders for oxygen administration and by not displaying required 'oxygen in use' signage. One resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and chronic bronchitis had a physician order for continuous oxygen at 2 L/min via nasal cannula. However, observations on multiple occasions revealed the oxygen concentrator was set at 3.5 L/min, exceeding the prescribed rate. Staff interviews confirmed that the medication aide did not check the flow rate at eye level and was unaware of the discrepancy, while the nurse had not checked the concentrator during her shift. The Medical Director confirmed that no order had been given to increase the oxygen rate and expected staff to follow the existing order. Additionally, there was no 'oxygen in use' signage on the resident's door during several observations, and the DON was unaware that such signage was required. Another resident with a history of shortness of breath and atherosclerotic heart disease had a physician order for oxygen at 2 L/min via nasal cannula to maintain oxygen saturation at 92% or above. Observations over two days showed the oxygen concentrator was set at 6 L/min, significantly higher than the ordered rate. The nurse responsible for this resident admitted she had not checked the oxygen settings on either day, despite signing the medication administration record as if the task had been completed. The Medical Director was not aware of any clinical need for the increased oxygen rate and expected staff to follow the prescribed orders and monitor oxygen saturations every shift. In both cases, the facility's staff failed to ensure that oxygen was administered at the prescribed rate and did not consistently check or document the oxygen settings as required. The lack of 'oxygen in use' signage and the failure to follow physician orders for oxygen therapy were confirmed through record reviews, direct observations, and staff interviews.
Failure to Discontinue Scheduled Acetaminophen After Initiation of Hydrocodone-Acetaminophen
Penalty
Summary
A deficiency occurred when a scheduled acetaminophen order was not discontinued after a new order for scheduled Hydrocodone-acetaminophen was received for a resident with a history of right hip pain, low back pain, and compression fracture of the thoracic spine. The hospice nurse had provided an order to discontinue both scheduled acetaminophen and as-needed Tramadol, and to begin Hydrocodone-acetaminophen for pain management. Despite this, the resident continued to receive both acetaminophen and Hydrocodone-acetaminophen for several days, as documented in the Medication Administration Record (MAR). The error was identified after a family member expressed concern that the resident was still receiving both medications. Review of the MAR confirmed that the resident received both drugs from the evening of the new order until the morning dose several days later. Interviews with the nurse responsible revealed that the failure to discontinue the acetaminophen order was an oversight. The DON and Medical Director confirmed that the routine acetaminophen order was not discontinued as directed, resulting in the resident receiving both medications concurrently.
Failure to Accurately Document and Administer Supplemental Oxygen
Penalty
Summary
The facility failed to maintain accurate Medication Administration Records (MAR) and ensure proper administration of supplemental oxygen for two residents. For one resident, the physician's order specified oxygen at 2 liters per minute (L/min) via nasal cannula to maintain oxygen saturation at or above 92%, with administration and verification required every shift. However, the MAR was signed by a nurse who admitted she did not verify the oxygen flow rate on the concentrator before signing, and the staff schedule confirmed her assignment to the resident. The Director of Nursing (DON) confirmed that nurses are expected to verify and document the correct oxygen flow rate as per orders. For another resident, the order required continuous oxygen at 2 L/min with instructions to check the concentrator's function and setting every shift. Despite MAR documentation indicating the correct administration and verification, observations on two separate days revealed the oxygen concentrator was set at 3.5 L/min. A medication aide acknowledged she did not fully check the concentrator and was unaware of the incorrect setting. Additionally, a nurse confirmed she had not checked the concentrator that morning. The DON stated that only nurses should perform the required assessment and documentation, and that records must be complete and accurate.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to properly educate and offer pneumococcal and influenza immunizations to residents upon admission, as well as to maintain accurate documentation of immunization status and refusals. For one resident with severely impaired cognition, there was no evidence in the medical record that either the pneumococcal or influenza vaccines were offered, administered, or refused, nor was there any signed consent or refusal form present. The Assistant Director of Nursing (ADON) confirmed the absence of immunization records and was unable to explain how this oversight occurred. For another resident with moderately impaired cognition, although the pneumococcal vaccine was reportedly offered and declined, the medical record lacked a signed refusal form and any documentation of education provided regarding the risks and benefits of refusing the vaccine. The ADON acknowledged the missing documentation and was unable to provide further information during the survey. The Administrator confirmed that immunizations should be discussed and documented on admission, but this process was not followed for the residents in question.
Failure to Educate, Offer, and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to educate and offer the COVID-19 vaccine to a resident upon admission and did not maintain proper documentation regarding the resident's vaccination status. Specifically, the resident's medical record lacked evidence that the COVID-19 vaccine was offered, refused, administered, or contraindicated, and there was no documentation of vaccine education or previous vaccination history. Staff interviews confirmed that the admitting nurse is responsible for discussing and offering vaccines on admission, and that all relevant information should be entered into the resident's medical record. However, the Assistant Director of Nursing verified that the resident's electronic medical record did not contain any documentation related to the COVID-19 vaccine, and the Administrator confirmed that required consent/refusal forms, education, and administration details were missing from the resident's chart.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services for a resident with a feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes.
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 a resident with Alzheimer's dementia. The resident, who was severely cognitively impaired and required assistance with all activities of daily living, was found with a bright red hand mark on her right hip/thigh after an altercation with a nurse aide. The incident was witnessed by the resident's cognitively intact roommate, who reported hearing a verbal exchange followed by a smack. The resident appeared agitated and expressed that she was hurt, although she lacked the cognitive capacity to articulate the incident further. The nurse aide involved, NA #1, was reported to have been attempting to redress the resident in the hallway after she repeatedly removed her shirt. According to another resident, NA #1 used force by bending the resident's arm behind her back, which led to the resident yelling in pain. The aide then took the resident to her room, where the altercation continued, resulting in the handprint. The facility's staff, including another nurse aide and the scheduler, observed the handprint and reported the incident to the appropriate authorities. Interviews with staff and residents, as well as a review of camera footage, indicated that NA #1 was the last person to provide care to the resident before the handprint was discovered. Although the footage did not show aggressive behavior in the hallway, the testimonies and physical evidence suggested otherwise. The facility's administration took immediate action by removing NA #1 from the premises and notifying the police and Adult Protective Services.
Resident Falls Due to Inadequate Bed Size and Supervision
Penalty
Summary
The facility failed to provide a safe environment for Resident #21, resulting in two falls from the bed. Resident #21, who was admitted with conditions including cellulitis, morbid obesity, and anxiety, was at risk for falls due to her medical history and physical limitations. The care plan for Resident #21 included interventions to prevent falls, but these were not effectively implemented. On two separate occasions, Resident #21 fell from her bed while being assisted by nursing assistants, leading to injuries including a laceration on her forehead that required stitches. The first incident occurred when a nursing assistant rolled Resident #21 onto her side for incontinence care, causing her to fall off the bed. The resident was using a regular-sized bed, which was inadequate for her size, and she did not have enough room to safely turn. Despite the resident's cognitive awareness and attempts to hold onto the bed frame, she fell and sustained injuries. The interdisciplinary team reviewed the incident and added an intervention to encourage toileting after meals to reduce the need for in-bed changes. The second fall happened under similar circumstances, with another nursing assistant turning Resident #21 onto her side, resulting in her falling off the bed again. This time, the resident sustained minor injuries, including an abrasion and bruising. Interviews with staff revealed that a bariatric bed, which would have been more suitable for Resident #21's size, was not provided until after these incidents. The facility's failure to assess and provide appropriate equipment contributed to the unsafe conditions that led to these falls.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their medical records. Resident #16 was incorrectly coded as receiving antipsychotic medication despite no such order in the physician's records. Resident #45's MDS assessment inaccurately reflected the number of insulin injections received during the lookback period, showing fewer injections than were actually administered. Resident #57's assessment incorrectly indicated bladder incontinence despite having an indwelling urinary catheter, which should have been coded as 'Not Rated'. Resident #18's dental status was inaccurately recorded as having no issues, despite a care plan noting decaying teeth and the resident's own report of dental problems. The MDS nurse, who had been working alone with remote assistance from corporate, verified these coding errors during interviews. The facility had undergone a change in ownership and a switch to a new computer program, which the MDS nurse suggested might have contributed to the mistakes. The administrator acknowledged that the MDS should be coded accurately, regardless of staffing changes or program transitions.
Failure to Update Care Plans and Notify Residents of Meetings
Penalty
Summary
The facility failed to review and revise care plans for several residents following the completion of Minimum Data Set (MDS) assessments. This deficiency was identified through record reviews, observations, and interviews with residents and staff. Specifically, the care plans for residents with issues related to falls, activities of daily living (ADLs), contractures, medications, and nutrition were not updated as required. For instance, Resident #27, who was receiving antidepressant and antipsychotic medications, had a care plan that was not revised after a quarterly MDS assessment. Similarly, Resident #40, who had a change in feeding tube type, did not have an updated care plan reflecting this change. The facility also failed to ensure that residents and their representatives were notified of care plan meetings. Residents #73 and #80 reported not being invited to such meetings, and there was no documentation to indicate that notifications had been sent. The Social Worker and MDS Nurse interviews revealed that the previous MDS Nurse was responsible for sending out meeting notices, but after their departure, this task was not consistently managed, leading to a lack of communication with residents and their families. The issues were compounded by staffing challenges and a transition to a new Electronic Medical Record (EMR) system. The MDS Nurse had been working alone until recently, with remote assistance from corporate, but care plans were not updated in the new EMR system. The facility's change in ownership and the switch to a new computer program in April 2024 further complicated the process, as care plans from the previous system were not transferred correctly. This resulted in incomplete or outdated care plans for several residents, including those with significant medical needs.
Improper Food Storage and Labeling in Walk-in Refrigerator
Penalty
Summary
The facility failed to properly date leftover food items and store raw meat below fresh produce in the walk-in refrigerator, as observed during a survey. During an inspection, unlabeled and undated plastic containers with leftover ground meat, pureed cornbread, and beef macaroni with noodles were found in the refrigerator. The Dietary Manager (DM) acknowledged that these items should have been labeled when placed in the refrigerator and stated that they must be discarded immediately due to the lack of labeling. Additionally, a large pork loin was found thawed in a cardboard box above a tray of fresh blueberries, which were packaged in containers with holes for air circulation. The DM confirmed that produce should not be stored below meats and discarded the blueberries immediately. The Regional Dietary Manager confirmed that all leftover food items should be labeled and discarded after 72 hours and that meat should never be stored above fruits or vegetables. A subsequent tour of the walk-in refrigerator revealed no further concerns. The DM attributed the oversight to being short-staffed and overwhelmed, but no further explanation was provided for the failure to adhere to proper food storage protocols.
Insufficient Dietary Staffing Leads to Meal Delays
Penalty
Summary
The facility failed to provide sufficient dietary staff to prepare and deliver meals to residents, resulting in nursing staff having to prepare breakfast on two consecutive days. On the first day, the dietary manager was the only staff member present in the kitchen until a dietary aide arrived later. The dietary manager reported that several staff members were absent due to no-shows and call-outs, and despite notifying her supervisor, assistance was delayed. As a result, residents experienced late meal deliveries, with lunch trays arriving significantly later than scheduled. Interviews with residents and staff confirmed the lack of dietary staff, with nursing assistants stepping in to prepare meals. Residents expressed dissatisfaction with the situation, noting that such staffing issues had not occurred before. The facility's administrator was not informed of the staffing shortage until the survey team arrived, and the regional dietary manager was only notified afterward. The situation was exacerbated by the resignation of the Director of Nursing, leaving the facility without immediate leadership to address the issue.
Unpalatable and Unappealing Food Served to Residents
Penalty
Summary
The facility failed to provide food that was palatable in taste and appealing in appearance to four residents. Observations and interviews revealed that the food served was often dry, overcooked, and unappetizing. Resident #84, who was cognitively intact and required only setup assistance, expressed dissatisfaction with the taste and appearance of her meals, noting that the food had become unpalatable in the past week. Similarly, Resident #13, also cognitively intact, found the chicken overbaked and inedible, preferring to order from the always available menu. Resident #23, on a special diet, did not eat her lunch due to its unappealing appearance, opting instead for food brought by her spouse. Resident #17, who was independent with meals, chose not to eat the facility's food, finding it unappealing and inconsistent in quality. The Regional Dietician (RD) and surveyor conducted a test tray tasting, confirming the residents' complaints. The baked ham was found to be dry, and the sweet potatoes were unpalatable due to excessive seasoning. The RD noted that the cook did not follow the corporate recipe, leading to the poor quality of the meals. The administrator was informed of these findings, and it was noted that the cook responsible for the meals during the survey period was working without assistance and had not previously had issues with meal preparation until the survey team's arrival.
Significant Meal Service Delays
Penalty
Summary
The facility failed to serve lunch meals at the posted times in the main dining room and on three different halls, leading to significant delays. On the day of observation, lunch was scheduled to be served at 12:00 PM in the main dining room, with subsequent deliveries to the 100, 200, and 300 halls at 12:15 PM, 12:30 PM, and 12:40 PM, respectively. However, the meals were delayed by over two hours, with trays arriving at 2:15 PM for the 100 and 200 halls and at 2:30 PM for the 300 hall. This delay was observed and confirmed through staff and resident interviews, as well as record reviews. Residents expressed dissatisfaction with the meal service, noting that this was the longest they had to wait for their meals. One resident mentioned having to eat something from her room due to the delay, while another resident reported contacting her daughter about the issue. The Regional Dietary Manager attributed the delay to insufficient staffing in the kitchen, which was not communicated to her or the Administrator in a timely manner. The Administrator acknowledged the unacceptability of meals being served more than 15-20 minutes outside the scheduled time.
Failure to Develop Comprehensive Care Plan for Resident's Contracture
Penalty
Summary
The facility failed to develop an individualized person-centered comprehensive care plan for a resident with a right hand contracture. The resident, who was admitted with diagnoses of Cerebral Vascular Accident (CVA) with right-sided hemiplegia and aphasia, was observed wearing a right resting hand splint. Despite the resident's severe cognitive impairment and dependency on staff for personal care, the comprehensive care plan did not address the contracture. This oversight was identified during a review of the care plan, which had not been updated to include the contracture since the resident's admission. The deficiency was attributed to several factors, including staffing changes and a transition to a new Electronic Medical Records (EMR) system. The MDS Nurse explained that her assistant had left earlier in the year and was only recently replaced, leading to reliance on remote assistance. Additionally, the facility switched to a new computer program, requiring manual transfer of care plans. Although the resident's MDS was completed after the system change, the care plan for the contracture was not transferred or updated in either the old or new system, which the MDS Nurse acknowledged as an oversight. The facility administrator confirmed that the contracture and splint should have been included in the care plan, indicating the issue was not related to the change in ownership.
Lack of Physician Orders for Resident's Therapy Devices
Penalty
Summary
The facility failed to obtain Physician orders for the use of a right resting hand splint and a pommel cushion for a resident who had been admitted with a Cerebral Vascular Accident (CVA) resulting in right-sided hemiplegia and aphasia. The resident was observed wearing the hand splint and using the pommel cushion without corresponding Physician orders. Interviews with staff revealed that the hand splint had been in use for approximately three months, and the pommel cushion was a recent intervention to prevent the resident from sliding out of the wheelchair. The lack of orders was attributed to confusion between nursing and therapy staff regarding responsibility for obtaining the necessary orders. The resident's comprehensive care plan did not include the use of the resting hand splint, and there was no Physician order for the pommel cushion at the time of review. The Nurse Manager and Rehabilitation Manager both acknowledged the absence of orders and indicated that there was uncertainty about who should write them. The Medical Director confirmed that orders should have been in place for both the hand splint and the pommel cushion, highlighting a lapse in adhering to professional standards of quality care.
Improper Air Mattress Setting for Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a low air loss mattress was set according to a resident's weight, which is crucial for pressure ulcer care and prevention. The resident, who was admitted with a chronic non-healing stage 4 pressure ulcer of the sacral region, had an air mattress that was supposed to be checked daily for proper functioning. However, the treatment administration records did not include an order for this daily check. Observations revealed that the air mattress was consistently set at 450 pounds, despite the resident weighing 136.6 pounds. The Wound Nurse, responsible for setting and monitoring the air mattress settings, confirmed that the mattress was incorrectly set and corrected it upon discovery. She was unaware of how the settings were changed and did not know that the order for the air mattress was missing from the treatment record. The Wound Physician Assistant emphasized that the air mattress should always be set to the resident's weight to aid in wound healing, highlighting the oversight in maintaining the correct settings.
Failure to Hold Metoprolol as Ordered
Penalty
Summary
The facility failed to adhere to physician orders regarding the administration of Metoprolol for a resident diagnosed with hypertension. The physician's order specified that the medication should be held if the resident's heart rate was below 60. However, a review of the July 2024 Medication Administration Record (MAR) revealed that the resident received Metoprolol on multiple occasions despite having a heart rate below the specified threshold. Specifically, the medication was administered on four separate dates when the resident's heart rate ranged from 52 to 59. Interviews with staff involved in the resident's care highlighted a lack of compliance with the physician's orders. Medication Aide #1 acknowledged the oversight in administering the medication despite being aware of the parameters. Attempts to contact other nurses responsible for the resident's care on different dates were unsuccessful. The facility's Administrator expressed an expectation for nursing staff to follow physician orders, and the Medical Director noted that while the administration of Metoprolol outside the parameters did not cause serious harm, the orders should have been followed as written.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #71, by not providing timely incontinent care. Resident #71, who was admitted to the facility with severely impaired cognition, required moderate assistance with toileting hygiene and was frequently incontinent of bladder and always incontinent of bowel. On the day of the incident, the resident was observed sitting at the nurses' station in a wheelchair with wet pants, initially appearing as if water had been spilled. Later, it was confirmed that the resident's pants were saturated with urine, and the resident expressed the need to be changed. Nurse #1 verified the resident's condition and acknowledged that the resident should not have been left in urine-soaked clothing. Nursing Assistant #1, who was responsible for the resident's care during the shift, admitted to not checking on the resident after her initial round at 2 PM. The facility's administrator stated that the expectation was for all residents to receive necessary incontinent care and to be treated with dignity and respect, which was not met in this instance.
Failure to Provide Necessary Medical Equipment at Discharge
Penalty
Summary
The facility failed to ensure that a resident was provided with the necessary medical equipment upon discharge, leading to a deficiency in the discharge process. The resident, who was cognitively intact and required assistance with mobility, was discharged to a family member's home without the standard wheelchair that was documented as needed in the Transition of Care Discharge Summary. The Occupational Therapist did not recall any indication from the resident or family that a standard wheelchair was required, and the resident was discharged with only a transport wheelchair. The Social Worker (SW) had ordered the wheelchair with the Durable Medical Equipment (DME) company, but due to a new process requiring a discharge summary, the order was not processed in time. The SW was not aware of this new requirement, and the Medical Director had to amend the order to meet the DME company's specifications. The family member was informed of the delay, but the wheelchair was not delivered until after the discharge. The facility's Administrator acknowledged the expectation that the resident should have had the necessary equipment upon discharge.
Deficiencies in Incontinence and Nail Care
Penalty
Summary
The facility failed to provide adequate incontinence care for Resident #71, who was admitted with diagnoses including dementia and Alzheimer's Disease. Observations revealed that Resident #71 was left in urine-soaked clothing for an extended period, indicating a lack of timely incontinence care. The resident's care plan required frequent checks and changes of incontinence pads to prevent pressure ulcers due to moisture. However, on the day in question, the Nursing Assistant responsible for Resident #71 did not check on him before her shift ended, leaving him in a saturated state. The facility's expectation was for residents to receive incontinent care every two hours and as needed, which was not met in this instance. The facility also failed to provide proper nail care for Resident #7, who had severe cognitive impairment and required assistance with personal hygiene. Observations showed that Resident #7's right hand had long, jagged fingernails pressing into her palm, with debris and a strong odor present. Although her left hand was clean and well-groomed, the right hand was neglected. Nursing Assistant #5, who was primarily responsible for Resident #7's care, admitted to not paying attention to her fingernails. The Nurse Manager acknowledged that the nursing staff should have ensured nail care was completed, especially when applying the resident's hand splint.
Failure to Update Wound Care Orders for Healed Ulcer
Penalty
Summary
The facility failed to update the treatment orders for a resident with a healed venous stasis ulcer on the lower extremity. The resident, who was admitted with diagnoses including diabetes and peripheral vascular disease, had an active physician order to cleanse the wound on the right heel with normal saline, apply calcium alginate, and cover with foam dressing every three days. However, a progress note from the Wound Nurse Practitioner (NP) dated July 10, 2024, indicated that the wound had resolved, and a new order for skin prep and leaving the area open to air was needed. Despite this, the original wound care order continued until July 22, 2024, without being updated to reflect the healed status and new care instructions. The Wound Care nurse acknowledged the oversight during an interview, noting that she received verbal instructions and written progress notes from the Wound NP, who visited weekly. The Wound NP confirmed that there was no harm from the delay in updating the treatment but emphasized the importance of using skin prep for extra protection on the newly healed ulcer. An observation on July 24, 2024, confirmed the presence of pink closed skin on the resident's right heel, indicating healing. The facility administrator expressed an expectation for the wound care to be accurate as per the NP's orders.
Inaccessible Bulletin Board for State Agency Information
Penalty
Summary
The facility failed to display pertinent State Agencies and advocacy group information in an accessible and visible location, as observed during a recertification survey. During a Resident Council meeting, 13 members expressed their inability to see the signs for State Agencies and advocacy groups because the bulletin board was not at eye level for all residents, particularly those in wheelchairs. An observation confirmed that the bulletin board was located in a hallway outside the kitchen near the main dining room and was not accessible for residents using wheelchairs. Further observations and interviews with residents and staff, including the Maintenance Director, confirmed that the bulletin board's placement was not suitable for residents in wheelchairs. A resident attempted to read the documents on the board from her wheelchair but was unable to do so. The Maintenance Director acknowledged the issue, agreeing that the bulletin board was not visible for some residents. The Administrator also recognized the problem, stating that residents and visitors should be able to view the information.
Inaccurate and Incomplete Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate staffing information for licensed and unlicensed nursing staff for 24 out of 32 days. The discrepancies between the scheduled and actual staffing levels were noted on multiple occasions. For instance, on 6/20/24, the schedule indicated 5 LPNs for the day shift, but only 4 were documented as working. Similarly, on 6/21/24, 6 LPNs were scheduled, but only 3 were recorded as working. These inaccuracies were consistent across several days, indicating a systemic issue in maintaining accurate staffing records. Additionally, the facility did not ensure that the daily nurse staffing sheets were completed and posted for 4 out of 30 days reviewed. On 7/21/24, the staffing sheet displayed at the front desk was dated 7/17/24, indicating a failure to update the information. Interviews with staff revealed a lack of clarity and responsibility regarding the posting of these sheets. The receptionist, who was responsible for posting the sheets, relied on the staffing schedule rather than actual attendance, leading to inaccuracies. The Staffing Scheduler, who was on vacation during the period when the sheets were not updated, confirmed the discrepancies upon her return. The Administrator acknowledged the expectation for accurate and timely postings but could not explain why the sheets were not updated during the scheduler's absence. This lack of oversight and communication contributed to the failure in maintaining accurate staffing records.
Inaccurate Medical Records for Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving wound care. The resident, who was admitted with peripheral vascular disease and diabetes, had a physician's order dated June 22, 2024, to cleanse a wound on the right heel with normal saline, apply calcium alginate, and cover with foam dressing every three days. However, a Wound Nurse Practitioner noted on July 10, 2024, that the wound had resolved, and a new order was given to apply skin prep and leave the area open to air. Despite this, the July 2024 Medication Administration Record (MAR) still included the outdated order for calcium alginate application, and the new order for skin prep was not recorded. The Wound Care nurse confirmed during an interview that the order for wound care should have been discontinued after the wound resolved on July 10, 2024, and acknowledged the oversight in not updating the resident's active physician orders. An observation on July 24, 2024, revealed the resident's right heel had pink closed skin, indicating the wound had healed. The facility administrator expressed an expectation for the resident's medical record to be accurate, highlighting the discrepancy between the documented orders and the actual care required.
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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