Emerald Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lillington, North Carolina.
- Location
- 54 Red Mulberry Way, Lillington, North Carolina 27546
- CMS Provider Number
- 345173
- Inspections on file
- 18
- Latest survey
- September 30, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Emerald Health & Rehab Center during CMS and state inspections, most recent first.
A resident with a recent knee replacement and multiple comorbidities experienced pain and difficulty during a transfer after refusing the recommended mechanical lift. Despite the resident's complaints of pain, requests to speak to a supervisor, and desire to go to the hospital, nursing staff did not notify the physician or respond appropriately. The resident ultimately called 911 herself and was found to have a patellar fracture. The deficiency involved the facility's failure to communicate with the physician and obtain further instructions in response to the resident's change in condition.
A resident with a recent knee replacement and multiple comorbidities was not assisted in accordance with physical therapy's recommended transfer method. Staff did not consult the care plan or confirm the appropriate transfer technique, proceeded with a stand and pivot transfer despite the resident's refusal of the mechanical lift, and failed to seek further direction from the DON or physician. The resident experienced significant pain during the transfer and was later found to have a displaced patellar fracture requiring surgery.
The facility did not provide correct menu portion sizes as ordered by physicians, resulting in several residents receiving single portions instead of large or double portions, pureed diet residents receiving less than the specified amount, and those on low concentrated sweets diets receiving full slices of cake instead of half. Staff and dietary management were unaware of these discrepancies, which affected multiple residents during meal service.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, or serve food according to professional standards, as identified by surveyors.
A resident with a DNR order had conflicting code status information in their care plan, and their code status was missing from the code status binder used by staff. Staff interviews revealed that code status was supposed to be clarified and documented at multiple points, but inconsistencies in the medical record and reference materials led to inaccurate information being available.
A resident with severe malnutrition and dysphagia was incorrectly coded on the MDS as being on a physician-prescribed weight-loss regimen, despite documentation and staff interviews confirming the resident was not on such a program. The error was attributed to a mistake by the RD, which was not identified by the MDS Coordinator.
A deficiency was cited when a resident was not provided with sufficient food and fluids to maintain their health, as required. The report does not include further details about the circumstances or the resident's condition.
The facility did not have RN coverage for a full 24-hour period due to a scheduled RN calling out and no replacement being found. The DON was unable to cover the shift due to the facility's census exceeding 60 residents.
The facility failed to maintain a clean and sanitary condition under the shelf of a steam table, as dark dried food particles were observed on two occasions. This deficiency was identified during a kitchen inspection and confirmed through interviews with the Dietary Manager and Administrator, highlighting a lapse in adherence to professional standards for food service.
The facility failed to accurately document medical records for residents, including blood glucose levels, insulin administration, enteral feedings, and medication administration. A resident with diabetes experienced missing documentation due to a new EMR system, while another resident's enteral feeding was not recorded due to shift changes. Additionally, a third resident's medication administration was inaccurately documented, leading to discrepancies in the records.
A resident with multiple diagnoses, including chronic respiratory failure and atrial fibrillation, experienced a medication administration error when an LPN crushed and mixed all prescribed medications together with a laxative solution, contrary to facility policy. The error resulted in a medication error rate of 20.69%. Interviews with the DON, pharmacist, and physician confirmed that medications should have been administered individually, and there was no order to administer them together.
A facility failed to verify that a staff member had an active nursing license before allowing her to perform LPN duties. The staff member, hired as a Nurse Aide while attending nursing school, was promoted to LPN without proper licensure verification. Despite her Nurse Aide I Registry listing being expired and not being listed as a Medication Aide, she was assigned to work as a nurse and documented medication administration for residents. Interviews revealed she worked the medication cart due to staff shortages, and the facility's Administrator admitted the oversight.
A resident was not involved in their care plan development after readmission to the facility, despite being cognitively intact. The care plan was updated for various health issues, but no meeting was held with the resident. Staff interviews revealed that the oversight was due to the resident's frequent hospitalizations, disrupting the scheduling of care plan meetings.
A resident with a subdural hematoma continued to receive the anticoagulant Eliquis after it was discontinued during a hospital stay. The error occurred due to a failure in the reconciliation process when the facility's electronic medical records system was changed, leading to outdated orders being used. The Director of Nurses and Medical Director acknowledged the oversight and the risk posed to the resident.
The facility was observed to have an open dumpster door with debris, including a disposable glove and a trash bag, on two occasions. The Dietary Manager confirmed the condition, and interviews revealed shared responsibility between kitchen and housekeeping staff for maintaining the area. The Administrator planned to remind staff to close the dumpster door.
A resident with diabetes and hypertension, who was dependent on staff for ADL care, experienced a delay in receiving incontinence care, resulting in missed therapy. Despite using the call bell, the resident waited two hours for a change of her adult brief. Staff interviews revealed inconsistencies, with some unable to recall the incident and others claiming to have provided care. The resident expressed irritation over the delay.
A resident with severe cognitive impairment and physical limitations experienced two falls in one day due to inadequate fall prevention interventions. Despite being at high risk, the resident's care plan was not effectively updated, and staff communication was lacking. The resident was found on the floor twice, once with a head injury requiring hospitalization. The facility failed to implement timely interventions such as moving the resident closer to the nurses' station and using fall mats.
The facility did not display survey results in an accessible location for residents. During a tour, the survey results were not found in the building. Residents believed the results were near the nurse's station, but further tours confirmed their absence. Staff interviews revealed a lack of awareness about the location of the survey results. The Administrator indicated the results were at the reception desk, but they were obscured by an easel and a plant, with no signage.
Failure to Notify Physician and Respond to Resident's Change in Condition During Painful Transfer
Penalty
Summary
The facility failed to communicate with the physician and obtain further instructions when a resident, who had recently undergone a total left knee replacement and had a history of rheumatoid arthritis, gout, osteoporosis, and muscle weakness, was experiencing pain and difficulty during transfers. The resident was admitted for rehabilitation and had specific transfer recommendations from physical therapy, including the use of a mechanical lift when fatigued or unable to safely perform a scoot transfer. On the evening in question, the resident refused the mechanical lift and attempted to transfer with staff assistance, resulting in significant pain and a loud scream during the process. Despite these events, the nursing staff did not contact the physician for further guidance or assessment. Following the painful transfer, the resident repeatedly requested to speak to a supervisor and later asked to be sent to the hospital due to ongoing pain. The nurse on duty did not respond promptly to these requests, nor did he notify the physician of the resident's complaints or her desire to go to the hospital. The resident ultimately called 911 herself after her requests were not addressed, and was transported to the hospital where imaging revealed a periprosthetic patellar fracture. Documentation and interviews confirmed that the physician was not notified of the resident's change in condition or her requests for medical evaluation prior to her self-initiated transfer to the hospital. Interviews with staff, the resident, and the facility's medical director confirmed that there was a lack of communication with the physician regarding the resident's pain, difficulty with transfer, and her request for hospital evaluation. The medical director stated that he should have been notified of the decrease in function and pain, and that appropriate interventions could have been initiated if he had been informed. The deficiency centers on the facility's failure to notify the physician and obtain further instructions in response to the resident's change in condition and expressed needs.
Failure to Follow Prescribed Transfer Technique and Communication Protocols
Penalty
Summary
A deficiency occurred when staff failed to assist a resident, who had recently undergone a total left knee replacement and had multiple comorbidities including rheumatoid arthritis, gout, osteoporosis, and muscle weakness, in a manner consistent with the transfer recommendations provided by physical therapy. The resident had a history of post-operative complications and was assessed by physical therapy to require a mechanical lift for transfers, with the possibility of performing an incremental scoot transfer if able. On the evening in question, the resident requested assistance to transfer from her wheelchair to her bed. The nurse aide and nurse involved did not consult the resident's care plan or confirm the appropriate transfer method, instead relying on the resident's statements and their own recollections. The resident refused the use of a mechanical lift and gait belt, and staff proceeded with a stand and pivot transfer, which was not the recommended method for her condition at that time. During the transfer, the resident experienced significant pain and reported a 'pop' in her left knee. Staff did not stop the transfer or seek further direction from the DON or physician when the resident refused the safe transfer technique. The nurse and nurse aide did not ensure the wheelchair was properly positioned, nor did they use the recommended incremental scoot transfer or mechanical lift. After the transfer, the resident continued to experience pain, which she later reported to staff. The nurse did not immediately notify the physician or escalate the situation when the resident's pain persisted and her functional ability had acutely declined. Subsequently, the resident called 911 herself and was transported to the hospital, where imaging revealed a displaced periprosthetic patellar fracture requiring further surgery. Interviews with staff and the resident confirmed that the plan of care was not followed, and there was a lack of communication and verification of the appropriate transfer method. The failure to follow the prescribed transfer technique and to seek further guidance when the resident refused the safe method directly led to the resident's injury.
Failure to Follow Physician-Ordered Menu Portion Sizes
Penalty
Summary
The facility failed to follow the approved menu and physician-ordered dietary requirements for multiple residents during meal service. Specifically, seven residents with physician orders for large or double portions were served only a single portion of chili, despite the menu specifying a double portion. Observations of the lunch service revealed that cooks used a single 6-ounce ladle for all residents, and no double portions were prepared or served. Staff interviews confirmed that all residents received the same portion size, and the dietary manager was unaware that double portions had not been provided as ordered. Additionally, seven residents on a pureed diet received only 4 ounces of chili instead of the 6 ounces specified on the menu. Twelve residents with orders for a regular or mechanical soft, low concentrated sweets (LCS) diet received a full slice of cake rather than the half slice indicated on the menu. Dietary staff confirmed that all residents received the same size dessert portion, and the dietary manager was not aware of the need to provide a half slice for those on an LCS diet. These failures were identified through direct observation, record review, and staff interviews, affecting a total of 26 residents.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or observed outcomes were provided in the report.
Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent code status information for a resident with a history of malignant neoplasm of the uterus, anxiety, depression, and non-Alzheimer's dementia. Upon readmission, the resident had a physician's order for Do Not Resuscitate (DNR) status, and the resident's representative confirmed that this status had been in place since a hospital stay in January and had not changed. However, the resident's care plan was updated to indicate full code status, which conflicted with the physician's order and the representative's statements. Interviews with staff revealed that code status information was obtained from admission orders and hospital records, and was supposed to be reviewed with the resident or responsible party. The MDS nurse was responsible for updating the care plan, and the DON stated that code status was clarified on admission and during care plan meetings. Despite these procedures, the code status for the resident was missing from the red code status binder at the nurses' station, and staff relied on this binder to verify code status in emergencies. This inconsistency in documentation and communication led to the deficiency.
Inaccurate MDS Coding for Nutritional Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Swallowing/Nutritional Status for one resident. The resident, who had diagnoses of severe protein-calorie malnutrition and dysphagia, was not on a physician-prescribed weight-loss regimen, as documented in the Registered Dietitian's (RD) progress note and confirmed by the care plan, which instead indicated interventions to address unintentional weight loss and underweight status. However, the MDS assessment incorrectly indicated that the resident was on a physician-prescribed weight-loss regimen. The MDS Coordinator stated that the RD completed the relevant MDS section and acknowledged the error, noting she had not noticed the incorrect selection. The Medical Director also confirmed that the resident required additional calories and was not on a weight-loss program.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Provide RN Coverage for 24 Hours
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, as required. On April 13, 2024, there was no RN coverage for the entire 24-hour period. The daily nursing staffing sheets and census posting sheets indicated that an RN was scheduled for the day shift, but there was no RN recorded for the evening and night shifts. Nurse #1, who was supposed to work on that day, called out, and the Director of Nursing (DON) was unable to find a replacement RN. The DON also believed she could not serve as the RN coverage due to the facility's census being greater than 60 residents.
Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, specifically under the shelf of a steam table. During observations on two separate occasions, dark dried food particles were found under the shelf of a five-well steam table. This unsanitary condition was noted during a kitchen inspection, indicating a lapse in the facility's adherence to professional standards for food storage, preparation, and service. The deficiency was identified through observations and confirmed during interviews with the Dietary Manager and the Administrator, who acknowledged the expectation for kitchen staff to maintain cleanliness in this area.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for several residents, leading to deficiencies in documenting blood glucose levels, insulin administration, enteral feedings, and medication administration. For one resident with diabetes, the facility's transition to a new electronic medical record (EMR) system resulted in missing documentation of blood glucose levels and sliding scale insulin administration over several days. Despite nurses performing the necessary checks and administering insulin, the new EMR system lacked a designated space for recording these actions, leading to incomplete records. Another resident, who required enteral feeding due to dysphagia, did not receive the prescribed feeding on two occasions. The feeding was scheduled to start during the day shift, but due to staff being occupied with other tasks, it was delayed until the night shift. However, the night shift nurse was unable to document the feeding in the EMR as it was not scheduled during her shift, resulting in a lack of recorded administration. Additionally, a third resident's medication administration was inaccurately documented. Medications scheduled for 8:00 p.m. were recorded as given at 10:50 p.m., as the nurse documented the administration after completing rounds for all residents. This practice led to discrepancies in the medication administration record, failing to reflect the actual time of administration.
Medication Administration Error Due to Misinterpretation of Orders
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 6 medication errors out of 29 opportunities, resulting in a 20.69% error rate during medication administration observations. This deficiency was observed in the case of a resident with chronic respiratory failure, Myasthenia Gravis, anxiety disorder, and atrial fibrillation, who was receiving medications via a gastrostomy tube. The resident's medications included Amiodarone, Apixaban, Glycopyrrolate, Vitamin D, Lorazepam, and polyethylene glycol powder. During the medication administration, Nurse #5 crushed and mixed all the medications together with the laxative solution, contrary to the facility's policy, which required each medication to be administered separately with water flushes before and after each dose. Nurse #5 misunderstood the physician's orders, believing that all medications could be administered together, despite the facility's policy and the absence of any specific physician order to do so. Interviews with the Director of Nursing, the pharmacist, and the physician confirmed that the medications should have been administered individually. The pharmacist noted that while no drug reaction would occur from mixing the medications, the proper procedure was not followed. The physician clarified that his review of the orders did not imply that medications should be given together, and there was no order in the resident's electronic medical record to crush and administer the medications together.
Failure to Verify Nursing Licensure Leads to Unqualified Staff Performing LPN Duties
Penalty
Summary
The facility failed to verify that a staff member, Nurse Aide #7, had an active professional nursing license with the North Carolina Board of Nursing (NCBON) before allowing her to perform the duties of a nurse. Nurse Aide #7 was hired as a Nurse Aide while attending nursing school and was later promoted to a Licensed Practical Nurse (LPN) without proper licensure verification. The North Carolina Health Care Professional Registry indicated that her Nurse Aide I Registry listing had expired, and she was not listed as a North Carolina Medication Aide. Despite this, she was assigned to work as a nurse on multiple occasions, as recorded in the daily nurse staffing sheets and timecard reports. Nurse Aide #7 documented medication administration and created nurse's notes for several residents, signing them with the title of LPN, even though she was not licensed as such. In interviews, Nurse Aide #7 admitted to working the medication cart due to staff shortages, despite not being licensed as a medication aide or LPN. Nurse #2, who was unaware of Nurse Aide #7's lack of licensure, confirmed that she performed LPN duties, including implementing physician orders and providing various types of resident care. The facility's Administrator acknowledged that the previous administration team did not ensure Nurse Aide #7 was licensed before assigning her LPN duties.
Resident Not Involved in Care Plan Development
Penalty
Summary
The facility failed to involve a resident in the development of their care plan, as required by regulations. Resident #66, who was cognitively intact, was admitted to the facility, discharged due to hospitalization, and then readmitted. Despite updates to the resident's care plan to address issues such as bladder incontinence, long-term placement for wound care, and edema, there was no documentation of a care plan meeting that included the resident's participation since their readmission. The resident expressed a need for a care plan meeting to discuss diabetes management, indicating a lack of involvement in their care planning process. Interviews with facility staff, including the MDS nurse and the Director of Nursing, revealed that care plan meetings were not scheduled or conducted for the resident since their readmission. The MDS nurse acknowledged the oversight, attributing it to the resident's frequent hospitalizations, which disrupted the scheduling of care plan meetings. The Director of Nursing confirmed that the resident should have had a care plan meeting or a 'Your Path' meeting since readmission, but it was missed. The facility administrator also noted the need for care plan meetings to be conducted around the time of quarterly MDS assessments, which did not occur in this case.
Failure to Discontinue Anticoagulant for Resident with Subdural Hematoma
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically an anticoagulant that had been discontinued. Resident #82, who was admitted with conditions including epilepsy, hemiplegia, and a cerebral infarction, was diagnosed with a subdural hematoma while hospitalized. During the hospital stay, the anticoagulant Eliquis was discontinued to prevent further bleeding. However, upon returning to the facility, the resident continued to receive Eliquis from 5/6/24 to 5/10/24, despite the absence of orders to restart the medication. The error occurred due to a failure in the reconciliation process when the facility's electronic medical records system was changed. The Director of Nurses acknowledged that the medication should have been removed from the medication cart when the resident was hospitalized, and staff should have identified the discrepancy. The Medical Director confirmed that the medication should not have been administered due to the resident's high risk of falls and noted that the pharmacy had used outdated orders during the transition to the new eMAR system.
Improper Disposal and Maintenance of Dumpster Area
Penalty
Summary
The facility failed to maintain the cleanliness and proper closure of the dumpster area, as observed on two separate occasions. On 5/08/24 at 8:10 AM, the dumpster door was found open, with a disposable glove and a clear plastic trash bag lying beside it. A similar observation was made on 5/10/24 at 10:02 AM, where the dumpster door remained open, and the same items were noted beside the dumpster. During a follow-up observation with the Dietary Manager on 5/10/24 at 10:17 AM, the area was still in the same condition. Interviews revealed that both kitchen and housekeeping staff shared the responsibility for maintaining the cleanliness of the dumpster area and ensuring the door was closed. The Administrator acknowledged the issue and indicated a plan to remind staff to keep the dumpster door closed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was dependent on staff for activities of daily living. The resident, who was admitted with diagnoses including Diabetes Mellitus and hypertension, was cognitively intact and frequently incontinent of stool. On the morning in question, the resident used the call bell to request a change of her adult brief, which was wet with urine. Despite notifying a staff member, the resident waited two hours without receiving the necessary care, resulting in her missing scheduled therapy. The resident expressed irritation over the delay and the impact on her therapy session. Interviews with staff revealed inconsistencies in the account of events. The nurse aide assigned to the resident could not recall responding to the call bell or providing care, while a nurse and the Director of Nursing claimed to have assisted the resident, stating the brief was not saturated. The Director of Nursing also mentioned reminding staff about the importance of regular rounding for personal care needs. However, the resident's account and the therapy aide's observation of the resident being tearful suggest a lapse in care, leading to the deficiency noted in the report.
Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement effective interventions to reduce the risk of falls for a resident identified as high risk. The resident, who had a history of severe cognitive impairment, fluctuating disorganized thinking, and physical impairments, experienced two falls on the same day. Despite being assessed as high risk for falls, the resident's care plan interventions were not adequately updated or implemented to prevent these incidents. The resident was found on the floor twice, once with a head injury that required hospitalization. Interviews with staff revealed a lack of consistent communication and understanding of the resident's fall risk and necessary interventions. Nurse #8, an agency nurse on her first shift, was not informed of the resident's high fall risk and did not implement additional safety measures beyond placing the call bell in the resident's hand, despite the resident's inability to use it effectively. The resident's room location, away from the nurses' station, and the absence of fall mats on both sides of the bed contributed to the risk of falls. The Interdisciplinary Team (IDT) did not adequately review and update the resident's care plan following the falls. Although the IDT discussed potential interventions, such as moving the resident closer to the nurses' station and using fall mats, these were not implemented in a timely manner. The Director of Nurses acknowledged the lack of effective interventions and communication among staff, which contributed to the resident's repeated falls and subsequent injury.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to display survey results in a location accessible to residents, affecting all residents in the facility. During a tour of the facility, it was observed that the survey results were not located in the building. Residents during a council meeting indicated that the survey results were supposed to be near the nurse's station. However, subsequent tours revealed that the survey inspection results binder was not present in the facility. Interviews with staff, including a nurse and a social worker, showed they were unaware of the location of the survey results. The Administrator later stated that the survey inspection results book was available at the reception desk, but it was obscured by a 5 ft. easel and a large leaf plant, with no signage to indicate its location.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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