Fleshers Fairview Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairview, North Carolina.
- Location
- 3016 Cane Creek Road, Fairview, North Carolina 28730
- CMS Provider Number
- 345413
- Inspections on file
- 19
- Latest survey
- September 22, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Fleshers Fairview Health Care during CMS and state inspections, most recent first.
The facility failed to promptly notify physicians of significant changes in condition for four residents, including the development of new pressure ulcers, a diabetic foot ulcer, and significant weight loss. In each case, staff either delayed or omitted notification to the physician or nurse practitioner, resulting in a lack of timely medical intervention and documentation. Interviews with clinical staff and review of records confirmed that the required notifications were not made as expected.
Due to ongoing staffing shortages, the facility failed to provide adequate ADL care, including missed showers for multiple residents, and did not consistently assess or treat pressure ulcers. Staff, including the Wound Nurse, were frequently reassigned to cover other duties, resulting in delayed wound assessments, incomplete documentation, and lapses in necessary medical care for residents with pressure ulcers and diabetes.
A resident with severe cognitive impairment and multiple comorbidities did not receive timely skin assessments or prompt identification of a new heel wound. Communication failures among staff led to a delay in notifying providers and in initiating antibiotic treatment after a wound culture showed infection, resulting in delayed care for the resident's wound.
Two residents at risk for pressure ulcers did not receive timely or adequate skin assessments, wound measurements, or appropriate treatment orders. In both cases, pressure ulcers were not promptly assessed or reported, and treatment orders were either delayed or not renewed, resulting in wounds going untreated and worsening in severity. Nursing staff failed to follow wound care protocols, and there was poor communication and documentation regarding wound care.
Two residents with cognitive and mobility impairments were not adequately supervised, resulting in one resident sustaining a left ankle fracture after being left unsupervised in the bathroom, and another resident with dementia eloping from the facility on two occasions. Staff interviews and documentation revealed inconsistent communication and lack of effective interventions to prevent falls and elopement.
Over several months, residents repeatedly voiced concerns during Resident Council meetings about staff cell phone use during work, slow call bell response times on second shift, and early morning ice distribution that disrupted sleep. Despite these ongoing complaints, facility responses remained largely unchanged, with assurances of monitoring and staff discussions but no effective resolution. Residents reported feeling their concerns were not taken seriously, and interviews with staff confirmed the persistence of these unresolved issues.
The facility did not provide two residents and their representatives with written information about advance directives or the right to accept or refuse medical or surgical treatment at admission. Interviews confirmed that only the MOST form was discussed, and neither written materials nor acknowledgment checklists were included in the admission process. Both residents and their representatives were unaware of advance directives, and staff admitted to not providing the required information.
Two dependent residents did not receive scheduled showers on multiple occasions because the designated shower team NAs were frequently reassigned to floor duties due to staffing shortages, and no process existed to ensure showers were provided by other staff. Facility leadership and staff interviews confirmed that missed showers were not rescheduled, and the issue persisted due to inadequate staffing and lack of a backup plan.
Confidential medical information, including a resident's narcotic sheet and two medication cards with residents' names and medication details, was left unattended and visible on a medication cart. No nurse was present, and the information was accessible to staff and a resident passing by. The nurse later acknowledged the privacy breach, and the DON confirmed it was a HIPAA violation.
A resident with dementia was physically abused by a staff member during care, but the incident was not immediately reported or acted upon by the witnessing nurse aide or nursing staff. The accused staff member continued working for the remainder of the shift, and the facility failed to promptly protect the resident or investigate whether other residents were affected, in violation of abuse prevention and reporting policies.
Two residents were incorrectly coded on their MDS assessments regarding PASRR Level II status, despite having Level II determinations in their records, due to staff input errors. Additionally, a resident was inaccurately coded as having a stage 1 pressure ulcer on the MDS, even though the wound developed after the assessment date.
A resident with severe cognitive impairment and multiple comorbidities developed an unstageable pressure ulcer after admission, but the care plan was not updated to address this new condition. Although the wound was identified and treatment orders were obtained, the MDS nurse did not revise the care plan as required, despite being informed of the new development.
A resident with dementia and malnutrition experienced significant unaddressed weight loss after staff failed to promptly reweigh her and report the results, despite a dietitian's recommendation. The reweight was delayed, not documented, and not communicated to nursing management or the physician, and the resident continued to receive inadequate assistance and encouragement during meals.
Surveyors found that several residents receiving oxygen therapy did not have their oxygen concentrator filters cleaned as required, lacked proper oxygen in use signage on their room entrances, and had oxygen tanks that were not properly secured or transported. Staff interviews revealed confusion about cleaning schedules, signage responsibilities, and safe handling procedures for oxygen equipment.
A staff member was employed as a nurse aide and assigned direct care tasks without having completed a state-approved NA training program, certification exam, or competency evaluation, and was not actively enrolled in a training program. The facility's practice allowed staff to work as NAs before enrollment in a program, contrary to regulatory requirements.
Surveyors found that medication carts contained loose, unlabeled pills and open, undated boxes of inhalation solutions, including budesonide, albuterol sulfate, and DuoNeb, which were not stored according to manufacturer guidelines. Nurses responsible for the carts were unaware of proper storage and labeling requirements, and the DON indicated that both individual nurses and the weekend supervisor share responsibility for maintaining medication cart organization.
A resident with multiple wounds, including a left heel wound suspected of infection, experienced a delay in antibiotic treatment after a positive wound culture result was not promptly communicated to the Wound Provider or NP. The Wound Nurse incorrectly reported the culture as negative without reviewing the results, and the actual findings were not shared with the providers until several days later, resulting in a missed day of necessary antibiotic therapy.
A Wound Nurse failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) policies during wound care for two residents with open wounds, including not donning a gown, not changing gloves, and not performing hand hygiene at required intervals. The nurse and facility leadership misunderstood CDC guidelines, resulting in the absence of EBP for residents with open, draining wounds.
Surveyors found that two dryers in the laundry room had significant lint and dust buildup, with lint traps containing thick sheets of lint. Despite staff claims of daily cleaning, the accumulation remained unexplained, and the Environmental Services Supervisor acknowledged that the cleaning frequency was not adequate.
Two residents experienced a lack of dignity during meal service: one was left waiting for her meal while others at her table were served, and another was fed by a nursing assistant who did not sit at eye level as required. Both incidents involved residents with cognitive impairment and special dietary needs.
A resident with severe cognitive impairment and a history of combative behavior was physically abused by a staff member during incontinence care. The staff member became angry at the resident's resistance, grabbed her wrists, and slapped her hand with an open hand, as witnessed by another aide. The incident led to the resident displaying fearful behavior towards staff and was later substantiated as abuse by the facility.
The facility did not post Nurse Staffing Information in a location that was easily accessible and failed to accurately complete the posted sheets, including incorrect census data and discrepancies between posted and actual staffing, as well as omitting Temporary Nurse Aides from the records.
Surveyors found that both laundry rooms had significant dust accumulation and improper storage of residents' clean clothing, including proximity to unclean housekeeping carts and storage of dusty items above clean laundry. Additionally, a pill crusher on a medication cart was observed to be visibly soiled with dried liquid and debris, with staff interviews confirming that cleaning responsibilities were not consistently followed.
A resident with functional quadriplegia and dementia fell from her bed during a bed bath, resulting in a fractured femur. The resident was resistant to care, and the nursing aide left her unattended on her side near the bed's edge. The resident lowered her leg, causing her to fall off the bed, hit a chair, and then the floor. The facility failed to provide adequate supervision and a safe environment, leading to the resident's injury.
The facility failed to ensure nursing staff were competent in glucometer disinfection, as observed in five out of six staff members. Nurses used improper methods, such as alcohol wipes, due to a lack of specific training. The skills checklist did not include glucometer disinfection, and an in-service was not mandatory, leading to inconsistent knowledge among staff.
A resident's antifungal powder was found unsecured at bedside without a self-administration order, and a medication cart was left unlocked and unattended in a hallway. The resident, with moderate cognitive impairment, required assistance with daily activities. The DON and Assistant Administrator confirmed the need for secure storage of medications.
A resident with severe cognitive impairment did not receive a Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) upon discharge from Medicare Part A services. The Business Office Manager issued a Notice of Medicare Non-Coverage (NOMNC) instead, due to a misunderstanding of the requirements.
A resident with COPD missed two doses of Doxycycline due to a delay in pharmacy delivery. The medication was not available in the facility's emergency backup kit, and the pharmacy was closed for a holiday. Nurses on duty did not contact the pharmacy, assuming the medication would arrive with the next delivery.
A resident with COPD did not receive an ordered antibiotic on time due to a series of oversights. The medication was not available in the emergency kit, and staff did not contact the on-call pharmacist despite a holiday affecting pharmacy deliveries. The delay exceeded 24 hours, which was deemed too long by the Medical Director.
A deficiency in infection prevention and control was identified when two nurses failed to properly disinfect a glucometer used for a resident's blood glucose testing. The facility's policy required disinfection before and after use but lacked specific instructions. Observations showed that one nurse did not disinfect the glucometer after use, while another reused a disinfectant wipe. Interviews revealed inconsistencies in the understanding of the disinfection process, contributing to the deficiency.
A facility failed to maintain the privacy of a resident's medical records when a computer screen on a medication cart was left open and unattended, displaying sensitive information. Nurse #1 left the cart twice without activating the privacy screen, exposing the resident's MAR. Interviews confirmed the expectation to use the privacy screen to protect resident information.
Failure to Notify Physician of Significant Changes in Resident Condition
Penalty
Summary
The facility failed to notify physicians in a timely manner regarding significant changes in condition for multiple residents, including the development of new pressure ulcers, a diabetic foot ulcer, and significant weight loss. In one case, a resident with a history of cerebral vascular accident and diabetes developed a pressure ulcer on her right heel, which was first observed by a nurse aide and nurse, but the physician was not notified until several weeks later when the wound had progressed to an unstageable ulcer with black eschar and foul odor. The wound nurse and medical director confirmed that they were not made aware of the wound until much later, and there was no documentation of earlier physician notification in the medical record. Another resident with vascular dementia and hemiparesis was found to have an unstageable open area on the left heel by the wound nurse, who treated the wound with standing orders and notified the wound nurse practitioner the following day. However, the resident's nurse practitioner and medical director were not notified of the new wound or subsequent lab results, and both stated they should have been informed to initiate appropriate interventions. Similarly, a resident with dementia and malnutrition experienced significant weight loss, but the physician was not notified promptly. The assistant director of nursing acknowledged responsibility for notifying the physician but admitted the notification was delayed due to waiting for a reweight and being busy with other tasks. Additionally, a resident with multiple sclerosis and hemiplegia reported a stage II pressure ulcer to the back of his thigh, which was documented and treated by a nurse without notifying the physician. The nurse believed the process was to enter a treatment order and document in the acute book, but not to notify the provider directly. The assistant director of nursing, nurse practitioner, and medical director all confirmed that the physician should have been notified of the new wound. These failures to notify the physician of significant changes in condition affected all four residents reviewed for notification.
Insufficient Staffing Leads to Missed ADL Care and Delayed Wound Treatment
Penalty
Summary
The facility failed to maintain sufficient nursing staff to meet the needs of residents, resulting in inadequate provision of activities of daily living (ADL) care, delayed and incomplete wound assessments, and insufficient medical treatment for pressure ulcers and diabetic care. Observations, record reviews, and interviews revealed that dependent residents did not consistently receive showers, and staff were frequently pulled from their assigned duties to cover staffing shortages, leading to missed care tasks. For example, shower team nursing assistants were reassigned to floor duties, resulting in multiple days when no showers were provided to residents. The facility also failed to obtain timely treatment orders and conduct routine assessments for residents with pressure ulcers. In several cases, pressure ulcers were identified but not promptly assessed or treated, leading to worsening conditions. One resident's pressure ulcer progressed to an unstageable wound with black eschar and foul odor due to delayed assessment and treatment. Another resident developed a stage 2 pressure ulcer that was not measured or reassessed after the initial treatment order expired, and no further treatment orders were obtained. Additionally, head-to-toe skin assessments were not completed accurately, failing to document the location, type, and measurements of wounds. Interviews with the Wound Nurse and administrative staff confirmed that staffing shortages significantly impacted the ability to provide consistent wound care and complete necessary documentation. The Wound Nurse reported being frequently reassigned to hall duties, making it difficult to monitor and treat wounds regularly. Administrative staff acknowledged that showers, wound treatments, and assessments were not being completed as required due to ongoing staffing challenges, including staff on leave and reduced availability.
Failure to Timely Assess, Identify, and Treat Resident Wound Infection
Penalty
Summary
The facility failed to provide appropriate skin assessments, timely identification of a new wound, and necessary medical treatment for a resident with significant comorbidities, including vascular dementia, hemiparesis, and hemiplegia. The resident was admitted with severe cognitive impairment and was care planned for comfort measures, with interventions to monitor and report changes in skin condition. Despite these interventions, there were no weekly skin assessments documented, and the process for skin checks relied on shower team observations rather than scheduled nursing assessments. A new wound on the resident's left heel was first noted as a red area by a nurse aide during a shower, but this information was not effectively communicated or documented by the assigned nurse. The wound was later identified as an open, unstageable area by the Wound Nurse, who treated it according to standing orders and notified the Wound Nurse Practitioner the following day. The Wound Nurse Practitioner found the wound to be deep, necrotic, and likely of diabetic etiology, ordering a wound culture, labs, and x-ray. However, there was a breakdown in communication regarding the results of the wound culture and sensitivity, which showed infection. The Wound Nurse Practitioner was incorrectly informed that the culture was negative and was not provided with the actual results, delaying the initiation of antibiotic therapy. Further interviews revealed that the NP and Medical Director were not notified of the new heel wound or the positive culture results in a timely manner. The Wound Nurse stated that lab results were faxed to providers only after all results were received, and the DON confirmed that the Wound Nurse Practitioner should have been shown the positive culture results during her visit. This lack of communication and failure to follow up on lab results led to a delay in the resident receiving appropriate antibiotic treatment for the infected wound.
Failure to Provide Timely Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. In the first case, a resident with a history of cerebral vascular accident and diabetes mellitus was admitted without pressure ulcers and was care planned for risk of impaired skin integrity. Despite this, no skin assessments were documented from admission onward. When a pressure ulcer was first identified on the resident’s right heel, there was no documented assessment or treatment order, and the wound was not reported to the medical director. The wound worsened over several days, eventually becoming unstageable with black eschar and foul odor before appropriate treatment and assessment were initiated. In the second case, another resident with multiple sclerosis and hemiplegia was identified as being at risk for pressure ulcers but did not receive routine skin assessments. When a stage 2 pressure ulcer was found on the back of the resident’s right thigh, the initial wound was not measured until several days later, and there was no ongoing assessment or documentation after the initial measurement. The treatment order for the wound was only in place for seven days and was not renewed, leaving the wound without further treatment orders or follow-up. The wound care nurse was not aware of the wound, and the wound was not followed by the wound care provider. Both cases revealed a lack of routine and systematic skin assessments by nursing staff, reliance on nurse aides to report skin issues, and inconsistent use of wound care standing orders. There was also a lack of communication and documentation regarding new wounds, failure to notify providers in a timely manner, and inadequate follow-up and monitoring of existing wounds. These deficiencies resulted in pressure ulcers going untreated for extended periods and worsening in severity.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall interventions for a resident with a history of repeated falls and cognitive impairment. One resident, who had diagnoses including hemiplegia, hemiparesis, muscle weakness, and a history of stroke, experienced 12 falls over a six-month period. On one occasion, the resident was left unsupervised in the bathroom after being assisted onto the toilet by an occupational therapy assistant (OTA). The OTA placed the call light in the resident's hand and verbally instructed her to call for assistance when ready, then notified a nursing assistant (NA) outside the room. However, the assigned NA was not aware the resident was in the bathroom, and the resident attempted to transfer herself, resulting in a fall and a left ankle fracture. Staff interviews revealed inconsistent understanding of the resident's supervision needs, and documentation did not reflect the resident's fall risk accurately on the MDS assessment. Additionally, the facility failed to provide adequate supervision for a cognitively impaired resident with Alzheimer's dementia who was at risk for elopement. This resident exited the facility unsupervised on two separate occasions. In the first incident, the resident was able to leave the building when a receptionist opened the door for visitors, and staff were unaware of her absence until she was observed outside. There was no clear system in place to identify elopement risk residents to all staff, and the incident was not documented in the facility's incident log. In the second incident, the resident was again found outside the building by a receptionist, and staff were unable to state when the resident was last observed on the unit. The care plan for this resident included frequent checks and ensuring hallway doors were alarmed, but these interventions were not effectively implemented. Interviews with staff, including nurses, nursing assistants, and administrative personnel, revealed gaps in communication and supervision practices. There was a lack of clear documentation and investigation of the incidents, and staff were often unaware of the residents' whereabouts or supervision needs at the time of the events. The facility's failure to maintain a safe environment and provide adequate supervision resulted in preventable accidents, including a fall with injury and two elopement incidents involving residents with known risks.
Failure to Resolve and Communicate Actions on Repeated Resident Council Concerns
Penalty
Summary
The facility failed to adequately resolve and communicate its efforts to address repeated concerns raised by residents during Resident Council meetings over an eight-month period. Resident Council minutes consistently documented complaints regarding certified nursing assistants (NAs) using cell phones while working, slow response times to call bells—particularly on the second shift—and the early timing of ice distribution, which disturbed residents before breakfast. Despite these recurring issues being noted in the meeting minutes, the facility's documented responses were largely repetitive, indicating that concerns had been addressed, were being monitored, or would be discussed with staff, without evidence of effective resolution. During interviews, multiple residents expressed ongoing dissatisfaction, stating that their concerns were not taken seriously and that the facility's responses were unchanged from month to month. The Activity Director confirmed that the same issues were repeatedly brought up and that residents were disappointed with the lack of satisfactory resolution. The Administrator acknowledged the presence of cameras and stated that no staff had been identified using cell phones during care or delaying call light responses, but admitted to not thoroughly documenting or investigating the residents' concerns. The deficiency centers on the facility's failure to resolve and communicate actions taken regarding persistent resident complaints, as required by regulations supporting resident rights to organize and participate in resident/family groups.
Failure to Provide Written Information on Advance Directives at Admission
Penalty
Summary
The facility failed to provide residents and their representatives with written information regarding advance directives and the right to accept or refuse medical or surgical treatment, as required by their own policy and federal regulations. Record review and interviews revealed that, for two residents, there was no evidence of an advance directive checklist, signed acknowledgment of receipt, or any documentation that written information about advance directives was provided at admission. The facility's admission packet did not include written materials about advance directives or the right to accept or refuse treatment, and there was no process in place to ensure residents or their representatives received or acknowledged this information. Interviews with the residents, their representatives, the Social Worker (who also served as the admission coordinator), and the Administrator confirmed that the facility's practice was to discuss only the Medical Order for Scope of Treatment (MOST) form, without providing any written literature about advance directives or the right to refuse care. Both residents and their representatives were unaware of what an advance directive was and did not recall receiving any information on the topic. The Social Worker and Administrator acknowledged that the facility did not include written information about advance directives in the admission process and were unaware of the requirement to do so.
Failure to Provide Scheduled Showers Due to Staffing and Process Gaps
Penalty
Summary
The facility failed to provide activities of daily living (ADL) care, specifically showers, to dependent residents as required. Two residents with significant physical impairments and care needs did not receive scheduled showers on multiple occasions. Documentation showed missed showers on several scheduled days, and both residents confirmed in interviews that they had not been receiving showers regularly. One resident reported that showers were often missed due to staff shortages, and that make-up showers were not provided if a scheduled shower was missed. Observations noted that while there was no body odor, one resident had greasy, uncombed hair, indicating a lack of personal hygiene care. Interviews with the shower team nurse aides (NAs) revealed that they were frequently pulled from their shower duties to work on the floor when the facility was short-staffed. The NAs stated that when they were reassigned, showers were not given by floor staff, and missed showers were not rescheduled. The shower team reported that even when not pulled, the workload was too high for two NAs to complete all scheduled showers, and they had requested additional help from facility leadership. Other staff, including the unit clerk and additional NAs, confirmed that showers were not provided when the shower team was reassigned, and that this was a frequent occurrence. Facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator, acknowledged that there was no process in place to ensure residents received showers when the shower team was pulled to the floor. The ADON was aware that residents did not receive showers in these situations and that some residents had complained. The DON and Administrator were not fully aware of the extent of the missed showers until the issue was brought to their attention. The lack of a contingency plan and insufficient staffing directly led to the failure to provide required ADL care for dependent residents.
Confidential Medical Information Left Unattended on Medication Cart
Penalty
Summary
A deficiency occurred when confidential medical information was left unattended and visible on top of a medication cart in the 500 hall. The narcotic book was open to a resident's narcotic sheet, displaying the resident's name, medication name, directions for use, frequency of use, indication, and remaining count. Additionally, two empty medication cards for two other residents, including their names, medication names, and usage directions, were also left exposed. During this time, no nurse was present at the cart, and two staff members along with one resident walked by, making the information accessible to unauthorized individuals. When a nurse returned to the cart, she acknowledged that she had forgotten to close the narcotic book and recognized that leaving the information visible was a violation of privacy and confidentiality. The Director of Nursing, in the presence of the Administrator, confirmed that this was a HIPAA violation and stated that staff receive education on HIPAA requirements during orientation and annually. The incident was identified through record review, observation, and staff interviews.
Failure to Implement Abuse Prevention and Reporting Policies
Penalty
Summary
The facility failed to implement its abuse policy and procedures in the areas of prevention, protection, reporting, and investigation following an incident in which a nurse aide witnessed another staff member physically abuse a resident with dementia during incontinence care. The incident involved the staff member grabbing both of the resident's wrists and slapping the resident's hand after the resident resisted care. The witnessing nurse aide did not immediately intervene or report the abuse, instead waiting until the end of her shift to inform the nurse on duty. As a result, the accused staff member continued to provide care and remained on the floor for the remainder of her shift. Upon being informed of the incident at shift change, the nurse and another nurse present did not immediately notify administration or take steps to protect the resident or other residents from further potential abuse. The nurse checked on the resident but did not observe any marks and decided, along with the oncoming nurse, to report the incident to management the following morning. The delay in reporting meant that the accused staff member was not suspended or removed from resident care until after the next shift, contrary to facility policy which required immediate reporting and protection of residents. The facility's investigation into the abuse allegation was incomplete, as it did not include interviews or assessments of other residents who may have received care from the accused staff member during the remainder of her shift. The investigation focused only on the direct witnesses and the accused, and did not determine whether other residents were affected. The facility's own policy required immediate reporting, collection of statements from all witnesses, and assessment of all potentially affected residents, but these steps were not followed.
Inaccurate MDS Coding for PASRR Level II and Pressure Wound
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents in the areas of Preadmission Screening and Resident Review (PASRR) Level II and pressure wounds. For one resident with a diagnosis of bipolar disorder, the electronic health record contained a PASRR Level II determination, but the annual MDS was incorrectly coded as Level I. Staff interviews confirmed this was a human error. Similarly, another resident with bipolar disorder had a PASRR Level II determination in the health record, but the annual MDS was also incorrectly coded as Level I, which staff attributed to a coding error. Additionally, a resident with vascular dementia and hemiparesis was incorrectly coded on the quarterly MDS as having a stage 1 pressure ulcer, even though the pressure ulcer developed after the assessment date. Staff interviews confirmed that the resident did not have a pressure wound at the time of the MDS assessment and that the coding was an input error. The administrator acknowledged that the MDS should accurately reflect the resident's conditions and that these were errors.
Failure to Revise Care Plan After Development of Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident who developed a pressure ulcer after admission. The resident, who had a history of cerebral vascular accident and diabetes mellitus, was admitted without pressure ulcers and was assessed as having severely impaired cognition, requiring substantial to maximal assistance with activities of daily living. The initial care plan identified the resident as being at risk for impaired skin integrity and included interventions such as frequent turning, skin monitoring, and prompt notification of nursing staff for any open areas. However, when an unstageable wound with black eschar and foul odor was discovered on the resident's right heel, the care plan was not updated to reflect this new development. Medical records showed that the wound nurse documented the new pressure ulcer and obtained treatment orders, including antibiotics, an X-ray, and a wound consult. Despite this, there was no evidence that the care plan was revised to address the new pressure ulcer. Interviews with the MDS nurse revealed that she was informed of the new wound during a clinical meeting but failed to update the care plan upon returning to her office. The administrator confirmed that it was the MDS nurse's responsibility to revise care plans promptly for new developments such as pressure ulcers.
Failure to Timely Reweigh and Report Significant Weight Loss
Penalty
Summary
The facility failed to act promptly on the Registered Dietitian's (RD) recommendation to reweigh a resident after a significant weight loss was identified. The RD had recommended a reweight and an increase in nutritional supplements after noting a 13.6% weight loss in one month. Although the diet order was revised to increase calories and supplement volume, the reweight was not performed until several days later, and the result was neither documented in the medical record nor reported to nursing management until more than two weeks after it was obtained. This delay prevented timely recognition and intervention for the resident's ongoing weight loss. The resident involved had multiple diagnoses, including dementia, hypothyroidism, nutritional deficiency, and protein-calorie malnutrition. She was noted to have severe cognitive impairment and required setup and clean-up assistance with eating. Despite her significant weight loss and poor oral intake, there was no evidence that her nutritional status or lack of eating was discussed by the interdisciplinary team or reported to the physician. During meal observation, the resident did not consume any food independently, and staff did not provide cues or encouragement to eat, even though she typically required such assistance. Interviews with facility staff revealed lapses in communication and follow-through regarding the resident's weight monitoring. The Assistant Director of Nursing (ADON) acknowledged responsibility for ensuring weights were completed but did not follow up in a timely manner. The Unit Clerk obtained the reweight but failed to enter it into the medical record or notify the ADON. The RD and Medical Director were not informed of the significant weight loss, and the Medical Director stated he would have taken further action if notified. The Director of Nursing (DON) and Administrator both indicated that reweights and documentation should occur promptly, but this did not happen in this case.
Failure to Provide Safe and Appropriate Respiratory Care and Oxygen Safety Measures
Penalty
Summary
Surveyors identified multiple deficiencies in the provision of respiratory care for three residents requiring oxygen therapy. For two residents with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and respiratory failure, observations revealed that the oxygen concentrator filters in their rooms contained significant debris build-up, described as fluffy, crumbly, and light brown in color. Staff interviews confirmed that the filters were not being cleaned daily as required, and there was confusion among staff regarding the cleaning schedule and responsibilities. Additionally, the oxygen tubing was not consistently labeled to indicate when it was last changed, making it difficult to track compliance with weekly tubing changes. Further deficiencies were noted in the lack of appropriate oxygen in use signage on the entrances to the rooms of all three residents receiving oxygen therapy. Observations on multiple occasions confirmed that the required signage was missing, and staff interviews revealed uncertainty about who was responsible for placing the signs. The Director of Nursing stated that signage should be present on or near the resident's door whenever oxygen is in use, but this was not being consistently implemented. Additional safety concerns were observed regarding the handling and storage of oxygen tanks. In one instance, an oxygen tank was found stored upright on the floor of a resident's room without being secured in a holder, and staff were unable to identify who had placed it there. In another instance, a nurse aide was observed transporting a full oxygen tank by carrying it in her arms rather than using a cart or secure holder, contrary to facility expectations. The aide later acknowledged that a cart was available for this purpose but was unsure of its location at the time.
Failure to Ensure Nurse Aide Competency and Training Enrollment
Penalty
Summary
The facility failed to ensure that a staff member working as a nurse aide (NA) met the minimum competency requirements as outlined by state and federal regulations. Specifically, one staff member was hired to work full-time as an NA without having completed a state-approved nurse aide training program, passed a certification exam, or undergone a competency evaluation prior to providing direct care to residents. Record review showed that this staff member was not enrolled in a state-approved training program at the time of hire and had not completed a skills competency checklist. The Director of Nursing (DON) confirmed that the staff member had only recently attempted to enroll in a hybrid online program but was advised to attend an in-person program at a later date. Despite this, the staff member was scheduled and assigned NA tasks over multiple shifts. Interviews with the Administrator and DON revealed that the facility did not have an in-house state-approved NA training program and routinely hired staff to work as NAs before enrolling them in external training programs. The Administrator stated that staff were allowed to perform all NA duties during their first four months of employment, regardless of their enrollment status in a training program. This practice continued after the expiration of a pandemic-related waiver, under the mistaken belief that staff could still work for four months before certification as long as they eventually enrolled in a program. The facility's approach did not comply with the requirement that staff must be actively participating in a state-approved NA program during the four-month grace period.
Improper Labeling and Storage of Medications on Medication Carts
Penalty
Summary
Surveyors observed that drugs and biologicals were not properly labeled or stored in accordance with professional standards on two medication carts. On the 200-hall medication cart, 13 loose pills of various shapes, colors, and sizes were found in the bottom of the drawers. Additionally, open and undated boxes of budesonide and DuoNeb solutions were present, despite manufacturer guidelines requiring budesonide vials to be used within two weeks of opening the foil pouch and DuoNeb vials within seven days. The nurse responsible for the cart was unaware of these guidelines and had not cleaned the cart during her shift. On the 500-hall medication cart, four loose albuterol sulfate solution vials and an open, undated box of DuoNeb solutions were found in the drawer. Manufacturer instructions specify that albuterol sulfate should be stored in the foil pouch to protect from light, and DuoNeb vials should be used within seven days of opening. The nurse assigned to this cart also had not cleaned the cart and was unaware of the storage and labeling requirements. The DON stated that while each nurse is responsible for keeping carts clean, the weekend supervisor is tasked with ensuring medication carts are organized and that medications are properly stored and labeled.
Failure to Notify Provider of Positive Wound Culture Result Delays Antibiotic Treatment
Penalty
Summary
A deficiency occurred when the facility failed to notify the Wound Provider of a positive wound culture and sensitivity laboratory result for a resident with vascular dementia, hemiparesis, and hemiplegia following a stroke. The resident was admitted with multiple wounds, including an unstageable left heel wound suspected to be of diabetic origin. The Wound Provider evaluated the wound and ordered a culture and sensitivity due to suspicion of infection. The laboratory report, completed and sent to the facility, indicated the presence of moderate proteus mirabilis and scant staphylococcus aureus. Despite the availability of the positive lab results, the Wound Provider was not informed of the findings when she visited the facility. Instead, she was incorrectly told by the Wound Nurse that the culture was negative, and she did not have access to the actual results. The Nurse Practitioner (NP) was also not notified of the laboratory results or the Wound Provider's treatment orders. The NP only became aware of the positive culture several days later, at which point antibiotics were ordered for the resident's infected heel wound. Interviews with facility staff, including the Wound Nurse, NP, and DON, revealed lapses in communication and delays in providing laboratory results to the appropriate providers. The DON acknowledged that the Wound Provider should have been shown the results during her visit, and the Medical Director confirmed that the delay resulted in the resident missing at least one day of antibiotic treatment. The Wound Nurse admitted to not having seen the results before reporting them as negative, contributing to the delay in appropriate care.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its own Hand Hygiene and Enhanced Barrier Precautions (EBP) policies and procedures during wound care for two residents. Observations revealed that the Wound Nurse did not don a gown, change gloves, or perform hand hygiene at required points during wound care procedures. Specifically, after removing soiled dressings and after cleansing wounds, the Wound Nurse did not change gloves or sanitize hands before applying new dressings. These lapses were observed during wound care for a resident with an unstageable right heel pressure ulcer and another resident with a diabetic foot ulcer. The Wound Nurse acknowledged during interviews that she did not follow proper glove changing and hand hygiene protocols, stating she "just forgot" to perform these steps. She also did not wear a gown during the procedures, explaining that she had questioned the need for EBP with the Assistant Director of Nursing (ADON), who advised that EBP was not required for these residents. The nurse was unaware that EBP should be used for open, draining wounds regardless of their chronicity or expected healing time. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed a misunderstanding of CDC guidelines regarding EBP. Both believed that EBP was only necessary for wounds present for six months or longer, and therefore did not implement EBP for the residents in question. The IP and DON were informed during the survey that EBP should be applied to any open, draining wounds, not just chronic wounds, and acknowledged the need to reevaluate their practices.
Failure to Maintain Clean and Safe Laundry Equipment
Penalty
Summary
Surveyors observed that two dryers in the facility's laundry room, located in a separate building, contained significant accumulations of dark-colored dust balls and thick sheets of lint in the lint traps. When the dryer doors were opened, lint approximately 1/4 inch thick fell from the traps. Staff interviews revealed that the laundry aide, who worked first shift, claimed to clean the dryer vents and filters every shift but could not explain the presence of the lint and dust buildup. The Environmental Services Supervisor stated that dryer vents and lint traps should be cleaned daily, but acknowledged that the observed buildup indicated the current cleaning frequency was insufficient.
Failure to Ensure Dignified Meal Service and Proper Feeding Assistance
Penalty
Summary
The facility failed to uphold residents' rights to dignity and self-determination during meal service for two residents. One resident with moderate cognitive impairment and a history of dysphagia, diabetes, and malnutrition was not served her meal at the same time as others at her dining table. Despite raising her hand and expressing hunger multiple times, her meal was delayed by nearly 20 minutes due to disorganization in the kitchen following a staff call-out and late arrival. The resident's meal was mistakenly sent to her floor instead of the dining room, and she only received her food after staff were alerted to the error. Another resident, who had severe cognitive impairment and required assistance with eating due to Alzheimer's dementia and dysphagia, was observed being fed by a nursing assistant who stood at the side of the bed rather than sitting at eye level, as required. Although a chair was available in the room, the nursing assistant did not use it. Both the nursing assistant and the facility administrator confirmed that staff are expected to sit when feeding residents, but this protocol was not followed during the observed meal.
Resident Physically Abused by Staff During Care
Penalty
Summary
A resident with severe cognitive impairment, dementia, and anxiety, who was dependent on staff for activities of daily living and personal hygiene, was subjected to physical abuse by a staff member during incontinence care. The resident was known to be combative and sometimes refused care, as documented in her care plan, which included interventions such as explaining procedures, using a calm approach, and providing reassurance. During an episode of care, the resident became agitated, verbally resisted, and attempted to push staff hands away. While two nurse aides were providing care, one staff member became angry at the resident's resistance, grabbed both of the resident's wrists, yelled at her, and slapped her on the hand with an open hand. The incident was witnessed by the other aide, who reported that the resident appeared startled and subsequently exhibited fearful and suspicious behavior towards staff. The staff member involved admitted to hitting the resident, stating it was an instinctive reaction after being slapped by the resident. The incident was not reported to the Director of Nursing until the following morning, after being relayed through multiple staff members. The resident was observed to be fearful during subsequent care, asking staff not to hurt her. The facility's investigation substantiated the abuse, confirming that the staff member had physically abused the resident during care.
Failure to Accurately Post and Complete Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that Nurse Staffing Information was posted in a prominent and readily accessible location for residents, staff, and visitors. Observations revealed that the staffing sheets were placed flat on the counter of the receptionist desk in the front lobby, requiring individuals to stand over the desk and look down to view them. Interviews with the receptionist and the administrator confirmed that this had been the standard practice, and neither was aware that this did not meet regulatory requirements for accessibility. Additionally, the facility did not accurately complete the Nurse Staffing Information sheets. On multiple days, the resident census section was either left blank or included both skilled nursing and assisted living residents, rather than only the skilled nursing census as required. The administrator acknowledged that the census for the entire facility had been included for an extended period and was unaware that this was incorrect until reviewing the regulations during the survey. There were also discrepancies between the posted Nurse Staffing Information sheets and the actual nursing assignment sheets. The posted sheets often listed incorrect numbers and hours for RNs, LPNs, NAs, and did not include Temporary Nurse Aides (TNAs) who were scheduled to work. The administrator stated she was not aware that the posted information needed to reflect absences due to illness or call-outs, but recognized the requirement after reviewing the regulations. These inaccuracies were observed across all reviewed days.
Deficient Sanitation in Laundry Rooms and Medication Equipment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in both laundry rooms and in the handling of medication equipment. In the laundry room located in a separate building, there were strings of dust hanging from a dryer, dust accumulation on the tops of washers, and a thick layer of dust on baseboard trim stored above a worktable where clean linens and residents' personal clothing were placed. The Environmental Services Supervisor confirmed that the laundry room should be cleaned daily, including dusting equipment, and acknowledged that the area was being used for storage of old furniture and personal items, which should not be near clean laundry. Inside the facility, a housekeeping cart was stored next to a rack of residents' clean clothing, and the cart was not deep cleaned daily. The Environmental Services Supervisor stated that the residents' clothing would need to be rewashed and covered to prevent contamination. Additionally, a pill crusher on the 100-hall medication cart was found to have a dried light brown liquid substance and dark brown debris embedded in its crevices, indicating it had not been cleaned in a long time. Both the Wound Nurse and another nurse assigned to the 100-hall medication cart confirmed that nurses are responsible for cleaning the pill crushers and medication carts, and both acknowledged the pill crusher was visibly soiled and needed cleaning. The DON stated that cleaning the pill crusher was part of the medication cart cleaning process and should be done by the weekend supervisor.
Resident Fall Due to Inadequate Supervision During Bed Bath
Penalty
Summary
The facility failed to provide a safe environment for a resident, resulting in a fall and injury. The resident, who had functional quadriplegia, dementia, and a traumatic brain injury, was at risk for falls and required maximum assistance for personal care. During a bed bath, the resident fell from the bed, striking a chair and then the floor, which resulted in a fractured right femur. The care plan for the resident included maintaining a clutter-free environment, keeping the bed in a low and locked position, and using M-rails for mobility and transfers. On the day of the incident, a nursing aide was providing a bed bath to the resident, who was resistant to care and exhibited behaviors such as yelling and attempting to hit. The aide continued with the bed bath despite the resident's resistance. The resident was positioned on her left side, holding onto the bed railing with her right hand, and was left unattended when the aide went to rinse a washcloth. During this time, the resident lowered her right leg, causing her to fall off the bed. The aide was unable to prevent the fall as the resident was wet and slipped from her grip. The incident report and interviews with staff indicated that the resident was screaming in pain and was resistant to being assessed for injuries. The medical director, who was present in the facility, ordered pain and anxiety medication and had the resident sent to the emergency room, where a fractured femur was confirmed. The director of nursing noted that the aide should not have left the resident unattended on her side near the edge of the bed, which contributed to the fall and subsequent injury.
Inadequate Training on Glucometer Disinfection
Penalty
Summary
The facility failed to ensure that nursing staff were competent in the disinfection of glucometers, as evidenced by observations and interviews with five out of six nursing staff members. Nurse #2 was observed returning a glucometer to the medication cart without disinfecting it after use, and she admitted to not receiving training on glucometer disinfection since being rehired. Similarly, Nurse #3 used a previously used disinfectant wipe to clean the glucometer, believing it was still effective. Both nurses' orientation skills checklists lacked specific education on glucometer disinfection. Nurses #4 and #5, along with the Weekend Nurse Supervisor, also demonstrated a lack of proper knowledge regarding glucometer disinfection. Nurse #4 used an alcohol prep pad for cleaning, which is ineffective against bloodborne pathogens, and could not recall receiving specific training on the process. Nurse #5 similarly used an alcohol wipe, citing a lack of education on the correct procedure. The Weekend Nurse Supervisor, responsible for completing the skills checklist, did not specifically review glucometer disinfection unless prompted by the nurse, despite knowing the correct procedure. The Staff Development Coordinator (SDC) and Director of Nursing (DON) acknowledged the absence of specific training on glucometer disinfection in the orientation skills checklist. The SDC conducted an in-service on glucometer cleaning, but it was not mandatory, and several nurses, including the Weekend Nurse Supervisor, did not attend. The DON and Assistant Administrator admitted that the facility lacked a specific policy on glucometer disinfection, and the skills checklist did not explicitly cover this area, leading to inconsistent training and understanding among the nursing staff.
Medication Security Lapses in LTC Facility
Penalty
Summary
The facility failed to properly secure medications, as evidenced by two separate incidents. In the first incident, an antifungal powder prescribed for a resident with dementia was found unsecured at the resident's bedside. The resident, who had moderate cognitive impairment and required assistance with daily activities, did not have a physician's order for self-administration of the medication. The antifungal powder was supposed to be stored in the treatment cart, but it was left on the bedside table, and neither the resident nor the wound nurse knew how long it had been there or which nurse had left it. In the second incident, a medication cart in the 600-hall was observed unattended and unlocked on two occasions. The cart was left unlocked while staff were distributing lunch trays, and Nurse #1 admitted to forgetting to lock it. The DON confirmed that the medication cart should have been locked when unattended to prevent unauthorized access. The Assistant Administrator also acknowledged that the cart should have been locked when Nurse #1 left it.
Failure to Provide SNF-ABN to Resident
Penalty
Summary
The facility failed to provide a completed Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to a resident prior to discharge from Medicare Part A skilled services. The resident, who was admitted with diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and dementia, was severely cognitively impaired according to the most recent Minimum Data Set assessment. Despite being informed that Medicare Part A coverage for skilled services would end on a specific date, the resident remained in the facility without receiving the required SNF-ABN. The Business Office Manager did not issue the SNF-ABN, mistakenly believing it was only necessary for managed care residents. She had been trained to issue a Notice of Medicare Non-Coverage (NOMNC) instead, which she did. The Assistant Administrator acknowledged awareness that a SNF-ABN should be issued for residents discharged from Medicare Part A services who remain in the facility, indicating a lapse in the facility's process for ensuring proper notification.
Missed Antibiotic Doses Due to Pharmacy Delivery Delay
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident, resulting in two missed doses of an antibiotic. The resident, who was admitted with conditions including hypoxemia, shortness of breath, and COPD, had an active order for Doxycycline to be administered twice daily. The order was entered into the system on the afternoon of 9/2/24, but the first dose was not administered until the evening of 9/3/24. This delay was due to the medication not being available in the facility's emergency backup kit and the pharmacy being closed for a holiday. Nurse #4, who was on duty when the order was placed, did not contact the pharmacy, assuming the medication would arrive with the next delivery. Similarly, Nurse #7, who was on duty the following day, also did not contact the pharmacy, expecting the medication to arrive with the afternoon delivery. The pharmacy technician confirmed that the pharmacy was closed on 9/2/24 but had an on-call pharmacist available. The Doxycycline order was received by the pharmacy on 9/2/24, but due to the holiday closure, it was not delivered until the afternoon of 9/3/24. The Director of Nursing and Assistant Administrator acknowledged that the nurses should have contacted the pharmacy when the medication was not found in the emergency kit.
Failure to Administer Antibiotic Timely
Penalty
Summary
The facility failed to administer an antibiotic as ordered for a resident, leading to a significant medication error. The resident, who was admitted with diagnoses including hypoxemia, shortness of breath, and COPD, had an active order for Doxycycline to be administered twice daily. However, the first dose scheduled for the evening of the order date was not administered, and the subsequent morning dose was also missed. The first dose was only given more than 24 hours after the order was placed. The delay in administering the antibiotic was due to several factors. Nurse #4, who was responsible for the resident on the day the order was placed, did not find the medication in the emergency kit and assumed it would arrive with the next pharmacy delivery. Similarly, Nurse #7, who was on duty the following day, also did not receive the medication and did not contact the pharmacy, assuming it would arrive with the regular delivery. Both nurses were unaware of the pharmacy's holiday schedule, which had been communicated in advance, indicating altered delivery times and the availability of an on-call pharmacist for urgent needs. The Assistant Administrator, who entered the order, did not check the emergency medication kit to ensure the availability of Doxycycline, which was not included in the kit. The pharmacy had been closed for a holiday, and although a memo had been posted about the closure and the procedure for obtaining medications, it was not acted upon. The Medical Director and Director of Nursing acknowledged that the delay in starting the antibiotic was too long, especially given the resident's condition, although the resident did not exhibit significant clinical symptoms at the time.
Deficiency in Glucometer Disinfection Protocol
Penalty
Summary
The facility failed to establish and implement a clear policy and procedure for the disinfection of glucometers, leading to a deficiency in infection prevention and control. Observations revealed that Nurse #2 and Nurse #3 did not properly disinfect a glucometer used for a resident's blood glucose testing. The facility's existing policy stated that each resident should have their own glucometer, which should be disinfected before and after use, but it did not specify the method for disinfection. Additionally, the facility lacked a separate policy specifically addressing glucometer disinfection. During the observations, Nurse #2 performed a blood glucose test for a resident without disinfecting the glucometer after use, despite having disinfectant wipes available on the medication cart. Nurse #2 believed that disinfection was only necessary before use. Similarly, Nurse #3 used a disinfectant wipe before the test but reused the same wipe afterward, contrary to the proper procedure of using a new wipe for disinfection. Both nurses stored the glucometer in the medication cart, which was a common practice in the facility, although it was intended for individual use and not shared among residents. Interviews with the Staff Development Coordinator, Director of Nursing, and Assistant Administrator highlighted inconsistencies in the understanding and implementation of the disinfection process. The Staff Development Coordinator described a two-step disinfection process, which was not followed by the nurses. The Director of Nursing and Assistant Administrator both emphasized the importance of using a new EPA-approved disinfectant wipe before and after each use to prevent blood-borne pathogen transmission. However, the facility's policy did not provide clear instructions on the disinfection process, contributing to the observed deficiency.
Failure to Maintain Privacy of Resident Records
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical records when a computer screen on a medication cart was left open and unattended, displaying sensitive resident information. During an observation, the 600-hall medication cart was found unattended with the computer screen displaying a resident's Medication Administration Record (MAR), which included the resident's picture, name, date of birth, room number, record number, special instructions, allergies, current vital signs, and medications. Staff were observed distributing lunch trays in the hallway at the time. Nurse #1 was responsible for the medication cart and returned to it after a few minutes, placing the privacy screen on the computer. However, shortly after, Nurse #1 left the cart again without activating the privacy screen, leaving the resident's information exposed once more. Interviews with Nurse #1, the Director of Nursing (DON), and the Assistant Administrator confirmed that the privacy screen should have been used to protect resident information when the nurse was not present at the cart. Nurse #1 acknowledged forgetting to activate the privacy screen, and both the DON and Assistant Administrator reiterated the importance of using the privacy screen to prevent unauthorized access to resident information.
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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