Fletcher Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fletcher, North Carolina.
- Location
- 86 Old Airport Road, Fletcher, North Carolina 28732
- CMS Provider Number
- 345522
- Inspections on file
- 21
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Fletcher Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with thoracic vertebrae fractures, weakness, pain, and impaired upper extremity ROM required partial to moderate setup assistance for oral hygiene per the care plan and MDS, including care for an upper denture. The resident reported not recalling recent setup assistance, had an upper denture with visible white buildup, and had no denture cup in the room. The assigned NA believed the resident only had natural teeth, stated the resident could brush independently with minimal setup, and was unaware of the denture due to the absence of a denture cup. Observations confirmed no improvement in denture cleanliness and no denture cup, while the DON and Administrator confirmed that daily oral hygiene, including denture care, was expected and that staff were to follow Kardex instructions.
A nurse aide independently transferred a dependent resident using a mechanical lift without the required second staff member, resulting in the lift tilting and the sling bar striking the resident's face and causing a laceration. The resident, who had severe cognitive and physical impairments, required hospital treatment for the injury. Staff interviews confirmed the aide was aware of the two-person policy but proceeded alone when assistance was unavailable.
A resident with muscle wasting and malnutrition was admitted with existing pressure ulcers, but the facility failed to obtain timely treatment orders and did not complete accurate or consistent skin assessments. Wound measurements and staging were omitted, wound care was delayed, and a new deep tissue injury developed without prompt identification. Staff interviews revealed lack of training, missed documentation, and communication lapses, resulting in delayed and inconsistent wound care.
Surveyors identified failures in food storage and labeling, including undated and uncovered food items in coolers, freezers, and dry storage, as well as visible spoilage not being addressed. Additionally, dietary staff were observed breaching infection control protocols by handling ice with bare hands and failing to perform hand hygiene after handling dirty dishes, contrary to facility policy.
Multiple residents had MDS assessments inaccurately coded, including errors in documenting medication administration, pressure ulcer presence and staging, and PASRR Level II status. These inaccuracies were confirmed through MAR reviews, staff interviews, and discrepancies with clinical documentation. Facility leadership acknowledged the expectation for accurate MDS completion.
Several dependent residents did not receive necessary assistance with oral hygiene, nail care, and scheduled showers, with observations showing unclean dentures, long dirty fingernails, and missed showers. Staff cited missing supplies, lack of familiarity with residents, and short staffing as reasons for not providing care, and documentation of refusals or missed care was incomplete or absent.
Staffing shortages, especially on weekends, resulted in missed or delayed bathing, incontinence care, and personal hygiene for several residents. Staff and residents reported that insufficient nurse and nurse aide coverage led to delayed medication passes, missed showers, and slower response to call lights, with administrative staff confirming ongoing challenges in maintaining adequate staffing levels.
The facility failed to ensure nurses and nurse aides demonstrated required competencies, resulting in missed documentation of code status, delayed pressure ulcer treatment, incomplete skin assessments, unreported skin irritation during catheter care, medication administration errors, and missed medication doses due to improper prescription management and failure to use the Pyxis system. These deficiencies affected multiple residents and were identified through staff interviews, record reviews, and observations.
Lunch meals were not served at the scheduled time on two observed occasions, with trays arriving late in the main dining room. A resident who was cognitively intact and required set-up assistance expressed frustration about the delay, and several residents reported that late meal service was a recurring issue. The deficiency was observed despite recent changes to the meal schedule intended to improve timeliness.
Staff failed to follow infection control and Enhanced Barrier Precautions protocols, including not donning gowns and not performing proper hand hygiene during incontinence and wound care for residents with pressure ulcers. Multiple staff members either did not understand or overlooked EBP signage and requirements, resulting in care being provided without appropriate PPE and hand hygiene, despite facility policies and available training.
Two residents experienced unmet needs due to facility inaction: one was unable to access a light switch because of a broken, out-of-reach cord, while another, with quadriplegia and above-average height, had his feet extending past the end of his bed, causing discomfort. Staff failed to identify, report, or address these issues, and maintenance was not made aware through proper channels, resulting in prolonged deficiencies in resident accommodation.
A resident admitted with acute respiratory failure and hypoxia did not have an advance directive or code status documented upon admission. The admitting nurse did not complete the required process, citing lack of training, and the omission was confirmed by the DON, MD, and Administrator, who all stated that the admission paperwork and code status order should have been completed.
A resident was admitted with existing pressure ulcers, but the admitting nurse did not notify the physician or obtain wound care orders at the time of admission. Instead, the nurse reported the wounds to the oncoming nurse and left a note for the NP to address the issue during the next scheduled visit, resulting in a delay in wound care treatment.
A resident with significant cognitive and physical impairments, fully dependent on staff for toileting, was left in a heavily soiled brief for about an hour after requesting incontinence care. The NA did not check or change the resident before going on break and delayed care further due to meal tray service, resulting in the resident remaining in soiled clothing and experiencing distress. Facility leadership confirmed that care should have been provided when requested.
A resident with severe cognitive impairment and multiple medical conditions was admitted and later assessed, but the MDS Coordinator failed to provide comprehensive analysis for 8 out of 9 triggered care areas in the CAA. The required documentation regarding the nature of problems, causes, and contributing factors was missing, as confirmed by staff interviews and record review.
A nurse administered medications intended for another resident to a cognitively intact individual with multiple chronic conditions after failing to verify the resident's identity. The error was discovered when the resident corrected the nurse after being called by the wrong name, and it was confirmed that the nurse did not follow proper identification procedures. The resident experienced anxiety but no adverse effects were observed.
A resident with an indwelling urinary catheter was not provided with proper catheter and perineal care, resulting in a buildup of a white substance, skin redness, irritation, and a strong odor resembling yeast. Staff failed to follow physician orders for daily hygiene and monitoring for complications, did not document or report skin changes, and primarily emptied the catheter bag without performing full care. Leadership interviews confirmed that appropriate care and monitoring were not provided.
Two residents experienced significant medication errors: one received medications intended for another resident due to a nurse's failure to verify identity, and another missed multiple doses of nerve pain, diabetic, and insulin medications because staff did not timely request a prescription for a controlled drug and failed to utilize available medications in the Pyxis system. These actions and inactions led to gaps in medication administration and resident distress.
An opened tube of antifungal cream was found left unattended on a bedside table in a resident's room. The resident, who had severely impaired cognition and had not been assessed for self-administration, was unable to respond to questions. Nursing staff confirmed the medication should have been secured in the med cart and not left in the room.
A resident who was cognitively intact and required assistance with meals did not receive a preferred bacon, lettuce, and tomato sandwich as listed on their meal card, and was instead served a ham and cheese sandwich, which they disliked. The meal card did not reflect the resident's food dislikes, and both the Dietary Manager and Administrator confirmed the error and incomplete documentation of preferences.
The facility did not ensure that daily nurse staffing sheets accurately reflected the actual nursing staff present for all reviewed days. Discrepancies were found between posted staffing sheets and time clock records, with differences in the number and type of staff reported for each shift. The Scheduler responsible for posting the sheets did not update them to account for call-outs or schedule changes, resulting in inaccurate staffing information being posted.
The facility failed to post oxygen use signs and maintain clean respiratory equipment for residents needing supplemental oxygen and nebulizer treatments. Observations showed oxygen concentrators with debris and uncovered nebulizer masks, confirmed by the DON. The Administrator cited conflicting guidance on signage requirements, contributing to the deficiency.
A resident's privacy was compromised when EMS personnel provided a detailed medical report to the ADON in a hallway, where it could be overheard by others. The resident, who has Alzheimer's disease, had just returned from a hospital visit. The ADON acknowledged the breach and the facility's Administrator confirmed that such discussions should occur in private.
A resident with dysphagia and cognitive impairments did not have fluids readily available, leading to a deficiency in hydration care. The resident, dependent on staff for assistance, reported only receiving drinks with meals. Staff interviews revealed a lack of awareness and availability of thickened liquids, with delays in providing fluids. The facility's dietary manager confirmed issues with labeling and availability of pre-poured liquids.
The facility failed to secure medications and biologicals, as observed with three residents who had nasal sprays and medicated creams left in their rooms. Despite not wishing to self-administer medications, these items were left in clear view, contrary to protocols. The DON confirmed that these should have been stored in the nurse medication cart.
Failure to Provide Required Setup Assistance With Oral Hygiene and Denture Care
Penalty
Summary
The facility failed to provide required setup assistance with oral hygiene for a resident with thoracic vertebrae fractures, weakness, and pain who had an identified self-care performance deficit. The resident’s Kardex and activities of daily living care plan, revised on 1/9/26, specified that routine oral care included brushing teeth, rinsing dentures, cleaning gums, rinsing with mouthwash, and that the resident required partial to moderate setup assistance with oral care. The admission MDS documented intact cognition, impaired upper extremity range of motion bilaterally, and a need for setup or clean-up assistance with oral hygiene. Despite these documented needs and instructions, the resident reported not recalling the last time setup assistance for oral care was provided and was unsure if a denture cup was available. On observation, the resident’s upper denture had a visible buildup of white-colored substance on the gums and teeth, and no denture cup was found in the resident’s room or bathroom. The NA assigned to the resident on two consecutive day shifts stated that the resident had his own teeth and could brush independently, reported providing setup assistance by positioning the resident and handing over a toothbrush and toothpaste, and stated she was unaware the resident had an upper denture, noting there was no denture cup in the room. A subsequent observation showed no change in the denture’s condition. During an interview and observation, the DON confirmed the presence of an upper denture, the continued buildup on it, and the absence of a denture cup, and stated that oral hygiene, including brushing teeth and dentures, was to be done daily. The Administrator stated she expected NA staff to review the Kardex to know if a resident had dentures and to offer daily oral hygiene, and that the assigned NA should have been aware of the upper denture and the need for setup assistance.
Failure to Provide Required Assistance During Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide independently transferred a dependent resident using a mechanical lift without the required assistance of a second staff member. The resident, who had a history of traumatic brain injury, abnormal posture, and multiple contractures, was totally dependent on staff for transfers and had severely impaired cognitive skills. During the transfer from bed to a reclining wheelchair, the mechanical lift tilted, causing the sling bar to strike the resident above the left eyebrow, resulting in a laceration. The nurse aide admitted to performing the transfer alone, despite being aware of the facility's policy requiring two-person assistance for mechanical lift transfers. She stated that she had attempted to find another staff member to assist but proceeded alone when no one was available. The incident was immediately reported to nursing staff, who assessed the resident and arranged for transfer to the emergency department. The resident received sutures for the laceration and returned to the facility the same day. Interviews with staff confirmed that the nurse aide had received prior training on the mechanical lift policy and was aware of the requirement for two-person assistance. The Director of Nursing and Administrator both verified that the nurse aide acknowledged her actions and the deviation from policy. Observations and record reviews indicated that the resident had a healing scar from the injury, and there were no signs of infection or ongoing pain at the time of follow-up.
Delayed Pressure Ulcer Treatment and Incomplete Skin Assessments
Penalty
Summary
The facility failed to obtain timely treatment orders for pressure ulcers identified on a newly admitted resident, resulting in a seven-day delay before wound care was initiated. Upon admission, the resident was noted to have pressure ulcers on the right and left buttock and sacrum, with documentation indicating the skin was not intact and at moderate risk for further breakdown. However, the admission assessment and baseline care plan lacked complete information regarding the size, depth, and stage of the wounds, and no treatment orders were obtained or administered for the pressure ulcers during the first week of admission. Additionally, the facility did not perform accurate or consistent head-to-toe skin checks to identify new or existing pressure ulcers. Several skin assessments and daily skilled charting entries incorrectly documented the resident's skin as intact, despite the presence of pressure ulcers. The nurse responsible for the admission assessment did not measure the wounds or check for blanching, and later admitted to not being trained on the full process for new admissions or daily skilled charting. The Wound Care MD was not notified of the resident's wounds and did not evaluate the resident due to a rescheduled visit and lack of communication from the facility. Further observations revealed that wound care orders were not consistently followed, as the prescribed dressing was not always in place, and some wound care treatments were missed or not documented. A new deep tissue injury was later identified on the resident's left heel, which had not been previously documented. Interviews with staff indicated gaps in communication, training, and adherence to protocols for skin assessments and wound care, contributing to the delay in treatment and failure to prevent the development of new pressure ulcers.
Deficiencies in Food Storage, Labeling, and Infection Control in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and handling within the facility's dietary department. In the walk-in cooler, opened containers of chicken and beef base were found without use-by dates, and one container had an illegible date. Additionally, two apples with visible spoilage were stored with other apples. The Dietary Manager confirmed that these items should have been labeled with use-by dates and discarded if spoiled or past their expiration, and acknowledged that the apples showed clear signs of spoilage. The Administrator stated that all food items should be labeled, dated, and checked regularly for spoilage or expiration. In the dry storage room, opened bags of egg noodles and croutons were found undated, and a plastic bag of red potatoes in the walk-in cooler was also undated. The Regional Director of Operations and the Administrator both confirmed that all opened food items should be dated when opened, and that the Dietary Manager was responsible for ensuring compliance with this policy. In the walk-in freezer, an open box of hamburger patties was found uncovered and undated, which was also confirmed as non-compliant by facility leadership. Surveyors also observed infection control breaches by dietary staff. One dietary aide was seen removing ice from the ice machine with her bare hand, touching ice that remained in the machine, and placing the ice in her personal beverage. Another dietary aide was observed handling dirty dishes and then touching clean items in the kitchen without removing gloves and performing hand hygiene. Both the Regional Director of Operations and the Administrator confirmed that these actions were not in accordance with facility policy, which requires the use of an ice scoop and proper hand hygiene when moving from dirty to clean tasks.
Inaccurate MDS Coding for Medications, Pressure Ulcers, and PASRR Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for multiple residents in several key areas, including medications, pressure ulcers, and Preadmission Screening and Resident Review (PASRR) status. For several residents, the MDS assessments indicated the administration of medications such as anticoagulants, insulin, and hypoglycemics, despite medication administration records (MARs) showing no physician orders or evidence that these medications were given during the assessment periods. The MDS Coordinator confirmed these discrepancies during interviews, acknowledging that the assessments were coded incorrectly. In addition, the facility did not accurately document the presence and status of pressure ulcers for certain residents. For example, one resident's admission MDS assessment failed to reflect the presence of pressure ulcers that were documented in nursing notes, while another resident's quarterly MDS assessment did not indicate that a pressure ulcer was present on admission, despite wound care documentation to the contrary. The MDS Coordinator attributed these errors to oversight and lack of clarification regarding wound staging and documentation. The facility also failed to correctly code PASRR Level II status for a resident with a serious mental illness, as the MDS assessment did not reflect the resident's active Level II PASRR determination. The Social Worker described a process of regularly auditing PASRR status and communicating updates to the MDS Coordinator, but the error was still not caught prior to the assessment. Throughout the report, the Administrator and Director of Nursing stated their expectation that MDS assessments be completed accurately.
Failure to Provide and Document Required ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several dependent residents, specifically in the areas of oral hygiene, nail care, and scheduled showers. One resident with moderate cognitive impairment and a self-care deficit was observed multiple times with a dirty upper denture and long fingernails with black debris. This resident reported not receiving assistance with denture care or oral hygiene due to missing supplies and lack of staff support, and was unable to locate a denture cup or brush. Staff interviews confirmed that oral hygiene was not provided as required, and nail care was either not offered or not documented as refused, despite visible buildup under the nails. Additionally, the same resident, along with two others, did not consistently receive scheduled showers. Documentation for showers was incomplete or missing, and staff interviews revealed that showers were often missed due to staffing shortages or lack of communication. Residents reported missing scheduled showers, with one stating that he was told he would not receive a shower due to insufficient staff, and another confirming that missed showers were not replaced with bed baths. Staff did not consistently document refusals or missed care, and did not always notify nursing leadership when showers were not provided as scheduled. The affected residents had significant physical or cognitive impairments, including quadriplegia and diabetes, requiring varying levels of assistance with ADLs. Observations and interviews indicated that the lack of assistance and documentation was a recurring issue, particularly on weekends or during periods of short staffing. The facility's failure to provide and document required ADL care, including oral hygiene, nail care, and showers, resulted in unmet care needs for multiple dependent residents.
Staffing Shortages Lead to Missed Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in missed or delayed assistance with bathing, incontinence care, and personal hygiene for four of eight sampled residents. Multiple staff interviews confirmed that staffing shortages, particularly on weekends, led to an inability to get residents out of bed, provide scheduled showers, and deliver timely incontinence and hygiene care. Staff reported that when short-staffed, their focus shifted to only essential tasks such as keeping residents clean, dry, and fed, with other care needs being delayed or omitted. Medication aides and nurses described being assigned to multiple halls and being unable to complete medication passes on time due to inadequate staffing. Nurse aides reported difficulty serving meals, making regular rounds, and responding promptly to call lights. The staffing scheduler and former interim DON acknowledged ongoing challenges with staff call-outs and no-shows, which left shifts uncovered despite efforts to use agency staff and administrative support. The facility's attempts to adjust shift lengths and scheduling practices did not consistently resolve the staffing gaps. Residents participating in a council meeting also voiced concerns about weekend staffing shortages, noting that showers were missed and call lights were answered more slowly. The administrator and staffing scheduler confirmed that the number of nurse aides and nurses on duty was often below the preferred minimums, especially on weekends and certain shifts, and that open positions remained unfilled. These staffing deficiencies directly resulted in unmet resident care needs as observed and reported during the survey.
Deficient Nursing Competency and Medication Management
Penalty
Summary
Nursing staff at the facility failed to demonstrate appropriate competencies and skills necessary to meet the individual care needs of residents. Specifically, a new nurse did not receive effective orientation on the facility's admission process, resulting in failure to obtain and document code status information, secure treatment orders for pressure ulcers, and complete accurate head-to-toe skin assessments. Additionally, a nurse aide did not report observed redness and irritation during catheter care, a nurse administered medications to the wrong resident, another nurse failed to request a prescription when refilling a controlled medication, and a nurse did not utilize available medication resources in the Pyxis system. These deficiencies were identified among five of eight staff reviewed for competency. The report details several resident care issues, including the lack of documentation of advanced directives and code status upon admission, a seven-day delay in treatment for pressure ulcers due to missing treatment orders, and incomplete wound assessments. One resident with a urinary catheter experienced skin breakdown and hygiene issues, with visible redness, irritation, and buildup of a white substance. Medication errors were also noted, including administration of another resident's medications and missed doses due to failure to request prescriptions and use available medication resources. These events were corroborated by record reviews, staff interviews, and observations.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to serve lunch meals at the scheduled time and in accordance with resident preferences on two observed occasions. According to the facility's posted schedule, lunch was to be served at 12:00 PM in the main dining room, but observations showed that meal trays arrived significantly late, at 12:38 PM and 12:48 PM on two consecutive days. During these observations, a resident expressed frustration about the extended wait for lunch. This resident was cognitively intact and required set-up assistance with eating, as documented in her quarterly MDS assessment. A group interview with the Resident Council revealed that multiple residents experienced late meal service, regardless of whether they ate in their rooms or in the main dining room. The Dietary Manager was unavailable for comment. The Regional Director of Operations and the Administrator acknowledged recent changes to the meal schedule intended to address timeliness, but the deficiency was observed during the implementation of these changes. The Administrator confirmed the expectation that residents should receive meals at the scheduled serving time.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement infection control policies during the provision of care to multiple residents requiring Enhanced Barrier Precautions (EBP) due to the presence of pressure ulcers. In several observed instances, nurse aides and nurses did not don gowns as required by EBP protocols when providing incontinence or wound care to residents with chronic wounds. Specifically, two nurse aides provided incontinence care to a resident with a pressure ulcer without wearing gowns, despite signage and available gowns at the door. These staff members also demonstrated a lack of understanding regarding the EBP signage and had not received education on when to use EBP precautions. Additionally, hand hygiene protocols were not followed during resident care activities. In one case, a nurse aide failed to remove soiled gloves and perform hand hygiene after cleaning stool and before touching other items in the resident's environment. In another instance, two nurse aides wore the same gloves throughout the process of cleaning a heavily soiled resident, applying a clean brief, and handling other items in the room, only removing gloves and performing hand hygiene upon exiting. Both staff members acknowledged that they were trained to remove gloves and perform hand hygiene after contact with body fluids but admitted to oversight during the observed care. Nurses also failed to don gowns when providing wound care to a resident on EBP, only correcting their actions after being prompted by a surveyor. Both nurses stated they had been trained on EBP but overlooked the signage and available PPE. Interviews with the Director of Nursing and the Administrator confirmed that staff were expected to follow EBP signage and hand hygiene protocols, including the use of appropriate PPE and hand hygiene after contact with body fluids.
Failure to Accommodate Resident Needs for Accessibility and Bed Length
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents regarding accessibility and comfort in their living environment. One resident, who was bedbound with impaired mobility on one side, was unable to access the light switch in his room due to a broken and shortened switch cord located out of reach. The resident reported that the cord had been broken since his admission and that he had to rely on staff to turn the light on and off, which he found frustrating and inconvenient. Observations confirmed the inaccessibility of the switch, and staff interviews revealed that although the issue had been reported to maintenance, no follow-up occurred, and the maintenance director was unaware of the problem due to lack of a formal work order. Another resident, with incomplete quadriplegia and a height of 75 inches, was found to have his feet extending past the edge of his bed mattress during multiple observations. The resident stated that the bed provided was not long enough to accommodate his height, resulting in discomfort. The maintenance director had removed the footboard to prevent pressure on the resident's feet but had not noticed the ongoing issue of the feet extending past the mattress. The director of nursing confirmed the resident's positioning and expressed concern about the resident's ankles resting at the edge of the mattress, noting the risk for skin breakdown. The administrator was unaware of the issue, as it had not been brought to her attention by staff. In both cases, the facility did not ensure that the residents' needs for accessibility and comfort were met, as staff failed to identify, report, or address the deficiencies in a timely manner. The lack of effective communication and follow-up among nursing, maintenance, and administrative staff contributed to the ongoing issues experienced by the residents.
Failure to Obtain and Document Advance Directive and Code Status Upon Admission
Penalty
Summary
The facility failed to obtain and document an advance directive, including code status information, upon admission for one resident with a diagnosis of acute respiratory failure with hypoxia. Review of the admission progress note revealed that there was no mention of the resident's advance directive or code status. The admitting nurse stated she had not been shown the full process for completing a new admission and learned procedures informally from other nurses. She admitted that she did not ask about the resident's code status during the admission process. Interviews with the former DON and the Administrator confirmed that the admitting nurse was responsible for reviewing and initiating the resident's advance directive and code status upon admission, but this was not completed. The DON indicated that the process should involve the nurse and, if available, the Social Worker, with communication to the NP or MD for orders. The MD stated that code status is typically obtained from hospital paperwork and confirmed with the resident. The Administrator acknowledged that the admission paperwork, including the advanced directive, was not completed for this resident.
Failure to Notify Physician of Pressure Ulcers on Admission
Penalty
Summary
The facility failed to notify the physician when pressure ulcers were identified on admission for one resident. Upon admission, the resident was found to have existing pressure ulcers on the right and left buttock and sacrum, as documented in the admission data collection assessment. The admitting nurse identified these wounds but did not notify the physician to obtain wound care orders at that time. Instead, the nurse reported the pressure ulcers to the oncoming nurse and left a note in the communication book for the Nurse Practitioner to see the resident during the next scheduled visit. No wound care treatments were initiated until several days after admission. Interviews with staff, including the admitting nurse, former DON, and Medical Director, confirmed that the physician was not notified as required when the pressure ulcers were identified. The Medical Director stated that he expected to be informed of such findings and that wound care treatments should have been implemented upon admission. The resident's medical history included muscle wasting, atrophy, and moderate protein-calorie malnutrition, which were relevant to the condition at the time of the deficiency.
Failure to Provide Timely Incontinence Care Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when a nurse aide (NA) failed to provide timely incontinence care to a resident who was dependent on staff for all activities of daily living due to Alzheimer's disease, vascular dementia, cerebrovascular accident, hemiparesis, and hemiplegia. The resident, who was always incontinent of bladder and bowel and required two staff for toileting, requested incontinence care prior to the NA going on break. The NA did not physically check the resident for incontinence at that time and did not provide care upon returning from break, citing instructions not to provide incontinence care during meal tray service. As a result, the resident remained in a soiled brief for approximately one hour, with a strong odor of bowel incontinence present in the room and hallway. When incontinence care was finally provided, the resident's brief was heavily soiled with bowel movement that had leaked onto her inner thighs and clothing. The resident reported being able to smell herself and stated this was not the first occurrence. Interviews with the NA, Director of Nursing, and Administrator confirmed that the resident's request for care was not addressed in a timely manner, and that the expectation was for incontinence care to be provided when requested, regardless of meal tray service schedules.
Incomplete Care Area Assessment Documentation for Resident
Penalty
Summary
The facility failed to complete a comprehensive Care Area Assessment (CAA) for a resident with multiple diagnoses, including traumatic brain injury, aphasia, dementia, and cognitive communication deficit. Upon review of the annual Minimum Data Set (MDS) assessment, it was found that 8 out of 9 triggered care areas lacked analysis of findings in Section V. Specifically, the MDS Coordinator did not document the nature of the resident's problems, possible causes, contributing factors, risk factors, or reasons to proceed with care planning for areas such as visual functions, communication, functional abilities, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use. Staff interviews confirmed that the MDS Coordinator responsible for the assessment worked remotely and part-time, and did not provide the required information in the CAA. The DON and Administrator both stated their expectations that all CAAs be individualized and completed comprehensively, with analysis of findings for all triggered areas included before submission. The deficiency was identified through record review and staff interviews, with no documentation provided for the majority of the triggered care areas.
Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A medication error occurred when a nurse administered an antidepressant, diuretic, hypoglycemic, and blood pressure medications to a resident that were prescribed for another resident. The nurse entered the resident's room, called him by the wrong name, and did not verify his identity before pulling and administering the medications. The resident was cognitively intact and had multiple diagnoses, including parkinsonism, type 2 diabetes, chronic kidney disease, hypertension, and a history of myocardial infarction. The nurse reported feeling overwhelmed and, after returning to the medication cart, mistakenly selected and administered the medications intended for a different resident. The error was discovered when the nurse called the resident by the wrong name after administering the medications, prompting the resident to correct her. The nurse immediately recognized the mistake, assessed the resident's vital signs, and notified the physician and DON. The medications administered in error included Lexapro, Lasix, Jardiance, Lisinopril, Metoprolol ER, and Prednisone, none of which were part of the resident's prescribed regimen for that time. The resident's regular morning medications were held except for Carbidopa-Levodopa. Interviews with facility staff, including the nurse, NP, DON, and Medical Director, confirmed that the nurse did not follow proper identification procedures before medication administration. The nurse did not ask the resident to state his name, despite the resident being alert, oriented, and a new admission. The incident was attributed to confusion and feeling overwhelmed, with two new admissions occurring that day. The resident experienced anxiety upon learning of the error but did not display any adverse effects or changes in vital signs following the incident.
Failure to Provide Adequate Catheter and Perineal Care
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not properly monitored or provided with adequate catheter and perineal care. The resident, who had multiple diagnoses including muscle wasting, atrophy, and congestive heart failure, had physician orders for daily catheter cleansing, perineal hygiene, and monitoring for complications such as redness, irritation, and infection. However, these orders were not reflected in the Medication Administration Record or Treatment Administration Record, and there were no treatment orders for skin redness, irritation, or antifungal use. During observation, the resident was found to have a buildup of a white substance on the genitals and between the groin folds, redness and irritation of the skin, and a strong odor resembling yeast. The Unit Manager noted that catheter care had not been performed, and the resident's skin was not properly cleaned. The assigned nurse aide stated she had performed catheter care and noticed redness but did not report it to the nurse. The nurse responsible for the daily skilled charting admitted she did not visually check the resident's skin integrity during her assessment. Interviews with facility leadership confirmed that catheter care was not being performed as ordered, and staff were primarily emptying the catheter bag without providing full hygiene care. The Director of Nursing and Administrator acknowledged that the resident should have been checked regularly for incontinence and that the need for catheter and perineal care should have been identified. The Medical Director confirmed that lack of proper catheter care could put the resident at risk for infection and that the resident was not refusing care.
Significant Medication Errors and Missed Doses Due to Staff Inaction and Process Failures
Penalty
Summary
A significant medication error occurred when a nurse administered a steroid medication, along with several other medications, to a resident for whom they were not prescribed. The nurse entered the resident's room, called him by another resident's name, and, after feeling overwhelmed and leaving the room to retrieve oxygen tubing, returned and administered the medications intended for a different resident. The error was discovered when the resident corrected the nurse about his name after receiving the medications. The nurse immediately notified the physician and Director of Nursing, and the resident was monitored closely. The resident was cognitively intact and had multiple diagnoses, including parkinsonism, diabetes, and chronic kidney disease. The medications administered in error included a steroid prescribed for another resident's pneumonia and COPD. Another deficiency involved a resident with diabetes and chronic pain who missed multiple doses of essential medications, including nerve pain medication, diabetic medication, and insulin. The facility failed to request a timely prescription for a controlled medication, resulting in a gap in administration. Additionally, nursing staff did not utilize available medication resources stored in the Pyxis automated dispensing system, despite the medications being present in the machine. Multiple nurses documented the unavailability of medications and did not retrieve them from the Pyxis, leading to missed doses. The resident reported experiencing pain due to the missed nerve pain medication and expressed frustration over the delay in receiving her medication. Interviews with staff and pharmacy personnel revealed that the refill process for the controlled medication was not initiated with sufficient time to avoid a lapse, and the pharmacy could not process the order without a prescription. The Pyxis system contained the necessary diabetic medications, but staff failed to check or utilize it, resulting in further missed doses. The facility's expectations were for staff to begin the refill process several days in advance and to be proficient in using the Pyxis system to prevent medication gaps.
Unsecured Topical Medication Left Unattended in Resident Room
Penalty
Summary
A deficiency occurred when an opened tube of Miconazole nitrate cream, an over-the-counter antifungal medication, was found left unattended on top of a bedside table in a resident's room. The resident had severely impaired cognition and had never been assessed for self-administration of medication. The medication was observed during a facility survey, and the resident was unable to answer questions during an interview attempt. Nursing staff, including a nurse and a nurse aide, confirmed that the antifungal cream should not have been left in the resident's room and that they had not noticed it during their rounds or medication pass. The Director of Nursing and the Administrator both stated their expectation that staff should ensure no medications are left unattended in resident areas, and that the facility should remain free of unattended medications at all times.
Failure to Provide Resident with Preferred Meal Option
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and required assistance with meal setup or clean-up, did not receive a food item listed as a preference on their meal card. The resident was supposed to receive a bacon, lettuce, and tomato sandwich for lunch, as indicated on their meal card, but was instead served a ham and cheese sandwich. The meal card did not include the resident's food dislikes. The resident reported not liking the ham and cheese sandwich and stated that he often did not receive the preferred sandwich, despite having discussed his preferences with someone at the facility. The Dietary Manager confirmed that the incorrect sandwich was served and acknowledged that dislikes were not included on the meal card. The Administrator also confirmed that the resident's preferred sandwich should have been served and that food dislikes had not yet been added to the meal cards due to ongoing staff turnover and updates being in progress. The failure to provide the resident with their stated food preference as listed on the meal card led to the deficiency.
Inaccurate Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that daily nurse staffing sheets accurately reflected the actual nursing staff who worked for all 16 days reviewed. The daily nurse staffing sheets were intended to specify the date, resident census, and the number and hours worked for RNs, LPNs, and CNAs for each shift. However, a comparison between the posted staffing sheets and the nursing staff time clock reports revealed multiple discrepancies in the recorded numbers of staff and hours worked across various shifts and dates. In several instances, the staffing sheets listed more staff than were actually present according to the time clock records, and in some cases, the staff categories and hours did not match at all. The discrepancies included differences in the number of RNs, LPNs, and NAs reported on the staffing sheets versus those recorded in the time clock system. For example, on certain shifts, the staffing sheets indicated the presence of RNs when none were recorded as working, or listed more NAs than were actually present. There were also instances where the resident census was not listed, and where the staff assignment schedule did not align with the posted staffing information. These inconsistencies were observed across all reviewed dates and shifts, affecting the accuracy of the facility's posted nurse staffing information. Interviews with facility staff revealed that the Scheduler, who was responsible for posting the daily staffing sheets, typically posted them in the morning and did not update them to reflect call-outs or schedule changes. The Scheduler was not aware that updates were required to ensure the posted information matched the actual staff present. The Administrator confirmed that the expectation was for the staffing sheets to be updated as needed to accurately reflect the nursing staff working each shift.
Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper respiratory care for residents using oxygen and nebulizer treatments. Observations revealed that cautionary and safety signs indicating the use of oxygen were not posted in the rooms of residents who were receiving supplemental oxygen. This was noted for several residents, including one with respiratory failure and another with chronic obstructive pulmonary disease (COPD). The absence of signage was confirmed by the Director of Nursing (DON) during interviews. Additionally, the facility did not maintain cleanliness and proper storage of respiratory equipment. Oxygen concentrators were found with dried debris, and nebulizer masks were left uncovered and dirty. In one instance, a nebulizer mask was observed hanging down the side of a nightstand, almost touching the floor. The DON acknowledged these issues and explained that the equipment should be cleaned regularly and masks should be stored in plastic bags when not in use. The facility's Administrator mentioned receiving conflicting information regarding the requirement for posting oxygen signage, which contributed to the deficiency. Despite this confusion, the expectation was that staff should ensure nebulizer masks are properly stored during rounds. The lack of proper signage and equipment maintenance was identified as a deficiency during the survey.
Privacy Breach During EMS Report
Penalty
Summary
The facility failed to protect a resident's right to privacy when the Assistant Director of Nursing (ADON) received a medical report from Emergency Medical Services (EMS) personnel in a public area. The incident involved a resident with Alzheimer's disease who had severe cognitive impairment. Upon returning from a hospital visit for an orthopedic appointment, EMS personnel provided a detailed medical report to the ADON in the hallway outside the resident's room. This conversation, which included the resident's name and medical details, was audible to other staff, residents, and visitors in the vicinity. The ADON acknowledged receiving the report in the hallway and admitted that she should have moved the conversation into the resident's room to ensure privacy. The Director of Nursing (DON) was present in the resident's room at the time but did not notice the breach of privacy occurring outside. The facility's Administrator confirmed that staff are expected to maintain resident privacy and should have conducted the conversation in a private setting, such as the resident's room with the door closed.
Failure to Provide Adequate Hydration for Resident
Penalty
Summary
The facility failed to ensure that fluids were available and accessible for a resident with dysphagia and other impairments, leading to a deficiency in hydration care. Resident #2, who was dependent on staff for feeding assistance and at risk for dehydration, was observed without accessible fluids in her room. The resident expressed thirst and reported only receiving drinks with meals, not in-between. Despite requests for assistance, there was a delay in providing the resident with fluids, highlighting a lapse in staff responsiveness and adherence to care plans. Interviews with staff revealed that the facility had been out of individual containers of thickened liquids, which were typically kept in the resident's room. Staff were unaware of the available fluids on the resident's nightstand and relied on the kitchen to provide drinks. The dietary manager confirmed that pre-poured thickened liquids were not dated, contributing to the oversight. The administrator acknowledged that staff should offer and assist residents with fluids during rounds, indicating a gap in the implementation of hydration protocols.
Failure to Secure Medications and Biologicals
Penalty
Summary
The facility failed to secure medications and biologicals in accordance with professional principles, as observed in the cases of three residents. Resident #3, who was alert and oriented, had a tube of skin protectant paste left on their overbed table by staff, despite not wishing to self-administer medications. The Director of Nursing (DON) confirmed that the paste should have been stored on the treatment cart when not in use. Similarly, Resident #4, who also did not wish to self-administer medications, had a bottle of saline nasal spray and a tube of skin cream left on their nightstand. The resident was unaware of the items being left there, and the DON noted that the nasal spray should have been stored in the nurse medication cart. Resident #5, who was alert and oriented but needed assistance with decisions, had a bottle of nasal spray left on their desk table. The DON observed this and stated that the nasal spray should have been stored in the nurse medication cart. These observations indicate a failure by the facility to properly secure medications and biologicals, as they were left in resident rooms in clear view, contrary to the facility's protocols and professional standards.
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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