Fuquay-varina Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fuquay Varina, North Carolina.
- Location
- 410 S Judd Parkway Se, Fuquay Varina, North Carolina 27526
- CMS Provider Number
- 345561
- Inspections on file
- 24
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Fuquay-varina Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required information about advance directives to a resident’s representative and did not obtain or maintain copies of advance directives for two residents. One cognitively impaired resident was care planned as full code without any documented discussion or written information about advance directives provided to the representative. For another resident, the responsible party repeatedly reported that an advance directive existed and confirmed full code status, but staff did not consistently follow up to obtain the document, and no advance directive was filed in the medical record despite multiple care plan meetings and psychosocial assessments noting its existence.
A resident with a documented Doxycycline allergy, noted in both a hospital after-care summary and the EMR allergy banner, was prescribed Doxycycline 100 mg BID for seven days after testing positive for an infectious disease. An RN texted the physician about the test result without the EMR open and entered the Doxycycline order, reporting no recall of an allergy alert. The physician, who did not have EMR access and relied on nursing staff to report allergies, was unaware of the allergy. A Guardian later identified the contraindicated order while reviewing the MAR. The DON stated nurses are expected to have the EMR open when contacting physicians, and the Administrator acknowledged that the physician ordered a medication to which the resident was allergic and that the nurse did not inform him of the allergy.
A resident with a tracheostomy and acute respiratory failure with hypoxia had physician orders and a care plan for routine trach care, including changing or cleaning the inner cannula as applicable. On two night shifts, an RN provided trach care and later reported that on one of those shifts there were no extra single-use disposable inner cannulas in the resident’s room. Instead of obtaining a new cannula from other supplies, the RN used a trach care kit with sterile gloves, sterile water, and a sterile brush to clean the disposable inner cannula and reinserted it, despite knowing it was labeled for single use and acknowledging that reuse could pose an infection risk. The DON and Administrator later confirmed that only single-use disposable inner cannulas are used and that they are not to be cleaned and reused.
Surveyors found a wound care cart at a nursing station left unlocked and unattended for several minutes while housekeeping staff, CNAs, visitors, and a resident passed by. No staff were in visual range of the cart during this time, and the nurse present could not identify who last accessed it. The cart contained multiple wound care supplies and medications, including topical agents and medicated dressings. A nurse and the DON both acknowledged that nurses are responsible for the cart and that it should remain locked when not attended due to safety concerns for confused residents.
The facility failed to ensure daily posting of nurse staffing information in a visible area for residents and visitors when the designated Scheduler was not on duty. Surveyors observed that the posted staffing sheet was several days out of date, and interviews revealed that the Scheduler, who did not work weekends, was solely responsible for creating and posting these sheets. The Scheduler acknowledged that no process existed to ensure postings occurred during her absence and that she had not discussed such a process with the Administrator. The Administrator confirmed reliance on the Scheduler and was unaware that staffing information was not being posted when the Scheduler was out of the office.
A resident with recent fractures and moderate cognitive impairment was left calling for help and with an unanswered call bell while a nurse aide used her personal cell phone at the nursing station. The resident's family member and other staff observed the aide ignoring the resident's needs for over 13 minutes, until another staff member intervened and provided care. Staff interviews confirmed the aide's inaction and inappropriate use of a personal device during the incident.
A resident with dementia recovering from femur surgery was prescribed Oxycodone for pain management. Discrepancies were found in the controlled drug records, including incorrect initial counts and multiple doses signed out before the medication was delivered. A nurse documented removing more tablets than prescribed and could not explain the inconsistencies, with no backup supply records supporting her actions. The issue was identified during a shift change and confirmed by pharmacy and staff interviews, resulting in a deficiency for misappropriation of a resident's medication.
A nurse with a history of drug diversion and active license restrictions was hired and allowed to work, despite the facility being aware of her disciplinary status. While caring for a resident, the nurse was unable to account for missing Oxycodone tablets, and discrepancies were found in medication records. The nurse was subsequently reported, suspended, and terminated after the incident.
A resident alleged being slapped by a nurse aide, but the accused staff member was not immediately suspended and the incident was not promptly reported to the Administrator, resulting in delayed investigation and failure to meet regulatory reporting timeframes. Staff interviews revealed confusion and breakdowns in communication regarding abuse reporting procedures.
A resident with a history of stroke, dysphagia, and renal disease was switched from bolus to continuous enteral feeding, but the previous bolus order was not discontinued in the MAR. This led to staff continuing to administer bolus feedings and not consistently providing the continuous feeding as ordered, due to confusion and lack of clear documentation. The issue persisted until identified during a survey, with staff interviews confirming the oversight and lack of communication.
The facility failed to accurately code MDS assessments for several residents, leading to documentation errors in hospice care, vision impairment, functional abilities, and dialysis treatment. A resident receiving hospice care was incorrectly coded as not receiving such services, while another resident who was legally blind was documented as having adequate vision. Additionally, a resident's functional limitations were not accurately reflected, and another resident with ESRD on dialysis was not coded for these conditions due to an oversight during a system transition.
The facility failed to schedule an RN for at least 8 consecutive hours a day, 7 days a week, for 25 out of 61 days reviewed. This issue arose due to significant staff turnover following a change in ownership and reliance on staffing agencies, which could not consistently provide the required coverage. Interviews revealed a lack of awareness and communication regarding staffing requirements among facility staff.
The facility did not resolve concerns raised by the Resident Council about staffing issues affecting residents' ability to get out of bed and receive showers. Despite repeated discussions in meetings, no resolutions were provided, and the DON was unaware of the issues due to a communication breakdown with the Activities Director.
The facility failed to provide advance directive information and opportunities for two residents to formulate directives. One resident with acute respiratory failure and another with dementia had no documentation of advance directive discussions, only code status was addressed. The responsibility for these discussions was moved to Social Services after a change in ownership, but the expected discussions were not conducted.
A facility failed to include the application of splints and multi podus boots in a resident's care plan. The resident, who was severely cognitively impaired, had physician orders for these interventions, but they were omitted when the facility switched computer systems. The MDS Coordinator and Administrator acknowledged the oversight.
Expired medications were found in the Rehab Medication Cart, including aspirin and Allergy Relief tablets. A CMA confirmed the presence of expired medications, stating it was the nurses' responsibility to check for them. A nurse acknowledged his responsibility but clarified that all nurses should check their carts. The Administrator expected nursing staff to discard expired medications.
A Physical Therapist Assistant and a Physical Therapist failed to wear gowns as required by Enhanced Barrier Precautions (EBP) while transferring a resident with an indwelling upper chest dialysis catheter. Although gloves were worn, the staff did not adhere to the facility's EBP policy, which mandates the use of gowns and gloves during high-contact activities. The staff acknowledged their oversight despite being trained on EBP protocols.
Two residents experienced misappropriation of property by an agency nurse. One resident, who was cognitively intact, had his air pods removed and tracked to the nurse's address. Another resident, with moderate cognitive impairment, had his debit card stolen and used for unauthorized transactions. Both incidents highlight a failure in the facility's security and oversight measures.
A facility failed to apply necessary orthotic devices for a resident with limited range of motion and contractures, as ordered by the physician. The resident, who was severely cognitively impaired, had orders for multi podus boots, a left-hand splint, and elbow extension splints. Observations and interviews revealed these devices were not applied, and staff were unaware of the orders due to a lack of communication and care planning.
A resident with Parkinson's disease was not scheduled for a neurology appointment despite a referral and hospital discharge instructions. The facility's scheduler and a nurse failed to ensure the appointment was made, leading to a deficiency in providing necessary medical services.
The facility failed to maintain accurate medical records for two residents. A resident's hospital transfer was not documented due to a reported computer glitch, and another resident's medication administration was not consistently recorded, despite being administered. The DON confirmed missing documentation in both cases.
The facility failed to provide written notification to the Resident Representative and Ombudsman for two residents transferred to the hospital. One resident's representative was aware of the transfer but did not receive written notice, while the other resident, who was her own representative, also did not receive written notice. The Social Worker, new to the facility, was unaware of the requirement, and the Administrator was not informed of the lack of notifications.
A facility failed to invite a resident with Alzheimer's disease and their representative to care plan meetings. The resident's representative reported not being invited since admission, and the social worker confirmed the oversight, unaware of the requirement to include them. The administrator acknowledged the lapse, noting the social worker's responsibility for invitations.
The facility was found to have several deficiencies in maintaining a safe and homelike environment, including stained privacy curtains, broken fixtures, and a black greenish substance around commodes. Damaged drywall and missing light covers were also observed. Interviews with staff revealed that these issues were known but not yet addressed, with the Administrator acknowledging ongoing efforts to improve the living environment.
Failure to Provide Information and Maintain Documentation of Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to provide required information about advance directives and to obtain and maintain documentation of residents’ advance directives in the medical record. For one resident admitted on an unspecified date, the admission MDS showed severe cognitive impairment, and the care plan dated 1/26/26 listed the resident as full code. However, there was no documentation in the record that the resident’s representative had been provided written information about the right to refuse medical or surgical treatment or to formulate an advance directive. The resident’s representative reported that no facility representative had discussed any information regarding an advance directive, and the social worker confirmed she had been on leave at the time of admission and indicated it would have been the previous social worker’s responsibility to address advance directives. For a second resident, multiple care plan notes and psychosocial discharge planning assessments documented that the responsible party reported the resident had an advance directive and confirmed full code status, and that guardianship paperwork would be brought in. Despite this, there was no documentation that the social worker requested or obtained a copy of the advance directive beyond the initial conversation, and subsequent care plan notes did not reflect follow-up requests. The psychosocial assessments repeatedly recorded that the resident was assessed to have an advance directive per the responsible party, but the medical record contained no copy of the advance directive. Interviews with social work staff and the administrator confirmed that the facility’s practice was to discuss advance directives upon admission, determine whether an advance directive existed, and request a copy for the medical record, with follow-up at subsequent care conferences if the document was not initially provided. In the case of the second resident, the current social worker acknowledged that the responsible party had not brought in the advance directive and that she did not follow up, and the prior social worker stated she believed she had not followed up due to difficulty reaching the responsible party. The administrator stated she expected social workers to discuss advance directives within three days of admission and to obtain and maintain copies in the medical record, which did not occur for these two residents.
Allergic Resident Prescribed Contraindicated Antibiotic
Penalty
Summary
A resident with a documented allergy to Doxycycline, causing shortness of breath, was prescribed this medication despite the allergy being clearly listed in multiple parts of the medical record. The hospital after-care summary and the allergy section on the resident’s EMR banner both identified Doxycycline as an allergen. On 1/19/2026, after the resident tested positive for an infectious disease, a nurse contacted the physician via text message about the positive test result without having the EMR open to review allergies. The physician responded by ordering Doxycycline 100 mg twice daily for seven days, and the nurse transcribed this as a telephone order in the EMR. The nurse later stated she did not recall any allergy alert appearing when she entered the order. The physician reported he was unaware of the resident’s Doxycycline allergy and did not have access to the EMR, stating that nursing staff typically inform him of allergies. Another nurse explained that allergies are displayed beneath the resident’s name in the EMR and that an alert appears when a contraindicated medication is entered. The resident’s Guardian discovered the Doxycycline order while reviewing the MAR and notified the facility of the known allergy. The DON stated that nurses are expected to have the EMR open when contacting physicians so they can review allergies, and the Administrator acknowledged that the physician prescribed a medication to which the resident was allergic and that the nurse did not inform the physician of the allergy when the medication was prescribed.
Improper Reuse of Single-Use Tracheostomy Inner Cannula
Penalty
Summary
The deficiency involves the facility’s failure to provide tracheostomy care consistent with professional standards of practice when a nurse cleaned and reused a single-use disposable tracheostomy inner cannula for a resident. The resident had been admitted with acute respiratory failure with hypoxia and had a physician’s order for tracheostomy care every shift and as needed, including cleaning or changing the inner cannula as applicable. The resident’s care plan identified a risk of complications related to the tracheostomy, with an intervention for tracheostomy care as ordered. Documentation on the Treatment Administration Record and nursing progress notes showed that the same nurse provided tracheostomy care on two consecutive night shifts, during which the care was documented as well tolerated. In a later interview, the nurse stated that the resident’s tracheostomy inner cannulas were always single-use disposable types and that during one of those night shifts there were no extra inner cannulas in the resident’s room. She reported that, needing to provide tracheostomy care, she used a tracheostomy care kit with sterile gloves, sterile water, and a sterile brush to clean the disposable inner cannula and then reinserted it instead of discarding it and using a new one, acknowledging she knew this was not permitted and that reusing a disposable inner cannula could risk infection. She also stated she did not look for additional cannulas outside the resident’s room and did not have access to the supply room. The DON and Administrator later confirmed they were unaware of the incident at the time and affirmed that the facility used only disposable inner cannulas intended for single use and that they should not be cleaned and reused.
Unlocked and Unattended Wound Care Cart Containing Medications
Penalty
Summary
Surveyors observed that the Station 2 wound care cart was left unlocked and unattended for at least seven minutes during a continuous observation period on a Sunday morning from 10:29 AM to 10:36 AM. During this time, there were no staff, residents, or visitors positioned so that they could see the cart. Multiple individuals, including housekeeping staff, nurse aides, visitors, and a resident, walked past the unlocked cart while it remained unattended. The cart was located at the nursing station, and no staff member was identified as the last person to access it. When the cart was inspected with a nurse at 10:39 AM, it was found to contain various wound care supplies and medications, including calcium alginate dressing, iodoform packing strips, collagen wound filler, xeroform medicated petrolatum dressing, zinc oxide paste, Silvasorb gel, diclofenac sodium topical gel 1%, 70% isopropyl alcohol, lidocaine ointment USP 5%, carbamide peroxide 6.5%, ciclopirox olamine cream USP 0.77%, nystatin cream USP 100,000, gentamicin sulfate cream USP 0.1%, and nystatin topical powder. The nurse interviewed stated that all nurses were responsible for the cart, acknowledged that it should be locked when unattended because it contained medications, and noted that many confused residents lived in the facility. The DON also stated that wound care carts should be locked at all times when not attended by a nurse due to safety concerns for confused residents.
Failure to Ensure Daily Posting of Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing information in a location visible to residents and visitors on one of four survey days, and the lack of an effective process to ensure this information was posted every day, including weekends. On a Sunday at 10:00 AM, surveyors observed that the daily staffing information sheet at the reception desk was dated three days earlier, indicating that current staffing information for the intervening days had not been posted as required. No residents or specific patient conditions were mentioned in relation to this deficiency. Interviews and record reviews showed that the Scheduler was solely responsible for preparing and posting the daily staffing information sheets and did not work on weekends or certain weekdays. The Scheduler acknowledged that she had not completed or posted the daily staffing information sheets for the days she was off and stated that there was no process in place to ensure postings occurred in her absence. She also reported that she had not discussed implementing such a process with the Administrator. The Administrator confirmed that the Scheduler was responsible for posting the staffing sheets and stated she was unaware that postings were not occurring when the Scheduler was out of the office, and that the facility had no process to ensure daily postings when the Scheduler was absent or on weekends.
Failure to Respond to Resident's Call for Help Due to Staff Cell Phone Use
Penalty
Summary
A deficiency occurred when a nurse aide failed to respond to a resident's verbal calls for help and an activated call bell, instead choosing to use her personal cell phone at the nursing station. The resident involved had a history of left hip surgery and recent fractures, including a left acetabular fracture and a sacral ala fracture, and was admitted to the facility with moderate cognitive impairment. He required substantial to maximum assistance for mobility and was receiving pain medication for significant discomfort. On the day of the incident, the resident was heard yelling for help by a family member who was approaching the facility. The family member observed a staff member at the nursing desk engrossed in her personal phone, ignoring both the resident's calls and the activated call light. The call light remained unanswered for approximately 13 to 14 minutes, during which time the resident continued to call out for assistance. The family member eventually confronted the staff member, who did not respond to the resident's needs and instead cursed at the family member. Another nurse aide, passing by, noticed the situation and provided the necessary care to the resident, after which the resident's distress subsided. Multiple staff interviews confirmed that the nurse aide at the desk was using her personal phone and did not respond to the resident's needs, despite being aware of the call light and the resident's vocalizations. Other staff members corroborated that this behavior was not an isolated incident. The nurse aide in question admitted to being at the nursing station with her personal phone and did not attend to the resident, citing a confrontation with the family member as her reason for not responding. The incident was witnessed by other staff and reported to facility leadership.
Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A resident with dementia was admitted to the facility for rehabilitation following surgical repair of a fractured femur. Upon admission, the resident was prescribed Oxycodone 5 mg every six hours as needed for pain and Acetaminophen 500 mg on a scheduled basis. Pharmacy records confirmed that 28 tablets of Oxycodone were delivered to the facility and received at 4:20 AM. However, documentation on the controlled drug receipt record showed discrepancies, including the initial count being marked as 26 tablets instead of 28, and multiple doses being signed out at times before the medication was actually delivered. Nurse documentation indicated that two tablets were removed at each administration, despite the order being for one tablet, and that four tablets were signed out prior to the medication's arrival at the facility. The nurse responsible could not provide a satisfactory explanation for these discrepancies, and there was no record of Oxycodone being removed from the facility's backup supply for the resident. The inconsistencies were identified by another nurse during a shift change and subsequently reported to the acting DON, who verified the discrepancies with the pharmacy and reviewed the documentation. Interviews with staff and pharmacy confirmed that the medication counts and documentation did not align with the actual delivery and administration records. The nurse involved was suspended and later terminated, and the incident was reported to the appropriate regulatory and law enforcement agencies. The facility's failure to accurately account for and protect the resident's controlled medication resulted in a deficiency related to misappropriation of resident property.
Failure to Prevent Employment of Nurse with Active Disciplinary Action for Drug Diversion
Penalty
Summary
The facility failed to ensure that it did not employ a nurse with an active disciplinary action on her professional license due to a history of drug diversion. Nurse #13 was hired despite having restrictions on her license imposed by the North Carolina Board of Nursing (NCBON) following an incident in 2021 where she admitted to diverting Oxycodone and having a substance abuse disorder. The facility was aware of these restrictions at the time of hiring, as they had obtained documentation from the NCBON outlining the disciplinary measures and employment limitations, including prohibitions on supervisory roles and certain types of employment. During her employment, Nurse #13 was involved in an incident where multiple Oxycodone tablets could not be accounted for while she was responsible for the care of Resident #2. The investigation revealed discrepancies in the number of tablets received and administered, with Nurse #13 unable to reconcile the missing medication or provide an adequate explanation. The facility reported the suspected drug diversion to the state agency and subsequently suspended and terminated Nurse #13. Interviews with facility staff and the NCBON compliance case analyst confirmed that Nurse #13's license restrictions were still in effect at the time of her hire and during the incident. The restrictions included specific employment limitations due to her participation in the Alternative Program for Chemical Dependency. Despite these known restrictions and her disciplinary history, the facility proceeded with her employment, which led to the deficiency identified in the report.
Failure to Timely Report and Respond to Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy when a staff member accused of slapping a resident was not immediately suspended, and the incident was not reported to the Administrator in a timely manner. According to the facility's policy, all employees are required to report suspected or witnessed abuse to the Administrator or Director of Nursing (DON) within two hours, and allegations of abuse should result in staff suspension and prompt investigation. In this case, the alleged incident occurred, but the Administrator was not informed until the following day, delaying both the suspension of the accused staff member and the initiation of an investigation. The incident involved a resident who alleged being slapped in the face by a nurse aide. Interviews with staff revealed that the resident was yelling and reported to a nurse that she had been slapped. The nurse assessed the resident and found no injuries, then reported the situation up the chain of command. However, the nurse aide accused of abuse was not immediately suspended and continued working. Other staff interviews indicated confusion about the reporting process and whether the DON had been adequately informed. The DON only became aware of the incident the next day and then took appropriate action, including suspension and starting an investigation. Further interviews revealed that the communication breakdown extended to the Administrator, who was also not informed until the day after the incident. The delay in reporting resulted in the facility failing to meet regulatory timeframes for reporting to state agencies and initiating an investigation. Additionally, there was inconsistency in staff understanding of the abuse policy and reporting requirements, contributing to the deficiency.
Failure to Discontinue Outdated Enteral Feeding Order Resulting in Incorrect Administration
Penalty
Summary
A deficiency occurred when the facility failed to discontinue a previous enteral feeding order after a new order was initiated for a resident with a history of stroke, dysphagia, cognitive impairment, and renal disease. The resident was initially receiving bolus tube feedings as ordered, but due to poor oral intake and refusal of bolus feedings, the Registered Dietician (RD) recommended switching to a continuous enteral feeding regimen. The new order for continuous feeding was entered into the electronic system, but the previous bolus feeding order was not discontinued, resulting in both orders appearing simultaneously on the Medication Administration Records (MARs). As a result, nursing staff continued to administer bolus feedings based on the old order, while the continuous feeding was not consistently provided as per the new order. Multiple staff members, including nurses and medication aides, were unaware of the change to continuous feeding or did not see the new order reflected on their shift's MAR. Documentation inconsistencies were noted, with some staff documenting administration of the continuous feeding when it had not actually been given, and others providing bolus feedings in error. Interviews revealed confusion among staff regarding which order was current, and no one sought clarification until the issue was identified during the survey. The resident's intake varied, but weights remained stable, and there was no reported negative outcome from the failure to implement the continuous feeding as ordered. The deficiency was attributed to the failure to discontinue the outdated bolus feeding order, leading to ongoing administration of the incorrect feeding regimen and lack of proper documentation and communication among staff.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of hospice care, vision impairment, functional abilities, and dialysis treatment. Resident #6, who was receiving hospice care, was incorrectly coded as not receiving such services in the quarterly MDS assessment. This error was acknowledged by MDS Nurse #1, who admitted to miscoding the hospice details. Similarly, Resident #13, who was legally blind due to absolute glaucoma, was inaccurately documented as having adequate vision in the MDS assessment, despite clear documentation and staff acknowledgment of the resident's blindness. Resident #56's MDS assessment failed to accurately reflect his functional limitations in the lower extremities, despite physician orders for podus boots to address foot drop. The MDS Coordinator admitted to the oversight. Additionally, Resident #350, who had end-stage renal disease (ESRD) and was on dialysis, was not coded for these conditions in the MDS assessment due to an oversight during a transition of electronic systems. The MDS Nurse acknowledged the error, and the Administrator confirmed the expectation for accurate coding. These inaccuracies highlight a pattern of documentation errors in the facility's MDS assessments.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 25 out of 61 days reviewed. This deficiency was identified through a review of daily assignment schedules from April 1, 2024, to May 28, 2024. The specific dates on which the facility did not provide the required RN coverage were listed, indicating a pattern of insufficient staffing. The issue arose amidst significant staff turnover, including RNs, following a change in facility ownership in June-July 2024. The facility had been relying on staffing agencies to fill gaps but was unable to consistently secure 8 hours of RN coverage. Interviews with facility staff revealed a lack of awareness and communication regarding the staffing requirements. The facility Scheduler was unaware of the necessity to schedule an RN for 8 consecutive hours daily. The Director of Nursing (DON), who assumed the role on November 25, 2024, acknowledged the staffing issues and the absence of RNs in supervisory roles. The Administrator also confirmed awareness of the RN coverage problem, both before and after the ownership change, and noted the facility's reliance on agency staff, including Medication Aides. However, the Administrator was not informed of the Scheduler's difficulties in filling the RN shifts.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and resolve concerns raised by the Resident Council regarding staffing issues that affected residents' ability to get out of bed and receive showers on their scheduled days. The Resident Council minutes from July 2024 documented these concerns, but no resolutions were provided by the administration. Subsequent minutes from August 2024 also showed a lack of administrative response to the issues raised in July. Interviews with residents revealed ongoing dissatisfaction with the facility's handling of grievances, as the same concerns were repeatedly discussed without resolution. The Director of Nursing (DON) was unaware of the concerns from the July 2024 Resident Council meeting, indicating a breakdown in communication between the Activities Director and the nursing department. The Administrator confirmed that the Activities Director, who resigned in November 2024, was responsible for forwarding concerns to the appropriate department heads. The failure to address these concerns highlights a lapse in the facility's process for managing and resolving resident grievances, particularly those related to staffing and care provision.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written advance directive information and an opportunity to formulate an advance directive for two residents. Resident #14 was admitted with acute respiratory failure, dysphagia, and end-stage renal disease, but there was no documentation in the medical record regarding education or an opportunity to formulate an advance directive. Interviews with the Director of Social Services and the Admissions Director revealed that prior to a change in ownership, only code status was discussed, and the responsibility for advance directive discussions was moved to Social Services in June 2024. The Director of Nursing and the Administrator both expected that advance directives should be discussed and documented upon admission. Similarly, Resident #17, who was readmitted with dementia, stroke, and diabetes, had a DNR order but no documentation of advance directive education or opportunity. Interviews with the Director of Social Services and the Regional Director of Clinical Services confirmed that only code status was discussed, and the responsibility for advance directive discussions was assigned to the Director of Social Services. A statement about advance directives was included in the current admissions packet, but the discussions were not being conducted as expected.
Omission of Splints and Multi Podus Boots in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically omitting the application of splints and multi podus boots. The resident, who was severely cognitively impaired, had physician orders for bilateral multi podus boots to be worn up to four hours daily and a left hand splint to be applied when sitting in a wheelchair. Additionally, the resident was to wear bilateral elbow extension splints daily. However, the comprehensive care plan revised on 10/22/2024 did not include these interventions. During an interview, the MDS Coordinator acknowledged that the current care plan did not include the necessary interventions for splints and multi podus boots. The omission occurred when the facility switched computer systems, and the care plan related to these interventions did not transfer over. The Administrator confirmed that the resident's care plan should have included these interventions, indicating a lapse in ensuring the care plan was comprehensive and up-to-date.
Expired Medications Found in Rehab Medication Cart
Penalty
Summary
The facility failed to dispose of expired medications in one of the three medication carts observed, specifically the Rehab Medication Cart. During an observation, a bottle of aspirin 325 mg tablets with an expiration date of 09/2024 and a bottle of Allergy Relief tablets with an expiration date of 04/2024 were found in the top drawer of the cart. Certified Medication Aide (CMA) #1, who was working with the Rehab Medication Cart, confirmed the presence of expired medications and stated that it was the responsibility of the nurses to check for expired medications. Nurse #8, during an interview, acknowledged that it was his responsibility to check the Rehab Med Cart for expired medications, but clarified that all nurses were responsible for checking their medication carts. The Administrator stated that it was her expectation for nursing staff to check and discard expired medications from the medication carts and storage rooms.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement infection control policy and procedures when a Physical Therapist Assistant and a Physical Therapist did not don Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) while providing high-contact resident care activities. This deficiency was observed during the transfer of a resident with an indwelling upper chest dialysis catheter from a wheelchair to a bed using a Hoyer lift. Although gloves were worn, the staff did not wear gowns as required by the facility's EBP policy. The facility's policy on Enhanced Barrier Precautions mandates the use of gowns and gloves during high-contact activities, such as transferring residents. An EBP sign was posted by the resident's room door, indicating the need for PPE during specific care activities. Despite this, the staff involved acknowledged their failure to adhere to the policy, citing forgetfulness, even though they had been trained on EBP protocols. Interviews with the Regional Director of Clinical Services and the Administrator confirmed that the staff should have donned gowns during the resident's transfer.
Misappropriation of Resident Property by Agency Nurse
Penalty
Summary
The facility failed to protect the property of two residents, leading to incidents of misappropriation. Resident #152, who was cognitively intact, reported that his air pods were removed from his room while he was away. The air pods were tracked to an address linked to a nurse who was assigned to him, indicating a breach of trust and security within the facility. The nurse was found to be in possession of the air pods, which were taken without the resident's consent. Another incident involved Resident #97, who had moderate cognitive impairment. The resident's family member discovered that his debit card was missing from his wallet, which was usually kept in his front shirt pocket. Unauthorized transactions were made using the card, and video surveillance at a local gas station identified the same nurse as the perpetrator. This incident further highlights the facility's failure to safeguard residents' belongings. Both incidents involved the same nurse, who was agency staff, and indicate a failure in the facility's oversight and security measures. The nurse's actions were in direct violation of the facility's policy on misappropriation of property, and the facility's initial response did not prevent these occurrences.
Failure to Apply Orthotic Devices for Resident with Contractures
Penalty
Summary
The facility failed to apply necessary orthotic devices for a resident with limited range of motion and contractures, as ordered by the physician. The resident, who was severely cognitively impaired, had orders for bilateral multi podus boots, a left-hand splint, and bilateral elbow extension splints to be applied at specific times of the day. Observations on multiple occasions revealed that these devices were not applied as required. Interviews with the resident's family member confirmed that the splints and boots were not applied during her visits, which spanned several hours each day. Interviews with facility staff, including a nursing assistant, a licensed nurse, and a certified occupational therapy assistant, revealed a lack of awareness and communication regarding the resident's need for these devices. The MDS Coordinator indicated that the splints and boots were not included in the care plan, which led to the omission of these tasks from the resident's information sheet and the nursing assistants' task list. This oversight resulted in a system failure, as the nursing staff was not informed of the need to apply the orthotic devices, leading to the deficiency.
Failure to Schedule Neurology Appointment for Resident
Penalty
Summary
The facility failed to ensure that a neurology appointment was scheduled for a resident who was admitted with diagnoses including Parkinson's disease, hypothyroidism, and failure to thrive. The resident, who was cognitively intact, expressed a desire to confirm her Parkinson's diagnosis with a neurologist. Despite a referral being made to neurology by the facility scheduler, the local neurology office indicated that the notes provided were insufficient, and no appointment was made. Following a hospital visit initiated by the resident's call to 911, discharge instructions again emphasized the need for a neurology appointment. However, the scheduler did not send a new referral after the hospital visit, as she was informed by a nurse that a referral already existed. The Director of Nursing acknowledged that either the scheduler or the nurse should have ensured the appointment was scheduled, but this did not occur, resulting in a deficiency in providing medically-related social services to the resident.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, leading to deficiencies in documentation. For Resident #250, there was no entry in the medical record indicating the resident's transfer to the hospital on 08/09/24, nor was there documentation of the resident's condition at the time of transfer. Nurse #2, who was responsible for the resident, stated that she documented the transfer in the electronic chart, but the information was lost due to a computer glitch after the resident was marked as discharged. The Director of Nursing (DON) confirmed the absence of a transfer order in the resident's medical record, and the Administrator noted that a verbal order for transfer should have been documented. For Resident #350, the facility failed to document the administration of sevelamer, a medication prescribed for high phosphate levels, on multiple occasions in February and March 2024. Although the medication was reportedly administered as ordered, it was not consistently documented in the Medication Administration Record (MAR). Interviews with nurses revealed that the medication was given with meals as prescribed, but documentation was missed. The DON acknowledged the issue of missing documentation despite the medication being administered.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the Resident Representative and Ombudsman regarding the transfer of two residents to the hospital. Resident #56 was discharged to the hospital on June 20, 2024, and readmitted to the facility later. The medical record did not contain any documentation of written notice of transfer being provided to the Resident Representative or Ombudsman. The Resident Representative was aware of the transfer because she was present at the facility but confirmed she did not receive any written notice. The facility's Social Worker, who had recently started, admitted to not notifying the Ombudsman or the Resident Representative in writing, citing a lack of awareness of the requirement. Similarly, Resident #21 was discharged to the hospital on November 14, 2024, due to concerning laboratory results and was later readmitted. The medical record lacked documentation of written notice of transfer to the resident or Ombudsman. Resident #21, who was her own representative, confirmed she did not receive any written notice. The Social Worker again acknowledged not notifying the Ombudsman or the resident in writing, attributing it to her recent start at the facility and lack of knowledge about the requirement. The Administrator was unaware of the lack of notifications and the regulatory requirement for written notification to the resident or their representative.
Failure to Invite Resident and Representative to Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings or invite residents and their representatives to these meetings for one of the residents reviewed. The resident in question was admitted with a diagnosis of Alzheimer's disease and was assessed as severely cognitively impaired. Despite the requirement to hold care plan meetings quarterly, the resident's representative reported not being invited to any care plan meetings since the resident's admission. The social worker confirmed that the representative had not been invited and was unaware of the requirement to include the resident or their representative in the care plan meetings. The administrator also acknowledged being unaware of the oversight, indicating that the responsibility for inviting participants to the care plan meetings lay with the social worker.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In resident room 304, large stains were found on the privacy curtain, a bedside dresser handle was broken, and a towel rack was missing. Additionally, a black greenish substance was noted around the base of commodes in rooms 304, 309, 708, 713, and 714, indicating a lack of proper maintenance and cleaning. Damaged drywall was observed in rooms 306, 309, 503, 605, and 713, and missing overhead bed light covers were noted in rooms 714 and 718. Interviews with the Housekeeping Supervisor and Maintenance Director revealed that these issues were known but had not been addressed in a timely manner. The Housekeeping Supervisor acknowledged the need for curtain replacement and stated that maintenance was responsible for other repairs. The Maintenance Director admitted to being behind on repairs due to limited resources. The Administrator confirmed that improvements were ongoing but acknowledged that several areas still required attention to ensure a safe and homelike environment for residents.
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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