Graham Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Robbinsville, North Carolina.
- Location
- 811 Snowbird Road, Robbinsville, North Carolina 28771
- CMS Provider Number
- 345355
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Graham Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with atrial fibrillation, CHF, and HTN received digoxin and losartan with physician-ordered hold parameters requiring pulse and BP checks, but staff failed to ensure these parameters were correctly transcribed and flagged in the electronic MAR. Digoxin was administered over several months without the hold parameter appearing on the MAR and with many days lacking documented pulse readings in the electronic record. Losartan was given daily without the hold parameter on the MAR and with only two BP readings documented for the month. Several nurses acknowledged that supplemental documentation to prompt vital sign monitoring was not set up, that they often did not document pulse or BP despite administering the medications, and that order entry and confirmation processes were inconsistently and inaccurately completed. The physician expected adherence to hold parameters, while the DON and Administrator were unaware that monitoring and documentation were not occurring.
A resident with dementia and severely impaired decision-making had a MOST form completed by an NP indicating DNR status, comfort measures, conditional use of antibiotics and IV fluids, and no feeding tube, but the form lacked the required signature of the resident or Resident Representative and did not document the name of the individual with whom the orders were discussed. Medical Records, the DON, the Medical Director, and the Administrator all acknowledged that a resident/representative signature is required for the MOST to be valid, yet the form was still processed and filed without this signature, and the SW’s audits focused only on whether a MOST existed rather than whether it was fully executed.
A resident admitted with diabetes and a history of Guillain-Barre Syndrome later had a diagnosis of intellectual disability added by the Medical Director based on family report and prior records, but no Level II PASRR request was submitted. The diagnosis was documented in the medical record and reflected in the facility’s processes, yet the Social Worker lacked a clear system to track PASRR needs or new diagnoses, and the DON acknowledged that the MDS nurse’s communication of new diagnoses should have triggered a PASRR referral. The Medical Director and Administrator both recognized that an intellectual disability diagnosis requires a Level II PASRR, but the evaluation was never initiated.
A consultant pharmacist failed to identify and report missing monitoring documentation for a resident receiving digoxin with a pulse-based hold parameter and losartan with a systolic BP-based hold parameter. Over several months, the MAR showed these medications were administered as ordered, but the electronic record contained many days without documented pulse and only two documented BPs for the month after losartan was started. Monthly drug regimen reviews by the consultant pharmacist did not include any recommendations regarding these omissions. During interviews, pharmacy staff acknowledged that supplementary orders prompting nurses to document pulse and BP had not been entered and that the consultant pharmacist, who was new, did not know how to verify this in the system, while the physician stated she expected notification when hold parameters were not monitored.
The facility failed to update PASARR evaluations for two residents after new mental health diagnoses were made. One resident, initially admitted with PTSD, was later diagnosed with Major Depressive Disorder, but a Level II PASARR was not completed due to a lack of communication between the NP and nursing staff. Another resident, admitted with dementia, was diagnosed with Major Depressive Disorder and anxiety, but a referral for a Level II PASARR was not made. The Social Worker was not informed of these diagnoses, and the NPs responsible had left the facility.
The facility failed to manage expired medications in both medication rooms and the South medication cart. In the North room, expired Normal Saline with Gentamicin and other medications were found. In the South room, an expired bottle of Multi-Vite was discovered. On the South cart, expired Hemorrhoidal suppositories and undated Latanoprost eye drops were noted. Staff interviews revealed a lack of awareness and oversight in checking for expired medications.
The facility failed to implement its infection control policy during meal service and catheter care. Three nurse aides did not perform hand hygiene between resident contacts, and a nurse did not use PPE or sanitize hands during catheter care for a resident with Enhanced Barrier Precautions. The staff acknowledged awareness of the policies but did not consistently follow them.
The facility failed to document education on the benefits and side effects of the COVID-19 vaccine for three residents, two of whom refused the vaccine. The residents, with varying levels of cognitive impairment, either received or refused the vaccine without documented evidence of being informed. The DON and Interim ADON were unable to provide the necessary documentation, and the Interim Administrator expected staff to educate and document the education provided.
A nurse in an LTC facility was observed by two nursing assistants misappropriating a resident's morphine medication. The nurse was seen taking medication from the cart and later drinking a blue liquid, identified as morphine. The incident was reported to the DON, who conducted a drug test on the nurse, resulting in termination after a positive result for morphine. The resident's medication was replaced, and the facility reported the incident to relevant authorities.
Failure to Monitor and Document Vital Signs for Medications With Hold Parameters
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document required vital signs for a resident receiving medications with physician-ordered hold parameters, resulting in a drug regimen that was not shown to be free from unnecessary drugs. The resident had paroxysmal atrial fibrillation, congestive heart failure, and hypertension, and was prescribed digoxin 125 mcg with instructions to hold the dose if the pulse was below 60. Over multiple months, the MAR showed daily administration of digoxin except on days the resident was out of the facility, but the hold parameter was not transcribed onto the MAR and there was no pulse documentation on the MAR. Review of the electronic health record revealed numerous dates across several months with no recorded pulse, despite ongoing administration of digoxin. The resident was also prescribed losartan 100 mg daily with a physician order to hold the medication if systolic blood pressure was less than 110. The MAR documented daily administration of losartan beginning in February, but again, the hold parameter was not transcribed on the MAR and there was no blood pressure documentation on the MAR. The electronic record contained only two blood pressure entries for that month, and the facility could not produce additional blood pressure documentation. Multiple nurses reported that parameters should have been entered into supplemental documentation to flag the need for pulse and blood pressure checks, acknowledged that this was not done, and could not explain why monitoring and documentation were missed. The nurse responsible for entering and confirming orders stated that orders with parameters were not always entered correctly due to lack of staff knowledge and that sometimes the same nurse both entered and confirmed orders. The physician stated she expected her hold-parameter orders to be followed and identified potential adverse effects, while the DON and Administrator both reported they were unaware that the parameter monitoring and documentation were not being carried out.
Failure to Obtain Required Signature on MOST Form for Cognitively Impaired Resident
Penalty
Summary
Facility staff failed to ensure a Medical Orders for Scope of Treatment (MOST) form was properly completed and validated for one resident reviewed for advance directives. The resident, who had dementia and severely impaired cognitive skills for daily decision-making, was rarely or never understood and had both short- and long-term memory problems, and had a designated Resident Representative. A MOST form dated 10/6/25 documented DNR status, comfort measures, antibiotics if indicated, IV fluids for a defined trial period, and no feeding tube. The form stated it had been discussed with and agreed to by an individual with an established relationship with the patient who could reliably convey the patient’s wishes, and it was signed by an NP. However, the form did not identify the name of the individual with whom it was discussed, and the patient or representative signature section at the bottom of the form was blank. Interviews revealed multiple staff were aware that a MOST form must be signed by the resident and/or Resident Representative to be valid, including Medical Records, the Medical Director, the DON, and the Administrator, all of whom confirmed that this resident’s MOST form was not valid due to the missing representative signature. Medical Records staff stated she was responsible for reviewing completed MOST forms for all required dates and signatures before scanning them into the electronic record and placing the hard copy in the code book, and acknowledged she missed that this resident’s form lacked the Resident Representative’s signature. The Social Worker reported she audited MOST forms mainly to see who had a form, and was unsure if an unsigned form was valid. The NP who completed the form stated she was not aware that the resident/representative signature was required, misinterpreting the language above the signature box as making the signature optional, and did not document the name of the person with whom the form was discussed or obtain a witness signature for a telephone review. The Administrator and Medical Director both indicated that, given the resident’s cognitive status, the Resident Representative’s signature was required and that, if completed by phone, the form should document the representative’s name, indicate telephone review, and include two witness signatures.
Failure to Initiate Level II PASRR After New Intellectual Disability Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a resident was diagnosed with an intellectual disability. A Level I PASRR completed in the hospital emergency room listed only diabetes and a history of Guillain-Barre Syndrome. The resident was admitted with these diagnoses, and upon admission the Medical Director completed a history and physical on the same day, adding a new diagnosis of intellectual disability based on information from the resident’s family representative and past medical records. This diagnosis was added to the resident’s diagnosis list in the facility’s medical record, and the resident’s subsequent MDS assessment showed the resident to be cognitively intact. However, there was no evidence in the medical record that a Level II PASRR request was ever submitted following the addition of the intellectual disability diagnosis. Interviews with staff revealed gaps in communication and tracking related to PASRR requirements. The Social Worker stated that hospitals typically completed PASRRs for residents admitted from the hospital and that she completed PASRRs for residents admitted from home, but she could not describe how she tracked PASRRs or how she became aware of new diagnoses. She later acknowledged that the resident had been diagnosed with an intellectual disability months earlier and that a Level II PASRR should have been submitted shortly after that diagnosis was added. The DON explained that new diagnoses were entered by the MDS nurse and then communicated at morning meetings so the Social Worker could initiate PASRRs as needed, and acknowledged that a Level II PASRR should have been completed for this resident but could not explain why it was not. The Medical Director confirmed that she added the intellectual disability diagnosis after reviewing family input and prior records, knew that such a diagnosis required a Level II PASRR, and stated she did not handle PASRR submissions. The Administrator also agreed that a Level II PASRR evaluation should have been submitted once the intellectual disability diagnosis was added.
Consultant Pharmacist Failed to Identify Missing Monitoring for Medications With Hold Parameters
Penalty
Summary
A deficiency occurred when the consultant pharmacist failed to identify and report missing monitoring documentation for a resident receiving medications with hold parameters. The resident was admitted with paroxysmal atrial fibrillation, congestive heart failure, and hypertension, and had a physician’s order for digoxin 125 mcg by mouth in the evening with instructions to hold the dose if the pulse was below 60. The MAR showed digoxin was administered daily over several months, except on two days when the resident was absent, while the electronic health record showed numerous days in October, November, December, January, and February with no documented pulse. Despite this pattern, monthly drug regimen reviews dated in November, December, January, and February contained no recommendations related to digoxin or the lack of pulse documentation. The same resident also had a physician’s order for losartan 100 mg by mouth daily with a hold parameter if the systolic blood pressure was less than 110, and the MAR showed daily administration beginning in February. However, documentation of blood pressures for that month was limited to two dates, and the facility could not produce additional blood pressure records. During interviews, the consultant pharmacist and supervisor consultant pharmacist stated that the facility had not entered supplementary orders prompting nurses to document pulse with digoxin or blood pressure with losartan, and the supervisor explained that the consultant pharmacist was new and did not know how to check this in the system. The consultant pharmacist did not identify the lack of monitoring documentation during monthly reviews, while the physician stated she expected the pharmacist to notify the facility when hold parameters were not being monitored, and the administrator reported she was unaware that the consultant pharmacist did not know how to review hold parameter documentation.
Failure to Update PASARR Evaluations for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for updated Pre-Admission Screening and Resident Review (PASARR) evaluations for two residents after they were diagnosed with additional mental health conditions. Resident #11, who was admitted with fibromyalgia, osteoarthritis, and PTSD, was later diagnosed with Major Depressive Disorder. Despite this new diagnosis, a Level II PASARR was not completed. The Social Worker, responsible for notifying the State Mental Health Authority, was not informed by nursing of the new diagnosis, and the Nurse Practitioner (NP) who diagnosed the resident did not communicate this to the nursing staff. The NP had since left the facility, and the new Physician Assistant (PA) was unfamiliar with the resident's case. Similarly, Resident #3, admitted with dementia and a history of bipolar disease, was diagnosed with Major Depressive Disorder and anxiety disorder. However, a referral for a Level II PASARR evaluation was not completed. The Social Worker was not notified of these new diagnoses by nursing, and the Psychiatric NP who diagnosed the resident had also left the facility. The new PA was unfamiliar with the resident's case. The Interim Administrator expected that a Level II PASARR would be completed for residents with new mental health diagnoses, but this was not done for either resident.
Expired Medications and Labeling Issues in Medication Rooms and Cart
Penalty
Summary
The facility failed to properly manage and discard expired medications in both the North and South medication rooms, as well as on the South medication cart. In the North medication room, five bags of Normal Saline with Gentamicin, intended for a resident's urinary catheter irrigation, were found with expiration dates ranging from 12/5/24 to 12/17/24, despite being punctured and only viable for 48 hours. Additionally, expired Bisacodyl suppositories and Guaifenesin were found in the same room. Interviews with Nurse #1 and the Consultant Pharmacist revealed a lack of awareness and oversight regarding the expired medications. In the South medication room, an unopened bottle of Multi-Vite with an expiration date of November 2024 was found. Nurse #2 indicated that night shift nurses were responsible for checking for expired medications, but the expired bottle was overlooked. The Nurse Supervisor admitted to checking the medication rooms monthly but failed to notice the expired items. The Director of Nursing (DON) expressed surprise that the expired medications were not identified and removed sooner. On the South medication cart, expired Hemorrhoidal suppositories and an opened bottle of Latanoprost eye drops without an open date were discovered. Nurse #2 acknowledged the oversight, noting that the suppositories were no longer needed and the eye drops were administered only at bedtime. The DON reiterated that supervisors should check stock medications, while nurses were responsible for the medication carts, but was unaware of why the expired medications were still available for use.
Infection Control Deficiencies During Meal Service and Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control policy during meal service in the dining room, as observed with three nurse aides. Nurse Aide #2 was seen touching a resident's hands and hair, then moving to another resident without sanitizing her hands. She also assisted multiple residents with meal setup without changing gloves. Nurse Aide #1 adjusted a resident's clothing protector and served another resident without hand hygiene. Nurse Aide #3 placed gloves in her pocket, washed her hands, then reused the gloves to touch a resident's sandwich. Interviews with the aides revealed they were aware of the hand hygiene policy but failed to consistently follow it. Additionally, the facility's policy for Enhanced Barrier Precautions (EBP) was not implemented correctly by Nurse #1 during urinary catheter care for Resident #4. Despite signage indicating the need for gloves and a gown, Nurse #1 entered the room without a gown, did not perform hand hygiene before donning gloves, and failed to sanitize hands between glove changes. Nurse #1 acknowledged the oversight, attributing it to the resident's agitation and her attempt to expedite care. The Director of Nursing confirmed that the staff should have followed the infection control policies, including hand hygiene and the use of PPE, especially in rooms with EBP signage. The DON stated that Nurse #1 had been educated on these protocols but did not adhere to them during the observed incident.
Lack of Documentation for COVID-19 Vaccine Education
Penalty
Summary
The facility failed to document the education provided to residents regarding the benefits and potential side effects of the COVID-19 vaccine for three residents. Resident #2, who was admitted with severely impaired cognition, received the COVID-19 vaccine, but there was no documentation in the medical record indicating that the resident or their legal representative was informed about the vaccine's benefits and potential side effects. The Interim Assistant Director of Nursing (ADON) and the Director of Nursing (DON) were unable to provide the required documentation when requested. Resident #11, who had moderate cognitive impairment, refused the COVID-19 vaccine, but there was no documented evidence that the resident or their legal representative was educated about the vaccine's benefits and potential side effects. The resident confirmed during an interview that they did not recall receiving such education. The DON acknowledged the lack of documentation regarding the education provided. Similarly, Resident #18, also with moderate cognitive impairment, refused the COVID-19 vaccine without documented evidence of education about the vaccine's benefits and potential side effects. The resident did not recall being educated about the vaccine, and the DON confirmed the absence of documentation. The Interim Administrator stated that staff were expected to educate and document the education provided, but this was not done for these residents.
Misappropriation of Controlled Medications by Nurse
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation of controlled medications. The incident involved a nurse who was observed by two nursing assistants during a night shift. The nurse was seen taking a brown bottle and another bottle of liquid from the medication cart, preparing a syringe with a clear liquid, and claiming he was going to administer it to the resident. The nursing assistants observed suspicious behavior, including the nurse drinking a blue liquid from a medication cup, which was later identified as morphine. The nursing assistants reported their observations to the Director of Nursing (DON) after being unsure of what to do. The DON conducted a urine drug test on the nurse, which returned positive for morphine and other substances. The nurse was subsequently terminated from his position. The resident's missing morphine medication was replaced at the facility's expense, and the physician confirmed that the resident did not suffer adverse effects from missing a dose of pain medication. The facility's policy on abuse, neglect, or misappropriation of resident property was not effectively enforced, leading to the misappropriation of the resident's medication. The incident was reported to the appropriate authorities, including the North Carolina Board of Nursing and the Drug Enforcement Agency. The facility conducted a thorough investigation, which substantiated the allegations against the nurse.
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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