Greenville Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, North Carolina.
- Location
- 2578 West Fifth Street, Greenville, North Carolina 27834
- CMS Provider Number
- 345181
- Inspections on file
- 22
- Latest survey
- July 30, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Greenville Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairment experienced significant safety incidents due to inadequate supervision and lack of effective identification systems. One resident fell from bed during incontinence care when not properly positioned, resulting in a forehead injury. Another resident exited the facility unsupervised after exhibiting exit-seeking behavior, traversing a busy highway before being found by staff. Staff were not adequately informed or equipped to identify or monitor residents at risk for elopement.
A PTAC unit in a resident's room was not properly secured to the wall, leaving a visible gap to the outdoors due to a missing screw. The Maintenance Director was unaware of the issue as it had not been reported, despite daily room inspections being the responsibility of department managers.
A resident with moderate cognitive impairment reported missing belongings to the SW after a hospital stay, but no grievance was filed and the items were not located. The SW did not inform other staff or initiate a search, and the Administrator was unaware of the issue. Facility policy required prompt response to grievances, but the resident's concerns were not formally addressed.
A resident's MDS assessment was inaccurately coded to indicate receipt of anticoagulant medication during the look-back period, despite no evidence in the MAR of such medication being ordered or administered since admission. Facility staff, including the MDS nurse and DON, misunderstood the requirements and included medication given in the hospital prior to admission in the MDS coding.
Two residents did not have comprehensive care plans addressing the use of bed rails and a CPAP machine. One resident's care plan omitted bilateral quarter length side rails despite their ongoing use, due to incorrect documentation and lack of direct observation. Another resident's nightly use of a CPAP machine for sleep apnea was not included in the care plan, as the device was not identified during the admission assessment and was missed in the MDS process.
Two residents did not receive proper respiratory care when a nurse failed to follow infection control protocols during tracheostomy care, including not changing gloves or performing hand hygiene, and did not change tracheostomy ties as ordered by the physician. Additionally, another resident used a CPAP machine nightly without a physician's order, and staff were unaware of the device's use or failed to document it appropriately.
The facility did not attempt or document alternative interventions, assess for entrapment risk, review risks and benefits, or obtain informed consent before installing bilateral quarter length side rails for three residents with various medical conditions. Staff interviews and record reviews revealed incomplete assessments and a lack of awareness of required procedures, while observations confirmed the ongoing use of side rails without proper documentation.
A resident with pressure ulcers did not have wound care treatments documented as completed in the medical record or TAR, despite the Wound Care Nurse confirming the treatments were performed. The DON and Administrator acknowledged the lack of documentation for the provided care.
A nurse failed to follow infection control protocols by administering a medication to a resident after the pill had fallen onto the medication cart and was picked up with bare hands. The nurse did not discard the contaminated pill, and the top of the medication cart was not cleaned during the process. Interviews with staff confirmed that the correct procedure would have been to throw away the pill and obtain a new one.
A resident with diabetes and an arterial ulcer on the left heel did not receive a provider-ordered soft protective boot as recommended by the Wound Care NP. Despite documentation and staff awareness of the recommendation, no provider order was obtained, and repeated observations showed the resident's heels in contact with the mattress without protection. Communication lapses among the Treatment Nurse, DON, and Wound Care NP led to the failure to implement the recommended pressure relief measure.
The facility failed to maintain grievance documentation for seven months, as required by policy. The grievance logs from June 2024 to January 2025 were unavailable, despite the previous Administrator stating they were left in the Administration office. The current Administrator was unable to locate the logs, which should be maintained for three years.
A nurse in an LTC facility borrowed gabapentin from one resident to administer to another due to unavailability in the automated dispensing system and pressure from a family member. The nurse was unaware of the policy against borrowing medications, leading to a deficiency in professional standards of care.
A resident's MAR was incomplete due to multiple instances where nurses failed to document the administration of enteral feeds and water flushes. Interviews revealed that the nurses forgot to sign the MAR after administering the treatments, despite being aware of the requirement to do so immediately. The facility's policy mandates that all medications be signed off in the MAR as soon as they are given, with codes used if not administered.
A resident with multiple health issues experienced a delay in addressing critically low lab results due to ineffective communication among nursing staff during shift changes. Despite a STAT CBC being ordered, the results were not communicated to oncoming shifts, and attempts by the lab to notify the facility were unsuccessful. The resident's condition worsened, necessitating a hospital transfer.
A resident experienced a delay in receiving critical lab results due to ineffective communication between the LTC facility and its contracted laboratory. The resident had a STAT CBC ordered due to vomiting, but the results, which showed critically low hemoglobin and hematocrit levels, did not populate in the electronic medical record. Attempts by the laboratory to notify the facility were unsuccessful, and staff were unaware of the critical values.
A resident sustained an avulsion and fracture to her right great toe while being loaded into a transportation van for dialysis. The incident occurred when the resident moved her foot during the lift process, causing it to get caught between the van ramp and the hydraulic lift platform. The Transport Driver, responsible for observing the lift, did not see the resident move her foot due to her size and positioning. The resident often preferred not to use the wheelchair footrests, contributing to the incident.
The facility lacked a documented water management program for Legionella, with staff unaware of necessary procedures. Additionally, a nurse failed to perform hand hygiene during medication administration, contrary to facility policy. The DON confirmed the nurse should have followed proper hand hygiene protocols.
The facility failed to manage medications properly, with an expired tuberculin solution found in storage and unsecured medication and treatment carts left unattended. The ADON and DON confirmed the oversight, while nurses admitted to being distracted, leaving carts unlocked with medications accessible.
A facility failed to clarify a resident's code status, resulting in conflicting documents in the physical chart and EMR. The resident, who was cognitively intact, had both a Full Code Agreement and a DNR document in the chart, causing confusion. Staff interviews revealed that the DNR should have been removed when the resident's status changed to full code.
Two residents had their MDS assessments inaccurately coded, leading to discrepancies in medication and diagnosis records. One resident's assessment incorrectly showed injections and insulin administration, while another's included unverified diagnoses of anxiety, depression, and schizophrenia. Interviews with MDS nurses and the DON confirmed these inaccuracies, highlighting the need for accurate MDS coding.
A facility failed to include a focus area for anticoagulant medication in a resident's care plan. The resident, diagnosed with atrial fibrillation, was prescribed apixaban, which was administered as ordered. However, the care plan lacked interventions related to this medication. The MDS Nurse admitted to the oversight, and the DON confirmed the care plan should have reflected the medication regimen.
The facility failed to invite residents and their representatives to care plan meetings, affecting three residents. A resident with cognitive impairment was not invited to any meetings, and there was no documentation in the EMR. Another resident, cognitively intact, did not receive recent invitations, and the Social Worker did not document grievance meetings as care plan meetings. A third resident did not recall attending any meetings, and the Social Worker confused family conversations with care plan meetings. The Administrator acknowledged a process breakdown.
A medication error rate of 8% was observed in an LTC facility due to staff oversight. A resident with severe cognitive impairment received ultra-lubricating eye drops and a steroid inhaler without following label instructions. The nurse failed to shake the medications and did not instruct the resident to rinse and spit after inhaler use, leading to the deficiency.
A cognitively intact resident verbally insulted another resident, leading to a physical altercation where the insulted resident, in a motorized wheelchair, intentionally collided with the other, causing injury. Despite staff intervention, the situation escalated quickly. Both residents had histories of behavioral issues, and the incident was reported to the police.
Two residents were affected by the misappropriation of their prescribed oxycodone medication by a medication aide. The aide documented administering the medication, but both residents confirmed they did not receive it. The incident was discovered when a pill crushing sleeve containing the medications was found on the floor. The aide tested positive for oxycodone and was terminated following an investigation.
Failure to Prevent Resident Elopement and Bed Fall Due to Inadequate Supervision and Identification Systems
Penalty
Summary
A resident with severe cognitive impairment and significant physical limitations was re-admitted to the facility and required substantial assistance for mobility and incontinence care. During incontinence care, the resident rolled out of bed and sustained a small skin tear on the forehead. The incident occurred while a nurse aide was providing care alone, did not have the resident positioned in the center of the bed, and turned the resident away from herself, resulting in the resident falling face-first onto the floor. There was no evidence of in-service education provided to staff after the incident regarding safe positioning and turning techniques, and the facility did not have a complete investigation file for the incident. Another resident with dementia and severe cognitive impairment was assessed as low risk for elopement but exhibited exit-seeking behavior the day before an elopement event. The resident attempted to leave the facility, became confused, and was redirected by staff. The following day, the resident exited the facility unsupervised by following a discharging resident and family member out the front entrance, which was unlocked during the day. The receptionist, who was unfamiliar with the resident, did not recognize him as a resident and did not intervene. The resident was later found by a staff member approximately 0.7 miles from the facility, having traversed a busy highway and multiple intersections. Staff were unaware the resident was missing until notified by the staff member who found him. The facility did not have a system in place to identify residents at risk for elopement or to ensure staff, including the receptionist, could distinguish between residents and visitors. There was no photo book or other method at the reception desk or nurses' stations to identify residents with exit-seeking behaviors. Communication lapses occurred, as staff working with the resident on the day of the elopement were not informed of the resident's exit-seeking behavior the previous day. The lack of supervision and identification systems contributed to the resident's unsupervised exit and the potential for serious harm.
PTAC Unit Not Secured, Creating Gap to Outdoors
Penalty
Summary
A packaged terminal air conditioner (PTAC) unit in a resident's room was found not secured to the wall, resulting in an approximately half-inch gap through which outdoor grass was visible. This issue was observed during a room inspection and confirmed by the Maintenance Director, who stated that the unit was coming away from the wall due to a missing screw. The Maintenance Director was unaware of the needed repair because it had not been reported to him. The Administrator indicated that department managers were responsible for conducting daily room inspections, which should have identified and reported the issue for repair.
Failure to File Grievance for Missing Resident Belongings
Penalty
Summary
The facility failed to file a grievance on behalf of a resident who verbally reported missing personal belongings to the Social Worker (SW) after returning from a hospital stay. The resident, who was moderately cognitively impaired and diagnosed with non-Alzheimer's dementia, reported on multiple occasions that a small suitcase, a pair of shoes, and two cotton nightgowns were missing. The SW acknowledged receiving these verbal reports but did not inform other staff, initiate a grievance, or attempt to locate the items, instead waiting for the resident to provide a written list with sizes. The missing items were never found. Facility policy required staff to immediately respond to concerns and allow residents to file grievances orally, in writing, or anonymously without fear of reprisal. The SW admitted responsibility for following up on the missing items and recognized that a grievance should have been filed, especially given the resident's cognitive status. The Administrator was unaware of the missing items and stated that a list should have been made for the resident, but did not believe a grievance was necessary until after a period of unsuccessful searching. No grievance was filed, and the resident's concerns were not formally addressed.
Inaccurate MDS Coding for High Risk Drug Class Medications
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of high risk drug class medications. Specifically, the MDS assessment indicated that the resident received anticoagulant medication during the look-back period, despite a review of the Medication Administration Record (MAR) showing no physician's order or administration of anticoagulant medication to the resident since admission. The resident had received heparin, an anticoagulant, in the hospital prior to admission, but not during the facility stay or the look-back period covered by the MDS. Interviews with the MDS nurse, Director of Nursing, and Administrator revealed a misunderstanding regarding the correct coding of the MDS. Staff believed that anticoagulant medication administered in the hospital prior to admission should be included in the MDS assessment's look-back period, even though the medication was not given in the facility. This misunderstanding led to inaccurate coding of the resident's MDS assessment.
Failure to Develop Comprehensive Care Plans for Bed Rail and CPAP Use
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents in the areas of bed rail use and CPAP machine usage. For one resident, although bilateral quarter length side rails were observed in use and the resident confirmed their ongoing use, the care plan did not include this intervention. The admission nurse had incorrectly documented that the resident did not use side rails, and the MDS nurse relied on this assessment without direct observation. Both the Director of Nursing and the Administrator acknowledged that the care plan should have included the use of side rails, but the omission occurred due to reliance on inaccurate documentation and automated care plan generation. For another resident, the facility did not include the use of a CPAP machine in the care plan, despite the resident bringing the device from home and using it nightly for sleep apnea. The admission nurse was unaware of the CPAP machine and did not note its presence during the assessment, and the MDS assessment also failed to capture this information. Staff interviews confirmed the resident's independent use of the CPAP machine, and the Administrator agreed that a care plan should have addressed this intervention. The deficiency resulted from a lack of direct observation and incomplete communication during the assessment and care planning process.
Failure to Follow Infection Control and Physician Orders in Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not adhering to infection control standards and physician orders. For one resident with a tracheostomy, a nurse did not remove soiled gloves, perform hand hygiene, or don new sterile gloves during tracheostomy care. The nurse used the same gloves throughout the procedure, including when handling sterile supplies and performing cleaning around the tracheostomy site. This was observed by surveyors and confirmed in interviews with the nurse, the Infection Preventionist, the DON, and the Administrator, all of whom stated that proper infection control practices were not followed. Additionally, the same resident had a physician's order for daily tracheostomy tie changes, but during observed care, the nurse failed to change the tracheostomy ties. The ties were noted to have a dried yellow substance near the tracheostomy site. The nurse acknowledged forgetting to change the ties during the procedure, and both the DON and Administrator confirmed that the physician's order was not followed. For another resident, the facility failed to obtain a physician's order for the use of a CPAP machine, despite the resident bringing her personal CPAP from the hospital and using it nightly for sleep apnea. The admissions nurse was unaware of the CPAP use, and the device was not documented in the resident's orders or coded in the MDS. Staff interviews confirmed the resident's nightly use of the CPAP, and the unit manager and Administrator acknowledged that a physician's order should have been in place for its use.
Failure to Assess and Document Alternatives Prior to Bed Rail Use
Penalty
Summary
The facility failed to follow required procedures before installing and using bilateral quarter length side rails for three residents. Specifically, staff did not attempt or document alternative interventions prior to the installation of side rails, did not assess for entrapment risk, and did not review the risks and benefits of side rail use with the residents or their representatives. Informed consent was also not obtained before the side rails were put in place. These failures were identified through observations, record reviews, and staff interviews. For one resident with dementia, arthritis, and heart failure, the Minimum Data Set (MDS) indicated moderate cognitive impairment and a need for assistance with bed mobility. The care plan did not address side rail use, and the bed side rail assessment tool was incorrectly completed, indicating no side rails were used. The admission nurse and DON confirmed that the assessment was inaccurate and that required steps such as risk/benefit review, consent, and entrapment risk evaluation were not performed. The resident was observed using the side rails, and both the DON and Administrator acknowledged the documentation errors and lack of awareness regarding the need for alternative interventions. Similar deficiencies were found for two other residents: one with an acquired loss of a limb and another with multiple medical conditions including diabetes and muscle wasting. In both cases, the bed side rail assessment tools were incomplete, lacking documentation of alternative interventions, entrapment risk assessment, and consent. Staff interviews revealed a lack of knowledge about the requirement to try and document alternative interventions before side rail installation. Observations confirmed that both residents were using side rails, and neither the DON nor the Administrator was aware of the procedural requirements that had been missed.
Failure to Document Completion of Wound Treatments
Penalty
Summary
The facility failed to document the completion of wound treatments provided to a resident with pressure ulcers. Physician's orders were in place for the resident to receive specific wound care treatments for a posterior scrotal skin tear and a right groin abrasion, including cleansing, application of collagen particles, zinc oxide paste, bordered gauze, and calcium alginate with silver. A review of the resident's medical record and Treatment Administration Record (TAR) did not show any documentation that these treatments were completed on the specified date. During interviews, the Wound Care Nurse confirmed that she had performed the ordered treatments but could not explain why she had not documented them in the resident's medical record or TAR. Both the DON and the Administrator acknowledged that the medical record should accurately reflect the care provided, and that the wound treatments should have been documented as completed.
Failure to Follow Infection Control During Medication Administration
Penalty
Summary
Nurse #3 was observed during a medication pass preparing several medications for a resident. While popping a pill out of a bubble pack, the pill missed the medication cup and landed on the top of the medication cart. Nurse #3 picked up the pill with her bare fingers and placed it in the medication cup, then administered the medications to the resident. She had last performed hand hygiene before starting to prepare the medications and, during the process, touched multiple medication bottles, bubble pack cards, and drawer handles on the cart. The top of the medication cart was not cleaned at any time during the observation. In interviews following the incident, Nurse #3 acknowledged that she should have discarded the pill after it touched the cart and her bare hands, recognizing this as proper infection control procedure. The Infection Preventionist, NP, and DON all confirmed that the correct action would have been to throw away the contaminated pill, as both the cart and hands could transmit disease-causing organisms. The Director of Clinical Services stated there was no specific policy addressing this scenario, but the Administrator indicated that standard nursing practice would be to discard the pill and obtain a clean one.
Failure to Implement Provider-Recommended Pressure Relief for Heel Wound
Penalty
Summary
A resident with diabetes mellitus and a non-pressure related arterial ulcer on the left heel was admitted to the facility. The Wound Care Nurse Practitioner (NP) recommended the use of a soft protective boot to float the resident's left heel while in bed, as documented in a progress note. However, a review of the resident's medical record and physician orders revealed that no provider order for a protective boot was obtained or implemented. Multiple observations over several days confirmed that the resident's heels were in contact with the mattress and no protective boot was in use. Interviews with facility staff, including the Treatment Nurse, Nurse Aide, Wound Care NP, and Director of Nursing (DON), revealed a breakdown in communication and follow-through regarding the NP's recommendation. The Treatment Nurse was aware of the recommendation but did not obtain a provider order, and the DON was not aware of the recommendation for the protective boot. As a result, the recommended pressure relief measure was not provided according to the resident's care needs and provider orders.
Failure to Maintain Grievance Documentation
Penalty
Summary
The facility failed to maintain documentation of grievances and evidence of the results of all grievances for a period of seven months. According to the facility's policy dated January 23, 2020, the Administrator is responsible for maintaining a file to track and reference grievances received and responses provided for a period of three years. However, a review of the grievance logs from June 2024 to January 2025 revealed that all logs for this period were unavailable. In a telephone interview, the previous Administrator stated that the grievance log binder was left on a shelf behind the desk in the Administration office when he left employment two weeks prior. The current Administrator reported being unable to locate the grievance log binder for the specified time period, despite being aware of the requirement to maintain complete grievance logs, including the results of grievance investigations, for three years or longer.
Medication Borrowing Incident in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of care when a nurse borrowed medication from one resident to administer to another. Resident #6, who was cognitively intact, had a physician's order for gabapentin to treat nerve pain. Meanwhile, Resident #5, who was moderately cognitively impaired, had a physician's order for the same medication to be administered three times a day for pain. On October 19, 2024, Nurse #1 borrowed two capsules of gabapentin from Resident #6 to administer to Resident #5 because the medication was not available in the automated dispensing system and Resident #5's medication supply had not yet arrived. The incident was brought to light when a family member of Resident #5 raised concerns about the medication borrowing. During interviews, Nurse #1 admitted to borrowing the medication due to the unavailability of Resident #5's medication in the automated dispensing system and the pressure from a family member to administer the medication immediately. The nurse was unaware that borrowing medication from one resident to give to another was against the facility's policy. The Director of Nursing and the Regional Director Clinical Consultant confirmed that the facility had a process in place to prevent missed doses of prescribed medications, which Nurse #1 failed to follow. The pharmacist also confirmed that the medication order for Resident #5 was received and processed, but Nurse #1 did not follow the correct protocol to obtain the medication from the backup pharmacy. This incident highlighted a lapse in following established procedures for medication administration in the facility.
Incomplete Medication Administration Record for a Resident
Penalty
Summary
The facility failed to maintain a complete and accurate Medication Administration Record (MAR) for a resident, identified as Resident #11, who was admitted with specific physician's orders for enteral feeding and water flushes. The orders required the administration of Jevity 1.5 enteral feed twice daily and a 150 ml free water flush every six hours. However, the MAR for December 2024 showed multiple instances where the administration of these feeds and flushes was not documented as given or refused by the nursing staff. Specifically, there were omissions on several dates by different nurses, indicating a lack of proper documentation. Interviews with the nursing staff involved revealed that the omissions were due to forgetfulness in signing the MAR after administering the feeds and flushes. Each nurse acknowledged awareness of the requirement to sign off medications in the MAR immediately after administration. The Director of Nursing and the facility Administrator confirmed that all medications should be signed off in the MAR as soon as they are given, and if not given, a code should be used to indicate the reason. The failure to document these administrations resulted in empty spaces in the MAR, which should not have occurred according to facility policy.
Communication Breakdown Leads to Delay in Addressing Critical Lab Results
Penalty
Summary
The facility failed to ensure effective communication during shift-to-shift reports among nursing staff, which led to a lapse in addressing critically low laboratory results for a resident. The resident, who had multiple health diagnoses including heart disease, anemia, liver disease, diabetes, parathyroid disease, a history of stroke, and hypertension, was admitted to the facility after a hospital stay. During a visit by the Nurse Practitioner (NP), the resident was noted to have episodes of vomiting, prompting the NP to order a STAT complete blood count (CBC) and request immediate notification upon receipt of the lab results. Despite the NP's instructions, there was a breakdown in communication among the nursing staff. The Minimum Data Set (MDS) Nurse Coordinator placed the STAT lab order and informed the resident's assigned nurse, but it is unclear if this information was effectively communicated to the oncoming shifts. Interviews with the nurses assigned to the resident during subsequent shifts revealed that they did not recall being notified of the pending STAT labs or seeing any documentation on the 24-hour Report Sheet. Consequently, the critically low lab results, which indicated a significant drop in hemoglobin and hematocrit levels, were not addressed in a timely manner. The facility's contracted laboratory attempted to contact the facility multiple times regarding the critical lab values without success. The resident's condition deteriorated, leading to a request from the responsible party to transfer the resident to the hospital for evaluation. Upon arrival at the emergency department, the resident's hemoglobin and hematocrit levels had further decreased, indicating a severe condition. The Director of Nursing (DON) later discovered that the lab results had not populated into the resident's electronic medical record, and there was no record of the facility receiving calls from the lab about the critical results. This communication failure among the nursing staff resulted in a delay in addressing the resident's critical condition.
Communication Failure Delays Critical Lab Results
Penalty
Summary
The facility failed to ensure effective communication between its staff and the contracted laboratory company, resulting in a delay in receiving critical laboratory results for a resident. The resident, who had episodes of vomiting, was assessed by the Nurse Practitioner (NP) who ordered a STAT complete blood count (CBC) to be drawn. The blood sample was collected and sent to the laboratory, which identified critically low hemoglobin and hematocrit levels. However, the results did not populate into the resident's electronic medical record, and the facility staff were not notified of the critical values. Interviews with facility staff revealed a breakdown in communication and follow-up procedures. The Minimum Data Set (MDS) Nurse Coordinator and the Director of Nursing (DON) were unaware of the critical lab results due to the failure of the results to appear in the electronic medical record. Additionally, there was no evidence that the laboratory had successfully communicated the critical results to the facility, as attempts to contact the facility were unsuccessful. The facility's staff, including the nurses on duty, did not recall being informed of the pending STAT labs or receiving any calls from the laboratory regarding the critical results. The contracted laboratory's Regional Service Representative confirmed that attempts were made to notify the facility of the critical lab results, but these attempts were unsuccessful. The laboratory was informed by a facility staff member that there was no resident by the name provided, and subsequent calls to the facility went unanswered. This lack of communication and follow-up resulted in the critical lab results not being addressed in a timely manner, which could have had significant implications for the resident's health.
Resident Injury During Transport Due to Improper Foot Positioning
Penalty
Summary
The facility failed to ensure a resident was free from injury while being loaded into a transportation van. The incident involved a resident who was being transported to dialysis. During the loading process, the resident's right foot became caught between the van ramp and the hydraulic lift platform, resulting in an avulsion to her right great toe and a minimally displaced fracture. The resident was cognitively intact and independent with certain functions, and she was documented to receive dialysis. The incident occurred when the Transport Driver placed the resident on the lift and began to operate it. The resident moved her foot up too far while the lift was in motion, causing her toe to get caught. The Transport Driver was responsible for observing the lift operation but did not see the resident move her foot due to her size and the positioning requirements. The resident was not wearing shoes at the time, which contributed to the injury. The facility's staff, including the Corporate Nurse Consultant and the Staff Development Coordinator, responded to the incident and provided initial wound care. Interviews with the resident, the Transport Driver, and facility staff revealed that the resident often preferred not to use the wheelchair footrests and would move her feet during transport. The Transport Driver had been trained to ensure residents' feet were on the footrests, but the resident's actions during the lift process led to the injury. The facility conducted an investigation and determined that the Transport Driver followed the correct procedure during a return demonstration, but the incident highlighted a gap in the ability to monitor the resident's entire body during the lift process.
Deficiencies in Water Management and Hand Hygiene Practices
Penalty
Summary
The facility failed to have a documented water management program for Legionella, as revealed through staff interviews and record reviews. The Assistant Maintenance Manager, who assumed responsibility for water management after the departure of the Director of Maintenance, admitted to having no knowledge of the water management system or how to assess and prevent Legionella. The Administrator also lacked awareness of measures in place to control Legionella and acknowledged that the water management plan was outdated and incomplete. The previous Director of Maintenance reportedly took the necessary documentation when leaving the position, leaving the facility without a proper water management policy. Additionally, the facility failed to ensure proper hand hygiene during medication administration, as observed with one of the two nurses. Nurse #1 did not perform hand hygiene between glove changes or after administering medications to a resident, despite the facility's policy requiring hand hygiene before and after contact with residents and after removing gloves. During an interview, Nurse #1 admitted to not performing hand hygiene during the medication administration, believing it was unnecessary after the initial handwashing. The Director of Nursing confirmed that Nurse #1 should have performed hand hygiene between glove changes and after leaving the resident's room.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication management protocols in the Hall 300/400 medication storage room and medication carts. An open vial of tuberculin purified protein derivative solution was found in the medication refrigerator with an open date of 4/25/24, exceeding the manufacturer's recommendation to discard after 30 days. The Assistant Director of Nursing (ADON) confirmed the oversight and was unable to explain why the expired medication was not removed. Additionally, the Director of Nursing (DON) acknowledged that the expired medication was missed during a prior check. Furthermore, the facility did not secure medication carts properly. On Hall 300, a medication cart was left unattended with the key in the narcotic drawer lock, and Nurse #1 admitted to being distracted and forgetting to secure it. Similarly, a treatment cart on Hall 500 was found unlocked with medicated treatments inside, and Nurse #5 realized the oversight only after being prompted by the surveyor. Both the DON and the Administrator confirmed that medication and treatment carts should be locked unless a nurse is present.
Failure to Clarify Resident's Code Status
Penalty
Summary
The facility failed to clarify the code status in the records of a resident, leading to a discrepancy between the physical chart and the electronic medical record (EMR). The resident, who was cognitively intact, had a Full Code Agreement signed by a family member and a Do Not Resuscitate (DNR) document in the physical chart. The EMR and a physician's order indicated the resident was a full code. However, the presence of both a Full Code Agreement and a DNR document in the physical chart created confusion about the resident's actual code status. Interviews with staff revealed that the DNR document should have been removed from the physical chart when the resident's advance directive changed to a full code. The Medical Records clerk acknowledged the oversight, and the Admissions Director confirmed that the resident had chosen to be a full code upon readmission. The Administrator also stated that the DNR document should not have been present if the resident was a full code. This oversight in maintaining accurate and up-to-date records led to a failure in honoring the resident's advance directive accurately.
Inaccurate MDS Coding for Medications and Diagnoses
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in medication and diagnosis records. Resident #98, who was admitted with a diagnosis of stroke, had her quarterly MDS assessment incorrectly coded to reflect that she received injections and insulin during the look-back period. However, a review of her physician orders and Medication Administration Record (MAR) for March 2024 showed no evidence of such orders or administration. Interviews with MDS Nurse #2 and the Director of Nursing confirmed the inaccuracy, acknowledging that the MDS should accurately reflect the medications the resident was receiving. Similarly, Resident #262, admitted with a diagnosis of debility, had his admission MDS assessment inaccurately coded with diagnoses of anxiety, depression, and schizophrenia, which were not present in his discharge summary. MDS Nurse #1, who completed the assessment, could not recall the source of these diagnoses and acknowledged the error upon review. The Director of Nursing indicated that any concerns regarding diagnoses should have been clarified before coding. Both the Director of Nursing and the Administrator emphasized the importance of accurate MDS assessments.
Failure to Include Anticoagulant Medication in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident receiving anticoagulant medication. The resident, who was admitted with a diagnosis of atrial fibrillation, was prescribed apixaban, an anticoagulant, to be taken twice daily. Despite the medication being administered as prescribed, the resident's care plan did not include a focus area or interventions related to the anticoagulant medication. This oversight was acknowledged by the MDS Nurse responsible for coding the resident's assessment, who admitted to not ensuring the care plan addressed the anticoagulant medication. The Director of Nursing also confirmed that the care plan should have accurately reflected the resident's medication regimen.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents' rights by not inviting residents or their representatives to participate in care plan meetings. This deficiency was identified for three residents. Resident #362, who was moderately cognitively impaired, was not invited to any care plan meetings since admission, and there was no documentation of such meetings in the electronic medical record (EMR). The Social Worker, who had been in the position since November 2023, did not have a formal system to track care plan meetings and admitted to not inviting Resident #362 or her representative. Resident #53, who was cognitively intact, also did not receive an invitation to recent care plan meetings. The last documented care plan meeting was in June 2023, and the Social Worker, who took the position in November 2023, did not hold a quarterly care plan meeting for this resident. The Social Worker had met with Resident #53 for grievances but did not document these interactions in the resident's chart or invite the resident to a care plan meeting. Resident #31, who was cognitively intact, did not recall being invited to or attending any care plan meetings. The Social Worker admitted to confusing conversations with the resident's family about concerns with actual care plan meetings. The Administrator acknowledged a breakdown in the process and the lack of a tracking system to ensure care plan meetings were held as required.
Medication Error Rate Exceeds 5% Due to Staff Oversight
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an observed rate of 8%. This deficiency was identified during a medication pass observation involving a resident with severe cognitive impairment and a diagnosis of asthma. Two medication errors were noted: the first involved the administration of ultra-lubricating eye drops without shaking the bottle as instructed by the label. Nurse #1 acknowledged awareness of the instructions but admitted to forgetting to shake the medication before administering it to the resident. The second error involved the administration of a steroid inhaler, budesonide formoterol fumarate inhalation aerosol, where Nurse #1 administered two puffs instead of one, failed to shake the inhaler before use, and did not instruct the resident to rinse and spit after use, as required. The pharmacist confirmed the importance of these steps to ensure proper medication delivery and to prevent potential side effects. The Director of Nursing also confirmed that Nurse #1 should have followed the label instructions for both medications.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a cognitively intact resident from verbal and physical abuse by another cognitively intact resident. The incident began when one resident verbally insulted another, calling her derogatory names. In response, the insulted resident, who was in a motorized wheelchair, purposefully ran into the other resident, causing an abrasion and bruising to his right leg. This incident was part of a review of four residents for abuse. The resident who initiated the physical contact had a history of verbally abusive behavior, as noted in her care plan, which aimed to reduce such behaviors by 50 percent. Despite interventions to reinforce the unacceptability of verbal abuse, the resident engaged in a verbal altercation that escalated to physical aggression. The other resident involved had a history of physically aggressive behavior and was on one-to-one supervision due to previous incidents of aggression and threats. Staff interviews revealed that the altercation was witnessed by multiple staff members, including a nurse and nursing assistants, who attempted to intervene and separate the residents. However, the situation escalated quickly, and the physical contact occurred before staff could prevent it. The incident was reported to the police by the injured resident, and an investigation was conducted, with witness statements collected from those involved.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed narcotic medication, oxycodone. Resident #84, who was cognitively intact and had rare pain, was prescribed oxycodone 10 mg to be taken at bedtime. On a specific date, it was documented that he received his medication, but during an interview, he stated he did not receive it. Similarly, Resident #72, also cognitively intact and with no reported pain, was prescribed oxycodone 5 mg as needed. It was documented that she received her medication, but she confirmed she did not request or receive it on the date in question. The incident was brought to light when a pill crushing sleeve containing two pills, identified as oxycodone 5 mg and 10 mg, was found on the floor near the time clock. This was initially observed by Patient Care Aide #1, who saw it fall from Medication Aide #1's bag. Nurse Aide #7 later picked up the sleeve and handed it to Nurse #6, who confirmed the pills' identity using a pill identification application. The pills were secured and reported to the Director of Nursing. An investigation revealed that the medications matched those prescribed to Residents #84 and #72, and both residents confirmed they did not receive their medications. Medication Aide #1, who was responsible for administering the medications, denied taking the pills but tested positive for oxycodone. She claimed the positive test was due to consuming gummies that might have been tampered with. Despite her denial, the facility's investigation concluded that she had diverted the medications, leading to her suspension and eventual termination. The facility's Director of Nursing and Administrator were involved in the investigation, and the incident was reported to the appropriate authorities.
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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