Guilford Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 2041 Willow Road, Greensboro, North Carolina 27406
- CMS Provider Number
- 345460
- Inspections on file
- 29
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Guilford Health Care Center during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to label, date, and properly seal multiple opened food items in the walk-in freezer and refrigerator, including pasta, bread, meat, cheese, and stewed apples, some of which showed frostbite, discoloration, and slimy or mushy appearance. The Dietary Manager acknowledged that open items should be labeled, dated, sealed, and discarded as needed. In addition, walls and ceilings in the dishwashing, steamtable/food line, and food prep areas were observed with black substances and deteriorating sheetrock and plaster around AC vents, and staff confirmed that these high surfaces were not being cleaned and had not been repaired.
A resident alleged that staff threw mashed bananas and ice water on her after she had thrown a banana at a nurse. An NP observed the resident wiping water from the floor and was told by the resident that staff were throwing things at her, then notified a nurse manager, who in turn notified the DON and Administrator. The Administrator asked a rehabilitation manager to investigate, and interviews with staff and the resident confirmed that a banana and water had been thrown on the resident, though specific staff were not identified by the resident at that time. Despite facility policy requiring immediate reporting of abuse allegations to the State Survey Agency, law enforcement, and APS, the initial allegation report to the State Survey Agency and law enforcement was not made until two days later, and there was no documentation that APS was notified. The DON later stated she was unaware of the requirement to report the allegation to APS, and leadership acknowledged the allegation was not reported within the required timeframe.
A resident with a history of stroke-related hemiplegia, hemiparesis, and a right tibial fracture was prepared for discharge to an assisted living facility with a goal of returning to the community. The facility’s Discharge Planner altered the resident’s FL2 form by changing ambulatory status and striking three medications, but these changes were not reviewed or signed by a provider. The Assisted Living Executive Director, having previously rescinded a bed offer due to an FL2 indicating non-ambulatory status, refused admission when the corrected but unsigned FL2 was received in the parking lot at the time of attempted admission. As a result, the resident, who reported being able to transfer with a cane and use a wheelchair for distance, was transported back and readmitted to the facility the same day.
Surveyors found that the facility failed to follow its oxygen therapy policy by not posting required "oxygen in use" safety signage for two residents receiving continuous oxygen and by not timely obtaining a provider order for oxygen for one of them. One resident with COPD and respiratory failure had a standing order and documented oxygen use but was repeatedly observed on oxygen without door signage. Another resident with CHF and a tracheostomy was treated for hypoxia and placed on continuous oxygen per a verbal NP order that was not entered into the record for several days, during which the resident continued to receive oxygen without an active order or posted safety signage. Multiple nurses, NAs, the DON, and the Administrator acknowledged that signs and orders should have been in place but could not explain the omissions.
Surveyors observed a nurse leaving a medication cart unlocked and unattended while entering a resident’s room and leaving three unused multiple-dose insulin syringes unsecured on top of the cart. The nurse placed an unlabeled cup containing digoxin, docusate, torsemide, and spironolactone that had been refused by a resident into a cart drawer, and later stored a finasteride tablet that had been dropped on the floor in another unlabeled cup in the same drawer. Additional review of the cart revealed three more unlabeled cups containing multiple unidentified pills, which the nurse attributed in part to medications refused earlier in the day by a resident and not properly wasted. The DON and Administrator stated they expected carts to be locked when unattended, insulin to be secured, and refused or dropped medications to be disposed of rather than stored on the cart.
Multiple residents reported that snacks were not available when requested, leading to feelings of hunger between meals. Staff interviews and observations confirmed that nourishment rooms often lacked snacks, and residents were sometimes told by staff or dietary personnel that no snacks were available. The Dietary Manager indicated that the contracted dietary company did not include snacks in the order guide, resulting in insufficient snack availability despite resident complaints.
Over several months, residents repeatedly voiced grievances during Resident Council meetings regarding issues such as food portions, staff behavior, noise, and environmental cleanliness. These concerns were not consistently documented, addressed, or communicated back to the residents, leading to ongoing frustration among the council members and a lack of resolution for their complaints.
A resident with a PEG tube received multiple crushed medications administered together, rather than individually with required water flushes between each, as ordered by the physician. An agency nurse was unaware of the specific administration protocol, resulting in a medication error rate of 20%, which exceeded the acceptable threshold. The DON confirmed that staff are expected to follow all medication orders.
During a lunch meal service, the facility did not follow the approved menu and diet orders for residents on pureed, renal, and heart healthy diets. Pureed bread was omitted for all residents on pureed diets, and salisbury steak was not provided to those on renal and heart healthy diets as required. Additionally, the recipe for beef stroganoff was not followed, with extra cream sauce added, affecting the nutritional content for residents on regular and mechanical soft diets.
Two cognitively intact residents were unable to access more than $20 per day from their personal funds and could only withdraw money during limited weekday hours, with no access after hours or on weekends. The Business Office Manager confirmed these restrictions, and the new Administrator was unaware of the policy.
A resident with multiple chronic conditions had conflicting code status information between the EMR, which listed Full Code, and a paper binder at the nursing station, which contained a signed DNR form. Staff interviews confirmed reliance on both sources for code status, and the inconsistency was acknowledged by nursing and management.
A comprehensive MDS assessment was not completed within the required timeframe for a resident after admission. The MDS nurse stated the delay was due to a recent increase in new admissions, and the DON was unaware of the specific reason for the late assessment but confirmed it should have been completed within 14 days.
Surveyors identified that the facility failed to accurately code the MDS assessments for two residents: one was discharged to another SNF but was incorrectly coded as discharged to a short-term general hospital, and another, who was exclusively tube-fed due to severe malnutrition and gastrostomy status, was not coded as receiving nutrition via feeding tube on the MDS. Staff interviews confirmed these errors and a lack of cross-departmental review for assessment accuracy.
A resident with an indwelling urinary catheter was repeatedly observed with the catheter drainage bag and tubing lying on the floor, and the tubing was not secured to the leg as required. Staff were aware of the issue but did not resolve it, resulting in a failure to provide appropriate catheter care and prevent infection.
Two residents requiring dialysis did not receive care in accordance with physician orders and facility procedures. One resident with a fluid restriction regularly received more fluids than prescribed due to unclear instructions and poor coordination between nursing and dietary staff. Another resident was not provided a bagged meal or snack on dialysis days because their name was missing from the list used to prepare food for dialysis patients, resulting in the resident going without food during dialysis sessions.
The facility did not consistently develop person-centered baseline care plans or provide summaries to new admissions and their responsible parties within 48 hours. In several cases, essential medical interventions such as urinary catheters and wearable defibrillators were omitted from care plans, and residents or their families were not given or offered copies of the care plan or medication list. Staff interviews revealed confusion about responsibilities, and the DON confirmed that required steps were not being completed.
A resident with severe cognitive impairment was not assessed for safe smoking upon resuming tobacco use after admission. The care plan and medical record lacked documentation of a smoking assessment, and the resident was observed smoking independently without staff supervision. Staff interviews confirmed that required assessments and care planning were not completed when the resident began smoking.
A resident with a gastrostomy tube and severe malnutrition did not receive tube feedings as ordered by the physician. The feeding pump was found off and disconnected, with most of the prescribed formula remaining unused. An agency nurse was unaware of the specific feeding orders and only intermittently administered the feeding, while the resident's private attendant had a history of turning off the pump. The RD confirmed the resident did not receive the required nutrition during the observed period, and the DON acknowledged the nurse's responsibility to ensure the feeding was administered as ordered.
Improper Food Storage and Unsanitary Kitchen Surfaces
Penalty
Summary
The facility failed to properly label, date, seal, and discard food items stored in the main kitchen’s walk-in freezer and refrigerator. During an observation with the Dietary Manager, surveyors found multiple opened, unlabeled, and unsealed items in the walk-in freezer, including cheese ravioli, lasagna pasta sheets, dinner rolls, and hamburger patties, several of which showed signs of frostbite, ice crystal formation, and grayish-brown discoloration. In the walk-in refrigerator, surveyors observed an opened, unlabeled 5-pound bag of shredded parmesan cheese, an opened, unlabeled container of stewed apples with a brownish discolored surface and mushy, slimy fruit, and an opened, unlabeled 1-pound bag of shredded cheese. The Dietary Manager acknowledged that open food items should be labeled and dated daily, sealed when stored, and discarded when needed, and stated that these freezer items needed to be discarded. The facility also failed to maintain clean and intact walls and ceilings in the main kitchen, including the dishwashing, steamtable/food line, and food preparation areas. Surveyors observed black substances on wall and ceiling surfaces in the dishwashing area, as well as on ceiling areas with AC vents over the steamtable/food line and over the food prep table, where the sheetrock and plaster showed deterioration and were no longer supported. Staff interviews revealed that dietary staff had a cleaning schedule and assignments for kitchen cleaning on their shifts but were not responsible for cleaning high walls or ceilings. The Administrator and Maintenance Supervisor confirmed the presence of the black substance and the deteriorated ceiling areas and acknowledged that no work had been performed to remove the black substance or repair the sheetrock or plaster since the issues were identified months earlier.
Failure to Timely Report Allegation of Staff-to-Resident Abuse to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of employee-to-resident physical abuse to law enforcement, the State Survey Agency, and Adult Protective Services (APS) within the required time frame. Facility policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of property be reported immediately, and no later than 2 hours if the allegation involved abuse or serious bodily injury, or within 24 hours if it did not. The policy also specified that the Administrator or designee must notify the State Survey Agency and other appropriate agencies, and notify law enforcement if the incident was reasonably believed to constitute a crime. On the date of the incident, a nurse practitioner (NP) entered the resident’s room and observed the resident wiping water from the floor with a few ice cubes present. The resident told the NP that staff were throwing things at her, such as mashed bananas. The NP did not observe mashed bananas on the resident or that the resident was wet, but she contacted a nurse manager (Nurse #5) so the DON and Administrator could be notified. Nurse #5 reported that she received a call from the NP stating that the resident had thrown a banana at a nurse and alleged that water was thrown back at her, and Nurse #5 then called the DON and Administrator that afternoon. The Administrator stated he requested the Rehabilitation Manager return to the facility to investigate and later received a call indicating the resident was upset but there was no evidence of abuse at that time. The Rehabilitation Manager reported that he returned to the facility, interviewed staff and the resident, and learned that the resident had thrown a banana at a nurse and that a banana and water were thrown on the resident, though the resident did not identify which staff members. The resident’s family member stated she received a call from the resident the same day reporting that a banana and water were thrown on her, and the family member was told later that an investigation was ongoing. An Initial Allegation Report documenting that staff allegedly threw mashed bananas and ice water on the resident was not completed and faxed to the State Survey Agency until two days after the allegation, and law enforcement was notified the same day the report was completed, not on the day of the allegation. APS notification was not documented in either the Initial Allegation Report or the subsequent Investigation Report. The DON later stated she was unaware that the allegation needed to be reported to APS, and the Divisional Director of Nursing acknowledged that the allegation should have been reported on the day it was made and that the report was not submitted timely.
Failure to Provide Accurate, Provider-Approved FL2 for Discharge to Assisted Living
Penalty
Summary
The facility failed to provide an accurate, provider-approved FL2 form to the assisted living facility to which Resident #117 was being discharged, resulting in the resident being denied admission. Resident #117 had been admitted with a right tibial fracture, hemiplegia and hemiparesis following a cerebral infarction, and difficulty walking. An admission MDS showed she was cognitively intact, required partial assistance for wheelchair mobility, and had a discharge goal of returning to the community. Her care plan identified a need for staff assistance with ADLs, use of a quad cane for transfers, and use of a wheelchair, and included a goal to return to the community with coordination between the facility and her physician regarding discharge plans. An FL2 form signed by Nurse Practitioner (NP) #1 on 5/5/25 documented an assisted living level of care and indicated the resident was semi-ambulatory, with NP #1’s initials noted beside that status. The FL2 also contained three medications that had been struck through, with the medication names rendered unreadable and no indication that NP #1 had approved these changes. The Assisted Living Executive Director later reported that the FL2 he initially received from the facility indicated the resident was non-ambulatory, leading him to rescind the bed offer. The Discharge Planner stated she then corrected the FL2 by changing the ambulatory status from non-ambulatory to semi-ambulatory and striking three medications the resident was no longer prescribed, intending to obtain provider review and signature but acknowledging that this approval had not occurred before discharge. On the morning of 5/13/25, Transportation Aide #1 transported Resident #117 to the assisted living facility for admission. Upon arrival, the Assisted Living Executive Director met them in the parking lot and stated he could not admit the resident because he did not have an approved FL2. Transportation Aide #1 contacted the nursing facility, and another FL2 dated 5/5/25 was sent, showing semi-ambulatory status with the non-ambulatory box whited out and three medications struck through, but without a provider’s signature approving the changes. The Assisted Living Executive Director contacted the Social Work Assistant and advised that he would not admit the resident because the FL2 changes were not provider-approved. NP #1 later confirmed she had signed the original FL2 on 5/5/25 but had not approved any subsequent changes and that her last working day at the facility was 5/5/25. The Administrator acknowledged that the resident should have remained at the facility until an accurate, provider-approved FL2 was provided to the assisted living facility and stated he did not know why this had not been done. Resident #117 reported that she was transported for admission on the morning of 5/13/25, was told in the parking lot that she could not be admitted due to missing paperwork, and was then transported back and readmitted to the nursing facility the same day. She stated that at the time of discharge she was able to transfer from wheelchair to bed using a cane and used a wheelchair for longer distances. The Social Work Assistant and Discharge Planner both confirmed that an amended FL2 was sent while the resident was still in the transportation van at the assisted living facility, but that the Assisted Living Executive Director refused admission because the changes lacked provider approval. The resident remained at the nursing facility until 5/17/25, when she chose to discharge home.
Failure to Post Oxygen Safety Signage and Obtain Timely Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow its own oxygen therapy policy requiring a provider order for oxygen and the posting of “oxygen in use” safety signage on door frames of rooms where oxygen is being used. The facility allows smoking by residents, staff, and visitors, yet surveyors observed that two residents receiving continuous oxygen therapy did not have cautionary signage posted on their doors. Staff interviews, including with multiple nurses and NAs, confirmed that they were aware of the policy and that signs should be posted, but they could not explain why signs were missing for these residents. One resident with COPD and acute and chronic respiratory failure had a physician’s order dated 7/22/2025 for continuous oxygen at 2 L/min via nasal cannula, and the annual MDS documented oxygen use. On multiple observations over two days, this resident was seen in bed receiving oxygen at 2 L/min without any oxygen-in-use signage on the room door. Several staff members, including nurses and NAs, acknowledged that the facility’s practice is to post oxygen signs for residents on oxygen and that such a sign should have been present, but none could account for the absence of the sign or reported having noticed it was missing. Another resident with a history of CHF and tracheostomy status was treated by an NP for hypoxia when oxygen saturations were reported in the 80s on room air. The NP stated she gave a verbal order on 3/13/2026 for continuous oxygen at 2–5 L/min via trach mask to maintain oxygen saturation at or above 90%, and expected the order to be entered into the medical record. Observations on subsequent days showed this resident receiving oxygen at 2 L/min via trach mask, including while using a wheelchair with a portable tank, but there was no oxygen order documented until 3/16/2026 and no oxygen-in-use signage on the door during those observations. The assigned nurse, the DON, and the Administrator all confirmed there was no oxygen order in the record for this period and no signage posted, and they were unable to explain why the verbal order had not been entered or why the required signs were not in place.
Improper Medication Cart Security and Handling of Refused and Dropped Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications on the 100 Hall Bottom medication cart. During continuous observation of a day-shift nurse, the medication cart was found unlocked while the nurse was inside a resident’s room, and the nurse confirmed the cart should have been locked when unattended. The same nurse left three unused multiple-dose insulin syringes in a plastic bag on top of the unattended cart instead of securing them inside the cart. In addition, after a resident refused a prepared dose of digoxin 125 mcg, docusate 100 mg, two torsemide 20 mg tablets, and spironolactone 50 mg, the nurse placed the unlabeled medicine cup containing these medications in the top drawer of the cart with the intention of offering them again. Later, when administering finasteride 5 mg to another resident, the tablet was dropped on the floor; the nurse picked it up, placed it in a medicine cup, and stored it in the medication drawer beside another unlabeled cup of medications, stating she still needed to waste the dropped tablet. Further inspection of the same medication cart with the nurse revealed three additional unlabeled medication cups in the top right drawer: one cup with a single pill, one with five pills of various sizes, shapes, and colors, and one with three pills of various sizes, shapes, and colors. The nurse indicated that one of these cups contained medications left by a previous-shift nurse after a resident refused a 6:00 a.m. dose, and acknowledged that the medications should have been wasted rather than stored on the cart. The previous-shift nurse confirmed that a resident had refused medications and that they should not have been left on the cart. The DON and Administrator both stated they expected staff to keep medication carts locked when unattended, secure insulin syringes inside the cart, and dispose of refused or to-be-wasted medications rather than storing unlabeled medications in the cart.
Failure to Provide Snacks Upon Resident Request
Penalty
Summary
The facility failed to provide snacks when requested for multiple residents, as evidenced by observations, resident and staff interviews, and review of resident council minutes. Cognitively intact residents, as well as one resident with moderate cognitive impairment, reported that snacks were not available throughout the day and that they often felt hungry between meals. Residents stated that when they requested snacks from staff, they were told there were none available or that staff were too busy to retrieve them from the dietary department. On several occasions, residents attempted to obtain snacks themselves from the kitchen but were informed by dietary staff that no snacks were available. Observations confirmed that nourishment rooms on two different halls lacked snacks, with one room containing only a few slices of bread and a bottle of mustard, and the other having only a single container of mandarin oranges in the refrigerator. Resident council meeting minutes from three separate dates documented ongoing concerns about the lack of snack availability. Staff interviews corroborated that snacks were inconsistently provided, with evening snacks sometimes delivered but daytime snacks often unavailable. The Dietary Manager acknowledged being aware of the residents' concerns and stated that the contracted dietary company controlled the food order guide, which did not include snacks. Despite attempts to order additional items, the supply was insufficient to meet residents' needs. The Administrator was aware of the residents' concerns but was not informed that nourishment rooms were lacking snacks.
Failure to Address and Resolve Resident Council Grievances
Penalty
Summary
The facility failed to act upon and resolve grievances reported by the Resident Council over a period of seven consecutive months. Resident Council meeting minutes consistently documented resident grievances, including issues with banking hours, food portion sizes, lack of snacks, staff behavior (such as not knocking on doors and using phones or earbuds), noise levels at night, and environmental cleanliness. Despite these recurring concerns, there was a lack of documented follow-up or resolution for most grievances from month to month. In some cases, only one grievance from a previous month was addressed, while others were left unresolved, and there was no evidence that the facility communicated efforts to address these concerns to the Resident Council. Interviews with residents, the Activities Director, and the Administrator revealed that grievances raised during Resident Council meetings were not consistently documented on grievance forms or formally communicated to department heads for follow-up. The Activities Director admitted to not filling out grievance forms for concerns brought up in Resident Council and not documenting follow-up actions in the meeting minutes. Residents expressed frustration that their repeated complaints were not being addressed or acknowledged by facility leadership or corporate staff. The Administrator, who was new to the position, was unaware of the lack of documentation and follow-up regarding Resident Council grievances.
Medication Error Rate Exceeds 5% Due to Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 25 opportunities, resulting in a 20% error rate. The deficiency involved a resident with dysphagia and a PEG tube, who had physician orders specifying that the tube should be flushed with water before and after each individual medication. During a medication pass, an agency nurse prepared and administered all of the resident's prescribed tablets together, crushing them and mixing them in water, rather than administering each medication separately with the required water flushes between each one. The nurse was unaware of the specific physician orders requiring individual administration and separate flushes, and there were no orders permitting the medications to be combined. The Director of Nursing confirmed that staff are expected to follow all medication administration orders. These actions led to the facility exceeding the acceptable medication error rate and not adhering to the resident's prescribed medication administration protocol.
Failure to Follow Approved Menus and Diet Orders During Meal Service
Penalty
Summary
The facility failed to follow the approved, dietitian-reviewed menu for multiple residents with specific dietary needs during a lunch meal service. Eleven residents on a pureed diet did not receive pureed bread as required, and instead only received pureed beef stroganoff, pureed noodles, and pureed peas, with no bread substitute provided. Additionally, three residents on a renal diet and fifteen residents on a heart healthy diet were served beef stroganoff instead of the prescribed salisbury steak. The dietary manager confirmed that the extended menu with detailed diet listings was not easily accessible and admitted to forgetting to provide pureed bread and not realizing the need for a different entrée for renal and heart healthy diets. Further, the recipe for beef stroganoff was not followed for fifty-five residents on regular and mechanical soft diets, as the dietary manager added approximately five cups of extra cream sauce to the beef without following the approved recipe. The registered dietitian confirmed that the additional cream sauce increased the fat content of the dish, which was not appropriate for residents on heart healthy diets. These actions resulted in residents not receiving meals that met their prescribed nutritional needs as outlined in the approved menu.
Failure to Provide Residents with Adequate Access to Personal Funds
Penalty
Summary
The facility failed to provide residents with adequate access to their personal fund accounts, as evidenced by the experiences of two cognitively intact residents. Both residents reported that they were only permitted to withdraw $20 per day from their personal funds, and could only access these funds Monday through Friday between 9:00 AM and 3:00 PM. There were no options for residents to access their funds after hours or on weekends, which limited their ability to manage their own finances and make purchases as desired. Interviews with the Business Office Manager confirmed that these restrictions were set by corporate staff, and that requests for amounts over $20 would be fulfilled by check on the following business day. The Administrator, who was new to the position, was unaware of these limitations and had expected residents to have unrestricted access to their funds. The deficiency was identified through staff and resident interviews, and affected at least two residents who were reviewed for management of personal funds.
Inconsistent Documentation of Advance Directive (Code Status)
Penalty
Summary
The facility failed to maintain consistent and accurate documentation of a resident's advance directive (code status) across both the electronic medical record (EMR) and the paper record kept at the nursing station. For one resident with a history of heart failure, renal insufficiency, and respiratory failure, the paper binder at the nursing station contained a signed Do Not Resuscitate (DNR) form, while the EMR and physician orders indicated a Full Code status. The care plan and recent assessments also reflected the Full Code status, despite the presence of the DNR form in the paper record. Interviews with facility staff revealed that both the EMR and the paper binder were used as sources for code status information, and staff expected these sources to match. Nursing staff and management acknowledged the discrepancy when it was brought to their attention, confirming that the two records did not align for this resident. The resident was noted to have moderately impaired cognition at the time of the deficiency.
Failure to Complete Comprehensive MDS Assessment Within Regulatory Timeframe
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required regulatory timeframe for one resident. The resident was admitted on a specified date, but review of the admission MDS assessment revealed it was still in progress and not completed as of the review date. During interviews, the MDS nurse acknowledged that the assessment was late, attributing the delay to a recent influx of new admissions. The Director of Nursing was unaware of the reason for the delay but confirmed that the assessment should have been completed within 14 days of admission.
Inaccurate MDS Coding for Discharge Location and Feeding Tube Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in key areas. For one resident, the Discharge Planner documented in the discharge planning note and nursing progress note that the resident was discharged to another skilled nursing facility. However, the MDS assessment was incorrectly coded as a discharge to a short-term general hospital. The Discharge Planner acknowledged the error during an interview, stating that the correct discharge location should have been selected. Additionally, the MDS Nurse reported that she did not review sections of the assessment completed by other departments for accuracy, and the Administrator confirmed that the Discharge Planner was responsible for ensuring the assessment's correctness. For another resident with diagnoses including severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status, the physician ordered continuous tube feeding via gastrostomy tube. Despite this, the resident's annual MDS did not indicate that nutrition and hydration were provided through a feeding tube. A subsequent MDS Reconciliation Note confirmed that the resident did not eat or drink by mouth and was fed exclusively by tube feeding, highlighting the inaccuracy in the MDS coding.
Failure to Secure Indwelling Catheter and Prevent Tubing from Contacting Floor
Penalty
Summary
A deficiency was identified when a resident with urinary retention, who had an indwelling urinary catheter, was observed with the catheter drainage bag and tubing lying on the floor beside the bed. The resident was cognitively intact and had a physician's order for the catheter. Multiple observations revealed that the catheter tubing was not secured to the resident's leg, and attempts by a nursing assistant to secure the tubing to the bed were unsuccessful, leaving the tubing on the floor. The nursing assistant reported the lack of a secure strap to a nurse, but the issue was not addressed. Interviews with staff confirmed awareness of the problem. The nurse acknowledged being informed about the unsecured catheter but stated she forgot to address it. Both the Director of Nursing and the Administrator confirmed that the catheter bag and tubing should not have been on the floor and that a device should have been used to secure the tubing. These actions and inactions led to the failure to provide appropriate catheter care and to prevent potential infection risks.
Failure to Adhere to Fluid Restrictions and Provide Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide dialysis care and services in accordance with physician orders and resident needs for two residents requiring dialysis. For one resident with end-stage renal disease and a physician-ordered daily fluid restriction of 1200 ml, the order did not specify how much fluid should be provided by dietary services with meals and how much should be given by nursing staff throughout the day. As a result, the resident's fluid intake records showed multiple days where intake exceeded the prescribed limit. Staff interviews revealed inconsistent knowledge and communication regarding the breakdown of fluid allocation between departments, and the Director of Nursing was unaware that nursing staff did not have clear instructions on fluid distribution. Additionally, the same resident's care plan indicated a fluid restriction, and laboratory results showed increased fluid weight gain, suggesting non-adherence to the restriction. Observations confirmed the resident had access to fluids beyond the prescribed amount, and staff reported that the resident would often request and receive additional fluids. The Registered Dietitian was aware of the dietary fluid allocation but did not know if nursing staff were informed of their portion, further highlighting the lack of coordination. For another resident dependent on dialysis, the facility failed to provide a bagged meal or snack on dialysis days. The resident reported not receiving food when going to dialysis and expressed a desire for a meal or snack. Staff interviews and review of the dialysis resident list revealed that this resident was not included on the list used to prepare and distribute food bags, resulting in the omission. The Director of Nursing confirmed that the resident should have received a snack, and the Administrator acknowledged the need for updated communication and documentation regarding new dialysis residents and their dietary needs.
Failure to Develop and Communicate Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement person-centered baseline care plans and provide summaries to residents and/or their responsible parties within 48 hours of admission for multiple new admissions. In several cases, essential medical needs and physician orders were not reflected in the baseline care plans. For example, one resident admitted with urinary retention and an order for an indwelling urinary catheter did not have catheter use documented in the baseline care plan. Another resident with end stage renal disease and a physician order for a wearable defibrillator (LifeVest) did not have this device included in their baseline care plan. Interviews with nursing staff and the Director of Nursing (DON) confirmed that these omissions occurred and that the care plans should have included these critical interventions. Additionally, the facility did not ensure that baseline care plans and medication lists were reviewed with residents or their responsible parties, nor did they provide copies of these documents within the required timeframe. In several instances, there was no documentation that the care plan or medication list was reviewed or provided, even for residents with cognitive impairment or those whose responsible parties were available. Interviews with staff revealed confusion regarding responsibility for reviewing and distributing these documents, with some agency nurses believing it was the facility staff's duty, and facility staff not consistently completing all required sections or providing the necessary information to residents and families. The deficiency was identified for five residents admitted with various diagnoses, including urinary retention, end stage renal disease, intracerebral hemorrhage, and a fracture. In each case, the baseline care plan was either incomplete, missing critical information, or not communicated to the resident or responsible party as required. The DON acknowledged that nurses were not consistently completing all sections of the baseline care plan or ensuring that residents and responsible parties received and reviewed the care plan and medication summary within 48 hours of admission.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to complete a smoking assessment for a resident who was reviewed for smoking. Upon admission, the resident was documented as not being a smoker and was assessed as severely cognitively impaired, with no tobacco use coded in the Minimum Data Set (MDS) assessment. The resident's care plan did not include any interventions or considerations related to smoking, and there was no evidence in the medical record that a safe smoking assessment had been conducted. Despite this, the resident was later observed smoking independently in the facility's designated smoking area without staff supervision. Interviews with the responsible party and staff revealed that the resident began smoking again several weeks after admission, but no updated assessment or care plan was created to address this change. Facility staff, including the nurse, unit manager, DON, and administrator, confirmed that a smoking assessment should have been completed when the resident resumed smoking, but this was not done.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident with severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status did not receive tube feedings as ordered by the physician. The resident's care plan required tube feedings to meet nutritional and hydration needs, with a physician order specifying continuous administration of formula at 65 ml per hour for 19 hours daily via gastrostomy tube. On observation, the feeding pump was not running, and the tubing was not connected to the resident, with 900 ml of formula remaining in the bag that was supposed to start at 6:00 AM. The resident's private attendant was not present at the time of observation. Nurse interviews revealed that the tube feeding was not consistently administered as ordered, with the nurse stating she was unaware of the specific tube feeding orders and had only intermittently started and stopped the feeding based on the resident's and attendant's requests. The Registered Dietitian confirmed that the resident had not received the required amount of formula for the observed period, and noted a history of the private attendant turning off the feeding pump. The DON stated that the nurse should have ensured the tube feeding was running as ordered and acknowledged the history of the attendant interfering with the feeding process.
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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