Harborview Lumberton
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, North Carolina.
- Location
- 1555 Willis Avenue, Lumberton, North Carolina 28358
- CMS Provider Number
- 345234
- Inspections on file
- 20
- Latest survey
- May 29, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Harborview Lumberton during CMS and state inspections, most recent first.
Surveyors found that medications and biologicals were not properly labeled, stored, or discarded as required. Unopened Latanoprost drops were not refrigerated, inhalers lacked opened dates or exceeded use periods, and expired medications were present on medication carts and in storage rooms. Nursing and supply staff acknowledged responsibility but cited oversights and lack of awareness regarding specific storage and labeling requirements.
Surveyors found an open package of sliced turkey in the walk-in refrigerator that was not labeled or dated, as well as expired containers of 2% milk in two nourishment rooms. The Dietary Manager confirmed that staff were responsible for labeling and removing expired items, but expired milk was not removed due to lack of weekend checks.
The facility failed to consistently implement and document wound care and weight monitoring as ordered for several residents with complex medical conditions, including those with chronic wounds, CHF, and recent amputations. Wound treatments and daily or weekly weights were frequently missed or not recorded, often due to unclear staff responsibilities and lack of backup systems, resulting in incomplete care and inaccurate records.
A resident with hypotension received Midodrine outside of prescribed blood pressure parameters on multiple occasions due to staff misinterpretation, oversight, and documentation errors. Several medication aides and nurses administered the drug incorrectly, and facility leadership, including the DON and Administrator, were unaware of the ongoing errors until the survey. The Consultant Pharmacist identified some errors but did not fully communicate the extent to the facility, and the Medical Director was not notified. The resident did not experience significant adverse outcomes.
A resident was admitted with a Stage IV pressure wound and other serious health conditions, but the Wound Care Physician was not notified of the wound for several weeks despite documentation and ongoing wound care by nursing staff. The wound was only brought to the physician's attention after a significant delay, with facility leadership unaware of the lapse until it was discovered during the survey.
The facility did not ensure complete and accurate documentation for two residents: one with hypertension did not have pulse readings recorded prior to administration of hydralazine as required by physician order, and another with congestive heart failure had daily weights inaccurately documented by an LPN who copied previous entries instead of obtaining new measurements. These actions resulted in incomplete medical records for both residents.
Two residents with severe cognitive impairment and existing pressure ulcers did not receive consistent wound assessments or daily wound care as ordered. Initial wound assessments with measurements were delayed or missing, and daily treatments were not documented or completed on multiple occasions due to unclear staff responsibilities and communication lapses. The Wound Care Physician was not notified of a stage IV ulcer on admission, and the DON was unaware of missed treatments, resulting in deficiencies in pressure ulcer care.
A resident admitted with severe cognitive impairment, malnutrition, and a Stage IV pressure wound, and who was receiving enteral tube feedings, did not have weekly weights obtained as required by facility policy and physician orders. The Restorative Aide, responsible for weights, was unable to complete them due to other assignments, and the assigned nurse did not obtain the weights in her absence. This resulted in missed documentation of the resident's weight on admission and during a required weekly interval.
A pharmacist did not identify or report repeated errors in the administration of Midodrine for a resident with hypotension, despite clear medication parameters. The medication was given outside of prescribed blood pressure limits dozens of times over several months, but these errors were not documented in monthly reviews or communicated to facility leadership. Nursing and administrative staff were unaware of the errors, and no staff education on medication parameters was provided. The resident experienced no significant outcome.
A resident admitted after a stroke and with a sacral pressure ulcer did not receive ordered physical, occupational, or speech therapy services. Therapy was withheld due to the absence of a PRAFO boot, which was not ordered by a physician and was incorrectly made a prerequisite for therapy. The resident, who was cognitively intact and expressed a desire for therapy, was not evaluated or treated as required by her care plan, and staff interviews revealed confusion about therapy initiation and equipment requirements.
Medication Storage and Labeling Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in medication storage and labeling across several medication carts and storage rooms. On the 400-hall medication cart, an unopened bottle of Latanoprost ophthalmic drops was not refrigerated as required by manufacturer guidelines, and two Fluticasone propionate salmeterol inhalers were found—one without an opened date and another with an opened date exceeding the recommended one-month use period. Additionally, expired Hemorrhoidal suppositories were present. Nursing staff interviewed acknowledged responsibility for checking for expired medications and proper labeling but admitted these tasks had not been completed due to workload or lack of awareness regarding specific storage requirements. On the 800-hall medication cart, an opened bottle of Latanoprost ophthalmic drops lacked an opened date, and a bottle of Lansoprazole suspension was present with a use-by date that had passed, contrary to manufacturer instructions for refrigeration and timely disposal. In the 300-hall and 400-hall medication storage rooms, expired wound cleansers and Lansoprazole suspension were found. Staff interviews revealed confusion and oversight regarding responsibility for checking both prescription and over-the-counter medications, with multiple staff members indicating that expired medications had not been identified or removed as required.
Failure to Label Opened Food and Remove Expired Milk from Nourishment Rooms
Penalty
Summary
During a survey, it was observed that an open package of sliced turkey in the walk-in refrigerator was not labeled or dated, contrary to facility policy requiring all open food items to be labeled with an opened date and an expiration date. Additionally, expired containers of 2% milk were found in the East Wing and Secured Unit nourishment rooms. The Dietary Manager confirmed that dietary staff were responsible for stocking and removing expired items from these rooms, and acknowledged that the expired milk should have been removed. The Administrator stated that no one was assigned to check the nourishment rooms on weekends, which resulted in the expired milk remaining in place.
Failure to Provide Ordered Wound Care and Weight Monitoring
Penalty
Summary
The facility failed to implement and consistently provide wound care and weight monitoring as ordered for multiple residents with complex medical needs. For one resident with a chronic venous wound and congestive heart failure, there was a delay in initiating wound treatment upon admission and after readmission, with daily wound care treatments frequently missed or undocumented over several months. Nursing staff often believed that wound care was the responsibility of the treatment nurse or aide, leading to confusion and missed treatments. The resident, who was cognitively intact and did not refuse care, reported not receiving wound care every day, and documentation confirmed multiple days where treatments were not completed or recorded. The Wound Care Physician and Medical Director were unaware that orders were not being followed as prescribed. Additionally, the same resident had physician orders for daily weights due to congestive heart failure and fluid restrictions, but daily weights were not consistently obtained or documented. The Restorative Aide, primarily responsible for obtaining weights, was sometimes unavailable due to other assignments, and nurses did not obtain weights in her absence. One nurse admitted to recording previous weights on the Medication Administration Record (MAR) without actually obtaining new weights, resulting in inaccurate documentation. The Registered Dietitian and physician confirmed that daily weights were necessary for monitoring the resident's condition, but the process for ensuring weights were obtained was not followed. For another resident with arterial ulcers and a history of amputation, wound care treatments were not completed as ordered on multiple days, particularly when there was no assigned treatment nurse. Floor nurses did not always complete or document the required wound care, and the Wound Care Nurse did not review the Treatment Administration Records (TARs) for completion. This resident also did not have weekly or daily weights obtained as ordered following readmission, despite significant changes in condition, including edema and elevated BNP levels. The Restorative Nursing Assistant, responsible for weights, reported difficulty obtaining all required weights due to other duties and a lack of a backup system or notification process for new admissions and readmissions.
Failure to Follow Medication Administration Parameters for Midodrine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to the prescribed parameters for administering Midodrine, a medication used to treat hypotension. The resident had active orders specifying that Midodrine should be held if the systolic blood pressure (BP) was greater than 120 mm Hg or the diastolic BP was greater than 80 mm Hg. However, medication administration records revealed that the medication was frequently given when the resident's BP readings were above the specified parameters and held when the readings were below, contrary to the physician's orders. Multiple medication aides and nurses administered Midodrine in error, either by not noticing the parameters, misunderstanding the order, or documenting incorrectly. Several staff members admitted during interviews that they were aware of the parameters but failed to follow them due to oversight, misinterpretation, or the hectic nature of their assignments. Some staff also reported being unfamiliar with the specific requirements of the order or being distracted by other duties, leading to the administration of the medication outside the prescribed parameters. The errors were not identified or reported by the facility's leadership, including the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and the Administrator, all of whom stated they were unaware of the medication errors until notified during the survey. The Consultant Pharmacist noted the errors but did not report the full extent to the facility, believing the issue was not clinically significant and that staff education was already underway. The Unit Manager also did not receive pharmacy recommendations regarding the errors. The Medical Director confirmed that she was not notified of the errors and expected medications to be administered according to the ordered parameters. Despite the significant number of errors, the resident did not experience a significant outcome.
Failure to Notify Wound Care Physician of Stage IV Pressure Wound on Admission
Penalty
Summary
The facility failed to notify the Wound Care Physician for evaluation and treatment of a Stage IV pressure wound on the left trochanter that was present upon admission for a resident with multiple diagnoses, including protein calorie malnutrition and anemia. Documentation showed that the resident was admitted with a Stage IV pressure wound, and physician orders were in place for wound care. Progress notes indicated the need for a wound care specialist consultation, but there was no evidence in the medical record that the Wound Care Physician was notified of the wound from admission through several weeks of the resident's stay. Interviews confirmed that the Wound Care Physician was not made aware of the resident's Stage IV wound until weeks after admission, despite the wound being documented and treated by nursing staff. The Wound Treatment Nurse, who was only present part-time, did not provide an explanation for the lack of notification, and the DON and Administrator were unaware of the failure until it was brought to their attention. The deficiency centers on the lack of timely notification to the Wound Care Physician for a serious wound present at admission.
Failure to Maintain Accurate Medical Records for Vital Signs and Weight Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in deficiencies related to documentation of vital signs and weight monitoring. For one resident with a history of stroke and hypertension, there was a physician order for hydralazine with specific parameters to hold the medication if the systolic blood pressure was less than 100, diastolic less than 50, or heart rate less than 60. Although the medication was administered and blood pressure readings were documented, there was no documentation of the resident's pulse or heart rate prior to administration, as required by the order. Multiple nurses confirmed that while they did check the pulse before giving the medication, the electronic Medication Administration Record (eMAR) did not require or provide a field to record the pulse, and this omission was due to an error in the transcription of the order by the DON. Another resident with diagnoses including congestive heart failure and chronic kidney disease had a physician's order for daily weights. Review of the Medication Administration Record revealed that the same weight was repeatedly documented over several days, and in some cases, the weight was not updated for over a week. During an interview, a nurse admitted to copying the previous weight from the record rather than obtaining and recording an actual daily weight, citing uncertainty about the method used by the Restorative Aide to obtain the weight. The nurse acknowledged that she had not obtained or documented accurate weights for the resident. Interviews with the DON, Administrator, and Nurse Practitioner confirmed that the expectations were for accurate and complete documentation of vital signs and weights as per physician orders. The lack of required documentation for the pulse prior to medication administration and the failure to obtain and record daily weights as ordered led to incomplete and inaccurate medical records for both residents.
Failure to Provide Consistent Pressure Ulcer Care and Assessment
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for two residents. For one resident admitted with a Stage IV pressure ulcer to the left trochanter, the facility did not conduct an initial wound assessment with a wound description and measurements upon admission. There was also a lack of documentation of wound assessments for both the stage IV hip and sacrum wounds for several days after admission. Additionally, daily wound care treatments were not consistently performed or documented according to physician orders, with multiple days where treatments were not signed off as completed. Staff interviews revealed confusion regarding responsibility for wound care, with some nurses believing the treatment nurse was responsible, while others thought the assigned nurse should complete the care in the absence of the treatment nurse. The Wound Care Physician was not notified of the stage IV wound upon admission, and the Director of Nursing was unaware that daily treatments were not being completed. Another resident with a Stage IV pressure ulcer to the sacrum and an unstageable ulcer to the right second toe did not consistently receive daily wound care treatments as ordered. The Treatment Administration Record showed multiple days where wound care was not documented as completed. Assignment sheets indicated that on these days, there was no assigned treatment nurse, and a Medication Aide was assigned to the resident with a nurse overseeing. However, both the Medication Aide and the overseeing nurse assumed the other was responsible for completing the wound care, resulting in missed treatments. The Wound Care Nurse, who was working part-time due to resignation, stated that floor nurses were responsible for wound care in her absence, but this was not consistently carried out. Both residents had significant medical histories, including severe cognitive impairment, malnutrition, and immobility, placing them at high risk for pressure ulcer development and complications. The lack of clear responsibility and communication among staff, as well as failure to follow physician orders for wound care, led to deficiencies in the care and monitoring of pressure ulcers. The Wound Care Specialist and Medical Director confirmed that wound care treatments were not completed as ordered, and the Director of Nursing was not aware of the lapses in care.
Failure to Obtain Weekly Weights for New Admission on Tube Feeding
Penalty
Summary
The facility failed to obtain weekly weights as ordered for a newly admitted resident who was receiving enteral tube feedings. The resident was admitted with diagnoses including a Stage IV pressure wound, protein calorie malnutrition, and anemia, and was identified as being at risk for dehydration. Facility policy and physician orders required weekly weights for new admissions, especially those on tube feedings, to monitor nutritional status. However, the resident's medical record showed missing weights on the admission date and on one of the required weekly intervals. Interviews with staff revealed that the Restorative Aide was primarily responsible for obtaining weights, but due to being assigned additional duties such as nurse aide tasks and transporting residents, weights were not always completed as required. The DON confirmed that if the Restorative Aide was unavailable, the assigned nurse was responsible for obtaining the weights, but this did not occur. The Registered Dietitian and the physician both confirmed the importance of weekly weights for this resident, and acknowledged that the required monitoring was not performed as ordered.
Pharmacist Failed to Identify and Report Repeated Medication Administration Errors
Penalty
Summary
A licensed pharmacist failed to identify and address repeated medication administration errors during monthly drug regimen reviews for a resident prescribed Midodrine for hypotension. The resident had specific parameters for administration, requiring the medication to be held if systolic blood pressure exceeded 120 or diastolic exceeded 80. Despite these parameters, the medication was administered outside of the prescribed limits 38 times in January, 44 times in February, and 35 times in March. The pharmacist's monthly reviews did not document these errors, and the majority of the errors went unreported to facility leadership. The pharmacist only partially acknowledged some errors in a February recommendation to nursing staff, listing a small sample of dates but not the full extent of the errors. No recommendations or notifications were made regarding the errors in January or March. Interviews with the pharmacist revealed she did not consider the errors clinically significant and believed that education provided to nursing staff would resolve the issue, though no such education had actually occurred. The pharmacist's monthly summary reports for all three months stated that no medication errors were noted. Facility leadership, including the DON, Unit Manager, Staff Development Nurse, and Administrator, were unaware of the medication errors until informed during the survey process. None of the nursing leadership had received reports or recommendations regarding the errors, nor had any education been provided to staff about medication parameters. The Medical Director confirmed that the pharmacist should have reported the errors as soon as they were discovered. The resident involved did not experience any significant outcome as a result of the errors.
Failure to Provide Required Rehabilitation Services per Care Plan
Penalty
Summary
The facility failed to provide required rehabilitation services to a resident who was admitted following a hospital stay for a stroke and sacral pressure ulcer. The hospital discharge summary recommended continued physical and occupational therapy due to the resident's significant mobility and activities of daily living (ADL) limitations. Upon admission, physician orders were in place for speech, occupational, and physical therapy evaluations and treatment as indicated. However, the therapy screening form was not fully completed, and therapy services were not initiated. The justification for not evaluating the resident was the absence of a PRAFO boot, which the facility was in the process of obtaining, despite there being no physician order for the device. The resident did not receive any occupational, physical, or speech therapy services after admission, despite being cognitively intact, expressing a desire to participate in therapy, and having no documented refusal of care. Interviews with staff revealed a lack of clarity regarding the resident's therapy status. The Therapy Director stated that therapy was withheld because the resident required total assistance and a PRAFO boot was needed, which the resident was expected to partially pay for. The Therapy Director also indicated that therapy services would not begin until the PRAFO boot was obtained, and was unable to explain why upper body therapy could not proceed in the meantime. Further interviews with the Nurse Practitioner and Administrator revealed that there was no physician order for the PRAFO boot and that it was not required for therapy participation. The Administrator was unaware that the resident had been asked to pay for the device and stated that the facility preferred insurance or the resident to cover the cost. Despite clear recommendations and orders for therapy, the resident did not receive the necessary rehabilitative services as required by her care plan.
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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