Harmony Hall Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kinston, North Carolina.
- Location
- 312 Warren Avenue, Kinston, North Carolina 28501
- CMS Provider Number
- 345156
- Inspections on file
- 21
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Harmony Hall Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with type 2 DM, who was cognitively intact and on insulin therapy, received a dose of glargine insulin from a pen that had been open beyond the manufacturer’s 28‑day discard date. Surveyors found an open glargine pen on the med cart labeled with an opening date that showed it was expired, as well as a second, unopened and undated pen for the same resident. The nurse who administered the insulin reported she did not check the expiration date before giving the dose and acknowledged she should have discarded the expired pen. The Pharmacy Consultant confirmed the 28‑day discard requirement, while the NP, DON, and Administrator each stated that nursing staff were expected to check med carts daily and ensure no expired medications were present or administered.
Surveyors found an open insulin glargine pen on a medication cart that remained in use past the 28-day discard period specified by the manufacturer. The pen was labeled with an opened date and an expiration date that had already passed, yet it was still stored on the cart during the survey. A medication aide assigned to the cart, the covering nurse, the Pharmacy Consultant, the DON, and the Administrator all acknowledged that nursing staff, including medication aides, were expected to check carts daily and remove expired medications, but this did not occur for the insulin pen on Station 2 medication cart #1.
A cognitively intact resident with hemiplegia and documented tobacco use, assessed and care planned as a safe, independent smoker, was found in his room with a pack of cigarettes and a lighter hidden under his shirt, contrary to facility policy requiring all smoking materials to be locked in a medication cart and accessed only with staff assistance. Staff, including a nurse, NA, medication aide, DON, and Administrator, reported that the resident normally obtained smoking materials from staff before going to the designated smoking area and returned them afterward, and that staff were responsible for ensuring the materials were secured. On this occasion, the resident kept his cigarettes and lighter after returning from smoking, reportedly because no staff were present at the medication cart, resulting in unsecured smoking materials in violation of the facility’s smoking policy.
A resident with a g-tube for nutrition and medication was found to have their 60 cc feeding syringe stored with the plunger inside the barrel and visible water droplets present, contrary to facility policy requiring separation of parts to prevent bacterial growth. Staff interviews confirmed the improper storage practice and awareness of the correct procedure.
A resident with dementia was observed with bilateral quarter length side rails in use without evidence of attempted alternatives, a completed side rail assessment, entrapment risk evaluation, or informed consent. Staff interviews revealed confusion about responsibility for assessments, and facility leadership confirmed that required assessments and documentation were not completed.
Two residents were left with medication cups on their bedside tables without being assessed for self-administration. Both residents were cognitively intact and had multiple medications prescribed. Nurse #3 left the medications unattended, leading to a confrontation with one resident and an admission of oversight. The DON confirmed that neither resident had been assessed for self-administration, and medications should not have been left unsupervised.
The facility failed to provide complete SNF ABN forms for two residents prior to their discharge from Medicare Part A skilled services. One resident's form lacked the section for the decision to continue services, while another resident's form was missing both the decision section and the signature. The facility Social Worker and Administrator acknowledged these oversights.
The facility failed to secure smoking materials for two residents identified as safe smokers. One resident was found with cigarettes and lighters in his room, while another had a lighter attached to his bag. Staff interviews revealed a lack of awareness and adherence to the facility's smoking policy, which requires smoking materials to be secured by staff.
Two residents with urinary catheters were observed with their catheter bags resting on the floor, contrary to infection control protocols. Despite the residents' cognitive impairments and dependency on staff, the catheter bags were not properly positioned, as confirmed by staff interviews. The DON expected catheter bags to be attached to the bed frame to prevent floor contact.
Expired Insulin Pen Administered Due to Failure to Check Expiration Date
Penalty
Summary
Surveyors identified a failure to meet professional standards of quality related to insulin administration for one resident with type 2 diabetes mellitus. The resident was cognitively intact, used insulin, and had a care plan directing finger stick blood sugars as ordered, medications as ordered, and monitoring for signs and symptoms of hypoglycemia. Manufacturer instructions for the resident’s glargine insulin pen required it be discarded 28 days after opening. Review of the Medication Administration Record showed the resident received a glargine insulin injection on 2/25/26 at 8:00 p.m. by a nurse. Observation of the medication cart the following day revealed an open glargine insulin pen for this resident dated as opened on 1/20/26 with an expiration date of 2/17/26, indicating it had been used beyond the 28‑day period. A second glargine pen for the same resident was present, unopened and undated. In an interview, the nurse who administered the insulin on 2/25/26 stated she was unaware the pen had expired on 2/17/26 because she did not check the expiration date prior to administration and acknowledged she should have discarded the expired pen. The Pharmacy Consultant confirmed the pen should have been discarded 28 days after opening due to decreased potency after the expiration date. The Nurse Practitioner stated she was unaware the resident had received expired insulin and indicated nursing staff were expected to check medication carts daily for expired medications. The DON and the Administrator both stated that floor nurses were responsible for checking medication carts daily for expired medications, discarding any expired medications, and ensuring no expired medications remained in the carts.
Expired Insulin Pen Not Removed From Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication storage and labeling when they found an expired multi-dose insulin glargine injector pen on one of five medication carts reviewed (Station 2 medication cart #1). The insulin pen had a manufacturer’s instruction to be discarded 28 days after opening, with labeling indicating an opened date of 1/20/26 and a handwritten expiration date of 2/17/26, yet it remained on the cart when observed on 2/26/26. The pen was open and still stored on the cart beyond the 28-day discard date specified by the manufacturer. During interviews, the medication aide assigned to that cart stated she did not administer insulin injections but acknowledged the insulin glargine pen should have been discarded after 28 days. The nurse covering that cart confirmed the expired insulin pen should have been removed and discarded and stated that nursing staff, including medication aides, were expected to check medication carts daily for expired medications. The Pharmacy Consultant also confirmed the pen should have been discarded 28 days after opening. The DON and the Administrator both stated that floor nurses and nursing staff, including medication aides, were responsible for checking medication carts daily and ensuring there were no expired medications, indicating that this expected practice had not been followed for the insulin pen found on Station 2 medication cart #1.
Failure to Secure Resident Smoking Materials per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to secure smoking materials in accordance with its smoking policy, which requires all resident smoking materials to be kept in a secure area (medication cart) and accessible only with staff assistance. One resident, who was cognitively intact and assessed and care planned as a safe, independent smoker with a preference to smoke at times of his choice, was found in his room with a pack of cigarettes and a lighter tucked under his shirt against his stomach. The resident reported that he smoked and acknowledged having his smoking materials in his possession in his room. Staff interviews revealed that the resident was expected to turn in his smoking materials to staff after each smoking episode so they could be locked in the medication cart. Nursing staff, including a nurse, a nurse aide, and a medication aide, stated that the resident typically obtained his cigarettes and lighter from staff before going to the designated smoking area and returned them afterward, and that he was aware he was not allowed to keep them. The DON and Administrator both stated that residents deemed safe independent smokers could go to the smoking area whenever they wanted, and that staff were responsible for ensuring smoking materials were returned and secured. However, they acknowledged that the resident likely retained his smoking materials after returning from smoking because no staff member was present at the medication cart, resulting in unsecured smoking materials in the resident’s possession in his room and a failure to follow the facility’s smoking policy.
Improper Storage of Enteral Feeding Syringe
Penalty
Summary
A deficiency was identified when a plastic 60 cc syringe used for enteral feeding, medication, and water flushes for a resident with a gastrostomy tube was observed to be improperly stored. The syringe, after use, was rinsed and placed back into its original bag with the plunger still inside the barrel, and water droplets were visible inside the bag. This method of storage did not follow facility policy, which requires the barrel and plunger to be separated after rinsing to prevent bacterial growth. The resident involved had a history of dysphagia following a stroke and was severely cognitively impaired, requiring a gastrostomy tube for nutrition, hydration, and medication administration. Staff interviews confirmed that the nurse responsible for the syringe did not separate the components after use, despite being aware of the correct procedure. The facility's Infection Preventionist and Administrator both acknowledged that the syringe should have been stored with the barrel and plunger separated to prevent potential bacterial contamination.
Failure to Assess and Document Side Rail Use Prior to Implementation
Penalty
Summary
The facility failed to follow required procedures before the use of bilateral quarter length side rails for a resident with Alzheimer's disease and non-Alzheimer's dementia. The resident, who required partial to moderate assistance with bed mobility and was moderately cognitively impaired, was observed on two occasions with both side rails raised. There was no evidence in the resident's electronic medical record that alternative interventions were attempted prior to the use of side rails, nor was there documentation of a side rail assessment, entrapment risk evaluation, or a review of risks and benefits with the resident or their representative. Informed consent for the use of side rails was also not obtained. Interviews with facility staff revealed a lack of clarity regarding responsibility for completing side rail assessments. The nurse interviewed stated she did not perform side rail assessments and was unsure who was responsible. The DON indicated that assessments were only completed if side rails appeared necessary for positioning and mobility, and was unaware that alternatives needed to be attempted and documented. The Administrator confirmed that side rail assessments were not completed on admission or quarterly for the resident in question.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of two residents to self-administer medications before leaving their medications on the bedside table. Resident #25, who was cognitively intact, had several medications prescribed, including atorvastatin, gabapentin, metoprolol, sertraline, amoxicillin, and doxycycline. There was no documentation in the Electronic Medical Record (EMR) indicating that Resident #25 had been assessed for self-administration, nor was there a physician's order or care plan addressing this. On the morning of the observation, Nurse #3 left a medication cup with several pills on Resident #25's bedside table without supervision, leading to a confrontation when she attempted to retrieve the cup. Similarly, Resident #62, also cognitively intact, had multiple medications prescribed, such as amlodipine, aspirin, oxybutynin, empagliflozin, meloxicam, a multivitamin, omega-3, and metformin. Like Resident #25, there was no assessment, physician's order, or care plan for self-administration documented in the EMR. During an observation, a medication cup was found on Resident #62's bedside table, and Nurse #3 admitted to leaving it there due to being called away to another resident's room. Resident #62 mentioned that she preferred to take her medications with milk and that the medications were often left for her to take with breakfast. Interviews with the Director of Nursing (DON) confirmed that neither resident had been assessed for self-administration of medications, and it was acknowledged that medications should not have been left on the bedside tables. Nurse #3 admitted to the oversight in both cases, recognizing that she should have supervised the residents taking their medications instead of leaving them unattended.
Incomplete SNF ABN Forms for Two Residents
Penalty
Summary
The facility failed to provide a complete Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two residents prior to their discharge from Medicare Part A skilled services. For Resident #170, the SNF ABN was missing the section indicating the resident's decision to continue Medicare Part A services, although the resident's name, the date services were to end, the estimated cost of the services, and the resident's signature were present. The facility Social Worker acknowledged that Resident #170 did not choose an option and that this was not documented. Attempts to contact Resident #170 were unsuccessful, and the facility Administrator confirmed that the SNF ABN should have included the resident's decision. For Resident #7, the SNF ABN was incomplete as it lacked both the section for the decision about continuing Medicare Part A services and the resident's signature. The facility Social Worker admitted it was an oversight that Resident #7 did not choose an option or sign the form, and it was typically signed alongside the Notice of Medicare Non-Coverage. Resident #7 did not recall being presented with the ABN form. The facility Administrator confirmed that the SNF ABN should have been completed with the resident's decision and signature.
Failure to Secure Smoking Materials for Residents
Penalty
Summary
The facility failed to secure smoking materials for two residents who were identified as safe and independent smokers. Resident #23 was observed with a pack of cigarettes and two lighters on his bedside table, despite the facility's policy requiring smoking materials to be kept in a secure area accessible only by staff. Although Resident #23 was noted to be cognitively intact and had a care plan indicating he was a safe smoker, the presence of an oxygen concentrator in his room posed a potential hazard. Interviews with staff revealed that smoking materials should be locked in the medication cart, but Resident #23 admitted to keeping his lighters at his bedside, and staff were unaware of this practice. Similarly, Resident #106 was observed with a cigarette lighter attached to his bag during a Resident Council meeting, contrary to the facility's smoking policy. Although Resident #106 was also assessed as a safe and independent smoker, staff interviews indicated a lack of awareness regarding the lighter in his possession. The facility's policy required residents to return all smoking materials to staff after use, but Resident #106 stated he kept his lighter with him. The Director of Nursing confirmed that residents were not supposed to keep lighters, and the Administrator acknowledged the challenge of residents being resourceful in keeping smoking materials.
Failure to Prevent Catheter Bags from Touching the Floor
Penalty
Summary
The facility failed to prevent urinary catheter bags from touching the floor, which is a critical measure to reduce the risk of infection. This deficiency was observed in two residents, both of whom had urinary catheters. Resident #87, who was admitted with chronic kidney disease, benign prostatic hyperplasia, and urinary retention, was found with his catheter bag resting on the floor on multiple occasions. Despite being dependent on staff for all activities of daily living due to severely impaired cognition, the catheter bag was consistently observed touching the floor, indicating a lapse in proper catheter care. Similarly, Resident #91, who was admitted with chronic kidney disease, a urinary tract infection, and urinary retention, also had her catheter bag resting on the floor. Observations confirmed that the catheter bag was not properly positioned, and interviews with Nurse #3 revealed an acknowledgment that the bags should not touch the floor. The Director of Nursing also confirmed the expectation that catheter bags should be attached to the bed frame in a manner that prevents them from touching the floor, highlighting a failure in adherence to infection control protocols.
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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