Hibriten Mountain Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenoir, North Carolina.
- Location
- 2030 Harper Avenue Nw, Lenoir, North Carolina 28645
- CMS Provider Number
- 345329
- Inspections on file
- 30
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Hibriten Mountain Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found systemic failures in controlled substance management, including a case where oxycodone doses were signed out for a resident after the resident had been sent to the hospital, with no corresponding MAR documentation and an unreadable second signature. In addition, two residents did not have their prescribed oxycodone available, leading multiple nurses and a Unit Manager to repeatedly borrow oxycodone from other residents’ supplies over several days, despite the absence of a borrowing policy and without consistent DON notification or documentation of replacement. Monthly pharmacy audits over several months documented missing nurse signatures on shift‑change counts, discrepancies between controlled substance records and MARs for opioids and lorazepam, incorrect card counts, early PRN administrations, and wasting without a second nurse witness, while facility leadership reported being unaware of these specific controlled substance issues and did not fully reconcile or act on the audit findings.
A resident who was cognitively intact had a personal bottle of calcium carbonate (Tums) in her room, brought in by family so she could take it for heartburn as needed, despite having no physician order for the medication and no documented self-administration assessment. Surveyors observed the bottle, partially full, on the bed and over-bed table when the resident was not present. A nurse reported she was unaware the medication was in the room, confirmed there was no self-administration order, and stated the resident sometimes became lethargic due to her medications. The DON also confirmed there was no order for the antacid or for self-administration, indicating the resident had unsupervised access to a medication without clinical evaluation or authorization.
Surveyors found that the facility failed to ensure DNR and advance directive information was accurately completed and consistent across records for three residents. One resident had a DNR order and EMR banner indicating DNR, but no corresponding DNR form in the code status notebook that staff rely on during emergencies. Another resident had a DNR physician order in the EMR while the care plan and a physician progress note documented Full Code, and there was no code status documentation in the notebook. A third resident had hospital and facility physician documentation indicating DNR, while the MOST and advance directive discussion forms signed by the responsible party indicated CPR and lacked a physician signature; these forms were placed in the code notebook instead of the physician’s folder for review, creating conflicting code status information.
A resident was admitted with a completed Level I PASRR that instructed the facility to resubmit for a Level II PASRR if a new mental health diagnosis or significant change in condition occurred. After admission, the resident exhibited a history of hallucinations, paranoia, and prior aggressive behavior in the hospital, was treated with multiple antipsychotics and anti-anxiety medications, and was later diagnosed in the facility with paranoid schizophrenia. The MDS reflected schizophrenia and psychotropic use but still indicated only a Level I PASRR. Although the MDS Coordinator recognized the new diagnosis and reported it to a former SW, neither the MDS Coordinator nor the SW had access to submit Level II PASRR requests, and the Assistant Business Office Manager reported never receiving a referral request. No Level II PASRR evaluation was requested for the resident despite the documented new mental health diagnosis and the Administrator’s understanding that such referrals should be made when new mental health diagnoses are identified.
A resident with dementia, Parkinson's disease, DM, bowel and bladder incontinence, and multiple ADL dependencies had only a single nutrition-focused care plan entry despite MDS and CAA findings identifying needs in cognition, self-care and mobility, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer risk, and psychotropic drug use. The MDS Coordinator confirmed that no other care plan areas were present, stated she had completed a comprehensive care plan, and attributed its absence to possible loss during recent computer upgrades, while acknowledging the requirement to complete a comprehensive care plan within 21 days of admission.
A resident admitted with urinary retention had an indwelling urinary catheter documented on the MDS and supported by physician orders for catheter maintenance, including catheter and bag changes, catheter care every shift, use of a stat lock, and placement checks every shift, with daily catheter care recorded on Treatment Administration Records. Despite this, the comprehensive care plan did not include any mention of the urinary catheter. The MDS Coordinator acknowledged the omission and attributed it to issues during an electronic medical record upgrade, while the Administrator stated that care plans are expected to accurately reflect each resident’s clinical condition, medications, and care needs.
A resident with dementia, Parkinson’s disease, DM, and arthritis, who required extensive assistance with ADLs and was at risk for pressure ulcers, did not receive appropriate foot care or podiatry services. The care plan addressed only nutritional issues, and weekly nursing assessments did not document the resident’s increasingly long, thick toenails. The resident was never placed on the podiatry schedule and had not been seen by a podiatrist since admission. During observations, the resident’s toenails were found to be thick, long, jagged, with discoloration of the great toenail, and both the resident and family reported the resident could not care for her own feet. A NA stated she had noticed the long toenails but did not remember reporting it, while the wound nurse and ADON acknowledged the resident had not been referred for podiatry despite her DM.
Surveyors found an open, undated box of DuoNeb inhalation solution on a medication cart, despite manufacturer instructions that vials be used within a set timeframe after opening the foil pouch. A nurse acknowledged that the box should be dated when opened and that unused vials should be discarded after a specified number of days. The DON reported that nurses are expected to check medication carts daily and ensure DuoNeb solutions are dated, with the nurse who opens the box responsible for dating it. The lack of dating on the opened DuoNeb box resulted in a deficiency related to proper labeling and storage of drugs and biologicals.
Staff failed to follow hand hygiene and Enhanced Barrier Precautions policies during suprapubic catheter care for a resident with an indwelling urinary catheter. An aide and a nurse entered the room, donned gloves from the PPE station, but did not wear gowns despite an EBP sign requiring gown and glove use for high-contact care. The aide removed a soiled dressing, changed gloves multiple times without performing hand hygiene between glove changes, and then cleaned the suprapubic site and catheter tubing. The nurse applied a new dressing and washed hands only after glove removal, later stating she had not noticed the EBP sign and did not believe her actions required a gown, while the aide acknowledged she should have worn a gown and performed hand hygiene.
A resident with scheduled and PRN oxycodone orders had two 30‑tablet cards of 5 mg oxycodone delivered from the pharmacy, with the delivery signed for by an RN who reported verifying both cards and then handing them to the nurse assigned to the resident’s medication cart. Review of the controlled drug count sheet for that cart showed no increase in the number of controlled medication cards during the relevant shift, and only one oxycodone card was ever documented on the count sheet. The DON later confirmed that 30 oxycodone tablets for this resident were unaccounted for and that, despite review of pharmacy delivery records and staff interviews, the missing card of controlled medication could not be located or explained.
Surveyors identified a medication error rate of 15.38% during observations, including multiple errors involving two residents. One resident with COPD and moderately impaired cognition was allowed to self-administer a nasal spray and two inhalers without instruction, resulting in extra sprays and puffs beyond ordered doses and no mouth rinse after a steroid inhaler as ordered. In a separate case, a resident with diabetes received Lispro insulin via a prefilled pen that the nurse dialed directly to the ordered dose without priming, contrary to manufacturer instructions requiring a 2-unit prime to expel air and confirm insulin flow. Both nurses later acknowledged they were aware of the correct procedures but failed to follow them.
A housekeeper at an LTC facility misappropriated approximately $4,000 from a resident's bank account by using the resident's debit card to set up a mobile payment account without permission. The resident, who was cognitively intact, discovered the unauthorized transactions after the BOM discussed his overdue bill. Despite reporting the incident to law enforcement, the case was closed due to insufficient evidence.
The facility failed to accurately code MDS assessments for two residents regarding bladder continence. One resident with a stage 4 pressure ulcer and a foley catheter was incorrectly marked as always incontinent, while another resident with paraplegia and a catheter was marked as always continent. Errors were due to unchecked system-generated answers.
A resident with severe cognitive impairment and wandering behaviors ingested wound cleanser, but the care plan was not updated to reflect the risk of ingesting non-food items. Despite the incident being discussed in an interdisciplinary team meeting, the MDS nurse responsible for care plan updates was unaware of the incident, and the care plan remained unchanged.
A medication error occurred when a resident was mistakenly given medications prescribed for another resident due to a distraction during medication pass. The resident, who was cognitively intact and had multiple diagnoses, did not experience adverse effects as the medications were weaker than his prescribed ones. The error was reported to the DON, NP, and MD, who determined it was not significant due to the lack of adverse outcomes.
A resident admitted with pneumonia and other conditions was using supplemental oxygen without a physician's order, and the facility failed to post required oxygen cautionary signage. Staff interviews revealed confusion about responsibilities for obtaining orders and posting signs.
A facility failed to report a misappropriation of a resident's property to the state agency within 24 hours and did not notify APS. The incident involved a resident's bank account being accessed by a former employee through a mobile payment app. The Business Office Manager discovered the issue and informed the Former Administrator, who delayed reporting to the state agency until after a police investigation concluded without charges. The Former Administrator did not report to APS, as the allegation was unsubstantiated based on the police's decision.
A resident with Fredrick's Ataxia fell off the bed during incontinence care due to inadequate assistance, while another resident with Alzheimer's ingested wound cleanser left unattended on a treatment cart. The facility failed to secure hazardous materials and ensure proper supervision, leading to these safety incidents.
A resident with a history of physical behaviors and moderate cognitive impairment did not have a comprehensive care plan addressing their need for 1 on 1 supervision. Despite ongoing supervision for nine weeks, the care plan was not updated to reflect this requirement. Interviews with facility staff, including the MDS Coordinator and DON, confirmed that the resident's behaviors and supervision needs should have been included in the care plan.
A resident admitted for respite services through Hospice was discharged from the facility without proper documentation or reason. Despite being informed of the resident's agitation and having medications sent to manage these behaviors, the facility did not administer the medications as ordered. The DON decided the facility could not provide care due to a lack of staff for one-on-one supervision, and the resident was sent to the hospital. Interviews revealed the resident's behaviors were easily redirected, and the interim Administrator was not fully informed of the situation.
A resident admitted for respite services was sent to the hospital due to agitation, and the facility refused to allow his return, citing inability to manage his care. Despite having orders to administer medications for his behaviors, the facility did not do so and insisted on discharging him. Interviews revealed a lack of communication and understanding of the resident's needs, leading to unnecessary hospitalization and transfer to another facility.
A resident with multiple health conditions did not receive timely incontinence care, resulting in her wetting through her brief and pants. The resident's care plan required peri-care every two hours, but due to the nurse aide's workload, the resident was not attended to until several hours later. The DON emphasized the expectation for regular checks and changes.
The facility failed to follow its Infection Control Policy for Enhanced Barrier Precautions during wound care for two residents. The Wound Nurse did not wear a gown, as required, despite the policy's guidelines for high-contact activities. PPE was not available for one resident, and although it was available for the other, the nurse forgot to don a gown. Interviews revealed the nurse was aware of the requirement but was nervous and forgot.
Systemic Failures in Controlled Substance Accountability and Availability
Penalty
Summary
The facility failed to maintain accurate control, accountability, and reconciliation of controlled substances for multiple residents over several months. One resident with a PRN order for oxycodone 30 mg was sent to the hospital after becoming unresponsive, hypotensive, and hypoxic. After the resident left the facility, two doses of this resident’s oxycodone were signed out on the controlled medication utilization record, including one dose documented by a nurse and another with an unreadable signature and time, even though the resident was no longer in the building. The resident’s MAR showed the last oxycodone dose administered earlier that afternoon, and there was no documentation supporting administration of the two later doses. The facility’s internal investigation could not determine who signed out the second dose, and the nurse identified as signing out at least one dose did not cooperate with inquiries. The facility also failed to ensure that physician‑ordered narcotic pain medications were available and properly supplied for two other residents, leading staff to repeatedly “borrow” controlled substances from other residents’ supplies. One resident with a scheduled oxycodone 15 mg order received doses documented on the MAR using another resident’s oxycodone 15 mg supply over several days, with at least 20 tablets signed out as borrowed by multiple nurses and the Unit Manager. Staff reported that it was common practice to borrow controlled medications when a resident’s supply ran out, often without notifying the DON, and they were unclear how borrowed medications were replaced or reimbursed. The DON acknowledged there was no policy for borrowing controlled substances, stated that nurses were not supposed to borrow medications, and could not produce records showing that the resident’s oxycodone had been reordered, delivered, or that the supplying resident had been reimbursed. Another resident with an order for oxycodone 10 mg PRN for pain had doses administered using two 5 mg tablets taken from a different resident’s oxycodone 5 mg supply, with documentation on that resident’s controlled substance accountability record indicating at least 12 tablets were borrowed by several nurses and the Unit Manager. The Unit Manager stated that the resident’s own oxycodone supply had been exhausted and that borrowing from another resident was common when medications ran out, despite the availability of a backup oxycodone 5 mg supply and without obtaining DON approval. The DON again reported no policy for borrowing controlled substances, was unaware of the frequency of borrowing, and could not provide documentation that the resident’s oxycodone had been reordered or that the supplying resident’s medication had been replaced. Over a five‑month period, monthly pharmacy storage audits conducted by the Consultant Pharmacist repeatedly identified systemic deficiencies in controlled substance management. These included missing nurse signatures on shift‑change controlled substance counts on multiple medication carts and halls, discrepancies between the number of doses signed out on controlled substance accountability records and the doses documented as administered on MARs for several residents receiving opioids and lorazepam, incorrect or unclear card counts, PRN controlled substances administered earlier than ordered intervals, and controlled substances wasted without a second nurse witness signature. The Consultant Pharmacist documented these findings on multiple monthly audit forms, noting ongoing issues with controlled substance documentation and reconciliation. The DON stated she was not aware of the specific controlled substance concerns cited in the audits, had not reviewed the monthly storage audit reports, did not perform full reconciliations of controlled substance records against MARs, and was unaware that nurses were wasting controlled substances without a second signature. The Administrator reported she was not aware of the audit‑identified controlled substance issues and stated that any such concerns should have been addressed by nursing leadership.
Failure to Assess and Authorize Resident Self-Administration of Antacid Medication
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident for the ability to self-administer medications and to ensure appropriate physician orders were in place. The resident was admitted on an unspecified date and had a quarterly MDS assessment indicating she was cognitively intact. Review of the resident’s physician orders showed no order for calcium carbonate (Tums), and review of the medical record revealed no self-administration assessment. Despite this, surveyors observed a bottle of Tums tablets, approximately one-quarter full, on the resident’s bed and later on her over-bed table when the resident was not present in the room. During an interview, the resident stated that her family had brought the Tums because she needed them when she had heartburn, that she did not take them often, but wanted to be able to take them when needed, and she could not recall when she last took them. A nurse later stated she was unaware the resident kept Tums in her room, confirmed there was no order for the resident to self-administer medications, and expressed that the resident would not be safe to self-administer due to periods of lethargy related to her medications. The DON also confirmed there was no order for the resident to self-administer and no existing order for an antacid for heartburn, demonstrating that the resident had unsupervised access to a medication without assessment or physician authorization.
Inconsistent and Incomplete DNR and Advance Directive Documentation
Penalty
Summary
The deficiency involves the facility’s failure to properly complete, maintain, and reconcile advance directive and DNR documentation for multiple residents. For one resident admitted with a physician order for Do Not Resuscitate (DNR), the EMR banner and physician orders reflected a DNR status, but there was no corresponding DNR form in the advanced directives notebook at the nurse’s station. Nursing staff reported that, in an emergency, they would rely on the EMR and the advanced directives notebook to determine code status. The DON confirmed that a DNR form should have been present in the notebook for this resident and stated that the Social Worker was responsible for completing advance directive forms at admission and auditing the notebook, but the prior Social Worker had left and it was unclear whether the family had been consulted or a DNR form completed. Another resident had conflicting code status information across the medical record. The EMR contained a physician order for DNR, but the resident’s care plan documented Full Code status, and a physician progress note also listed the advanced directive status as Full Code Blue. The quarterly MDS indicated this resident was cognitively intact. The code status notebook at the nursing desk contained no advanced directive information for this resident. The Administrator and DON both stated that advanced directive information should match throughout the record and that the Social Worker was responsible for initiating and auditing this paperwork, but the Social Worker had recently resigned. Staff interviews showed that nurses and the Unit Manager relied on either the EMR profile page or the code status notebook, depending on accessibility, and expected these sources to match. A third resident had discrepancies between hospital documentation, physician orders, and paper advance directive forms. The hospital discharge summary and a physician order in the facility EMR both indicated a DNR status, and a physician progress note documented “Do Not Attempt Resuscitation (DNR/no CPR).” However, the MOST form in the code book, signed by the resident’s Responsible Party (RP), indicated a preference for attempted CPR, and the Advanced Directive Discussion Document also indicated CPR. The MOST form lacked a physician signature. The resident, who had moderately impaired cognition per the admission MDS, stated that he and his RP had decided he would not want CPR. The Director of Sales and Marketing/admission Coordinator, who had been completing advance directive paperwork in the absence of a Social Worker, reported that the RP had chosen CPR on both forms and that she placed these documents in the code notebook rather than in the physician’s folder for review and signature. The DON verified that the physician’s DNR order did not match the paper forms in the code notebook and acknowledged the missing physician signature on the MOST form.
Failure to Initiate Level II PASRR After New Schizophrenia Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to submit a required Level II Preadmission Screening and Resident Review (PASRR) referral for a resident who developed and was documented with a new mental health diagnosis after admission. A Level I PASRR was completed prior to admission with instructions to resubmit paperwork for a Level II PASRR if a new mental health diagnosis was suspected or if there was a significant change in condition. The resident’s hospital discharge summary documented hallucinations, delusions, and treatment with multiple antipsychotic and anti-anxiety medications, but did not list a diagnosis of schizophrenia. Upon admission, the resident’s EMR showed no mental health diagnoses, and the admission MDS later reflected that the resident had schizophrenia and had received antipsychotics, anti-anxiety medications, and anticonvulsants during the look-back period, while still indicating only a Level I PASRR. Subsequent psychiatric evaluation documented that the resident had a history of military service, long-standing mental illness related to war experiences, hallucinations, paranoia, and an incident in the hospital where a nurse was physically injured. The psychiatric NP confirmed that the resident reported a history of paranoid schizophrenia and that this history was verified with a family member. The resident was diagnosed in the facility’s EMR with paranoid schizophrenia on a specific date, but there was no evidence in the record that a Level II PASRR referral was submitted following this new diagnosis, despite the prior Level I PASRR instructions and the resident’s mental health history and current psychotropic medication regimen. Interviews with facility staff revealed communication and process failures that contributed to the lack of a Level II PASRR referral. The MDS Coordinator stated she identified the paranoid schizophrenia diagnosis from a psychiatric note and reported it to the former social worker, who no longer worked at the facility, but could not recall when this occurred. The MDS Coordinator and the former social worker did not have access to submit Level II PASRR requests and were reliant on the Assistant Business Office Manager, who reported she had not received any information or request regarding this resident and typically received such information during morning clinical meetings. The Administrator acknowledged that a Level II PASRR should be completed upon admission of a resident with a mental health diagnosis or when a new mental health diagnosis or change in condition occurs, and stated that the resident should have had a Level II PASRR referral when the paranoid schizophrenia diagnosis was added, but could not explain why the referral was not submitted.
Failure to Maintain Comprehensive Person-Centered Care Plan After Admission
Penalty
Summary
Surveyors identified that the facility failed to develop an individualized, person-centered comprehensive care plan for one resident. The resident was admitted with dementia, Parkinson's disease, DM, hypertension, and arthritis, and the admission MDS showed moderately impaired cognition, need for supervision or assistance with eating, bed mobility, oral hygiene, toileting, transfers, bathing, and dressing, as well as bowel and bladder incontinence. The MDS also documented that the resident was on a therapeutic diet, at risk for pressure ulcer development with no current wounds, had no pain or weight loss, had received antipsychotic, antianxiety, and hypoglycemic medications, and was planning to discharge back to the community. Review of the resident’s comprehensive care plan showed only one entry, developed by the RD, addressing potential nutritional problems, with no other care areas included despite multiple triggered CAAs. The CAAs completed by the MDS Coordinator identified needs in cognitive loss/dementia, functional abilities for self-care and mobility, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer injury, and psychotropic drug use, but these were not reflected in the written care plan. During interview, the MDS Coordinator confirmed that the only care plan entry present was for nutrition, stated she remembered completing the comprehensive care plan, and acknowledged awareness that a comprehensive care plan must be developed within 21 days of admission. She reported that there had been two recent computer upgrades and thought something may have happened to the resident’s care plan during those updates. The Administrator stated she expected all residents to have an accurate and complete comprehensive care plan reflecting their clinical condition, medications, and care needs.
Failure to Include Indwelling Urinary Catheter in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing an indwelling urinary catheter for one resident, as required to be completed within 7 days of the comprehensive assessment and prepared by an interdisciplinary team. The resident was admitted with urinary retention and had an indwelling urinary catheter documented on the admission MDS assessment. Physician orders dated 06/23/25 directed that the urinary catheter be maintained with catheter changes as needed, catheter bag changes as needed, catheter care every shift and as needed, placement of a stat lock to secure the catheter, and verification of catheter placement every shift. Treatment Administration Records for June and July 2025 showed the resident had a urinary catheter and received daily catheter care. However, review of the comprehensive care plan dated 07/03/25 revealed no mention of the urinary catheter. During an interview, the MDS Coordinator acknowledged that the urinary catheter was not included on the care plan and stated that at the time of the resident’s admission the facility was undergoing a company change and electronic medical record upgrade, and it was possible the system did not accept her care plan input. The Administrator stated she expected all residents to have an accurate and complete comprehensive care plan reflecting their clinical condition, medications, and care needs.
Failure to Provide Foot Care and Arrange Podiatry for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a resident with dementia, Parkinson’s disease, and diabetes mellitus. On admission, the nursing assessment did not note any toenail issues, and the admission MDS documented moderately impaired cognition, need for assistance with mobility, toileting, transfers, bathing, and dressing, as well as diagnoses of Parkinson’s disease, dementia, DM, and arthritis, and risk for pressure ulcer development. The resident’s care plan, developed by the RD, addressed only potential nutritional problems and did not include any other care areas. Weekly nursing assessments over several months contained no notation that the resident’s toenails were long, thick, or needed trimming. Review of the podiatry clinic schedule and EMR showed the resident was not scheduled for, nor seen by, a podiatrist since admission. During observations, surveyors noted the resident had thick, long, jagged toenails on both feet, with a brownish discoloration at the base of the left great toenail extending toward the middle of the nail. The resident stated her toenails looked “nasty,” that she could not bend down to care for her feet, and that her daughter had trimmed her toenails before admission. The wound nurse acknowledged she did not notice the resident’s toenails and had not requested that she be added to the podiatry list. The ADON stated the resident should be seen by a podiatrist because she was diabetic and confirmed that, although responsible for adding residents to the podiatry schedule in the absence of a Social Worker, she had not referred this resident since admission. A NA who frequently provided showers reported noticing that the resident’s toenails were very long and needed trimming but could not recall if she reported this to a nurse. The resident’s family member confirmed the resident had been unable to care for her feet for a long time and that she previously kept the toenails trimmed due to the resident’s diabetes.
Failure to Date Opened DuoNeb Inhalation Solution on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices involving DuoNeb inhalation solution on one of three medication carts reviewed (the C and D cart). Manufacturer guidelines for DuoNeb require that, after opening the foil pouch, individual vials be used within 14 days. During an observation of the C and D medication cart with a nurse, surveyors found an open, undated box of DuoNeb solutions stored in the cart drawer and available for use, with a delivery date on the box of 12/23/25. The nurse interviewed stated that the box should be dated when opened and that vials not used within 7 days should be discarded. In a separate interview, the DON stated that nurses are expected to check medication carts daily and that ensuring DuoNeb solutions are dated is part of those daily checks, and that the nurse who opens the box is expected to date it. This failure to date the opened box of DuoNeb solution, despite manufacturer instructions and facility expectations for daily cart checks and dating by the opening nurse, led to the cited deficiency in ensuring drugs and biologicals are labeled in accordance with accepted professional principles.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The deficiency involves failure to follow the facility’s Infection Control and Hand Hygiene policies during suprapubic catheter care for Resident #26. The facility’s Hand Hygiene policy required staff to perform hand hygiene before donning gloves and immediately after removing them, and the Enhanced Barrier Precautions (EBP) policy required use of gown and gloves for high-contact resident care activities, including providing hygiene to residents with indwelling urinary catheters. An EBP sign specifying the need for gown and gloves was posted on the resident’s door. During an observation of suprapubic catheter care, Nurse Aide #1 and Nurse #4 entered the resident’s room, removed gloves from the PPE tower, and applied gloves without donning gowns, despite the posted EBP sign. While providing suprapubic catheter care, Nurse Aide #1 removed a dirty dressing from the suprapubic site, then removed her dirty gloves and applied clean gloves without performing hand hygiene. She then cleaned the suprapubic site and catheter tubing, removed her dirty gloves again, and applied clean gloves without using hand sanitizer between glove changes. Nurse #4 applied a dressing to the suprapubic site, then removed her gloves and washed her hands. In interviews, Nurse Aide #1 acknowledged the resident was on enhanced barrier precautions, stated she should have worn a gown, and admitted she did not wash her hands between glove changes. Nurse #4 stated she did not initially know the resident’s precaution status, did not pay attention to the EBP sign on the door, and believed she had not performed any care that warranted wearing a gown. The DON confirmed that both staff should have worn gowns for EBP and that hand hygiene should have been performed between glove changes.
Unaccounted Controlled Medication Following Pharmacy Delivery
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s narcotic medications from misappropriation. A resident admitted on an unspecified date had physician orders for oxycodone 5 mg tablets, one tablet every 12 hours for pain, and an additional 5 mg oxycodone order every 6 hours as needed for breakthrough pain, which was later discontinued. Pharmacy records showed that two 30‑tablet cards (total 60 tablets) of 5 mg oxycodone immediate‑release were delivered for this resident on 09/04/25 at 10:38 PM, with the delivery receipt signed by a nurse (Nurse #3). The medications were supposed to be handled as controlled substances and documented on controlled drug count sheets kept with the medication cart. Nurse #3 reported that opioid or narcotic medications arrived in sealed purple bags and that the receiving nurse was responsible for verifying the medication and quantity before signing the delivery sheet. She verified that she signed for the resident’s oxycodone delivery on 09/04/25 and stated she distinctly remembered two 30‑tablet cards being delivered and that she verified the count and medication before signing. She further stated that after signing, she gave the resident’s oxycodone to the nurse assigned to the resident (Nurse #4) so that two separate controlled drug count sheets could be completed, one for each card. However, only one controlled drug count sheet was ultimately completed, and Nurse #3 stated she did not know what happened to the resident’s oxycodone and that it never made it to the medication cart as expected. Review of the controlled drug count sheet for the relevant medication cart from 08/31/25 through 09/06/25 showed that at the 3:00 PM shift change on 09/04/25 there were 41 cards of medications on the cart, verified by the oncoming nurse, Nurse #4. At 11:00 PM, Nurse #4 again signed that there were 41 cards, with no additions or subtractions documented during her shift, and the two oxycodone cards delivered for the resident on 09/04/25 were not added to the controlled drug count sheet. The DON later confirmed awareness that 30 oxycodone tablets were missing for this resident and that the discrepancy came to light when a nurse attempted to refill the oxycodone and the pharmacy reported it was too early because 60 tablets had already been delivered and at least 30 should still have been available. The DON reported that a search of the medication cart did not locate the additional card and that, despite interviews and review of records, it could not be determined whether the pharmacy failed to deliver both cards or whether one card went missing between pharmacy delivery and placement on the medication cart. The former Administrator similarly recalled that the investigation focused on the nurse assigned to the cart at the time but that the missing card of oxycodone could not be accounted for.
Medication Administration Errors and Failure to Follow Inhaler and Insulin Pen Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 4 errors out of 26 opportunities (15.38%) during medication administration observations. For one resident with COPD and moderately impaired cognition, physician orders included a daily fluticasone nasal spray, a twice-daily budesonide/glycopyrrolate/formoterol steroid inhaler with instructions to rinse the mouth after use, and albuterol inhaler four times daily. During a medication pass, a nurse handed the resident the nasal spray and two inhalers and allowed her to self-administer without providing instructions. The resident then administered two sprays of the nasal spray in each nostril and three puffs of albuterol, exceeding the ordered doses, and after using the steroid inhaler, the nurse did not instruct her to rinse her mouth with water as ordered. The nurse later acknowledged awareness that the resident had taken too many puffs of the nasal and albuterol inhalers and that the steroid inhaler required a post-use mouth rinse to prevent oral thrush but stated he did not think about it at the time. In a separate incident, another resident with diabetes mellitus had a physician order for 8 units of Lispro insulin subcutaneously before meals when blood sugar was between 301 and 350. During an observed insulin administration using a prefilled insulin pen, a nurse removed the Lispro pen from the medication cart, dialed the dose directly to 8 units, and administered the insulin without priming the pen as required by the manufacturer's instructions. The manufacturer’s directions specified priming the pen each time by dialing 2 units, pressing the injection button to expel air and confirm insulin flow, and checking for a drop of insulin at the needle tip, repeating if necessary. When questioned, the nurse stated she followed the five rights of medication administration but then acknowledged she was aware of the need to prime the pen and realized she had forgotten to perform this step. The consultant pharmacist and DON confirmed that residents should be instructed on inhaler use, including mouth rinsing after steroid inhalers, and that insulin pens must be primed to remove air and ensure full dosing.
Misappropriation of Resident's Funds by Housekeeper
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a housekeeper used the resident's debit card without permission. The housekeeper set up a mobile payment application account on his phone and transferred approximately $4,000 from the resident's bank account over several months. The resident, who was cognitively intact, was unaware of these transactions and only discovered the issue when the Business Office Manager (BOM) discussed his overdue bill with him. The resident had initially given his debit card to the housekeeper to purchase a drink from a vending machine, which was the only time he recalled the housekeeper having access to his card. Upon realizing his card was missing, the resident, with the help of the BOM, contacted the bank and discovered the unauthorized transactions. The BOM reviewed the bank records and identified the transactions linked to the housekeeper's mobile payment account, prompting a report to law enforcement. Despite the facility's efforts to report the crime and assist the resident, the police investigation did not result in charges due to insufficient evidence. The mobile payment application company claimed to have no record of the housekeeper's account, and the case was eventually closed. The resident expressed distress over the loss of his funds and the breach of trust by someone he relied on.
Removal Plan
- The Business Office Manager obtained bank statements for Resident #70 and identified unauthorized transfers by Housekeeper #1.
- The Business Office Manager, with consent from Resident #70, requested a direct deposit for Resident #70's Social Security checks into his RFMS account.
- Resident #70's Social Security checks were direct deposited into his resident trust account managed by the facility.
- The Executive Director reported the misappropriation of Resident #70's property to local law enforcement.
- The Executive Director filed the initial allegation to the State agency.
- Resident #70 was seen by the psychiatric nurse practitioner and continued to be followed by psychiatric services.
- Resident #70's liability with a total balance of $628 has been written off.
- The Business Office Manager audited the current Resident Financial Management System (RFMS) to ensure no unauthorized activity had occurred.
- The Business Office Manager reconciled the asset account to the resident trust fund liability account monthly.
- A Resident Trust fund statement is mailed to the patient and/or Guardian/Responsible Party quarterly.
- The Social Worker interviewed alert and oriented residents to ensure no employee had asked any resident for money or use of their debit, credit, EBT, and/or Ucard.
- The Executive Director and/or Director of Nursing re-educated current staff on the Abuse Policy with emphasis on misappropriation of resident property.
- Education included the use of a sign-out sheet for snacks and drinks purchases.
- Staff were educated to not accept debit cards from residents for vending machine purchases.
- The Executive Director verbally educated residents that the use of debit cards by staff is not allowed for vending machine purchases.
- Residents are made aware upon admission and throughout their stay of having the option to secure valuables.
- The Maintenance Director handles the request of a resident's need for a lock on their nightstand.
- All residents/responsible parties were offered a RMFS account upon admission.
- The Executive Director held an ADHOC Quality Assurance Performance Improvement meeting.
- The Executive Director and/or Director of Nursing to complete quality monitoring of five residents weekly for twelve weeks.
- The Business Office Manager reconciled the asset account to the resident trust fund liability account monthly.
- The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting monthly for 3 months.
- The Executive Director is responsible for overseeing the plan of correction.
Inaccurate MDS Coding for Bladder Continence
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents regarding bladder continence. Resident #74, who was admitted with a stage 4 pressure ulcer and had a foley catheter in place, was incorrectly marked as always incontinent of bladder on the MDS assessment. The MDS Coordinator acknowledged that the assessment should have been marked as 'Not Rated' due to the presence of the indwelling catheter. The error was attributed to the system-generated answers that were not properly checked. Similarly, Resident #35, who had paraplegia and neuromuscular dysfunction of the bladder, was also inaccurately coded. Despite having an indwelling catheter since before admission and throughout the lookback period, the resident was marked as always continent of bladder. MDS Nurse #1 admitted to missing the correction in the system-generated answers, which should have been marked as 'Not Rated'. The Director of Nursing confirmed that the resident's bladder continence should have been coded accurately to reflect her condition.
Failure to Update Care Plan After Resident Ingests Non-Food Item
Penalty
Summary
The facility failed to update a resident's care plan after an incident where the resident ingested wound cleanser. The resident, who was admitted with diagnoses including Alzheimer's disease, anxiety, major depressive disorder, and adult failure to thrive, was noted to have severe cognitive impairment and daily wandering behaviors. An incident report dated March 11, 2024, documented that the resident ingested an unknown amount of wound cleanser, and although the resident was assessed and monitored with no negative side effects observed, the care plan was not updated to address the potential for ingesting non-food items. Interviews with facility staff revealed a lack of communication and follow-through regarding the incident. MDS Nurse #1, who was responsible for updating care plans, was unaware of the incident and stated that such behavior should have been included in the care plan. MDS Nurse #2, who was the MDS nurse at the time of the incident, also reported being unaware of the incident and did not recall any discussion of it in the interdisciplinary team meeting. The Director of Nursing confirmed that the incident was discussed in a team meeting and that the care plan should have been updated immediately, but it was not. This oversight resulted in the resident's care plan not reflecting the risk of ingesting non-food items, despite the known wandering behaviors and cognitive impairment.
Medication Error Involving Incorrect Administration
Penalty
Summary
The facility failed to ensure the correct medications were administered to the correct resident, resulting in a medication error involving Resident #80. Resident #80, who was cognitively intact and had diagnoses including peripheral vascular disease, neuropathy, and necrotizing fasciitis, was mistakenly given Baclofen and Norco, medications prescribed for another resident, Resident #59. This error occurred during a medication pass by Nurse #2, who was distracted by another resident while preparing the medication. Upon realizing the mistake, Nurse #2 informed Resident #80 of the error and monitored his vital signs before contacting the on-call provider. The provider instructed Nurse #2 to continue monitoring Resident #80's level of consciousness and breathing. Resident #80 reported that the medication error did not significantly affect him, as the medications he received were weaker than his prescribed pain medication, and he did not experience any breakthrough pain. The Director of Nursing (DON) and the Nurse Practitioner (NP) were notified of the incident. Both the NP and the Medical Director (MD) assessed the situation and concluded that the medication error was not significant due to the lack of adverse effects on Resident #80. The DON confirmed that Nurse #2 followed the necessary steps after the error, including notifying the appropriate parties and monitoring the resident's condition.
Failure to Obtain Oxygen Order and Post Signage
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen for a resident who was admitted with diagnoses including left lower lobe pneumonia, sepsis, and pleural effusion. Despite the resident being cognitively intact and continuously using oxygen at 1.5 liters via nasal cannula since admission, there was no documented order for this treatment in the resident's medical record or Medication Administration Record (MAR) for several months. This oversight was confirmed during an interview with a nurse who regularly checked the resident's oxygen saturation but was unaware of the lack of a formal order. Additionally, the facility did not post the required oxygen cautionary signage on or near the resident's door, as observed on multiple occasions. Interviews with staff, including a nurse aide and the Director of Nursing (DON), revealed a lack of clarity regarding responsibility for posting such signage. The DON acknowledged that the nurse who initiated the oxygen should have obtained an order and posted the cautionary sign, and that department managers should ensure signage is in place during their rounds.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency within the required 24-hour timeframe and did not report the incident to Adult Protective Services (APS). The incident involved a resident who had money stolen from their bank account, with transactions traced to a former employee's mobile payment application account. The Business Office Manager (BOM) discovered the issue when the resident mentioned losing their debit card and needing assistance with the bank. Upon reviewing the bank statements, the BOM found multiple unauthorized transactions and informed the Former Administrator, who then filed a police report. The Former Administrator delayed submitting the initial allegation report to the state agency, waiting until the police investigation concluded without charges against the former employee. Consequently, the report was filed 20 days after the facility became aware of the issue, and no report was made to APS. The Former Administrator unsubstantiated the allegation of misappropriation based on the police's decision not to file charges, which contributed to the failure to report the incident to APS.
Safety Lapses Lead to Resident Incidents
Penalty
Summary
The facility failed to provide care in a safe manner when a dependent resident, identified as Resident #57, fell off the bed during incontinence care. Resident #57, who was admitted with Fredrick's Ataxia, required extensive assistance for bed mobility and personal hygiene. On the day of the incident, a nurse aide, NA #2, was providing incontinence care and rolled the resident onto her side. Despite keeping a hand on the resident's hip, the resident continued to roll off the bed and onto the floor. The resident reported ankle pain, and an x-ray was ordered, which showed no fracture. The nurse aide admitted to not reviewing the care plan, which indicated the need for assistance, and relied on the resident's statement that only one person was needed for care. Another incident involved Resident #8, who ingested an unknown amount of wound cleanser left unattended on a treatment cart. Resident #8, diagnosed with Alzheimer's disease and exhibiting wandering behaviors, accessed the wound cleanser from the cart. The ingestion was reported to the nurse, who assessed the resident and contacted poison control. The resident was monitored for adverse effects, but none were observed. The wound cleanser was routinely stored on top of the cart or in a side pocket, rather than being locked away, which allowed the resident to access it. Interviews with staff revealed that the wound cleanser was not typically secured, and the Director of Nursing acknowledged that it should have been locked away. The facility's failure to secure hazardous materials and ensure adequate supervision during care led to these incidents, highlighting lapses in safety protocols and staff adherence to care plans.
Failure to Develop Comprehensive Care Plan for Resident with Behavioral Needs
Penalty
Summary
The facility failed to develop a comprehensive, individualized, and person-centered care plan for a resident with a history of physical behaviors. The resident, who was admitted with diagnoses including cerebral infarction, anxiety disorders, metabolic encephalopathy, and vascular dementia, was observed to have moderate cognitive impairment. Despite the need for 1 on 1 supervision due to physical behaviors towards other residents and staff, the care plan did not address these behaviors. Nursing Assistant #4 reported providing 1 on 1 supervision for the resident for approximately nine weeks, yet the care plan, last reviewed on December 6, 2024, did not reflect this need. Interviews with the MDS Coordinator and the Director of Nursing revealed that the resident's need for 1 on 1 supervision and history of behaviors should have been included in the care plan. The MDS Coordinator acknowledged that changes in a resident's condition, such as the need for 1 on 1 care, should have been discussed and care planned during morning meetings. The Director of Nursing confirmed awareness of the resident's behaviors and the ongoing supervision since July 2024, indicating that the care plan should have been updated to reflect these needs. The Administrator also expected all care plans to be completed accurately, highlighting a lapse in the facility's care planning process.
Failure to Administer Medications and Improper Discharge of Resident
Penalty
Summary
The facility failed to allow a resident with behaviors to remain in the facility and did not provide written documentation stating the reason they could not meet the resident's needs. The resident, admitted for respite services through Hospice, exhibited agitation and attempted to get up from his wheelchair unassisted. Despite being informed of the resident's behaviors and having medications sent with him to manage these behaviors, the facility did not administer the medications as ordered by Hospice. The Director of Nursing (DON) communicated with the Hospice nurse about the resident's agitation and received verbal orders to administer medications to calm the resident. However, the medications were not administered, and the facility decided they could not provide care for the resident, citing a lack of staff for one-on-one supervision. The DON informed the on-call Hospice nurse that the resident could not stay at the facility, and the resident was subsequently sent to the hospital. Interviews with the Hospice nurse, on-call Hospice nurse, and Hospital Nurse Practitioner revealed that the resident's behaviors were easily redirected and that the facility was aware of the resident's needs prior to admission. The interim Administrator was not fully informed of the situation, including the availability of medications to manage the resident's agitation. The failure to administer the prescribed medications and the decision to discharge the resident without adequate documentation or reason led to the deficiency.
Facility Fails to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. The resident, admitted for respite services through Hospice, was sent to the hospital due to agitation and behaviors that the facility claimed they could not manage. Despite having orders to administer medications to address the resident's agitation, the facility did not administer these medications and instead decided to discharge the resident to the hospital without attempting to manage the behaviors as per the orders. The Director of Nursing (DON) and the interim Administrator were involved in the decision to not allow the resident to return, citing the facility's inability to provide the necessary care. The DON did not administer the prescribed medications and did not allow the Hospice nurse to do so either. The resident was described as being easily redirected and not aggressive, yet the facility insisted on sending him to the hospital and refused his return, even after the hospital confirmed that the resident was stable and could be managed with the prescribed medications. Interviews with various staff members, including the Hospice nurse, hospital nurse practitioner, and facility nurses, revealed a lack of communication and understanding of the resident's needs and the available resources to manage his care. The facility's decision to not allow the resident to return was made without fully utilizing the prescribed interventions or considering the hospital's assessment that the resident was stable and manageable. This resulted in the resident spending unnecessary time in the hospital and being transferred to another facility the following day.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident, resulting in the resident wetting through her brief and pants. Resident #4, who has a history of cerebral vascular accident, hypertension, diabetes mellitus type II, congestive heart failure, and muscle weakness, was observed on 05/31/24 at 11:17 AM being assisted to the bathroom by two nurse aides. The resident's brief was found to be saturated with urine and had stool smears, indicating a lack of timely care. The resident's care plan required peri-care every two hours and as needed to prevent skin breakdown and infection, but this was not adhered to. During an interview, NA #4, who was responsible for Resident #4's care during the 7:00 AM to 3:00 PM shift, admitted to not having rounded on the resident until 11:17 AM due to being busy. The Director of Nursing stated that it was expected for all residents to be checked every two hours and changed as needed, and if NA #4 was busy, she should have sought assistance from other staff members. The failure to provide timely incontinence care was attributed to NA #4's workload and the resident being left without care for an extended period.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to its Infection Control Policy for Enhanced Barrier Precautions (EBP) during wound care for two residents. The Wound Nurse did not wear a gown while providing wound care to these residents, despite the policy requiring gown and glove use during high-contact activities such as wound care. The facility's policy, last updated in August 2022, mandates the use of EBPs to prevent the spread of multi-drug resistant organisms, especially for residents with wounds or indwelling medical devices. During observations, it was noted that personal protective equipment (PPE) was not available at the door or in a bin outside the room of one resident, and although PPE was available for the other resident, the Wound Nurse still failed to don a gown. Interviews with the Wound Nurse and the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed that the Wound Nurse was aware of the requirement but forgot to wear a gown due to nervousness. The ADON/IP acknowledged the oversight and indicated that additional education would be provided to the Wound Nurse.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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