Highfield Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Cary, North Carolina.
- Location
- 6590 Tryon Road, Cary, North Carolina 27518
- CMS Provider Number
- 345403
- Inspections on file
- 31
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Highfield Nursing And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident who regularly used a specific shower room reported seeing black mold-like buildup on the shower walls and ceiling for several months. Surveyors observed broken and loose floor and wall tiles, black-colored buildup on tiles and grout, and a large discolored ceiling ring with black spotting in that shower room. A nurse aide admitted knowing about the buildup but not reporting it, and the maintenance log contained no entries about these issues. The Maintenance Director acknowledged knowing about loose tiles for at least two months and described the ceiling discoloration as likely from a leak, while attributing mold or mildew on tiles to housekeeping. Housekeeping staff gave conflicting accounts about who was responsible for cleaning the shower, with the assigned housekeeper stating she had not cleaned it for about six months due to physical limitations and that others were supposed to do it, and the Housekeeping Supervisor stating he was unaware of the ceiling spot despite performing periodic deep cleaning.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring gown and gloves during high-contact care for a resident with a PEG tube. An EBP sign on the resident’s door directed staff to wear gloves and a gown for activities such as bathing and device care, but two nurse aides provided a bed bath with only one wearing gloves and neither wearing a gown, despite acknowledging awareness of the posted precautions. The DON, acting as Infection Preventionist, and the Administrator confirmed that the aides had been trained on EBP and should have worn the required PPE for this care activity.
Two cognitively impaired residents were not protected from abuse in a facility. One resident, who returned inebriated from an outing, was found twice in another resident's room, with the second incident involving inappropriate contact. Another resident with aggressive behavior was seen pulling her roommate's hair. Staff intervened and contacted the police, but the incidents highlight a deficiency in safeguarding residents.
A resident in an LTC facility reported unsanitary conditions in a shared bathroom, which was not adequately cleaned by staff. Despite the resident's complaints and observations of fecal matter on various surfaces, the bathroom remained unclean throughout the day. Staff interviews revealed a lack of clarity regarding cleaning responsibilities, contributing to the deficiency.
A resident with a documented dislike for potatoes was repeatedly served them, despite the issue being reported to the dietary department and kitchen staff. The facility failed to ensure a system was in place to prevent serving food items that residents preferred not to have, affecting multiple residents.
A resident did not receive a beverage with her lunch meal as per her preference, despite being cognitively intact and having a regular diet order. The resident had to drink water from her bedside instead of the preferred tea. The Dietary Manager confirmed that tea should have been served, and staff reported ongoing issues with meal tray accuracy.
A resident with a history of dementia, diabetes, and heart failure exhibited signs of dehydration and was unable to provide a urine sample, yet the facility failed to notify the physician. Despite symptoms of burning urination and decreased fluid intake, staff continued administering Lasix without consulting the physician. The resident's condition worsened, leading to septic shock and death after being transferred to the hospital.
A resident with a history of dementia, diabetes, and heart failure experienced a significant change in condition, including decreased intake and altered mental status. Despite orders for a urinalysis and urine culture, staff failed to collect the specimen and continued administering diuretics, worsening the resident's dehydration. The resident's condition deteriorated, leading to a delayed hospital transfer where he was found in septic shock and later died. The facility's failure to act promptly on the resident's condition resulted in a deficiency.
A resident with a history of congestive heart failure and chronic kidney disease, admitted for rehabilitation, exhibited signs of dehydration while on Lasix. Despite decreased fluid intake and unsuccessful attempts to collect urine, staff continued administering Lasix without notifying a physician or addressing the dehydration. The resident's condition worsened, leading to hospital transfer and subsequent death from septic shock and dehydration.
A facility failed to accurately code the MDS assessment for a resident regarding hypnotics medication. The resident, diagnosed with dementia, was incorrectly coded as having taken hypnotics, despite MARs showing no such orders. The DON confirmed the absence of hypnotic orders, and the MDS nurse admitted to a data entry error. The Administrator expected accurate MDS assessments.
A resident's call bell system was found non-functional as it was not plugged into the wall panel, despite being tied around the bedrail. The resident, who was moderately cognitively impaired and incontinent, was unable to signal for assistance. Staff interviews revealed that the call bell should have been within reach and operational, but the oversight was not noticed until a nurse rectified the issue.
A resident's Oxycodone medication was misappropriated by a nurse, who admitted to taking the medication and inventory sheet. The incident was reported to the Board of Nursing and police, and the facility initiated corrective actions.
Two residents were not provided with necessary bathing services due to a shortage of washcloths and towels, leading to feelings of anger, frustration, and embarrassment. Despite being aware of the supply issue, the facility's staff, including the DON and Administrator, failed to ensure that residents received their required care. This deficiency affected the residents' dignity and respect, as they were unable to receive baths on their scheduled days.
A facility failed to provide adequate bathing care for three residents due to a shortage of towels and washcloths. One resident, who required substantial assistance, reported missing baths multiple times a week. Another resident, needing maximum assistance, did not receive scheduled showers or bed baths. A third resident, with severe cognitive impairment, also missed baths. Staff confirmed the daily shortage of supplies, impacting care delivery. The DON and Administrator were unaware of the issue's extent.
A long-term care facility failed to maintain an adequate supply of washcloths and towels, affecting resident care. Multiple residents reported missing baths due to the shortage, and staff confirmed the issue, often resorting to makeshift solutions. The Housekeeping Director noted a significant shortfall in inventory, and both the DON and Administrator were aware but had not resolved the problem.
A facility failed to protect a resident's PHI by leaving a medication cart unattended with the MAR exposed on a computer screen. A nurse left the cart twice, allowing staff and family to view the resident's PHI. The nurse acknowledged the oversight, and the administrator confirmed that PHI should not be accessible in plain view.
A resident with cognitive impairment reported inappropriate touching by a male NA during care. Despite the report to staff, the allegation was not immediately escalated to the Administrator as required by policy. The NA continued working with the resident for days, and the Administrator only learned of the incident when APS intervened, indicating a failure in communication and policy adherence.
A facility failed to create a baseline care plan for a resident with multiple diagnoses, including a recent leg amputation. The resident was admitted and discharged without a documented care plan in the electronic medical record. Although a paper care plan was filled out, it was unsigned by staff or the resident. The DON noted the absence of a consistent system for care plan preparation and no monitoring for compliance.
A resident's care plan was not updated after the quarterly assessment due to the social worker's workload and lack of assistance. Despite being cognitively intact, the resident was unaware of any care plan review meetings since January. Facility staff acknowledged the delay, attributing it to prioritization of urgent matters and a changeover in the social worker position.
Failure to Maintain Clean, Intact Shower Room Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike shower environment, specifically in the 100/200 shower room. A cognitively intact resident, as coded on a quarterly MDS, reported receiving showers in this room several times per week and stated she had observed what she described as black mold and filth on the walls and ceiling for at least three months, dating back to after her admission. She had not reported these concerns to facility staff. Surveyor observation of the 100/200 shower room confirmed broken and loose 1-inch floor tiles under the shower head, broken 6-inch wall tiles along the base of the wall, black-colored buildup on the tile walls and grout, and black-colored buildup on the tile floor and grout. A large tan ring with black spotting, approximately 2–3 feet in diameter, was also observed on the ceiling. Staff interviews revealed awareness of the conditions but a lack of reporting and follow-through. A nurse aide acknowledged she was aware of the black-colored buildup on the shower floors and walls but had not reported it to anyone and did not provide a reason for not reporting. The maintenance log covering several months contained no entries regarding loose or broken tiles or buildup on the shower floor or walls. The Maintenance Director stated he had observed the loose tiles since starting work at the facility at least two months earlier and had heard about the loose and broken tiles by word of mouth, but he could not recall who informed him or when. He described the loose tiles as large sections with visible old mortar underneath and identified the ceiling ring as likely caused by a leak, while stating that black and pink areas on the tiles were mold or mildew and the responsibility of housekeeping rather than maintenance. Housekeeping staff interviews further demonstrated gaps in cleaning and oversight of the shower room. The Housekeeping Assistant Supervisor initially thought the black and pink buildup on the tiles and grout was shower grime, then stated it looked like mold and grime upon closer inspection, and acknowledged the area did not look clean. She stated the shower room was supposed to be cleaned daily by a designated housekeeper and had last been cleaned the day before the survey observation, but also noted that housekeeping could not address the ceiling discoloration due to its height and that maintenance would need to handle it. The assigned housekeeper later reported she had not been cleaning the 100/200 shower room for about six months due to being physically unable to clean it and said the task had been shifted to other housekeepers and the Housekeeping Assistant Supervisor. She stated there had been mold all over the tile when she saw the shower the previous day and that the discolored ceiling spot had been present for her entire nearly two-year employment, and she claimed to have previously informed prior maintenance workers about the ceiling and loose tiles. The Housekeeping Supervisor stated he had not been aware of the ceiling spot, had not been notified, and did not look up when in the room, and although he reported deep cleaning the floors weekly and cleaning ceiling vents near the area, he had not noticed the discolored ring on the ceiling. The Administrator stated that housekeepers and maintenance workers should keep the shower room clean and in good repair.
Failure to Follow Enhanced Barrier Precautions During Bathing of PEG Tube Resident
Penalty
Summary
A deficiency occurred when staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) requirements for personal protective equipment (PPE) while providing care to a resident with a PEG tube. The facility’s EBP policy, revised 11/13/25, specified that gown and gloves must be used for high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and device care or use of a PEG tube. An EBP sign posted outside the resident’s room directed that everyone must clean their hands before entering and when leaving, and that providers and staff must wear gloves and a gown for high-contact activities such as bathing and PEG tube care. During an observation, two nurse aides were seen in the resident’s room providing a bed bath without adhering to the required PPE. Neither aide was wearing a gown, and only one aide was wearing gloves, despite both acknowledging awareness of the EBP sign on the door. One aide stated she typically only wore a gown when working with the resident’s external urine collection device, though she recognized that bathing was a task requiring EBP and that gowns should have been worn. The other aide agreed that gowns and gloves were required for bathing this resident. The DON, who also served as the Infection Preventionist, and the Administrator both confirmed in interviews that the aides should have followed the EBP sign and worn at least gloves and a gown prior to bathing the resident, and that staff had received EBP training during orientation and annual competency training.
Failure to Protect Cognitively Impaired Residents from Abuse
Penalty
Summary
The facility failed to protect two cognitively impaired residents from abuse. On the evening of February 6, 2025, a resident returned from an outing and was observed to be inebriated. This resident was later found in the room of another cognitively impaired resident, who was unable to consent to his presence. Despite being removed once, he was found a second time in the same resident's room with the privacy curtain pulled. Staff witnessed him with his hand under the resident's leg, and her brief was unfastened, exposing part of her private area. The resident was saying 'No, no, no' during the incident. Another incident involved a resident with a history of aggressive behavior who was observed standing over her cognitively impaired roommate and pulling her hair, causing the roommate to scream and cry. The facility's failure to prevent these incidents of abuse indicates a deficiency in protecting residents from harm. The staff's observations and the subsequent police involvement highlight the severity of the situation. The facility's records and staff interviews revealed that the inebriated resident had never been reported for inappropriate behavior before this incident. However, the staff's immediate response to the situation, including contacting the police and removing the resident, was noted. The facility's investigative file included statements from staff and a photograph taken as evidence, which was provided to the police. Despite these actions, the incidents demonstrate a failure to ensure the safety and protection of vulnerable residents.
Removal Plan
- Resident #2 was removed from Resident #1's room and placed on 1:1 supervision.
- Police were contacted and Resident #2 was arrested and formally discharged from the facility.
- Resident #1 was monitored for psycho-social needs with no concerns identified.
- Resident #1 was relocated to a private room.
- The Medical Director was notified.
- Both residents' Responsible Parties were notified.
- A physical exam and skin assessment were conducted for Resident #1 following the adverse event.
- Resident #1 was sent to the hospital emergency department for an additional exam.
- Adult Protective Services (APS) was contacted.
- Allegation of abuse was submitted to North Carolina Division of Healthcare Service Regulation (NCDHSR).
- Nursing managers completed skin assessments and abuse questionnaires for residents.
- Abuse and neglect education was provided to staff.
- A Resident Council meeting was held to ensure residents understood sexual abuse and to report any allegations.
- Signage was posted in all common areas as a reminder to report abuse.
- Facility Administrator and Director of Nursing re-educated staff on Abuse/Neglect policy and procedures.
- Existing staff not present during initial training were required to undergo abuse and neglect training.
- Social Worker will interview five residents weekly to inquire about abuse.
- Skin audits will be conducted for randomly selected residents.
- Results of audits/interviews will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee.
- An Ad hoc QAPI meeting was conducted to review the event and conduct a root cause analysis.
- The Administrator will report monitoring results to the QAPI committee for ongoing compliance.
Failure to Maintain Clean Shared Bathroom
Penalty
Summary
The facility failed to provide adequate housekeeping services to ensure a clean and safe bathroom environment for Resident #5, who shared a bathroom with two other residents. Resident #5, who was cognitively intact and continent, expressed concerns about the cleanliness of the shared bathroom, particularly after another resident with confusion and adaptive needs used it. This resident often left fecal matter on various surfaces, and Resident #5 reported difficulty in getting staff to clean the bathroom promptly, leading him to clean it himself on one occasion. Observations made with Resident #5 revealed unsanitary conditions, including brownish black matter on the toilet, walls, and adaptive equipment, as well as trash behind the toilet. Despite housekeeping being informed, the bathroom remained unclean throughout the day. The Director of Nursing (DON) acknowledged the issue and planned to report it to the housekeeping supervisor. Interviews with staff, including Nurse #6 and NA #10, indicated a lack of clarity regarding responsibilities for cleaning fecal matter, with NA #10 not realizing it was her duty to clean obvious signs of feces before alerting housekeeping. The Housekeeping Director and Housekeeper #1 confirmed that the bathroom should have been cleaned more thoroughly and frequently, especially given the known issues with the other resident's bathroom habits. Housekeeper #1 admitted to not cleaning the walls or adaptive equipment during his morning cleaning and did not return to clean again that day. The Housekeeping Director noted that there was no communication about the need for more frequent checks and cleaning of Resident #5's bathroom, highlighting a breakdown in communication and responsibility between housekeeping and nursing staff.
Failure to Respect Resident Food Preferences
Penalty
Summary
The facility failed to ensure a system was in place to prevent serving food items that a resident preferred not to have. Specifically, Resident #4, who was cognitively intact, had a documented dislike for potatoes, which was noted on her dietary tray card. Despite this, she was repeatedly served potatoes, which she reported made her nauseated. The issue was known to the dietary department, as well as the nurse aides, who had communicated the problem to the kitchen staff. Interviews with staff revealed that the dietary manager was aware of at least one instance where potatoes were served to Resident #4, and nurse aides confirmed that the issue had been reported multiple times. Additionally, it was observed that other residents also received items on their trays that they were not supposed to be served according to their tray cards. The facility's administrator acknowledged that there should be a person responsible for checking tray cards and trays to ensure residents' food preferences are respected.
Failure to Provide Beverage per Resident Preference
Penalty
Summary
The facility failed to provide a resident with a beverage according to her preferences during a lunch meal. The resident, who was cognitively intact and admitted after a hip fracture, was observed to have completed her lunch without any drink on her tray. She expressed that she would have preferred tea with her meal, but only had water from a Styrofoam cup at her bedside, which she drank with her meal. This incident was confirmed by Nurse #5, who validated that no beverage was served with the resident's lunch. Further investigation revealed that the dietary menu indicated tea should have been served with the lunch trays. The Dietary Manager confirmed that food items and beverages are listed on tray cards, which include residents' preferences. Interviews with two Nurse Aides working on the resident's hall indicated ongoing issues with meal tray items not matching the tray cards. The Administrator acknowledged that there should be a person checking the tray cards against the trays to ensure accuracy before serving them to residents.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who exhibited signs and symptoms of dehydration and was unable to provide a urine sample on multiple occasions. The resident, who had a history of dementia, type 2 diabetes, chronic kidney disease, and congestive heart failure, was experiencing decreased nutritional and fluid intake, and complained of burning urination. Despite these symptoms, the nursing staff continued to administer Lasix, a diuretic, without consulting the physician, which likely exacerbated the resident's dehydration. The nursing staff made several unsuccessful attempts to collect a urine sample via an in and out catheter, but did not notify the physician of these failures or the resident's deteriorating condition. The resident's condition worsened, leading to altered mental status, tachypnea, poor perfusion, hypothermia, and severe lactic acidosis, consistent with septic shock. The resident was eventually transferred to the emergency room at the request of a family member, where he was found to be critically ill and later died. Interviews with the nursing staff revealed a lack of communication and failure to follow protocols for notifying the physician of significant changes in the resident's condition. The staff did not recognize the severity of the resident's symptoms or the potential impact of continued Lasix administration without adequate fluid intake. This deficiency in care and communication contributed to the resident's rapid decline and eventual death.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- A quality review of current residents with an order for UA/C&S were audited by the Director of Clinical Services and Unit Managers to ensure urine sample was obtained.
- Residents identified as having a physician order to administer diuretics were audited by the Director of Nursing and Unit Managers to ensure no signs and symptoms of dehydration as evidenced by the inability to collect urine.
- A root cause analysis was completed by the Director of Clinical Services and the Executive Director regarding notifying the physician for Resident #294 when staff were unable to obtain a urine sample.
- The Director of Clinical Services and Nurse Managers re-educated licensed nurses on notifying physician for residents identified as having a change in condition via Situation, Background, Assessment and Recommendation (SBAR) as it relates to assessing residents with signs and symptoms of dehydration.
- The Director of Nursing and Unit Managers re-educated licensed nurses on recognizing signs and symptoms of dehydration to ensure prompt physician notification for change in condition.
- Staff (licensed nurses/ Certified Nurse Assistants) not educated will be educated by the Director of Nursing and or Unit Manager prior to working the floor.
- Newly hired staff will be educated during orientation by the Director or Nursing or Unit Manager on notifying physician for residents identified as having a change in condition via SBAR as it relates to assessing residents with signs and symptoms of dehydration.
- The Director of Clinical Services and Nurse Managers re-educated licensed nurses on notifying physician via change in condition (SBAR) for residents with an order for UA/C&S and unable to obtain urine sample.
- The Director of Clinical Services and Nurse Managers re-educated certified nursing assistants on signs and symptoms of dehydration and immediately report the change in condition to the licensed nurse.
- Newly hired staff will be educated during orientation by the Director of Clinical Service and or Unit Managers.
- Staff (licensed nurses/ Certified Nurse Assistance) not educated will be educated by the Director of Nursing and or Unit Manager prior to working the floor.
Failure to Recognize and Respond to Resident's Change in Condition
Penalty
Summary
The facility staff failed to recognize the seriousness of a significant change in condition for a resident, leading to a deficiency in providing appropriate treatment and care. The resident, who had a history of dementia, type 2 diabetes, chronic kidney disease, and congestive heart failure, experienced a sudden decrease in food and fluid intake, and reported burning with urination. Despite obtaining an order for a urinalysis and urine culture, the staff made no successful attempts to collect the urine specimen over several days. The resident continued to receive diuretics despite decreased intake, leading to further deterioration in his condition. The resident's condition worsened over several days, with staff noting minimal urine output, incontinence, and the need for assistance with feeding. Despite these signs, the staff did not take urgent action to address the resident's dehydration and altered mental status. When a Physician Assistant evaluated the resident, they noted clinical dehydration and ordered intravenous fluids, but the nurse was unable to insert a peripheral line due to dehydration and did not contact the vascular team promptly. The resident's family member eventually requested hospital transfer, but by the time emergency services arrived, the resident was critically ill with signs of septic shock. The resident was transferred to the emergency department, where he was found to be in a critical state with severe lactic acidosis, hypothermia, and poor perfusion, consistent with septic shock. Despite efforts to sustain his life, the resident died shortly after arrival at the hospital. The facility's failure to recognize and respond to the resident's significant change in condition and to obtain necessary medical attention in a timely manner resulted in this deficiency.
Failure to Address Dehydration in Resident on Diuretics
Penalty
Summary
The facility failed to recognize and appropriately respond to signs and symptoms of dehydration in a resident who was receiving a diuretic, Lasix, and had decreased fluid intake. The resident, who had a history of congestive heart failure, chronic kidney disease, and other conditions, was admitted for rehabilitation therapy. Despite being identified with decreased nutritional and fluid intake, the staff continued to administer Lasix without addressing the resident's hydration needs. The resident exhibited signs of dehydration, such as the inability to collect urine via catheter, but the staff did not take adequate measures to address these symptoms. Nursing staff documented the resident's poor oral intake and attempted to push fluids, but the resident consumed less than 25% of meals and drinks. Multiple attempts to collect a urine sample were unsuccessful due to insufficient urine output, yet the staff continued to administer Lasix. The resident's condition deteriorated, showing signs of altered mental status and dehydration, but the staff did not notify the physician or take appropriate action to address the emergent situation. The situation escalated when the resident's family member requested hospital transfer due to the resident's worsening condition. Upon arrival at the emergency room, the resident was diagnosed with severe dehydration, septic shock, and other critical conditions, leading to the resident's death. The facility's failure to recognize and respond to the resident's dehydration and continued administration of Lasix without adequate fluid intake contributed to the adverse outcome.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Conduct a quality review of current residents with an order for UA/C&S to ensure a urine sample was obtained.
- Audit residents with a physician order to administer diuretics to ensure no signs and symptoms of dehydration.
- Assess current residents to include obtaining vital signs, observation of dry cracked lips, poor skin turgor, and altered mental status, and chart review to ensure no other residents exhibited signs and symptoms of dehydration.
- Complete a root cause analysis regarding staff failure to recognize the signs and symptoms of dehydration and provide necessary medical services.
- Re-educate all licensed nurses on how to recognize signs and symptoms of dehydration, assess the resident, observe, and chart review to include medications, and notify the physician to obtain necessary medical services.
- Re-educate certified nursing assistants on signs and symptoms of dehydration and immediately report the change in condition to the licensed nurse.
- Ensure staff not educated will be educated by the Director of Nursing and/or Unit Manager prior to working the floor.
- Educate newly hired staff during orientation by the Director of Clinical Services and/or Unit Managers.
Inaccurate MDS Coding for Hypnotics Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of hypnotics medication. The resident, who was admitted with a diagnosis of dementia, was coded as severely cognitively impaired and as having taken hypnotics during the look-back period on the annual MDS. However, a review of the Medication Administration Records (MAR) for August and September 2024 showed no orders for hypnotics. The Director of Nursing (DON) confirmed that there had been no hypnotic orders for the resident as far back as April 2024, indicating a coding error. The MDS nurse admitted to a data entry error, acknowledging that the resident was not receiving hypnotics during that time. The Administrator expressed an expectation for accurate MDS assessments.
Call Bell System Not Properly Connected for Resident
Penalty
Summary
The facility failed to ensure that a call bell system was properly connected and functional for a resident, identified as Resident #6, who was moderately cognitively impaired and always incontinent with bowel and bladder. During an observation and interview, it was found that the call bell wire was tied around the bedrail and not plugged into the wall panel, rendering it non-functional. When Resident #6 attempted to use the call bell, the light outside the room did not activate, indicating the system was not operational. Nurse #7 discovered the issue and rectified it by untangling the wires and plugging the call bell into the outlet. Interviews with staff revealed that the call bell should have been within reach and operational at all times. Nurse #7 mentioned that she had checked on the resident an hour prior, and NA #4 was providing care to another resident in the room. NA #4 stated that she usually ensured call bells were within reach and plugged in but did not notice the issue before leaving the room. The Director of Nursing confirmed that staff are trained to ensure call bells are accessible and functional before exiting a resident's room.
Misappropriation of Controlled Medication
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medication. Resident #5, who had diagnoses of vascular dementia, hemiplegia, and osteoarthritis, was prescribed Oxycodone for pain management. Despite receiving a shipment of 30 tablets of Oxycodone on July 12, 2024, there was no documentation of the medication being administered to the resident after that date. On July 18, 2024, Nurse #1 discovered that the entire card of 30 Oxycodone tablets and the corresponding inventory sheet were missing from the medication cart. Nurse #1, who worked the night shift, confirmed the presence of the medication during her shift change with Nurse #6. However, after Nurse #6's shift, the medication was found missing. Nurse #1 immediately reported the missing medication to the evening shift supervisor, Nurse #3, and they conducted a search but could not locate the Oxycodone. The Director of Nursing (DON) was informed, and instructions were given to notify the morning shift supervisors to contact the pharmacy and Nurse #6. Upon further investigation, Nurse #6 admitted to taking the Oxycodone and the inventory sheet. She communicated her actions to the Board of Nursing and was contacted by the police. The DON confirmed the incident was reported to the relevant authorities, including the state health department, the board of nursing, and the police. The facility initiated an immediate corrective action plan following the incident.
Failure to Provide Bathing Services Due to Supply Shortage
Penalty
Summary
The facility failed to treat two residents with dignity and respect by not providing them with necessary bathing services due to a shortage of essential supplies such as washcloths and towels. Resident #1, who was cognitively intact and required assistance with activities of daily living, including bathing, expressed anger and frustration when she was unable to receive a bath on two consecutive days. Similarly, Resident #2, who also required substantial assistance with bathing, reported feeling uncomfortable and embarrassed due to the lack of bathing services on her scheduled shower day and the following day. Both residents were affected by the facility's ongoing issue of running out of necessary supplies, which had been occurring for the past 2 to 3 months. Interviews with nursing assistants and other staff members revealed that the shortage of towels and washcloths was a known issue, and staff had to wait for supplies to become available before they could provide bathing services. Nursing Assistant #5 confirmed that she had informed the Director of Nursing about the shortage a month prior, but the problem persisted. The Director of Nursing and the Administrator were both aware of the supply shortage but were not informed that residents were missing their baths. This lack of communication and resource management led to the residents' needs not being met, resulting in feelings of anger, frustration, and embarrassment among the residents.
Deficiency in Bathing Care Due to Supply Shortage
Penalty
Summary
The facility failed to provide adequate bathing care for three dependent residents, resulting in a deficiency in activities of daily living (ADL) care. Resident #1, who was cognitively intact and required substantial assistance with bathing, reported not receiving a bath on multiple occasions due to a lack of clean towels and washcloths. Staff interviews confirmed that the shortage of these supplies was a recurring issue, causing residents to miss baths several days a week. Similarly, Resident #2, who required maximum assistance with bathing, did not receive a shower or bed bath on scheduled days due to the same supply shortage. Resident #12, who was severely cognitively impaired and required moderate assistance with bathing, also did not receive a bath due to the unavailability of towels and washcloths. Staff interviews revealed that the shortage of these essential supplies was a daily occurrence, impacting the ability to provide proper care. The Director of Nursing and the Administrator were unaware of the extent of the issue, although they acknowledged that residents should receive daily baths or showers unless they refuse.
Inadequate Supply of Washcloths and Towels in LTC Facility
Penalty
Summary
The facility failed to provide effective leadership and implement systems to ensure an adequate supply of washcloths and towels for resident care. This deficiency was identified through record reviews and interviews with residents and staff. Multiple residents reported not receiving baths or showers due to the lack of clean towels and washcloths. Staff interviews corroborated these reports, indicating that the shortage was a persistent issue, with some residents missing baths 3 to 4 days a week. Staff members resorted to using disposable wipes or makeshift solutions like wetting paper towels to provide basic care. Nurse aides and nurses consistently reported the shortage of washcloths and towels, noting that clean linens were often unavailable until late morning. The Housekeeping Director, who was an outside contractor, confirmed the shortage and stated that the facility had only about 100 washcloths available, far below the recommended inventory level. The Director of Nursing (DON) and the Administrator were aware of the issue, with the DON noting that disposable wipes had previously been used but were discontinued due to plumbing issues. The Administrator acknowledged the shortage and was working with the Housekeeping Director to establish a proper inventory level. The deficiency affected the facility's ability to provide adequate care, as staff were unable to perform essential hygiene tasks for residents. The shortage of washcloths and towels was attributed to several factors, including the disposal of soiled washcloths, staff hoarding, and insufficient inventory management. Despite being aware of the problem, the facility had not yet resolved the issue, leading to ongoing challenges in maintaining resident hygiene and care.
Failure to Safeguard Resident PHI
Penalty
Summary
The facility failed to safeguard protected health information (PHI) for one resident by leaving confidential PHI unattended and exposed in an area accessible to the public. This deficiency was observed when a nurse left a medication cart on the 200 Hall with the Medication Administration Record (MAR) displayed on the computer screen, showing the name, picture, and other PHI of a resident. The nurse walked away from the cart, leaving the screen exposed to staff and family members passing by. This incident occurred twice within a short period, with the nurse acknowledging the oversight and stating that he had been trained not to leave resident PHI visible to others. The facility administrator confirmed that all residents' confidential PHI should be protected and not accessible in plain view.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse immediately to the Administrator, as required by their policy, for a resident who was moderately cognitively impaired and dependent on staff for certain activities. The resident reported being touched inappropriately by a male nursing assistant during incontinence care. Despite the resident's report to two staff members, the allegation was not escalated to the Administrator in a timely manner. The nursing assistant involved reported the allegation to a nurse and later to the social worker, but neither took immediate action to report the incident to the Administrator. The nurse did not consider the incident as abuse and failed to report it, while the social worker delayed reporting the allegation until Adult Protective Services intervened. This lack of immediate reporting was a direct violation of the facility's policy, which mandates reporting such allegations within two hours. The facility's failure to adhere to its abuse reporting policy resulted in the nursing assistant continuing to work with the resident for several days after the allegation was made. The Administrator only became aware of the situation when Adult Protective Services arrived at the facility, highlighting a significant breakdown in communication and policy enforcement among the staff.
Failure to Create and Document Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan with the resident or responsible party for a resident upon admission. The resident, who had multiple diagnoses including acquired absence of the right leg below the knee, type 2 diabetes mellitus, peripheral vascular disease, rheumatoid arthritis, and lymphedema, was admitted and later discharged without a documented baseline care plan in the electronic medical record. Although a paper copy of a baseline care plan was filled out with the resident's care needs, it was unsigned by facility staff, the resident, or a resident representative. The resident reported that no one discussed his plan of care with him or his wife during his stay. The Director of Nursing (DON) explained that prior to her full-time appointment in March, the facility lacked a consistent system for preparing baseline care plans, resulting in incomplete documentation and failure to upload paper documents into the electronic record system. At the time of the incident, the facility did not have a performance improvement plan or monitoring in place to ensure compliance with baseline care plan completion.
Failure to Update Resident Care Plan After Quarterly Assessment
Penalty
Summary
The facility failed to update the care plan for a resident after the quarterly assessment, as required. The resident, who was admitted with diagnoses including diabetes, muscle weakness, and a right below the knee amputation, was found to have a care plan that had not been updated since January 25, 2024. Despite being cognitively intact, the resident was unaware of any care plan review meetings since that date. The MDS assessment for the resident was last updated on April 28, 2024, but no subsequent care plan review meeting was held. Interviews with facility staff revealed that the social worker, responsible for planning care plan review meetings, had not conducted these meetings regularly due to a lack of assistance and prioritization of more urgent matters. Both the MDS nurse and the Director of Nursing acknowledged that care plan meetings should occur quarterly and were aware that the reviews were behind schedule. The facility's administrator also confirmed the delay in care plan meetings, attributing it to the social worker's workload and a recent changeover in the position.
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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