Highland House Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, North Carolina.
- Location
- 1700 Pamalee Drive, Fayetteville, North Carolina 28301
- CMS Provider Number
- 345353
- Inspections on file
- 30
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Highland House Rehabilitation And Healthcare during CMS and state inspections, most recent first.
The facility failed to protect residents from misappropriation of property when a nurse assumed control of a narcotic cart and, after a documented count of 103 Oxycodone tablets for a resident, the resident’s Oxycodone and associated narcotic sheets were later found missing, and when an Activities Assistant took and used the healthcare spending cards of two cognitively intact residents without their knowledge or consent. The Activities Assistant accessed cards that residents kept in their personal belongings, used them for in‑store purchases, and later claimed the residents had given permission and received cash back, which both residents denied. The Activities Director reported that the Activities Assistant had been facilitating online shopping with residents’ cards and that cards were supposed to be used only with the resident present, but the residents’ statements and transaction records showed unauthorized use of their benefits for the staff member’s personal purchases.
A resident with diabetes, glaucoma, and moderate cognitive impairment was referred to an outpatient ophthalmologist for bilateral eye burning and was ordered Refresh Tears QID and PRN Tylenol. A transport requisition was completed and a contracted Transportation Aide took the resident to the eye clinic, but clinic staff reported the resident could not be seen without someone accompanying him. After the facility informed the Transportation Aide that no one would accompany the resident, the appointment was not completed, and the resident experienced a medical emergency at the clinic and was sent to the ED. Facility records showed no evidence that the missed ophthalmology appointment was ever rescheduled, and the staff member responsible for tracking appointments had no record of any upcoming eye visit for this resident, despite leadership expectations that missed specialty appointments be rescheduled.
A resident with type 2 DM, severe cognitive impairment, and an unstageable sacral pressure ulcer was admitted with a documented sacral wound dressing in place, but no wound measurements were taken and no wound care orders or treatments were documented for the first four days after admission. Review of the TAR and medical record showed that wound care orders were not entered until several days later, at which point daily cleansing and topical treatments were initiated and then revised. Interviews with the former wound nurse, corporate nurse consultant, medical director, and wound PA confirmed there was no documentation that staff implemented wound care orders or contacted a provider or wound care company for orders during the initial gap, despite standing orders requiring MD or wound specialist direction for Stage 3 and 4 pressure injuries.
The facility failed to accurately code MDS assessments for three residents in the areas of falls and restraints. Two residents with neurological and mobility-related diagnoses had multiple documented falls without injury shortly after admission, yet their admission or discharge MDS assessments were coded as having no falls or inaccurately reflected the number and type of falls. A third cognitively impaired resident with no physician orders for restraints was incorrectly coded on a quarterly MDS as having a trunk restraint used less than daily, despite staff stating that no restraints were used. The MDS Coordinator acknowledged these errors as incorrect coding or oversight, while leadership stated they expected MDS assessments to be accurate and timely.
Surveyors found that two resident bathrooms on one hall were not maintained in a safe, clean, and homelike condition. In one shared bathroom, there was a strong urine odor, wet flooring near the toilet, visibly aged and discolored VCT tiles, and an uneven patch of cut tiles, while the door frame paint was peeling to bare metal. A resident reported disliking the persistent odor, and staff acknowledged noticing wet, foul-smelling floors but did not report the issue, despite awareness that a broken toilet flange caused water to back up and wet the floor. In another bathroom, the floor was extensively discolored, scuffed, and unwaxed, and door frames had peeling paint exposing metal; a resident stated the appearance made her feel bad and that she had previously raised the concern with the Administrator. Housekeeping and maintenance staff confirmed that discoloration could not be resolved by cleaning and that water sometimes seeped up through tiles when stepped on.
The facility failed to follow its smoking policy requiring all smoking materials to be secured in a lock box when not in use. A cognitively intact resident with a history of stroke, hemiplegia, vascular dementia, and anxiety, who required assistance with several ADLs and was coded for tobacco use, was observed in a day room with a lighter and cigarettes concealed in his clothing. One nurse reported not providing the materials and being unfamiliar with the smoking policy on that hall, while another nurse admitted knowing the resident did not turn in his lighter and that residents were allowed to smoke at any time, making supervision difficult. The Administrator stated that cigarettes were to be kept locked and lighters confiscated after smoking, but acknowledged that residents had been allowed to decide when to turn in their lighters, and some kept them due to frequent smoking.
A resident with a stroke diagnosis and moderately impaired cognition was not provided with showers as per her preference and care plan, receiving bed baths instead. Despite being able to communicate her desire for showers through head nods, staff documentation showed 'NO' or 'N/A' for scheduled shower days. Interviews revealed a lack of communication and coordination among staff, leading to the failure to honor the resident's preference.
A resident with chronic obstructive pulmonary disease reported an error on his facility trust fund account, where over $600 was taken without notification. Despite notifying the business office in April, no grievance was completed, and the issue remained unresolved. The Business Office Manager acknowledged the billing error but did not inform the Administrator or complete the necessary documentation. The Administrator only learned of the issue months later.
A resident with Parkinson's disease was incorrectly documented as having a feeding tube in the MDS assessment due to human error by the Assistant Dietary Manager. Interviews with staff confirmed the resident never had a feeding tube, highlighting a failure in accurate coding.
A facility failed to submit a PASRR application for a resident diagnosed with bipolar II disorder, despite a significant change in mental health status. The oversight was confirmed through record reviews and staff interviews, revealing that the Social Worker responsible for PASRR submissions did not submit a new application following the diagnosis.
A resident with a diagnosis of adult failure to thrive did not receive adequate nail care as per their care plan, resulting in long, uneven, and dirty nails. Despite being able to communicate her needs, the resident's request for nail care was not addressed by the facility staff, who were responsible for this task if not completed by hospice staff. The facility administrator was unaware of the resident's need for nail care, indicating a communication gap and failure to adhere to the care plan.
A resident was incorrectly charged for a full month's PML for skilled nursing care, despite only receiving care for two days. The error was identified in April, but the facility failed to correct it or reimburse the resident by December. The Business Office Manager and Administrator were unaware of the issue's extent until December, and DSS staff confirmed the billing should have been prorated.
Misappropriation of Narcotic Medication and Healthcare Spending Cards by Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their property, including a controlled substance and healthcare spending cards. For one resident receiving Oxycodone 10 mg every 4 hours as needed for pain, the contracted pharmacy documented delivery of 180 tablets, but the packing slip was not signed by a receiving nurse. A nurse working the day shift reported that at the end of her shift she counted 103 Oxycodone tablets for this resident on the narcotic cart with another nurse who presented herself as the oncoming agency nurse, took the keys, and assumed control of the cart. The following morning, another nurse reported that the resident had no Oxycodone available. Statements indicated that when the night nurse later counted narcotics with the next nurse, all narcotic counts and sheets matched what was called out, but there were no medications or narcotic sheets for this resident. The Quality Assurance nurse reported that the nurse who had taken over the cart was not actually scheduled to work that shift, had previously worked as an agency nurse, and left within about an hour of assuming the cart, after which the Oxycodone tablets and narcotic sheets for this resident were discovered missing. The deficiency also includes misappropriation of healthcare spending cards belonging to two cognitively intact residents by an Activities Assistant. One resident reported that her healthcare spending card, which she kept in a wallet in the bottom drawer of her nightstand, was missing and could not be located when staff searched her room. The resident’s insurance provider confirmed that the card had been used at a local retail store for a transaction of $95.00. The Activities Assistant stated that the resident had given her permission to take and use the card to purchase items for the resident and claimed she returned the card and cash, explaining that about $50.00 represented her portion of the items purchased. The resident denied giving permission for the Activities Assistant to take or use the card, denied knowing the Activities Assistant had possession of the card, and denied receiving any cash. The resident reported that the Activities Assistant later told her the purchases were made because the Activities Assistant’s children were hungry, and the resident expressed disappointment and concern that a similar incident could occur again. During the investigation of this first misappropriation, the facility identified a second cognitively intact resident whose healthcare spending card had also been used without permission. This resident had previously reported her card as misplaced to the Activities Assistant, who assisted her in canceling the card and ordering a replacement. Transaction records showed that the card had been used for multiple in-store purchases totaling $337.01, both before and after it was identified as missing. The resident stated she never made any in-store purchases with the card and that her last use of the card was for an online purchase with the help of the Activities Assistant. She reported being upset and believed the Activities Assistant should be held accountable for using her card without permission. The Activities Director confirmed that the Activities Assistant facilitated online shopping for residents using a tablet and that healthcare spending cards were supposed to be used only when the resident was present during the transaction. The Activities Director also reported that the Activities Assistant later claimed to have gone to a store after hours for one resident with alleged permission to use the card, while the resident denied granting such permission. The Administrator stated that her expectation was that all staff follow the facility’s policy related to misappropriation of resident property. The facility’s abuse policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s money or belongings and affirmed residents’ right to be free from misappropriation of their property. Despite this policy, the events described show that a resident’s narcotic pain medication and two residents’ healthcare spending cards were wrongfully taken or used without their knowledge or consent, constituting misappropriation of resident property.
Failure to Reschedule Missed Ophthalmology Appointment After Unaccompanied Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident obtained ordered ophthalmology services after a missed appointment. The resident had diagnoses including type 2 diabetes, glaucoma, and coronary artery disease, and a physician progress note documented bilateral eye burning. On the following day, the physician ordered a referral to an outpatient ophthalmologist, along with Refresh Tears ophthalmic solution four times daily for dry eyes and PRN Tylenol for pain. A quarterly MDS showed the resident had moderate cognitive impairment, was coded as having adequate vision without corrective lenses, and was coded as not having pain or receiving pain interventions. A transport requisition was completed for an eye appointment at an outpatient office, and the contracted Transportation Aide reported picking up the resident and signing him in for the appointment. Shortly after leaving, the outpatient office called the Transportation Aide to report that the resident could not be seen without someone accompanying him. The Transportation Aide called the facility and was told there was no one available to accompany the resident. When the Transportation Aide returned to the outpatient office, she learned the resident was having a medical emergency and had been transported by ambulance to the ED. Later that day, she picked the resident up from the ED and returned him to the facility. Record review showed no evidence that the missed ophthalmology appointment was ever rescheduled. The Medical Supplies Personnel, who maintained a calendar and transportation requisition forms, had no record of any upcoming eye appointment for the resident. The MARs indicated the ordered eye drops were administered four times daily and PRN Tylenol was given once for a reported pain level of 4/10, with all other documented pain assessments at 0. Attempts to interview the resident about his vision and eye appointments were unsuccessful. The Unit Manager confirmed the resident did not receive ophthalmology services on the day of the missed appointment and stated she had called the eye clinic and was waiting for a call back to reschedule, but there was no documentation of a new appointment. The Medical Director and Administrator both stated their expectations that specialty referrals and any missed appointments be scheduled or rescheduled so residents receive needed medical services, which did not occur in this case.
Failure to Initiate Timely Wound Care for Admitted Resident With Sacral Pressure Ulcer
Penalty
Summary
Facility staff failed to initiate and document pressure ulcer treatment for a newly admitted resident with a known sacral pressure injury for four days following admission. The resident was admitted with type 2 diabetes, severe cognitive impairment, dependence on staff for hygiene, mobility, and transfers, and an unstageable sacral pressure ulcer documented as present on admission. The admission MDS and skin assessment identified the sacral pressure ulcer and noted a clean, dry dressing, but the skin assessment did not include wound measurements. Review of the medical record and Treatment Administration Record (TAR) showed no wound care orders or documented sacral wound treatment on the four days immediately following admission. On a later date, a wound care order was entered on the TAR for daily cleansing of the sacrum and application of medical grade honey for a Stage 3 pressure injury, and this order was then discontinued and replaced the same day with a new order for cleansing, Santyl, and quarter-strength antimicrobial-moistened gauze for an unstageable pressure injury. Interviews with the former Wound Treatment Nurse, Corporate Nurse Consultant, Medical Director, and Wound PA confirmed there was no evidence that wound care orders had been implemented or that staff had contacted a provider or the wound care company for wound treatment orders during the four-day gap after admission, despite standing orders that required MD or wound specialist orders for Stage 3 and 4 wounds. The Wound PA noted that weekly wound evaluations began only after the initial wound consult, and there was no documentation that facility staff had reached out to the consulting company prior to that evaluation.
Inaccurate MDS Coding for Falls and Restraints
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for falls and restraints for three residents. One resident with epilepsy experienced multiple documented falls over several days, including being found on the floor on his buttocks, lying on his side on a fall mat, sliding from a wheelchair to the ground, and being observed on the floor beside his wheelchair, all with no injury noted. Despite these documented events, his discharge MDS indicated no falls with no injury, one fall with injury, and no falls with major injury. The MDS Coordinator, who completed this assessment, acknowledged awareness of the resident’s multiple falls and confirmed that the discharge MDS was incorrectly coded for falls, though she was unsure how the error occurred. The Administrator stated she expected all MDS assessments to be accurate and timely. Another resident admitted with cerebrovascular accident and muscle weakness had two documented falls on the same day, both witnessed and without injury, one from attempting to get out of bed and another from trying to get out of a chair. However, the admission MDS for this resident indicated there had been no falls since admission. The MDS Coordinator, who completed this assessment, confirmed the MDS was incorrectly coded for falls and could not explain how the error occurred. A third resident, admitted with cerebral infarction and vascular dementia and with no physician orders for physical restraints, was coded on a quarterly MDS as having a trunk restraint used less than daily. The MDS Coordinator stated that this resident did not have a restraint and that there were no restraints used in the facility, characterizing the restraint coding as an oversight. The Regional Nurse Consultant and the Administrator both stated their expectation that MDS assessments be coded correctly.
Failure to Maintain Clean, Odor-Free, and Well-Maintained Resident Bathrooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain two resident bathrooms and associated door frames in good repair and to ensure one bathroom was free of urine odor on one hall, affecting three cognitively intact residents. Surveyors observed that the shared bathroom for two residents had a very strong urine odor detectable upon entering the room, with cream VCT flooring that was grayish, aged, scuffed, scratched, and lacking finish or wax. The floor near the toilet base was wet, and a corner of the bathroom floor had three cut tile pieces placed on top of the original floor, creating an uneven, non‑smooth surface that was not easily cleanable. One resident in this room, who was incontinent and did not use the bathroom, reported that he could smell the odor from his bed and did not like it, and he had not reported it because he believed anyone entering the room could smell it. The other resident using the toilet independently did not provide details about the duration or his feelings about the bathroom condition. Staff interviews confirmed awareness of the bathroom’s condition and odor. A nursing assistant stated that the resident who used the toilet did so all the time and that she had noticed the floor to be wet at times with a bad smell, but she did not report it because she believed anyone entering the room could see and smell the problem. The housekeeper assigned to the hall reported finding water on the floor and an odor in the shared bathroom and stated that the Housekeeping Supervisor was aware. The Housekeeping Supervisor later reported that water would sometimes seep up through the bathroom floor tiles in this bathroom when someone stepped on the floor. The Regional Maintenance Manager stated that the toilet flange in this bathroom was broken, causing water to back up and wet the floor when the toilet was flushed, and acknowledged that it should have been fixed. A separate bathroom used by another cognitively intact resident on the same hall was also found to be in poor condition. Surveyors observed that this bathroom’s cream VCT floor had black and gray discoloration over most of the surface, appeared aged, scuffed, scratched, and lacked finish or wax, and that the lower portions of the bathroom door frames on both sides had peeling paint exposing brown metal. The resident reported using the bathroom but stated she did not like how it looked, that it made her feel bad, and that she sometimes tried to clean it herself to improve its appearance. She also reported having discussed the bathroom condition with the Administrator months earlier and was told the facility would try to wax and buff the floor to improve it. The Housekeeping Supervisor stated that attempts to clean and treat the floors in both this bathroom and the shared bathroom had not resolved the discoloration and that the floors required replacement, and he indicated the door frames would be repainted when the bathroom floors were fixed. The Administrator acknowledged being aware of the bathroom floor discoloration and environmental issues on the hall since several months prior, based on her rounds.
Failure to Secure Resident Smoking Materials per Facility Policy
Penalty
Summary
The facility failed to secure smoking materials in accordance with its smoking policy, which required all resident smoking materials to be maintained in a secure lock box at the nurses' station when not in use. A cognitively intact resident with a history of cerebral infarction with resulting hemiplegia, hemiparesis, aphasia, dysphagia, vascular dementia with mood disturbance, and anxiety was observed sitting in a day room with a lighter and two cigarettes concealed in the bottom of his shirt. His MDS indicated he required assistance with several ADLs and was coded for tobacco use. A smoking evaluation documented that he was considered an independent, safe smoker whose preference to smoke independently at times of his choice was honored. During interviews, one nurse stated she had not provided the resident with smoking materials and did not know where the cigarettes or lighter came from, and also reported she was unfamiliar with the smoking policy because it was her first time working on that hall. Another nurse, who regularly worked with the resident, acknowledged she was aware that he did not turn in his lighter after smoking and that residents were allowed to smoke whenever they wished, making it difficult for staff to track smoking times. She stated that residents were supposed to give their lighters and cigarettes to the nurse upon returning from smoking, but this was not occurring with this resident, who liked to keep his lighter due to frequent smoking. The Administrator confirmed that cigarettes were to be kept in a locked box at the nurses' station and that nurses were supposed to confiscate lighters after each smoking session, but also stated that residents had effectively been allowed to decide whether to turn in lighters at the end of each session or at the end of the day, with some residents keeping lighters because they smoked frequently.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's preference for showers, instead providing bed baths, which constitutes a deficiency in respecting resident self-determination and choice. The resident, who was admitted with a diagnosis of stroke and had moderately impaired cognition, was able to communicate her needs through head nods. Her care plan specified assistance with activities of daily living, including scheduled showers twice a week. However, documentation and interviews revealed that the resident consistently received bed baths instead of showers, with staff marking 'NO' or 'N/A' on the Kardex for scheduled shower days. Interviews with staff and the resident's family member confirmed the resident's desire for showers, which were not provided as scheduled. Nursing assistants reported various reasons for not providing showers, including shifts not completing the task and the resident's occasional refusal due to pain. Despite these refusals, the resident's family and the resident herself indicated a preference for showers, which were not consistently offered or provided. The lack of communication and coordination among staff contributed to the failure to meet the resident's preferences, as some staff were unaware of the resident's desire for showers or the need to offer them even after a bed bath.
Failure to Address Resident Grievance Regarding Trust Fund Error
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without discrimination or reprisal, as required by regulations. A resident, diagnosed with chronic obstructive pulmonary disease, reported an error on his facility trust fund account statement, where over $600 was taken without notification. The resident noticed this discrepancy in April 2024 and reported it to the business office. However, the business office did not complete a written grievance, and the issue remained unresolved for several months. The Business Office Manager acknowledged the error in billing for a second patient monthly liability for February 2024 but did not notify the Administrator or complete the necessary grievance documentation. The Administrator only became aware of the issue in December 2024, after speaking with the resident and the Business Office Manager.
MDS Coding Error for Feeding Tube
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) Assessment for a resident in the area of feeding tubes. The resident, who was admitted with a diagnosis of Parkinson's disease, was documented as having a feeding tube in the quarterly MDS assessment, despite being moderately cognitively impaired and never having had a feeding tube while at the facility. This error was identified through interviews with staff, including a nurse, the MDS Coordinator, and the Assistant Dietary Manager. The Assistant Dietary Manager admitted to mistakenly marking the resident as having a feeding tube due to human error. The Director of Nursing expressed that it was expected for the MDS assessment to be coded accurately.
Failure to Submit PASRR Application for New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident who developed a new mental health diagnosis. The resident, who was readmitted to the facility with vascular dementia and psychotic disturbance, was later diagnosed with bipolar II disorder. Despite this significant change in mental health status, a new PASRR application for a level II screen was not submitted as required. The oversight was identified during a review of the resident's records and confirmed through staff interviews. The Social Worker, responsible for submitting PASRR determinations, acknowledged that a new application should have been submitted following the resident's diagnosis of bipolar II disorder. The Administrator also confirmed that the PASRR level I was negative and recognized the failure to submit a new application after the new diagnosis was made.
Failure to Provide Adequate Nail Care for a Resident
Penalty
Summary
The facility failed to provide adequate nail care for a dependent resident, identified as Resident #23, who was admitted with a diagnosis of adult failure to thrive. The resident's care plan indicated a need for assistance with activities of daily living, including personal care such as bathing and dressing. Despite this, observations and interviews revealed that the resident's nails were long, uneven, jagged, and had black soil underneath, indicating a lack of proper nail care. The resident, who was cognitively impaired but able to communicate her needs, expressed a desire for her nails to be cleaned and trimmed, which she could not do herself. Interviews with nursing assistants and a nurse confirmed that the facility staff were responsible for providing nail care if it was not completed by hospice staff during bathing. However, the assigned nursing assistant had not offered nail care and was unaware of the reason for this oversight. The facility administrator was also unaware of the resident's need for nail care, highlighting a communication gap and a failure to adhere to the resident's care plan. This deficiency affected one of the three sampled residents, demonstrating a lapse in the facility's duty to provide necessary personal care to its residents.
Failure to Correct Billing Discrepancy in Resident's Trust Fund
Penalty
Summary
The facility failed to manage a resident's financial affairs properly, specifically regarding a billing discrepancy in the resident's facility trust fund account. Resident #24 was charged for a full month's patient monthly liability (PML) for skilled nursing care in February 2024, despite only receiving care for two days starting on February 27, 2024. This error was identified in April 2024 by the Business Office Manager, who had just started the position. Despite the resident's repeated complaints and the Business Office Manager's communication with the corporate billing office and the Department of Social Services (DSS), the error was not corrected, and the resident was not reimbursed by December 2024. The Business Office Manager and the Administrator were not aware of the full extent of the issue until December 2024, when the resident reiterated his complaint. The DSS staff and supervisor were also unaware of the discrepancy until December 2024, despite previous communications from the facility. The DSS staff confirmed that the PML should have been prorated for the two days of care, but the system had billed for the entire month. The DSS supervisor initiated the process to correct the billing error and reimburse the resident, but this action was not completed at the time of the report.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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