Lenoir Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenoir, North Carolina.
- Location
- 322 Nuway Circle, Lenoir, North Carolina 28645
- CMS Provider Number
- 345138
- Inspections on file
- 32
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Lenoir Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetic polyneuropathy and chronic pain had an order for Gabapentin 800 mg TID, but eight scheduled doses over several days were not administered because the medication was repeatedly unavailable in the med cart and not adequately obtained from the pharmacy or the automated dispensing machine. Multiple nurses and medication aides documented missed doses, citing absent stock and assumptions that other shifts would reorder, and no one escalated the issue to the unit manager, NP, Medical Director, or pharmacy in a timely manner. The resident, who was cognitively intact, reported extremely severe leg pain rated 10/10 with twitching and inability to sleep for several nights, stated he had not refused the medication, and said staff told him they would check on it but did not return with his medication. Pharmacy records showed a 30‑day supply had been delivered earlier in the month and that an early refill could have been provided and billed to the facility if staff had called, while clinical leaders and the regional pharmacy consultant confirmed that missing multiple Gabapentin doses would significantly affect pain control and could disrupt mood, behavior, and sleep.
A resident with diabetes and diabetic polyneuropathy had a standing order for Gabapentin 800 mg three times daily, but multiple doses over several days were not administered because the medication was missing from the med cart. Medication aides and nurses documented the missed doses and reordered the drug through the electronic system, and one aide reported informing the nurse on duty, but no staff notified the NP or other provider as required by facility protocol. The unit manager was not informed of the missing medication, and the NP later stated she had been unaware of the missed doses and that the facility should have contacted her.
A resident with diabetic polyneuropathy had an order for high‑dose Gabapentin three times daily, but the drug was repeatedly unavailable in the med cart and not adequately supplied in the dispensing machine, resulting in eight missed doses over several days. Multiple medication aides and nurses documented the drug as not administered, reordered it electronically, or attempted to piece together doses, yet none contacted the pharmacy to verify status or secure an override when the refill was initially rejected as too early by insurance. The unit manager was not informed of the ongoing unavailability, and the pharmacist later confirmed that a 30‑day supply had been delivered earlier and that no follow‑up calls were received from staff, while leadership stated nursing staff were responsible for reordering and follow‑up.
Surveyors observed a black substance on the splash guard of a dining room ice machine, which was not in contact with the ice. The Dietary Manager reported that the machine was due for its first deep clean and that monthly wipe-downs were the responsibility of maintenance, but a new supervisor had just started and prior cleanings may have been missed. The Administrator confirmed that routine cleaning was expected.
A resident with a surgical wound and a positive CRE culture was not placed on enhanced barrier precautions (EBP) as ordered, and no precaution signage or PPE was present at the room. Nursing staff were unaware of the resident's precaution status, and the DON missed critical communications from health authorities regarding the need for EBP and further resident testing. The facility did not act on recommendations from the health department until after the deficiency was identified.
A resident with multiple psychiatric and medical diagnoses was started on antianxiety and antidepressant medications without documented informed consent or advance discussion of risks and benefits. Staff interviews revealed inconsistent practices for obtaining consent, and the DON acknowledged that consents for psychotropic medications were not consistently obtained.
A resident with Alzheimer's disease and dementia was admitted to hospice care, but the required significant change in status MDS assessment was not completed within 14 days as mandated. The MDS Nurse reported overlooking the assessment due to multiple hospice admissions occurring simultaneously, and both the MDS Nurse and DON confirmed the assessment should have been completed within the required timeframe.
Nursing staff failed to administer enteral tube feedings as ordered for a resident with diabetes and dysphagia, repeatedly stopping the feeding early in response to high blood glucose levels without provider authorization or proper documentation. This resulted in the resident not receiving prescribed nutrition, with staff interviews confirming a lack of understanding and communication regarding proper tube feeding protocols.
Surveyors found expired magnesium citrate bottles in the medication room and noted that staff failed to discard them as required. Additionally, influenza vaccines were not consistently stored according to manufacturer recommendations, with temperature logs showing infrequent and incomplete recordings, and some temperatures falling outside the recommended range. The DON and Administrator confirmed that staff were responsible for monitoring and reporting, but these procedures were not followed.
Nursing staff did not immediately notify the physician when a resident on antiplatelet therapy developed significant abdominal bruising, despite multiple staff observing the change. In a separate case, nurses discontinued a resident's continuous tube feeding early in response to high blood glucose without provider notification or orders, relying on nursing judgment instead. Both incidents involved a lack of timely communication with the provider regarding significant changes in condition or treatment.
A resident alleged rough handling and verbal mistreatment by night shift NAs during incontinence care, later presenting with a bruise. Staff failed to immediately notify the Administrator or remove the alleged perpetrators from resident care, and confusion among staff about reporting responsibilities led to a significant delay in reporting the abuse allegation. The facility's abuse prevention policy lacked clear directives for immediate resident protection and was not effectively implemented in practice.
Two residents did not receive appropriate care as ordered: one did not have thorough or documented assessments of abdominal bruising while on antiplatelet therapy, and another did not receive daily surgical wound care as ordered, with staff failing to perform or document dressing changes on multiple occasions.
A resident admitted with pneumonia was placed on continuous oxygen therapy without a physician's order, and required 'oxygen in use' cautionary signage was not posted outside the room. Staff interviews revealed a lack of clarity regarding responsibility for obtaining orders and posting safety signage.
The facility did not accurately post RN staffing information for multiple days, as staffing sheets were completed in advance based on schedules and not updated to reflect the actual RNs present, despite timecard records confirming RN coverage. The Scheduler was unaware of the requirement to update postings, and the Administrator was not aware this was not being done.
A resident with left-sided weakness, muscle wasting, and vascular dementia, who was at risk for falls, experienced two falls from bed due to the facility's failure to provide adequate supervision and implement new fall prevention interventions after the first incident. The second fall resulted in a scalp laceration requiring staples and a cervical spine fracture, necessitating a cervical collar.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
A resident with a history of stroke, dementia, and seizures was found to have a positive urine drug screen for Fentanyl and MDMA after being transferred to the hospital for severe dehydration. The resident, dependent on staff for all ADLs, was reported to have had a seizure by a family member. EMS noted signs of an opioid overdose, but no physician's order for Fentanyl was found. The facility's investigation, involving law enforcement and the DEA, focused on a family member with a criminal history.
A resident with severe cognitive impairment hit another resident in the head during a dispute over a TV channel. The aggressor lacked a care plan for aggressive behaviors, and the incident was not documented in the nurse's notes. The facility did not substantiate the abuse due to the aggressor's mental status, despite the incident being reported to the administrator and police involvement.
A resident with severe cognitive impairment hit another resident on the head after a TV channel dispute. The incident was not reported to the state survey agency within the required two-hour timeframe, as it was only communicated to management the following morning. The delay was due to a lack of immediate reporting by night shift staff, contrary to the facility's policy.
A resident with severe cognitive impairment hit another resident over a TV channel dispute, but the facility failed to thoroughly investigate the incident. The investigation lacked staff statements, skin assessments, and resident interviews. The Social Services Director and Administrator did not document interviews, and the Director of Nursing acknowledged the lack of documentation.
A resident with severe cognitive impairment was involved in an aggressive incident, but their care plan was not updated to include interventions for aggressive behaviors. The MDS Coordinator was on vacation at the time, and there was no one to update care plans, leading to a lapse in addressing the incident. The DON and Administrator acknowledged the oversight.
A resident with chronic pain was mistakenly given melatonin instead of oxycodone by an LPN. The resident, who had no cognitive impairment, reported the error to a CNA. The LPN retrieved the pills after realizing the mistake but did not document the incident as a medication error. The DON and Administrator later confirmed it was a medication error, highlighting the need for proper documentation and notification.
The facility failed to provide RN coverage for at least 8 hours a day, 7 days a week, on 25 occasions over a 213-day period. The Administrator confirmed the issue, citing the resignation of the scheduler and difficulties with staffing agencies. An RN was on-call but not physically present on these days.
The facility failed to provide group activities outside for residents, leading to feelings of sadness and frustration. Despite requests, no outings were scheduled due to broken vans and staffing issues. The Activity Director and Administrator confirmed the lack of outside activities, attributing it to transportation problems and previous ownership's refusal to address the issue.
A facility failed to protect residents from the misappropriation of controlled medications by a nurse, affecting nine residents. Discrepancies were found between narcotic count sheets and MARs, indicating potential drug diversion. Nurse #6 signed out medications at unscheduled times and after orders were discontinued. Residents reported not receiving medications as ordered, and one received a pill that looked different. The nurse was terminated, and the issue was reported to authorities. No residents suffered harm as the facility had an adequate supply of medications.
A resident experienced a loss of dignity when a nurse aide failed to change him, resulting in a bowel movement that filled his brief and dripped onto the floor. The resident, who was moderately cognitively impaired and dependent on staff for care, was unable to alert staff due to an inaccessible call bell. The incident was discovered by a family member, and staff interviews revealed that the nurse aide had not checked on the resident, relying on the call bell for alerts.
Two residents with impaired cognition were unable to access light switches behind their beds due to broken cords. Despite routine checks, staff and maintenance failed to notice or report the issue, leaving residents without control over their lighting. The DON and Administrator expected better attentiveness and reporting from staff.
A resident in an LTC facility was found soaked with urine and soiled with bowel movement on multiple occasions due to inadequate incontinence care. The resident, who was dependent on staff for all ADLs, was left in a urine-soaked state on two consecutive mornings and later found with bowel movement overflowing from the brief. The call bell was out of reach, preventing the resident from alerting staff. The nursing staff's failure to provide timely care and ensure call bell accessibility led to the deficiency.
Multiple Missed Gabapentin Doses for Neuropathic Pain
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple scheduled doses of Gabapentin, prescribed for diabetic polyneuropathy, were not administered over a four-day period. The resident had diabetes mellitus with diabetic polyneuropathy and an order for Gabapentin 800 mg by mouth three times daily. The admission MDS documented that the resident was cognitively intact and experienced frequent pain that interfered with activities, with a pain intensity of 6/10 during the assessment period. In January, the MAR showed Gabapentin 800 mg TID for diabetes mellitus, with eight doses marked as not administered on specific dates and times by various staff, including medication aides and nurses. On the first missed day, a medication aide reported that the Gabapentin was not in the medication cart and stated she reordered it in the electronic charting system but did not recall whom she informed about the missed dose. On subsequent evening shifts, a nurse documented additional missed doses, stating the medication was not in the cart and that the automated medication dispensing machine did not have enough Gabapentin to cover the prescribed dosage. She did not reorder the medication from the pharmacy, explaining that day-shift staff typically handled reorders, and she did not recall the resident reporting severe pain or leg twitching during her shifts. Another nurse documented a missed morning dose when the medication was again not in the cart and reported trying to piece together doses from the dispensing machine; she stated the resident later refused a noon dose, so she did not attempt to obtain it from the machine. She also stated the facility was having issues with the pharmacy obtaining medications, that she was unaware the resident had missed several doses, and that she had not personally contacted the pharmacy about the medication status. A medication aide observed preparing the resident’s noon medications stated that the Gabapentin had been missing from the cart for at least three days, that she reordered it that day, and that she informed the nurse on duty. She confirmed the resident missed his morning and noon doses that day because the medication was unavailable and noted that the resident was alert and aware he was not receiving it. The MAR showed the resident was also receiving scheduled and PRN Oxycodone-Acetaminophen, with documented pain ratings ranging from 0 to 9 on a 0–10 scale during the same period. When interviewed, the resident reported not receiving Gabapentin for about a week, stated he took it for neuropathic pain, and described his leg pain as extremely bad, rating it 10/10 day and night, with twitching that kept him awake for at least three nights. He stated he had never refused his medication, had asked staff about it, and was told they would check on it but they did not return with information. The unit manager stated no staff had informed her that the resident was missing medication and that she could have pulled medication from the dispensing machine or contacted the Nurse Practitioner or Medical Director and followed up with the pharmacy if she had been notified. The pharmacist reported that a 30-day supply of 90 Gabapentin tablets had been sent earlier in the month, sufficient through the following month, and that a refill request on one of the dates in question was too early for insurance but could have been filled and billed to the facility if staff had called; he stated no one from the facility contacted the pharmacy about the medication status. The regional pharmacy consultant stated that missing several doses of Gabapentin for diabetic nerve pain would result in recurrence of pain and that the drug’s sedating and calming effects meant mood, behavior, and sleep could be disrupted without it. The Nurse Practitioner and Medical Director both stated they were unaware of the missed doses and indicated that missing Gabapentin would affect the resident’s pain level, with the Nurse Practitioner noting that the missed doses would be significant for pain control and that Gabapentin and Oxycodone act on different nerve receptors.
Failure to Notify Provider of Multiple Missed Gabapentin Doses
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician/Nurse Practitioner when a resident did not receive multiple prescribed doses of Gabapentin ordered for diabetic polyneuropathy. The resident had diabetes mellitus with diabetic polyneuropathy and a physician’s order for Gabapentin 800 mg by mouth three times daily. Review of the Medication Administration Record showed that several doses over multiple days were marked as not administered. Medication Aide and nursing staff reported that the Gabapentin was not in the medication cart on several shifts, and they documented the missed doses on the MAR. However, they did not notify the provider when the first or subsequent doses were missed, despite facility expectations that the provider be notified immediately when a resident does not receive a prescribed medication. Medication Aide #2 stated she reordered the medication in the electronic system when she found it missing but did not recall whom she informed about the missed dose. Nurse #1 documented the missed doses on two night shifts and assumed the provider was already aware because the medication had also been missed on the first shift, but she did not contact the provider. Medication Aide #1 reported the medication had been missing for at least three days, stated she reordered it and informed Nurse #2, and indicated that as a Medication Aide she would not notify a provider. Nurse #2 acknowledged that she did not notify the Nurse Practitioner or medical provider, believing it was a pharmacy delay. The Unit Manager reported that no staff had informed her of the missing medication, and the Nurse Practitioner confirmed she was unaware of the missed doses and stated the facility should have notified her. The Director of Nursing and Administrator stated that staff were expected to notify the Nurse Practitioner or on-call provider when a resident missed a prescribed medication dose, which did not occur in this case.
Failure to Ensure Availability of Prescribed Gabapentin Leading to Multiple Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure the availability and delivery of a resident’s prescribed Gabapentin, resulting in eight missed doses over a four-day period. The resident was admitted with diabetes mellitus with diabetic polyneuropathy and had a physician’s order for Gabapentin 800 mg by mouth three times daily for neuropathy related to diabetes. Review of the MAR showed that multiple scheduled doses on several consecutive days were documented as not administered because the medication was unavailable. On one morning, a medication aide found that the Gabapentin was not in the medication cart, reordered it in the electronic charting system, and did not recall whom she informed about the missed dose. On two night shifts, a nurse also found the medication absent from the cart, knew the dispensing machine did not have enough Gabapentin to cover the ordered dose, and did not reorder from the pharmacy or contact the pharmacy to check on the medication status, assuming day shift would handle reorders. Another nurse reported that on a later date the morning dose was not in the cart, that medication aides could not access the dispensing machine, and that staff were trying to piece together doses from the machine; she stated the resident eventually refused a noon dose and acknowledged she did not personally contact the pharmacy and was unaware of the multiple missed doses. Further observations showed that the dispensing machine contained only two 300 mg Gabapentin tablets and no 100 mg tablets, which was insufficient to provide one full scheduled dose. A medication aide reported that the Gabapentin had been missing from the cart for at least three days and that the resident had missed both morning and noon doses on one of those days due to unavailability. The unit manager stated no staff had informed her that the resident was missing medication, although she could have pulled from the dispensing machine if available. The pharmacist reported that a 30‑day supply had been delivered earlier in the month, that an electronic reorder on one of the dates was too early for insurance refill, and that the facility could have requested medication billed to the facility, but no one from the facility called to check on the status. The DON and Administrator both stated that nursing staff were responsible for reordering and should have called the pharmacy after the medication was not received, and confirmed that the resident should not have been missing doses of the high‑dose Gabapentin.
Ice Machine Not Properly Cleaned, Black Substance Observed
Penalty
Summary
During a kitchen tour, surveyors observed a black substance on the plastic splash guard above the ice in the dining room ice machine. The substance was not in direct contact with the ice. The Dietary Manager (DM) stated that the ice machine was less than six months old, still under warranty, and scheduled for its first deep clean in about two weeks, with subsequent deep cleans every six months. The DM also indicated that maintenance staff were responsible for monthly wipe-down cleanings, but a new Maintenance Supervisor had recently started, and the cleaning schedule may not have been maintained prior to this hire. The DM expected the ice machine to be free of any black substances, and the Administrator confirmed that routine cleaning was expected, acknowledging that the machines may not have been cleaned on schedule before the new supervisor's arrival.
Failure to Implement Enhanced Barrier Precautions and Respond to CRE Case
Penalty
Summary
The facility failed to implement its infection control policy and procedures for enhanced barrier precautions (EBP) for a resident who tested positive for Carbapenem Resistant Enterobacterial (CRE). Despite a nurse practitioner (NP) order for EBP following preliminary lab results indicating a wound infection, the resident was not placed on EBP, and no precaution signage or personal protective equipment (PPE) was present at the resident's room. Multiple staff interviews revealed that nursing staff were not made aware of the resident's precaution status, and the only notification system in place was the presence of signage, which was absent. The wound nurse and unit manager both stated that residents requiring wound care should be on EBP, but neither was aware that the resident was not on precautions, and the wound nurse had not noticed the lack of signage or PPE. The Director of Nursing (DON) acknowledged receiving the NP's verbal order for EBP but did not recall why the resident was not placed on precautions or why signage was not posted. The DON had been on vacation and did not designate anyone to cover her responsibilities, resulting in missed communications from the local and state health departments regarding the resident's positive CRE results and recommendations for further action. The DON admitted to not reviewing the toolkit or returning calls and emails from health authorities, and was unaware of the need to test other residents for CRE until after her return. Both the local and state health department representatives reported multiple attempts to contact the facility to discuss the positive CRE result, the need for EBP, and the importance of testing other residents. These communications went unanswered, and the facility did not act on the recommendations until after the deficiency was identified. The administrator and NP both stated that EBP should have been implemented for the resident, and that staff should have been informed of the precaution status, but neither was aware of the lapse until after the fact.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent and provide advance information regarding the risks and benefits of psychotropic medications prior to initiating treatment for a resident with chronic obstructive pulmonary disease, bipolar disorder, and depressive disorder. The resident was started on clonazepam for anxiety and venlafaxine for depression, as documented in physician orders and progress notes. However, a review of the medical record revealed no documentation that the resident was informed about the risks and benefits of these medications or that consent was obtained prior to administration. The Medication Administration Record confirmed that both medications were administered as ordered. Interviews with facility staff, including the Nurse Practitioner, Psychiatric Nurse Practitioner, and Director of Nursing, revealed inconsistent practices regarding the process for obtaining informed consent for psychotropic medications. The Psychiatric Nurse Practitioner indicated that discussions with the resident focused on symptoms rather than explicitly covering risks, benefits, or obtaining formal consent. The Director of Nursing acknowledged that consents were not consistently obtained, and the Administrator recognized the need for improvement in this area. The resident involved was cognitively intact and reported well-controlled anxiety and depression at the time of the survey.
Failure to Complete Timely Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within the required 14-day period following a resident's election of hospice services. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and senile degeneration of the brain, was admitted to hospice with a primary diagnosis of senile degeneration of the brain. Despite this significant change in condition, the significant change in status MDS assessment was not completed until nearly a month after hospice admission. The MDS Nurse acknowledged that the assessment was overlooked due to multiple residents being admitted to hospice around the same time. Both the MDS Nurse and the Director of Nursing confirmed that a significant change in status MDS assessment should have been completed within 14 days of hospice admission, but this did not occur for the resident in question.
Failure to Administer Tube Feedings as Ordered for Resident with Diabetes and Dysphagia
Penalty
Summary
A deficiency occurred when nursing staff failed to administer enteral tube feedings as ordered by the physician for a resident with a history of diabetes mellitus type 2, anxiety, major depressive disorder, and dysphagia requiring a gastrostomy tube. The resident had specific physician orders for continuous tube feeding during nighttime hours and for regular blood glucose monitoring and insulin administration. Despite these orders, nursing staff on multiple occasions turned off the resident's tube feeding early in response to elevated blood glucose levels, without obtaining a physician's order or notifying the provider as required. Documentation of these actions was not consistently entered into the medical record or medication administration record (MAR). Interviews with staff revealed that at least two nurses had independently decided to stop the tube feeding early due to concerns about high blood sugar, believing it was appropriate nursing judgment. One nurse reported being told by another nurse to turn off the feeding, and both indicated a lack of clear guidance or understanding that tube feedings should not be stopped without a provider's order. The unit manager and nurse practitioner confirmed that tube feedings were being stopped early by night shift nurses, and that this practice was not in accordance with the resident's care plan or physician orders. The registered dietician and medical director both stated that stopping tube feedings early could result in the resident not receiving their minimal nutritional needs, potentially contributing to weight loss. The resident's guardian raised concerns about the tube feeding not running for the full prescribed duration and noted observed weight loss. The issue was brought to the attention of facility leadership, including the DON and nurse practitioner, who confirmed that staff had not consistently followed the physician's orders for tube feeding administration. The DON acknowledged that she was not aware of the full extent of the issue and had only addressed it with one nurse, despite evidence that multiple staff were involved.
Expired Medications and Improper Vaccine Storage Identified
Penalty
Summary
Surveyors identified several deficiencies related to the storage and management of drugs and biologicals in the facility's medication room. During an observation, eight unopened bottles of magnesium citrate were found to be expired and still present on the bottom shelf of the medication storage room. The expiration date on all bottles was confirmed to be past due, and both the DON and Administrator acknowledged that expired medications should not be available for use and should have been discarded. The DON stated that nursing staff were responsible for weekly checks for expired medications, but this process was not followed as required. Further deficiencies were noted in the storage and monitoring of influenza vaccines. The facility had two refrigerators containing Seqirus influenza vaccines, and temperature logs revealed that temperatures were not being recorded twice daily as recommended by the manufacturer. For multiple months, temperatures were only recorded once daily on a limited number of days, with many days missing any temperature documentation. Although the recorded temperatures for September and October were within the recommended range, the lack of consistent monitoring did not meet manufacturer guidelines. In November, the only recorded temperatures were below the recommended range, and there were significant gaps in documentation. Interviews with the DON, Administrator, and Consultant Pharmacist confirmed that staff were expected to record refrigerator temperatures twice daily and report any out-of-range readings. However, the DON was unaware of the incomplete logs and temperature deviations, and the Administrator could not explain why the process was not followed. The Consultant Pharmacist emphasized the importance of proper temperature monitoring and reporting, especially when temperatures fall outside the recommended range.
Failure to Notify Physician of Significant Changes and Treatment Alterations
Penalty
Summary
The facility failed to immediately notify the physician of a significant change in condition for a resident who was receiving antiplatelet medications, specifically Plavix and aspirin. The resident, who had a history of type-2 diabetes, chronic kidney disease, peripheral vascular disease, and atherosclerotic heart disease, developed a large purple/blue bruise on the left lower quadrant of the abdomen. Multiple nursing staff, including a nurse, two unit managers, and another nurse, observed or were informed of the bruise over the course of several days but did not notify the provider. The nurse practitioner was not made aware of the bruising until two days after it was first observed, at which point the resident was seen in clinic. Additionally, the facility failed to notify the physician before discontinuing a continuous enteral feeding for another resident with diabetes and a gastrostomy. Nursing staff stopped the tube feeding early on multiple occasions in response to elevated blood glucose readings, without obtaining a physician's order or notifying the provider. Nurses believed it was within their judgment to stop the feeding and did not consider it necessary to contact the provider, even when blood glucose levels were significantly elevated and there were no sliding scale insulin orders in place. Interviews with the nurse practitioner, medical director, DON, and administrator confirmed that the expectation was for nurses to administer tube feedings as ordered and to notify the provider for elevated blood sugars or before making changes to physician-ordered treatments. Documentation and staff interviews revealed a pattern of not notifying the provider as required for both the bruising incident and the management of tube feedings in response to high blood glucose levels.
Failure to Immediately Protect Resident and Report Abuse Allegation
Penalty
Summary
The facility failed to develop and implement effective abuse prevention policies and procedures, specifically lacking clear direction for staff on how to immediately protect residents following an abuse allegation. The written abuse policy did not instruct staff to remove alleged perpetrators from resident access after an allegation was made. Additionally, the policy was not effectively implemented in the areas of timely reporting and staff training, as evidenced by staff not being aware of or following the correct reporting process. An incident occurred involving a cognitively intact resident who alleged that night shift nursing assistants were rough and spoke harshly to her during incontinence care. The resident reported feeling abused and later showed a bruise to her left lower abdomen, which she attributed to the care provided by the staff. Multiple staff members, including nursing assistants and unit managers, were involved in the incident and subsequent reporting. However, none of the staff immediately notified the Administrator of the abuse allegation, and the alleged perpetrators were not promptly removed from resident care duties. Staff interviews revealed confusion about reporting responsibilities, with some assuming others had reported the incident or were unaware of the need to escalate the allegation. The delay in reporting resulted in the Administrator not being informed of the abuse allegation until more than 24 hours after the incident. During this time, at least one of the alleged perpetrators remained in the facility and was scheduled to work additional shifts. Staff involved in supervisory roles indicated they had not received adequate training on the reporting process for abuse allegations. The facility's failure to ensure immediate protection of residents and timely reporting of abuse allegations constituted a deficiency in both policy development and implementation.
Failure to Document Skin Assessments and Provide Ordered Wound Care
Penalty
Summary
The facility failed to complete and document thorough assessments of abdominal bruising for a resident who was receiving daily Plavix and aspirin, both of which increase the risk of bleeding. Multiple nurses and unit managers observed a large, painful bruise on the resident's left lower abdomen but did not document measurements or detailed skin assessments in the electronic medical record. The resident reported significant pain, and the bruise was noted by several staff members over multiple days without proper documentation or timely notification to the nurse practitioner. Laboratory and imaging studies were eventually ordered, but the initial lack of assessment and documentation was evident. Additionally, the facility failed to follow physician orders for daily scheduled treatment of surgical wounds for another resident with a right foot amputation and a history of infection risk. The resident's wound care orders specified daily dressing changes, but documentation showed that wound care was not performed or recorded on several weekend days. The resident reported that his wound dressing had not been changed as ordered, and observation confirmed that the dressing was saturated and dated from a previous day. Nursing staff, including contract nurses, either refused or were unaware of their responsibility to perform wound care, resulting in missed treatments. Interviews with staff, including nurses, the unit manager, the nurse practitioner, the DON, and the administrator, confirmed that wound care orders were not consistently followed and that documentation of care and assessments was lacking. The failures involved both the lack of proper assessment and documentation for a resident at risk of bleeding and the failure to provide and document wound care as ordered for a resident with a surgical wound, as observed and reported by both residents and staff.
Failure to Obtain Physician Order and Post Oxygen Signage for Resident on Continuous Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for a resident who was admitted from the hospital on continuous oxygen therapy. Upon admission, the resident had diagnoses including pneumonia and was using an oxygen concentrator via nasal cannula at 2 liters per minute. Review of the resident's admission orders and Minimum Data Set (MDS) revealed no documented order for oxygen use, and the care plan referenced administering oxygen as ordered, but no such order was present. Multiple observations confirmed the resident was receiving continuous oxygen without a corresponding physician's order. Additionally, the facility did not post cautionary 'oxygen in use' signage outside the resident's room, as required for safety. Observations over several days confirmed the absence of this signage while the resident was on continuous oxygen. Interviews with staff, including a medication aide, unit manager, nurse practitioner, and DON, revealed a lack of awareness regarding responsibility for posting signage and a failure to ensure proper physician orders were in place prior to initiating oxygen therapy.
Failure to Accurately Post RN Staffing Information
Penalty
Summary
The facility failed to post accurate Registered Nurse (RN) staffing information for 10 out of 79 days reviewed. Record review showed that on specific dates, the daily posted nurse staffing sheets did not document any RN as working for all three shifts, despite employee timecard punches verifying that RN coverage was present in the building on those days. The Scheduler, who was responsible for staff posting, stated she was unaware of the requirement to adjust the posted staffing information to reflect the actual staff present and completed the sheets ahead of time based on the staff work schedule. When the Scheduler was off on weekends or vacation, the posted staffing sheets were completed in advance and not updated to accurately reflect the actual staffing. The Administrator confirmed awareness of the requirement to adjust posted staffing but was unaware that this was not being done and that the Scheduler did not know the posted staffing information should be updated with the actual staff on each shift.
Failure to Implement Fall Prevention Interventions After Initial Fall
Penalty
Summary
The facility failed to provide adequate supervision and implement new fall prevention interventions for a resident with left-sided weakness, muscle wasting, vascular dementia, and a known risk for falls. The resident initially fell from a bed in the low position, and no new interventions were put in place following this incident. Subsequently, the resident experienced another fall from a bed that was not in the low position and was found face down on the floor. As a result of the second fall, the resident required emergency medical treatment for a large scalp laceration with significant bleeding, which was repaired with staples, and was diagnosed with a cervical spine fracture necessitating the use of a cervical collar at all times. This deficiency was identified through record review and interviews with a Nurse Practitioner and staff, and it affected one of three residents reviewed for falls.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pest infestations within the facility. No additional details regarding specific residents, staff, or observed pests were provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Resident's Positive Drug Screen and Dehydration Raise Concerns
Penalty
Summary
The facility failed to protect a resident from an injury of unknown source and potential abuse or neglect. The resident, who had a history of cerebral vascular accident, dementia, seizure disorder, and hypertension, was found to have a positive urine drug screen for Fentanyl and MDMA after being transferred to the hospital. The resident was dependent on staff for all activities of daily living and was receiving tube feedings. The incident occurred when the resident's family member reported a seizure, prompting an immediate response from the Nurse Practitioner and Nurse #1, who found the resident leaning to one side of the bed. Upon assessment, the resident was transferred to the hospital, where EMS noted signs of an opioid overdose. The resident's condition was later identified as severe dehydration, a side effect of MDMA. The facility's records showed no physician's order for Fentanyl, and the resident's medical history did not indicate any social history of drug abuse. Interviews with staff revealed that the resident was last seen alert and responsive before the family member's visit, and no staff observed any powder or signs of drug use around the resident. The investigation involved multiple agencies, including local law enforcement, the DEA, and APS, who were notified by the hospital due to concerns about the resident's severe dehydration and positive drug screen. The DEA agent expressed concerns about a family member with a criminal history, and the investigation focused on this individual. The facility's administrator was unaware of the incident until informed by the authorities, and the facility cooperated with the investigation. The deficiency affected one of three residents reviewed for abuse or injury of unknown origin.
Removal Plan
- Education was started by the Director of Nursing to current staff including all departments on monitoring for behaviors of any visitors outside of the normal expected behaviors both physical and mental. Employees not receiving this education will not be allowed to work until the education is received. The Staff Development Coordinator will track the education to ensure that current staff have received.
- Education was started by the Director of Nursing to current staff including the abuse policy that included injury of unknown source, of what is considered abuse and who to report suspected abuse to and that there will be no tolerance for illegal substances. Employees not receiving this education will not be allowed to work until education is received. The Staff Development Coordinator will track the education to ensure that current staff have received. Education to agency staff will be completed when they enter for their shift by the charge nurse on duty.
- A statement is being added to the kiosk that visitors sign in on when they enter the building that states that I acknowledge the statement: No firearms or illegal substances while on premises. The Administrator of the facility gets a notice of all kiosk sign ins by email and monitors to ensure the acknowledgement has been checked. The Administrator can login to the kiosk system and ensure that the acknowledgement was checked by all visitors that sign in.
- A sign is being placed in the front entrance that states no firearms and no illegal substances while on the premises. The signage placed was created and laminated. This signage was placed on all doors that someone could enter the facility from.
- Alert and oriented residents will be notified by the Administrator or designate that there is no tolerance for abuse including illegal substances. This will be done verbally. Resident that are not alert and oriented, the responsible parties will be notified by telephone by the Administrator or designee.
- Staff members will be notified via mass message that is sent to the employee's cell phone via the payroll system regarding there will be no tolerance for abuse including illegal substances.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. The incident involved a resident with severe cognitive impairment who hit another resident on the back of the head after a dispute over a TV channel. The resident who was hit had intellectual disabilities and was rarely understood, making it difficult to complete a mental status interview. The aggressor, who had a BIMS score indicating severe cognitive impairment, did not have a care plan addressing aggressive behaviors. There was no documentation in the nurse's notes regarding the incident, and the investigation concluded that the incident occurred but did not substantiate abuse due to the aggressor's mental status. Interviews with staff and residents revealed that the incident was reported to the administrator, who acknowledged that the aggressor admitted to hitting the other resident. However, the administrator did not substantiate the abuse allegation, citing the aggressor's mental capacity. A CNA reported the incident to an LPN, who instructed the victim to return to his room. The police were involved but did not take further action. The facility's failure to document the incident properly and address the aggressive behavior in the care plan contributed to the deficiency.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse immediately to the Administrator and within two hours to the state survey agency. The incident involved a severely cognitively impaired resident, R2, who hit another resident, R1, on the back of the head after a dispute over a TV channel. The facility's policy requires that any suspected or witnessed incidents of abuse be reported immediately, but the incident was not reported to the state survey agency until more than four hours after it occurred. The incident was first observed by a Certified Nurse Aide (CNA) who reported it to a Licensed Practical Nurse (LPN) during the night shift. However, the Unit Manager (UM) was not informed until the morning, and the Administrator was only made aware of the incident at 7:15 AM. The delay in reporting was due to a lack of immediate communication among staff, as the night shift nurses did not report the incident to management promptly. The Director of Nursing (DON) and the Administrator both acknowledged that the incident should have been reported immediately to ensure timely notification to the state survey agency.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident of resident-to-resident abuse involving two residents. One resident, who was severely cognitively impaired, hit another resident on the back of the head after a dispute over a TV channel. The facility's policy requires all reported incidents of abuse to be thoroughly investigated and immediately reported, but this was not adhered to in this case. The investigation summary provided by the facility lacked staff statements, skin assessments, and interviews with other residents related to the allegations. Interviews with staff revealed that the Social Services Director did not interview anyone related to the incident, as she was not instructed to do so. The Director of Nursing acknowledged that there should have been documented interviews with staff and residents. The Administrator admitted to verbally interviewing staff but did not document these interviews or any resident interviews. Additionally, a skin assessment for the resident who was hit was not documented. This lack of documentation and thorough investigation had the potential to lead to continued episodes of physical abuse.
Failure to Update Care Plan for Aggressive Behavior
Penalty
Summary
The facility failed to update the care plan for a resident with aggressive behaviors, which was identified during a review of staff interviews and records. The resident, who had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of five out of 15, was involved in an incident where they admitted to hitting another resident and using derogatory language. Despite this incident, the resident's care plan did not include any interventions related to aggressive behaviors, as noted in the care plan dated several months prior to the incident. The MDS Coordinator acknowledged that care plans should be revised to include interventions for aggressive behaviors, but stated that the incident was missed due to her absence on vacation and the lack of a designated person to update care plans in her stead. The Director of Nursing and the Administrator both confirmed that the incident should have been care planned, indicating a lapse in communication and procedural follow-through after the resident-to-resident incident occurred.
Medication Error Due to Incorrect Pill Administration
Penalty
Summary
The facility failed to maintain professional standards of practice by allowing a medication error to occur with one of its residents. A resident, who was admitted with diagnoses including insomnia and chronic pain, was mistakenly given two melatonin pills instead of the prescribed two oxycodone pills for pain management. The resident, who had no cognitive impairment, realized the error and reported it to a CNA. The LPN involved acknowledged the mistake, stating that she initially believed the resident had swallowed the melatonin pills, but later retrieved them after being informed by the CNA. The incident was not documented in the facility's Incident Report log, and no medication error report was completed. The LPN did not consider it a medication error since the resident did not swallow the melatonin. However, both the DON and the Administrator later confirmed it was a medication error, emphasizing the importance of adhering to the five rights of medication administration and the necessity of completing an incident report in such cases. The Administrator also noted that the physician should have been notified about the error.
Facility Fails to Provide Required RN Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours per day, 7 days a week, for 25 out of 213 days reviewed. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report for the second quarter of the fiscal year 2024 and daily assignment schedules from April to July 2024. Specific dates were noted where no RN coverage was provided, and the facility's Administrator confirmed these findings. The Administrator acknowledged the issue of insufficient RN coverage, particularly on weekends, and attributed part of the problem to the recent resignation of the facility's scheduler. Despite having contracts with several staffing agencies, the facility was often unable to secure RN coverage. The Administrator also mentioned that an RN was always on-call and available via telephone, but not physically present in the facility on the days without RN coverage. The facility was under new management, and the Administrator expressed an expectation of receiving more staffing support to ensure compliance with the regulations. However, at the time of the report, the facility was not meeting the regulatory requirement of having an RN on duty for at least 8 hours a day, 7 days a week, which had the potential to affect all residents in the facility.
Lack of Scheduled Group Activities Outside Facility
Penalty
Summary
The facility failed to provide group activities outside of the facility for residents who expressed the importance of such activities. This deficiency was identified for four residents who were cognitively intact and had been at the facility for varying lengths of time. These residents reported feelings of sadness, depression, and frustration due to the lack of opportunities to leave the facility for social activities, dining, and shopping. Despite repeated requests during resident council meetings, no outings were scheduled due to transportation and staffing issues. The facility's activity calendar for August 2024 showed no scheduled activities outside the facility, despite its location being within driving distance to various shops and restaurants. Interviews with the residents revealed that they had not been able to participate in any group activities outside the facility since their admission. The residents expressed dissatisfaction with the repeated excuses given by the facility, such as broken vans and insufficient staff, which prevented them from engaging in community activities. The Activity Director confirmed that no outside activities had been scheduled due to transportation issues, as two facility vans had been broken for years, and the remaining van was reserved for medical appointments. The Administrator, who had been in her role since 2019, acknowledged the lack of outside activities and attributed it to the previous owners' refusal to repair the vans or provide alternative transportation. Although the facility had recently changed ownership, the Administrator had not yet discussed the transportation issue with the new owners but recognized the importance of outside activities for the residents' well-being.
Misappropriation of Controlled Medications by Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, affecting nine residents. Discrepancies were identified between narcotic count sheets and medication administration records (MARs), indicating potential drug diversion by Nurse #6. The discrepancies involved 17 tablets of controlled medications, and two residents reported not receiving their medications as ordered. Nurse #6 was found to have signed out medications at times she was not scheduled to work, and in some cases, medications were signed out after the orders were discontinued. Resident interviews revealed that some residents were notified by management about the potential diversion of their medications. For instance, one resident denied receiving Norco at 3:00 AM, as documented by Nurse #6, and another resident recalled being informed about a nurse signing out a tablet of Percocet that was not ordered. Additionally, a resident reported receiving a pill that looked different from their usual medication, raising further concerns about the integrity of the medication administration process. The facility's investigation confirmed the misappropriation of medications, leading to the termination of Nurse #6. The discrepancies were reported to local law enforcement, the North Carolina Board of Nursing, and the Drug Enforcement Agency. Despite the issues, the affected residents did not suffer any harm or changes in condition, as the missing medications were used on an as-needed basis, and the facility had an adequate supply of the medications.
Resident Dignity Compromised Due to Inadequate Care
Penalty
Summary
The facility failed to treat a resident in a respectful and dignified manner when a nurse aide did not change the resident, resulting in a bowel movement that filled his brief, pooled in his wheelchair, and dripped onto the floor. The resident, who was moderately cognitively impaired but able to make some needs known, was dependent on staff for incontinent care and other activities of daily living. On the day of the incident, the resident's call bell was placed out of reach, preventing him from alerting staff to his needs. The incident was discovered when the resident's family member arrived and found the resident soiled with bowel movement running out of his wheelchair. The family member informed a nurse, who then sought assistance from nurse aides to clean the resident. The nurse aide assigned to the resident admitted to being extremely busy and had not checked on the resident since the start of her shift, relying instead on the resident to use the call bell, which was not accessible. Interviews with staff revealed that the nurse aide responsible for the resident had not performed regular checks and was unaware of the call bell's placement. The Director of Nursing and the Administrator both emphasized the importance of regular rounding and ensuring call bells are within reach, but these expectations were not met, leading to the resident's undignified experience.
Inaccessible Light Switches for Residents
Penalty
Summary
The facility failed to accommodate the needs of two residents by not ensuring they could access the light switch located behind their beds. Resident #36, who has moderately impaired cognition and is bedbound, was unable to reach the light switch cord, which was broken and only 4 inches in length. Despite being in the room for over a year, she had not reported the issue to staff but expressed frustration over her lack of control over the light fixture. Observations confirmed the inaccessibility of the light switch cord over several days. Similarly, Resident #57, with severely impaired cognition, was also unable to access the light switch cord behind his bed. The cord was similarly broken and inaccessible, and he expressed a desire for it to be fixed. Staff, including a nurse aide and a nurse, acknowledged the issue during joint observations but had not noticed the problem previously. The Maintenance Manager, who routinely checks for repair needs, also failed to identify the issue, relying on staff reports for maintenance requests. The Director of Nursing and the Administrator both expected staff to be attentive to residents' environments and report repair needs promptly.
Inadequate Incontinence Care and Call Bell Accessibility
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident, resulting in the resident being found soaked with urine and soiled with bowel movement on multiple occasions. The resident, who was moderately cognitively impaired and dependent on staff for all activities of daily living, was found on two consecutive mornings with urine-soaked briefs, incontinence pads, sheets, and mattress. The resident's family member discovered the situation and reported it to the nursing staff, who confirmed the resident's condition. The night shift staff had reported the resident as not voiding, but the morning staff found evidence of incontinence that had not been addressed. Additionally, the resident was found with a bowel movement that had overflowed from the brief, pooling in the wheelchair and dripping onto the floor. The resident's call bell was out of reach, preventing him from alerting staff to his needs. The family member again discovered the situation and informed the nursing staff. The nurse aide responsible for the resident's care during the shift admitted to being overwhelmed with other duties and had not checked on the resident, relying instead on the call bell, which was not accessible to the resident. The facility's failure to provide timely incontinence care and ensure the resident's call bell was within reach led to the resident being left in an unhygienic and potentially harmful state. The nursing staff's inaction and reliance on the call bell system, without verifying its accessibility, contributed to the deficiency in care provided to the resident.
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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