Liberty Commons Nursing & Rehabilitation Center Of
Inspection history, citations, penalties and survey trends for this long-term care facility in Benson, North Carolina.
- Location
- 2315 Highway 242 North, Benson, North Carolina 27504
- CMS Provider Number
- 345519
- Inspections on file
- 21
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Liberty Commons Nursing & Rehabilitation Center Of during CMS and state inspections, most recent first.
The facility did not consistently resolve or communicate outcomes for repeated concerns about call-light response, housekeeping, and dietary services raised by residents during group meetings. Residents reported ongoing dissatisfaction, lack of updates, and difficulty voicing dietary complaints due to the separation of Resident and Dietary Councils. Staff interviews confirmed inconsistent documentation and follow-up, with no formal records kept for Dietary Council meetings and unclear processes for informing residents of resolutions.
A resident with bilateral below the knee amputations and hemiplegia was not accurately coded for limb prostheses on the MDS assessment, despite the care plan indicating use of bilateral prosthetic legs. Staff interviews confirmed the assessment error.
A resident admitted with heart disease and chronic venous hypertension was documented as receiving oxygen by nasal cannula, but the baseline care plan did not include oxygen therapy as a focus area. Staff interviews revealed the omission was due to the lack of a physician order for oxygen in the EMR at admission, and the care plan was not updated after oxygen use was identified.
A resident with cognitive impairment and multiple medical conditions did not receive quarterly smoking assessments as required by facility policy. Although the resident was identified as a supervised smoker and staff were notified electronically of pending assessments, only two assessments were completed during the review period, and staff were unaware of the missed assessments.
A resident with a PICC line for IV antibiotics did not receive a weekly sterile dressing change as ordered. The dressing remained unchanged for over a week, with documentation marked as not applicable and staff expressing confusion about responsibility and timing. Observations and interviews confirmed the order was not followed, resulting in a deficiency related to safe IV administration.
A resident with a history of heart disease was admitted and received oxygen therapy without a physician's order, and staff failed to post required 'oxygen in use' signage outside the resident's door. Multiple nurses documented oxygen use but did not record the amount administered, and the MAR/TAR lacked documentation of oxygen therapy. Staff interviews and observations confirmed these omissions, which were attributed to oversight and lack of communication among nursing staff.
The facility did not send the required transfer notice to the LTC Ombudsman when a resident was transferred to the hospital and did not return. Interviews and record review confirmed that the Ombudsman did not receive notifications for any discharges or transfers during that month, and facility staff could not provide documentation of such notification.
A resident with cognitive impairment and urinary incontinence experienced a delay in treatment for a urinary tract infection due to a failure in the facility's process for urine specimen collection and delivery to the laboratory. The initial specimen was not picked up as expected, leading to a three-day delay in diagnosis and treatment. Interviews with staff revealed a lack of communication and follow-up regarding the specimen pickup process.
A facility failed to document the return of a discontinued medication, Hydroxyzine HCl, for a resident. The medication was prescribed for 14 days, with 20 tablets delivered and seven doses administered. However, there was no documentation accounting for the remaining 13 tablets after discontinuation. Interviews with staff revealed that the facility lacked a return to pharmacy form, and the pharmacist confirmed no record of the medication's return.
A facility failed to conduct a PASRR screening for a resident with schizophrenia and anxiety before admission. The resident had a Level II PASRR for serious mental illness, which was changed to Level I without a new screening. The facility accepted the hospital's PASRR without submitting a new request, unaware of the requirement for a PASRR evaluation prior to admission.
Two residents requiring supplemental oxygen did not have proper physician orders or signage indicating oxygen use outside their rooms. Staff interviews revealed confusion and lack of responsibility for ensuring these protocols were followed, with the DON and Administrator acknowledging the absence of a consistent Lead Nurse to oversee these procedures.
A facility failed to maintain communication with a dialysis center for a resident with end-stage renal disease. The resident's dialysis communication forms were often incomplete, lacking vital signs and medication lists. Staff interviews revealed lapses in procedure adherence, with a nurse aide unable to recall obtaining vital signs and a nurse failing to complete necessary documentation, mistakenly believing the dialysis schedule had changed.
A resident admitted with dementia, depression, and anxiety was prescribed multiple antipsychotic medications, but the facility failed to conduct necessary monitoring for side effects. The baseline care plan required an AIMS assessment, which was not completed, and monitoring was discontinued shortly after admission. Staff interviews revealed that the oversight was due to a lapse in updating orders and the absence of clinical meetings during a holiday weekend.
The facility failed to ensure complete and accurate medical records for two residents, leading to deficiencies in medication administration and pressure sore care. Nurses reported issues with the electronic MAR system, and the Wound Nurse admitted to incomplete documentation due to difficulties with the new electronic medical record system.
The facility's QAPI Committee failed to maintain procedures and monitor interventions, leading to repeat deficiencies in maintaining accurate and complete medical records. During a complaint investigation, it was found that the facility failed to ensure medical records were complete and accurate for two residents, specifically regarding medication administration and pressure sore assessment and care. Additionally, during a previous survey, the facility failed to maintain an accurate MAR for a resident.
A resident who experienced an unwitnessed fall did not receive a timely x-ray due to a communication failure and transfer to a different section of the facility. The x-ray, eventually completed, revealed significant cervical spine injuries, leading to hospital evaluation and conservative treatment.
Failure to Address and Communicate Resolutions for Resident Concerns
Penalty
Summary
The facility failed to resolve and communicate resolutions for repeat concerns raised by residents during organized group meetings, specifically regarding call-light response times, housekeeping services, and dietary services. Over a six-month period, meeting minutes and communication forms showed that concerns were repeatedly voiced by residents, but there was inconsistent or absent documentation of follow-up actions or resolutions. In several instances, only select issues were addressed, while others, such as dietary and housekeeping concerns, were not documented as resolved. Residents reported that their concerns remained unaddressed over multiple months, and they did not receive updates about any actions taken. Residents expressed ongoing dissatisfaction with the facility's handling of their concerns, particularly regarding food quality, call light response, and room cleanliness. They reported feeling unable to voice dietary concerns during Resident Council meetings due to the creation of a separate Dietary Council, which they felt was not effective. Residents described the Dietary Manager as unapproachable and dismissive, and stated that they were not informed about the outcomes of their complaints. There was also a lack of formal documentation or minutes for Dietary Council meetings, and residents could not recall when these meetings last occurred or if the Dietary Manager attended. Interviews with staff, including the Activities Director, Dietary Manager, and Administrator, revealed a lack of consistent processes for documenting, tracking, and communicating the resolution of resident concerns. The Activities Director did not bring resolved or pending issues back to subsequent Resident Council meetings and did not keep formal records of Dietary Council meetings. The Administrator was unaware of the specifics of concerns discussed in Dietary Council meetings and did not consistently document follow-up actions. This lack of communication and documentation contributed to residents' perceptions that their concerns were not being addressed.
Inaccurate MDS Coding for Prosthetics
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident with bilateral below the knee amputations and a history of hemiplegia and hemiparesis following cerebral infarction. Record review showed that the resident's care plan included the use of bilateral prosthetic legs, but the quarterly MDS assessment did not indicate the presence of limb prostheses. During interviews, the MDS Coordinator acknowledged that the assessment should have reflected the resident's use of bilateral prosthetics and confirmed the coding error. The Administrator also confirmed that the MDS assessments should have been coded accurately for the resident's prosthetics.
Omission of Supplemental Oxygen in Baseline Care Plan
Penalty
Summary
The facility failed to include the use of supplemental oxygen on the baseline care plan for a resident who was admitted with diagnoses including atherosclerotic heart disease and chronic idiopathic venous hypertension with ulcers to both lower legs. Although the hospital discharge summary did not indicate the use of oxygen, nursing documentation showed that the resident was receiving oxygen by nasal cannula shortly after admission. The baseline care plan created for the resident addressed pressure ulcers, wound care, pain and anti-anxiety medications, and the use of a PICC line for IV antibiotics, but did not mention oxygen therapy as a focus area. Interviews with staff revealed that the MDS Coordinator was unaware the resident had been receiving oxygen since admission, and the omission was attributed to the absence of a physician order for oxygen in the electronic medical record at the time of admission. The MDS Nurse later assessed the resident for oxygen use but did not update the baseline care plan accordingly. The administrator confirmed that the individualized, person-centered baseline care plan should be accurate and updated as needed, and acknowledged that the omission occurred because the hospital discharge orders did not include oxygen therapy.
Failure to Complete Required Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for a resident who was identified as a smoker. According to the facility's smoking policy, smoking assessments are required upon admission, quarterly, and upon any change in the resident's condition. Record review showed that the resident, who had diagnoses including hypertension, muscle weakness, dementia, and partial blindness, was admitted and coded for tobacco use on both annual and quarterly Minimum Data Set (MDS) assessments. The resident required assistance with most activities of daily living and used a wheelchair. Despite the policy, only two smoking assessments were documented within the review period, and there were missed quarterly assessments. Staff interviews revealed that Team Leaders and the Assistant Director of Nursing (ADON) were responsible for completing these assessments, with the computer system set to notify staff when assessments were due. However, both the Team Leader and the ADON were unaware that the required quarterly smoking assessments for the resident had not been completed as scheduled. The resident was observed smoking under supervision, and the care plan indicated the need for quarterly assessments, but this intervention was not consistently implemented as per policy.
Failure to Perform Timely PICC Dressing Change as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to perform a weekly dressing change to a resident's peripherally inserted central catheter (PICC) as ordered. The resident, who was admitted with chronic idiopathic venous hypertension and ulcers, had a physician order for weekly sterile PICC dressing changes and daily monitoring for catheter migration. Despite these orders, there was no documentation that the PICC dressing had been changed since admission, and the Medication Administration Record (MAR) showed that the dressing change was marked as not applicable on the scheduled day. Observations confirmed that the PICC dressing remained unchanged for more than a week, with the original dressing date still present during multiple checks. Interviews with nursing staff revealed confusion regarding responsibility for the dressing change and the correct timing, with Nurse #1 stating she did not change the dressing because she believed it was not yet due and was told to record it as not applicable. Team leaders and the Assistant Director of Nursing clarified that the assigned nurse was responsible for the dressing change and that the order should have been followed as written. Further interviews indicated a lack of communication and clarity among staff regarding the implementation of the physician's order and facility policy. The Director of Nursing and Administrator both confirmed that the dressing should have been changed according to the order and policy, but this was not done. The deficiency was identified through record review, observation, and staff interviews, which established that the facility did not ensure the safe and appropriate administration of IV fluids by failing to perform the required PICC dressing change.
Failure to Obtain Physician Order and Post Oxygen Use Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of atherosclerotic heart disease was admitted to the facility and began receiving oxygen therapy without a physician's order. The hospital discharge orders did not include oxygen therapy, and there was no documentation in the physician progress notes or the electronic medical record (EMR) indicating an order for oxygen. Multiple nurses documented that the resident was receiving oxygen via nasal cannula, but none recorded the amount of oxygen administered. Interviews with nursing staff revealed confusion and lack of recall regarding the presence of an oxygen order, with several staff members acknowledging that an order should have been obtained and entered into the EMR but was not done until several days after admission. Additionally, the facility failed to ensure that appropriate signage indicating 'oxygen in use' was placed outside the resident's door while the resident was receiving oxygen therapy. Nursing documentation and staff interviews confirmed that the signage was not posted, and staff could not recall why this step was missed. Observations confirmed that the resident was receiving oxygen therapy without the required signage being present on the door. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect documentation of oxygen use for the resident during the period in question. Interviews with the Director of Nursing and other team leaders confirmed that it was the responsibility of nursing staff to ensure both the physician order and the signage were in place when oxygen therapy was initiated. The deficiency was attributed to oversight and lack of communication among the nursing staff and team leaders during the admission process.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to send a required notice of transfer to the Long-Term Care (LTC) Ombudsman for one of two residents who were transferred to the hospital. Record review showed that a resident was transferred to the hospital and did not return to the facility. Interviews with the Social Services Director revealed that, although the department typically notifies the Ombudsman via email about discharges and transfers, there was no documentation in facility records confirming that the Ombudsman was notified of any discharges or transfers for the month in which the resident was transferred. The LTC Ombudsman confirmed that no notifications were received for that month, including for the resident in question. The Administrator acknowledged that the required email was not sent for that month, although documentation was available for subsequent months.
Delay in Urine Specimen Collection and Analysis
Penalty
Summary
The facility failed to ensure a collected urine specimen was delivered to the laboratory for analysis, resulting in a delay in treatment for a urinary tract infection for a resident. The resident, who was admitted with pneumonia and was moderately cognitively impaired, frequently incontinent of urine, and required assistance with toileting, complained of burning on urination. A urine specimen was collected by a nurse and placed in a refrigerator for laboratory personnel to pick up. However, the specimen was not picked up as expected, and there were no urinalysis results for the initial specimen. The laboratory patient log sheet indicated that the urine specimen was not picked up on the date it was collected, and the nursing staff was not aware that laboratory personnel would not be picking up specimens on weekends. As a result, another urine specimen had to be collected three days later, which was then picked up and analyzed. The delay in specimen collection and analysis postponed the diagnosis and treatment of the resident's urinary tract infection. Interviews with facility staff, including the nurse who collected the specimen, the administrator, and the director of nursing, revealed a lack of communication and follow-up regarding the specimen pickup process. The physician involved in the resident's care explained that antibiotics were not ordered until the urinalysis and culture and sensitivity results were available, which further delayed the start of treatment for the urinary tract infection.
Failure to Document Return of Discontinued Medication
Penalty
Summary
The facility failed to document the return of a discontinued medication, Hydroxyzine HCl, for a resident. The resident was prescribed Hydroxyzine HCl 25 mg every six hours as needed for anxiety or itching for 14 days. A total of 20 tablets were delivered to the facility, and seven doses were administered to the resident. However, there was no documentation on a medication return to pharmacy form accounting for the remaining 13 tablets after the medication was discontinued. Interviews with facility staff, including a nurse, the Assistant Director of Nursing, and the Director of Nursing, revealed that the facility did not have a return to pharmacy form indicating the return of the medication. The staff explained that discontinued medications were placed in a box for pharmacy pickup, but the return to pharmacy form was sometimes not copied for the facility's records. The pharmacist confirmed that the pharmacy had no documentation of the medication's return and stated that it was the facility's responsibility to request the necessary forms.
Failure to Conduct PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of schizophrenia and anxiety had a Preadmission Screening and Resident Review (PASRR) conducted prior to admission. The resident, who had a Level II PASRR for serious mental illness from 2015 to 2022, was changed to a Level I PASRR on March 30, 2022. However, there was no evidence of a PASRR screening conducted since that date. The resident was admitted to the facility with severe cognitive impairment and had not received psychotropic medication in the past seven days. The facility's administrator revealed that the Level I PASRR received from the hospital was accepted without submitting a new request, as the facility's policy was to use an open and active PASRR regardless of its age. The administrator was unaware that residents with serious mental illness required a PASRR evaluation prior to admission. The marketing director confirmed that the facility accepted the hospital's PASRR and did not submit a new Level I PASRR at admission, relying on the state PASRR system's information.
Failure to Ensure Proper Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents requiring supplemental oxygen. Resident #197 was admitted with diagnoses of pneumonia and congestive heart failure, requiring oxygen therapy. However, there was no physician order for the use of oxygen in the resident's medical record, despite the resident receiving 2.5 liters per minute of oxygen via nasal cannula. Additionally, there was no signage indicating oxygen use outside the resident's room. Interviews with staff revealed confusion and lack of responsibility regarding the placement of oxygen signage, with multiple staff members acknowledging the oversight but unable to explain why it occurred. Similarly, Resident #196, admitted with pneumonia and chronic obstructive pulmonary disease, had a physician order for continuous oxygen therapy at 3 liters per minute. Despite this, there was no signage outside the resident's room to indicate oxygen use. Staff interviews indicated that the responsibility for placing the signage was unclear, with several staff members acknowledging the absence of the sign but failing to rectify the situation. The Director of Nursing and the Administrator both acknowledged the deficiencies, noting the absence of a consistent Lead Nurse to ensure proper procedures were followed. The lack of clear responsibility and oversight led to the failure to post necessary oxygen signage and obtain physician orders, compromising the facility's compliance with safety protocols for residents requiring oxygen therapy.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis treatment center for a resident with end-stage renal disease who required dialysis. The resident was scheduled to receive hemodialysis three times per week, and the care plan included interventions such as checking for bleeding, observing for signs of infection, and assisting with transfers post-dialysis. However, a review of the resident's dialysis communication notebook revealed that 8 out of 13 communication forms were not completed by the facility staff prior to dialysis treatment. These forms lacked essential information such as pre-dialysis vital signs, weight, and vascular access details. Additionally, the dialysis center requested a current list of the resident's medications on two occasions, but the facility failed to provide this information. Interviews with facility staff revealed lapses in communication and procedure adherence. A nurse aide responsible for the resident's pre-dialysis preparation could not recall obtaining vital signs on a specific date. A nurse admitted to not completing the dialysis communication form or sending the medication list, mistakenly believing the resident's dialysis schedule had changed. The dialysis center nurse confirmed that the facility staff were not completing the necessary communication forms and had not sent the requested medication list. The Director of Nursing acknowledged that the assigned nurse was responsible for completing the communication form and sending the medication list, which was not done as required.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to implement proper monitoring for side effects in a resident receiving antipsychotic medications. The resident, who was admitted with diagnoses including dementia, depression, and anxiety, was prescribed multiple antipsychotic medications such as Risperidone, Quetiapine Fumarate, Lorazepam, and Haloperidol. Despite the baseline care plan indicating the need for an Abnormal Involuntary Movement Scale (AIMS) assessment and monitoring for side effects, there was no documentation of such assessments being conducted. Additionally, the monitoring for antipsychotic side effects was discontinued shortly after the resident's admission. Interviews with nursing staff revealed that the order to monitor for antipsychotic side effects from a previous admission was not properly updated, and a new batch order for monitoring was not activated. The Director of Nursing acknowledged that the nursing staff should have completed an AIMS assessment and documented side effects on the Medication Administration Record (MAR). The oversight was attributed to the resident's admission occurring before a holiday and weekend, during which no morning clinical meetings were held to address the need for an AIMS assessment.
Deficiencies in Medication Administration and Pressure Sore Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for two residents, leading to deficiencies in medication administration and pressure sore assessment and care. For Resident #2, the Medication Administration Records (MARs) from February through April 2024 showed inconsistencies and potential errors in documenting the administration of Carvedilol. Multiple nurses reported that they would not have administered the medication if the resident's pulse was below the specified threshold, yet the MARs indicated otherwise. Additionally, there were instances where the MARs were left blank without proper documentation of whether the medication was refused or the resident was away from the facility. The Director of Nursing (DON) also found her initials on the MARs despite not administering medications, suggesting a possible error in the electronic record system. For Resident #6, the facility failed to accurately document the presence and treatment of pressure sores. Upon admission, a nurse incorrectly documented a sacral pressure sore that was actually scar tissue. Furthermore, a physician's order for wound care did not specify the site initially, leading to incomplete documentation in the Treatment Administration Record (TAR). The Wound Nurse admitted to difficulties with the new electronic medical record system, resulting in missed entries for dressing changes and incorrect measurements being recorded for the sacral pressure sore. The Wound Nurse prioritized actual wound care over documentation, leading to incomplete records. The deficiencies in documentation and record-keeping were further highlighted by the interviews with the nursing staff and the DON. Nurses reported issues with the electronic MAR system, including glitches and lockouts, which may have contributed to the inaccuracies. The DON acknowledged the need for more training on the electronic medical system to prevent such errors. The incomplete and inaccurate records for both residents indicate a systemic issue with the facility's documentation practices, particularly concerning the electronic medical record system.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility's Quality Assurance/Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor interventions following the recertification survey. This resulted in a repeat deficiency related to the failure to maintain accurate and complete medical records. During a complaint investigation, it was found that the facility failed to ensure medical records were complete and accurate for two residents, specifically regarding medication administration and pressure sore assessment and care. Additionally, during a previous recertification survey, the facility failed to maintain an accurate Medication Administration Record (MAR) for one resident. The Administrator, who was not employed at the time of the previous citation, indicated that the nursing staff had not reported any issues with documentation accuracy in the residents' electronic medical records, preventing the QAPI program from addressing these problems effectively.
Failure to Obtain Timely X-ray for Resident After Fall
Penalty
Summary
The facility failed to obtain an x-ray as ordered for a resident who experienced an unwitnessed fall. The resident, who had multiple diagnoses including stroke, muscle weakness, and severe cognitive impairment, was found on the floor by a nurse aide. The nurse assessed the resident and found no immediate signs of pain or injury. However, the nurse practitioner later noted the resident was experiencing neck pain and ordered a cervical and lumbar spine x-ray. This order was confirmed in the electronic medical record but was not communicated to the x-ray vendor, resulting in the x-ray not being completed before the resident was transferred to the assisted living section of the facility the following day. The x-ray order did not carry over to the new record in the assisted living section, leading to a delay in the diagnostic test being performed. The resident's responsible party discovered the x-ray had not been completed during a visit and informed the nurse practitioner, who reordered the x-ray. The x-ray was eventually completed and revealed significant findings, including a cervical spine subluxation and a Type II dens fracture. The resident was then transferred to the hospital for further evaluation. The hospital confirmed the fracture and, after consulting with the family, decided against surgical intervention. The resident was placed in a cervical collar and returned to the facility for conservative treatment. Interviews with the Director of Nursing and other staff revealed that the failure to complete the x-ray was due to a misunderstanding of responsibilities. The nurse who confirmed the order in the electronic medical record assumed the nurse practitioner had contacted the x-ray vendor. This oversight, combined with the resident's transfer to a different section of the facility, resulted in the x-ray order being overlooked. The facility identified this issue and implemented a corrective action plan to prevent future occurrences.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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