Lillington Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lillington, North Carolina.
- Location
- 1995 East Cornelius Harnett Boulevard, Lillington, North Carolina 27546
- CMS Provider Number
- 345213
- Inspections on file
- 25
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Lillington Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
A resident was transferred or discharged without the facility ensuring that their needs and preferences were met, and without adequate preparation for a safe transition.
A resident with a recent hip replacement did not receive proper accounting and administration of a controlled pain medication when a nurse mistakenly removed Tramadol from another resident's supply and failed to document the error correctly. The MAR and controlled drug records contained discrepancies, and required procedures for reporting and documenting the incident were not followed.
Breakfast meal trays were delivered significantly later than scheduled to all residents due to a staffing shortage in the dietary department, resulting from two cooks calling out. Staff provided cereal and milk as an alternative during the delay, and communication about the delay was managed through group chat. The Administrator confirmed that timely meal delivery is expected and that snacks should be offered if meals are late.
Due to the absence of a scheduled cook and reliance on a replacement from another facility who arrived late, breakfast was not served on time to all resident halls. Only three dietary staff were scheduled, and ongoing staff turnover contributed to the inability to provide timely meal service.
Surveyors found that all dumpster doors were left open on multiple occasions, with debris observed nearby. Both dietary and housekeeping staff were identified as responsible for maintaining cleanliness and closing the dumpster doors, but the issue persisted over several days.
A medication error rate above 5% was observed when a resident did not receive a scheduled omeprazole dose due to the medication being out of stock, and three residents with diabetes received fast-acting insulin more than an hour before their meals, contrary to recommended administration timing. Nursing staff did not ensure medication availability or proper timing of insulin administration, resulting in multiple errors.
Surveyors identified that fast-acting insulin was administered to three residents with diabetes more than an hour before their meals were served, contrary to manufacturer instructions and physician orders. Nursing staff gave insulin based on scheduled blood sugar checks without confirming meal tray delivery times, leading to significant medication errors. Facility leadership confirmed that insulin should only be administered shortly before meals are available.
Surveyors found that leftover food items, including chicken soup, diced ham, spinach, cauliflower puree, and sliced turkey, were stored in a refrigerator beyond the facility's 48-hour holding policy. Despite established procedures for labeling and disposing of leftovers, these items were not removed as required, as confirmed by interviews with the Dietary Manager and Administrator.
A resident who is legally blind and dependent on staff for mobility was repeatedly unable to access their adaptive flat call bell, as it was found out of reach on several occasions. Staff interviews confirmed inconsistent placement of the call bell and a lack of care plan interventions to address the resident's needs, resulting in the resident being unable to request assistance when needed.
A cognitively intact resident with a known history of aggressive behaviors was able to leave supervised areas and physically assault another resident in the courtyard, resulting in multiple skin tears. Despite interventions such as 15-minute checks and keeping the resident at the nurse's station, staff were unable to prevent the altercation, and there was confusion among staff regarding the implementation of one-to-one supervision at the time of the incident.
A resident with a chronic venous ulcer did not receive daily wound care as ordered on multiple occasions. Nursing staff failed to provide or offer wound care on specific days due to lack of awareness of updated orders, and there was no documentation of care or refusal. The wound dressing was observed unchanged, and both the resident and their representative confirmed missed care over the weekend.
A resident with severe cognitive impairment and dysphagia, who required a pureed diet, was given a meal containing mechanically chopped sausage instead of the ordered pureed consistency. The NA left the resident alone with the meal, did not report the dietary error, and the Resource Nurse was unaware of the incident until later. This resulted in a failure to ensure the resident received the correct diet and adequate supervision.
A resident with dysphagia and a physician's order for a pureed diet was served a mechanically chopped breakfast meal. The assigned nursing assistant recognized the error but did not replace the food or report the incident. Dietary and nursing staff interviews confirmed the resident's diet order was in the system, but the error was not identified or corrected before the meal was served.
A resident with severe cognitive impairment and a history of falls with major injury returned from the hospital after hip surgery with a care plan intervention for fall mats at the bedside. Despite this, staff failed to place fall mats beside the bed while the resident was in bed, leaving them folded in the room corner. Staff interviews confirmed the intervention was not implemented as required.
Surveyors found that both a wound care cart containing topical medications and a blood glucose cart containing insulin were left unlocked and unattended in hallways, accessible to residents. Nursing staff confirmed that the carts could not be secured due to missing keys or improper use of locks, and the DON was unaware of the issues with cart security. Both incidents involved staff leaving medication carts out of their sight while performing care, with medications and insulin pens accessible during these times.
Two residents who were transferred to the hospital did not have written notification of transfer/discharge or the bed-hold policy mailed to their representatives. Staff relied on telephone calls for notification and were unaware of the requirement to send written notices, as confirmed by interviews with admissions staff and the administrator.
Two residents had inaccurate MDS assessments: one was not properly coded following re-admission after a hip fracture, and another's assessment failed to reflect an updated Level 2 PASRR status due to outdated information in the electronic medical record.
A facility failed to maintain accurate documentation for a resident's wound care treatments. A physician's order for daily treatment of a sacral wound was incorrectly entered as 'as needed' (PRN), leading to a lack of documentation throughout August. Additionally, daily treatments for a left heel wound were not documented on several occasions. Staff reported completing the treatments but often forgot to document them. The DON and Administrator were unaware of these issues, which may have been affected by a recent change in the documentation system.
A resident with a history of stroke and severe cognitive impairment experienced a skin tear that became infected due to the facility's failure to provide timely wound management. Despite initial treatment, there were lapses in documentation and communication, leading to delayed wound care and lack of weekly assessments.
The facility failed to meet the nutritional needs of residents by not having a pre-approved renal diet menu, not serving pureed bread to residents on a pureed diet, and serving incorrect portion sizes of meat and potatoes to residents on mechanical soft and regular diets. These deficiencies were confirmed by the CDM, RD, and Cook #1.
The facility failed to implement its abuse policy in reporting, investigating, and protecting residents in response to allegations of physical abuse. One resident alleged being pushed by a nursing assistant, and another reported being punched by a resident from an adjoining ALF. The incidents were not reported to the state agency within the required timeframe, and proper investigation procedures were not followed.
The facility failed to prevent ice build-up on boxes of frozen food in the walk-in freezer, leading to potential contamination. Observations revealed icicles from the condenser pipe dripping onto boxes of vegetables, which were not properly sealed. The issue was confirmed by the CDM and Cook #2, and the Maintenance Director was unaware of the problem.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies. These included failure to protect a resident from abuse, inadequate wound management, failure to schedule a medical appointment, and improper food storage practices.
The facility failed to protect a resident from physical abuse when a verbal disagreement between two residents escalated into a physical altercation, resulting in one resident sustaining a laceration to the left upper eyelid. Despite interventions in the care plan, the altercation occurred, and staff interviews revealed that the residents were separated by staff members after the fight. The facility's DON and Administrator acknowledged the incident, with the Administrator stating that the altercation could be considered abuse if performed willfully.
A resident with obstructive uropathy and an indwelling catheter did not have a urology consult scheduled as ordered by the physician. The Medical Records Coordinator admitted to overlooking the appointment, and both the DON and Administrator confirmed that the appointment should have been scheduled when the order was placed. The Physician stated the delay did not cause harm.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Accurately Account for and Administer Controlled Pain Medication
Penalty
Summary
The facility failed to ensure accurate accounting and administration of a controlled pain medication for one resident following hip replacement surgery. The resident, who was cognitively intact, had a physician's order for Tramadol 50 mg twice daily. On the evening in question, the Medication Administration Record (MAR) indicated that a nurse had documented administration of the medication, but the Controlled Drug receipt/Record/Disposition Form showed no Tramadol was removed from the resident's supply. Instead, the nurse had mistakenly removed Tramadol from another resident's supply and did not properly document the error or the actual recipient of the medication. The resident reported receiving the medication late that evening, while the nurse provided conflicting times for administration and inaccurately recorded the removal time on the other resident's controlled drug form. Further review revealed that the nurse did not follow proper procedures for documenting and reporting the medication error, including failing to notify a supervisor and obtain two signatures on the controlled drug forms as required. The documentation on both the MAR and the controlled drug forms did not match the actual events, leading to discrepancies in the records. Interviews with the Director of Nursing and the facility's Nurse Consultant confirmed that the documentation and handling of the controlled medication did not meet facility protocols for accuracy and accountability.
Delayed Breakfast Meal Service Due to Dietary Staffing Shortage
Penalty
Summary
On 5/22/2025, the facility failed to provide breakfast meals at the scheduled times for all residents who received food by mouth across all seven halls. Scheduled breakfast serving times ranged from 7:00 AM to 8:00 AM depending on the hall, but observations revealed that, except for the 500 hall, breakfast trays did not arrive on any hall by 9:00 AM. The 100 hall, for example, did not receive breakfast trays until 9:40 AM. During this delay, nursing staff offered cereal and milk to residents as an alternative, and there were no issues identified with diabetic residents receiving their meals later than usual. Interviews with staff indicated that the delay was due to two cooks calling out, which left the dietary department short-staffed. The Dietary Manager became aware of the staffing shortage at 7:00 AM and was unable to schedule replacement staff in time. A team from a sister facility arrived to assist, but meal preparation did not begin until 8:00 AM. Staff reported that they typically communicate tray delays and snack availability through a group chat. The Administrator confirmed that food trays are expected to be delivered on time and that snacks should be offered if trays are late.
Insufficient Dietary Staffing Delays Breakfast Service
Penalty
Summary
The facility failed to provide sufficient dietary staff to serve breakfast on time for all seven halls on the morning of 5/22/2025. Breakfast was scheduled to be served between 7:00 AM and 8:00 AM, but observations showed that breakfast carts did not arrive on the halls until between 9:00 AM and 9:40 AM. The delay occurred because the scheduled cook did not report to work, and the facility had to call in a replacement from a sister facility, who arrived at 7:30 AM. The replacement cook was not regularly assigned to the dietary department and had to travel two hours to reach the facility, further contributing to the delay in meal preparation and service. Interviews with the Dietary Manager and Administrator confirmed that only three dietary staff were scheduled for the morning, and the absence of the cook led to the need for last-minute coverage. The Administrator also noted ongoing concerns with staff turnover and the need to re-educate new dietary staff, which has prevented consistent improvement in resident satisfaction with dietary services. No specific residents were identified as being directly affected in the report, but the deficiency impacted all resident halls scheduled for breakfast service.
Failure to Close Dumpster Doors and Maintain Cleanliness
Penalty
Summary
Surveyors observed that all four dumpsters at the facility had their doors left open during multiple site visits, with debris such as paper and blue plastic gloves found on the ground near one of the dumpsters. These observations were made on several occasions over consecutive days, indicating a repeated failure to close the dumpster doors and maintain cleanliness in the area. Interviews with the Dietary Manager and Housekeeping Manager confirmed that both dietary and housekeeping staff were responsible for the cleanliness and closure of the dumpster doors, with dietary staff primarily responsible due to the proximity of the dumpsters to their work area. The Administrator also stated that it was her expectation for staff to keep the area clean and the dumpster doors closed.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed and Improperly Timed Doses
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with 4 errors observed out of 33 opportunities, resulting in a 12.12% error rate. One incident involved a resident with a physician's order for omeprazole oral suspension via G-tube twice daily for GERD, scheduled for administration at 9:00 AM and 9:00 PM. During a medication pass, the nurse did not administer the scheduled 9:00 AM dose because the medication was out of stock and had not been reordered or refilled in advance. The nurse acknowledged not realizing the medication was unavailable and planned to contact the provider after the omission was identified. Additional errors involved the administration of fast-acting insulins (insulin lispro and insulin aspart) to three residents with diabetes. The insulins were administered more than an hour before the residents received their meal trays, contrary to manufacturer instructions and facility expectations that such insulins be given 15–30 minutes before meals. The nurse responsible stated she administered the insulin after scheduled blood sugar checks, anticipating meal trays would arrive soon, but was unsure of the exact timing. Both the DON and the facility Administrator confirmed that insulin should not be administered until meals are imminent and that medication refills should be requested in advance to prevent missed doses.
Significant Medication Errors: Early Administration of Fast-Acting Insulin
Penalty
Summary
Surveyors found that the facility failed to prevent significant medication errors involving the administration of fast-acting insulin to three residents with diabetes. Nurses administered insulin lispro and insulin aspart to these residents more than one hour before their meal trays were delivered, despite manufacturer instructions and physician orders specifying that these medications should be given within 15 minutes before or immediately after a meal. Specifically, one resident received insulin 1 hour and 30 minutes before eating, another 1 hour and 28 minutes before, and a third 1 hour and 23 minutes before their meals arrived. All three residents had orders for sliding scale insulin to be administered before meals and at bedtime due to their diabetes diagnoses. Nurse interviews revealed that blood sugar checks and insulin administration were performed according to a scheduled time, without confirmation of when meal trays would actually be delivered. The nurse involved acknowledged that insulin should not have been administered more than 30 minutes before meals. The DON and Medical Director both confirmed that fast-acting insulin should be administered 15-30 minutes before meals and not before meal trays are present, as per facility expectations and standard practice. The administrator also confirmed that insulin should not be given until meal trays are in the vicinity.
Failure to Remove Expired Leftover Food from Refrigerator
Penalty
Summary
Surveyors observed that leftover prepared food items were stored in the reach-in refrigerator past the facility's stated 48-hour holding policy. Items such as chicken soup, diced ham, spinach, cauliflower puree, and sliced turkey were found with preparation dates ranging from 5/10/25 to 5/15/25, exceeding the allowable storage time. The Dietary Manager confirmed that leftovers are to be cooled, wrapped, dated, and disposed of after 48 hours, with cooks responsible for daily checks and disposal. Despite these procedures, the outdated food remained in the refrigerator, indicating a failure to follow established food storage protocols. No specific residents or patient medical histories were mentioned in relation to the deficiency. The deficiency was identified through direct observation and staff interviews, with the Administrator confirming that food storage should align with facility policy and food safety guidelines.
Failure to Ensure Adaptive Call Bell Accessibility for Legally Blind Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a legally blind resident's adaptive flat call bell was consistently placed within reach, preventing the resident from being able to request assistance as needed. The resident, who was moderately cognitively impaired and dependent on staff for all mobility, was observed on multiple occasions unable to locate or access the adaptive call bell. On one occasion, the call bell was hanging from the back side of the mattress, out of the resident's reach, and the resident was observed searching for it without success. On another occasion, the call bell was found in a chair four feet away from the bed, again out of reach, while the resident attempted to locate it. The resident stated that staff placed the call bell wherever they wanted, and staff interviews confirmed that the call bell was not always positioned appropriately. The resident's care plan, which noted legal blindness, did not include specific interventions to ensure the call bell was kept within reach. Staff interviews revealed a lack of awareness regarding the proper placement of the adaptive call bell, and it was also noted that the resident's adaptive call bell had been mistakenly switched with a push button call bell intended for a roommate. Both nursing staff and the Director of Nursing acknowledged that the adaptive call bell should have been within the resident's reach at all times and that the use of a push button call bell was not appropriate for a blind resident.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
A cognitively intact resident with a history of behavioral issues, including aggression toward staff and other residents, was involved in a physical altercation with a moderately cognitively impaired resident. The aggressive resident had documented behaviors such as throwing items, cursing, and hitting, and was supposed to be under close supervision, including 15-minute checks and being kept at the nurse's station due to agitation earlier in the day. Despite these interventions, the resident was able to leave the nurse's station and enter the courtyard, where the incident occurred. On the day of the incident, the aggressive resident exhibited escalating behaviors, including attempting to hit a physician and being verbally abusive. Staff, including the Rehabilitation Director and a Physical Therapy Assistant, intervened during these episodes but were unable to prevent the resident from later accessing the courtyard. In the courtyard, the resident engaged in an argument with another resident and subsequently struck him multiple times with an ashtray holder, causing several small skin tears on the victim's arms and finger. Witnesses, including a medication aide and a housekeeper, intervened to separate the residents and remove the weapon. The incident was reported by staff who witnessed the altercation, and it was confirmed that the aggressive resident was not under one-to-one supervision at the time of the event, despite prior behavioral concerns and interventions. The staff interviewed were unclear about the timing and implementation of the one-to-one observation, and the Director of Nursing was unable to explain how the resident left the nurse's station. The failure to maintain effective supervision and prevent the resident from accessing and harming another resident resulted in a deficiency related to protecting residents from abuse.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide wound care as ordered for a resident with a chronic left lower extremity venous ulcer and pyoderma gangrenosum. The resident had a care plan and physician orders specifying daily wound care, including cleansing, application of collagen particles, Xeroform, ABD pads, and Kerlix. Despite these orders, there was no documentation of wound care being provided or refused on four specific dates, and staff interviews confirmed that wound care was not offered or performed on those days. The nurse supervisor responsible for the resident's wound care on weekends did not provide or offer wound care, mistakenly believing the treatment was only required three times a week. She was unaware of the updated daily wound care order and had not checked the electronic medical record for new orders. The unit manager also could not recall a change in the frequency of wound care, indicating a lack of awareness and communication regarding the resident's current treatment plan. Observations revealed that the resident's wound dressing was not changed over the weekend, as confirmed by both the resident and their representative. The dressing was found with dried drainage and lacked date or initials to indicate when it was last changed. The wound nurse practitioner confirmed that the frequency of wound care had been increased to daily to ensure more consistent care, and stated that wound care should have been attempted on the missed dates.
Failure to Provide Ordered Pureed Diet to Resident with Dysphagia
Penalty
Summary
A severely cognitively impaired resident with diagnoses including progressive supranuclear palsy, secondary parkinsonism, and dysphagia was admitted with a physician's order for a pureed diet, thin liquids, and double protein. The resident's care plan noted a risk for injury related to his medical conditions, a history of pocketing food, and a tendency to refuse staff assistance during meals. On the observed morning, the resident was found eating from a bowl containing grits, scrambled eggs, and sausage, with the eggs and sausage appearing to be of mechanically chopped texture rather than the required pureed consistency. The resident was able to feed himself and was left alone with the meal by the assigned nursing assistant (NA). The NA admitted to placing some of the remaining eggs and sausage into the resident's bowl of grits and leaving it with him, despite knowing the sausage was not pureed as ordered. The NA did not report the dietary error to the Resource Nurse, who was also unaware of the incident until interviewed. The dietary staff confirmed that pureed and mechanically chopped sausages were stored separately and looked different. Both the DON and the Administrator stated their expectation that residents receive the correct food consistency as ordered. The failure to ensure the resident received the prescribed pureed diet and to report the dietary error constituted a deficiency in providing adequate supervision and accident hazard prevention.
Resident Served Incorrect Food Texture Despite Pureed Diet Order
Penalty
Summary
A deficiency occurred when a resident with a physician's order for a pureed diet was served a mechanically chopped breakfast meal. The resident, who had diagnoses including Progressive Supranuclear Palsy, secondary Parkinsonism, and dysphagia, required a pureed diet due to swallowing difficulties. Documentation confirmed the diet order for pureed texture and thin liquids, and the care plan included interventions to ensure the resident received the appropriate diet and assistance as needed. On the morning of the observed deficiency, the resident was served a breakfast containing grits, scrambled eggs, and sausage, with the eggs and sausage appearing to be mechanically chopped rather than pureed. The nursing assistant assigned to the resident acknowledged that the sausage was not pureed and stated she had intended to replace it but did not do so after the resident indicated he did not want sausage. The nursing assistant did not report the dietary error to the Resource Nurse as initially claimed, later admitting she had not reported it at all. Interviews with dietary and nursing staff revealed that the resident's diet order was entered into the computer system and tray tickets were used to guide meal preparation. The Dietary Manager could not explain how the mechanically chopped food was served instead of pureed, and the staff member responsible for preparing the food stated she was unaware of the error. Both the Director of Nursing and the Administrator confirmed their expectation that residents receive food in the correct consistency as ordered.
Failure to Implement Care Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement a care planned intervention for a resident with a history of falls and major injuries. The resident, who had diagnoses of non-Alzheimer's dementia and Parkinson's disease, was identified as being at risk for falls due to cognitive impairment. After sustaining a right hip fracture from a fall and undergoing surgery, the resident's care plan was revised to include the use of fall mats at the bedside upon return from the hospital. Despite this intervention being documented in the care plan, observations on multiple occasions revealed that fall mats were not placed beside the resident's bed while the resident was in bed. Instead, the fall mats were found folded in the corner of the room. Staff interviews confirmed that the fall mats should have been positioned beside the bed and that it was the responsibility of the nursing staff to ensure this intervention was in place. Both a medication aide and a nurse acknowledged the omission, and the Director of Nursing also stated that fall mats should have been present when the resident was in bed. The lack of implementation of this care planned intervention was directly observed and corroborated by staff, indicating a failure to follow the established care plan for accident prevention.
Unsecured Medication and Insulin Carts Observed Unattended
Penalty
Summary
Surveyors observed that the facility failed to secure medications on two separate medication carts: a wound care cart containing topical medications and a blood glucose cart containing insulin. On one occasion, two nurses prepared and administered wound care to a resident while leaving the wound care cart unlocked and unattended in the hallway, with the lock extended outward and covered in tattered medical tape. The cart, which contained various topical medications and wound care solutions, was left out of sight of the nurses while they were inside the resident's room, and self-propelling residents in wheelchairs were present nearby. Interviews with the nurses revealed that the wound care cart had been left unlocked for several weeks due to a lack of a key, and the Director of Nursing was unaware of the reason for the tape on the lock or the lack of access to a key for the wound care nurse. In a separate incident, the blood glucose cart was found unattended in a hallway with the lock extended and the key inserted. This cart contained insulin flex pens for sixteen residents. The nurse responsible for the cart confirmed that it should have been locked when unattended but could not provide a reason for leaving it unlocked with the key in place. The Director of Nursing also confirmed that the insulin pens were stored on the cart and that the key should have remained with the nurse at all times when the cart was unattended. Throughout these observations, it was noted that both medication carts were left unsecured in areas accessible to residents, and staff interviews confirmed a lack of adherence to proper medication storage protocols. The failure to secure these carts was directly observed by surveyors and acknowledged by the staff involved, with no immediate explanation or corrective action provided at the time of the incidents.
Failure to Provide Written Transfer/Discharge Notices and Bed-Hold Policy
Penalty
Summary
The facility failed to provide written notification to resident representatives regarding the reason for transfer or discharge to the hospital, and did not mail a copy of the bed-hold policy for two residents who were hospitalized. For one resident with moderate cognitive impairment, nursing progress notes indicated that staff attempted to contact the responsible party by telephone at the time of transfer, but there was no documentation that a written notice or bed-hold policy was provided. Similarly, for another resident with severe cognitive impairment, the medical record showed that the representative was notified by telephone, but again, there was no evidence of written notification or bed-hold policy being sent. Interviews with admissions staff confirmed that their practice was to call or attempt to call families or resident representatives on the day of transfer or the next business day, but they did not mail any written notices regarding the bed-hold policy or the reason for transfer/discharge. The admissions staff was unaware that mailing these notices was a requirement. The administrator confirmed that both the bed-hold information and written notice of transfer or discharge, including the reason for transfer, should be mailed to the family or resident representative and given to the resident when sent to the hospital.
Inaccurate MDS Coding for Admission and PASRR Status
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents. One resident with non-Alzheimer's dementia and Parkinson's disease was re-admitted to the facility following a hospital stay for surgical repair of a right hip fracture. The significant change MDS assessment completed after re-admission was incorrectly coded, as it should have been marked as the first assessment following re-entry. This error was acknowledged by the MDS nurse, who stated the assessment was not coded accurately. Another resident with diagnoses including paranoid schizophrenia and anxiety disorder had a Level 2 Pre-admission Screening and Resident Review (PASRR) determination indicating the need for specialized services due to serious mental illness. However, the significant change MDS assessment did not reflect the updated PASRR status, as the resident profile had not been updated from Level 1 to Level 2. The MDS Coordinator and Social Services staff confirmed that the PASRR information was not current in the electronic medical record at the time of the assessment, resulting in inaccurate MDS coding.
Inaccurate Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain an accurate Treatment Administration Record (TAR) for wound care treatments for a resident. The resident had a physician's order for daily application of alginate calcium with silver sodium and Dakins solution to a sacral wound, but the order was incorrectly entered into the TAR as 'as needed' (PRN). Consequently, there was no documentation of the sacral wound treatment from the beginning to the end of August. Additionally, the resident had another order for daily application of a hydrogel impregnated dressing to a left heel wound, but there were multiple days in August where this treatment was not documented in the TAR. Interviews with staff revealed that the treatments were reportedly completed daily by a nursing assistant and a nurse, but documentation was often forgotten. The nursing assistant admitted to not documenting the sacral wound treatments due to the incorrect PRN entry and was unsure if she informed the supervising nurse about the error. The supervising nurse, who had recently assumed the role, was unaware of the documentation issues and the incorrect order entry. The Director of Nursing and the facility Administrator were also unaware of the inaccuracies in the TAR, attributing potential issues to a recent change in the documentation system.
Failure to Provide Timely Wound Management
Penalty
Summary
The facility failed to provide appropriate wound management for a resident who initially sustained a skin tear on 3/12/2024 and experienced a reoccurrence on 3/30/2024. The resident's skin tear became infected on 4/3/2024, and although antibiotics were prescribed, no wound care treatments were ordered until 4/9/2024. Additionally, there were no weekly wound assessments documented for the resident's skin tear as of 4/26/2024. This deficiency was identified for one of three residents reviewed for skin conditions. The resident, who was admitted to the facility with a diagnosis of stroke and was severely cognitively impaired, had a care plan that included interventions for skin alterations and potential bleeding due to anticoagulation therapy. Despite these interventions, the facility's nursing staff failed to consistently document and manage the resident's wound. The initial skin tear was reported and treated on 3/12/2024, but subsequent documentation and communication lapses led to inadequate wound care and delayed treatment. Interviews with various nursing staff and the Director of Nursing revealed that there was a lack of proper communication and documentation regarding the resident's wound. The treatment nurse responsible for wound management was not consistently notified of the resident's condition, and there were no documented assessments or measurements of the wound. The Director of Nursing acknowledged that the facility's plan of correction for wound management was not effectively implemented, resulting in the resident's wound care being neglected until 4/9/2024.
Failure to Meet Nutritional Needs and Follow Approved Menus
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents, particularly those on specialized diets. Specifically, there was no pre-approved renal diet menu for eight residents on a renal diet, leading to inappropriate food choices such as black-eyed peas, which are high in phosphorus. Additionally, the facility did not follow the approved pureed diet menu, as pureed bread was not served to seven residents on a pureed diet, which is necessary for their caloric intake. The Certified Dietary Manager (CDM) and Registered Dietitian (RD) confirmed these deficiencies, citing changes in food suppliers and reliance on experience rather than pre-approved menus. Furthermore, the facility did not serve the correct portion sizes for residents on mechanical soft and regular diets. Residents on a mechanical soft diet received 3 ounces of ground meat instead of the required 4 ounces, and residents on both regular and mechanical soft diets received 3 ounces of diced potatoes instead of the prescribed 4 ounces. These discrepancies were confirmed by Cook #1 and the RD, who acknowledged that the correct serving sizes are essential for residents to meet their nutritional needs.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement its abuse policy in the areas of reporting, investigating, and protecting residents in response to allegations of physical abuse. This deficiency affected two residents. Resident #6, who had moderate cognitive impairment, alleged that a nursing assistant pushed her into bed. The night shift supervisor, Nurse #5, reassigned the nursing assistant and notified the Director of Nursing (DON) but did not notify the Administrator immediately as required by the facility's policy. The DON and Administrator later decided to address the issue as a grievance rather than an abuse allegation, despite the initial report of physical abuse. Resident #8 reported being punched multiple times in the eye by a resident from the adjoining Assisted Living Facility (ALF) during a disagreement in the courtyard. Nurse #1 documented the incident and informed the DON, who instructed her to notify the Administrator. The Administrator did not report the incident to the state agency within the required two-hour timeframe, believing that the altercation did not constitute abuse because it involved a resident from the ALF. The incident was later reported to law enforcement and the state agency, but not within the required timeframe. Both incidents highlight the facility's failure to follow its abuse policy, including timely reporting and proper investigation of abuse allegations. The staff involved did not adhere to the mandated procedures for handling and reporting abuse, leading to delays in addressing the allegations and ensuring resident safety. The facility's actions and inactions in these cases demonstrate a significant lapse in compliance with regulatory requirements for abuse prevention and response.
Ice Build-Up on Frozen Food in Walk-In Freezer
Penalty
Summary
The facility failed to prevent ice build-up on boxes of frozen food stored in the walk-in freezer, which had the potential to affect the quality of frozen foods served to residents. During an initial tour of the facility kitchen, it was observed that the pipe from the condenser was insulated but had multiple icicles attached to it. These icicles were dripping onto boxes of frozen food, including sweet peas and corn, causing significant ice accumulation on and inside the boxes. Some of the boxes were open, allowing ice to form inside the storage bags of vegetables, which were not properly sealed. This condition was confirmed by the Certified Dietary Manager (CDM) and Cook #2 during a follow-up observation, where four boxes with ice build-up were identified and subsequently discarded due to potential contamination risks. In interviews, the CDM stated she was unaware of the ice formations and would alert maintenance, while Cook #2 acknowledged the ice had been present for some time but was unsure of the duration. The Administrator also confirmed that the boxes should not have ice on them and contacted the Maintenance Director, who admitted he was not aware of the issue and had not reported the last check on the freezer. This lack of awareness and failure to address the ice build-up in the walk-in freezer led to the deficiency noted in the report.
Repeated Deficiencies in Quality Assurance and Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following previous recertification and complaint investigation surveys. This resulted in four deficiencies being recited during the current survey. These deficiencies included failure to protect a resident from physical abuse, inadequate wound management, failure to schedule a medically necessary appointment, and improper food storage practices. Specifically, a resident was physically abused by another resident, a skin tear was not properly treated or documented, a urology consult was not scheduled as ordered, and there was ice build-up on boxes of frozen food in the walk-in freezer. The deficiencies were identified through record reviews, observations, and interviews with residents, staff, and a physician. The facility had previously been cited for similar issues, indicating a pattern of non-compliance. The Administrator acknowledged the QAA Committee's monitoring efforts but attributed the freezer issue to equipment failure. Despite these efforts, the facility's inability to sustain an effective QAA Program was evident through the repeated citations for the same deficiencies.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when a resident was punched in the face multiple times by another resident from the Assisted Living Facility (ALF) on the same campus. On the evening of 4/22/24, while in the facility's courtyard, Resident #8 and the ALF resident engaged in a verbal disagreement that escalated into a physical altercation, resulting in Resident #8 sustaining a small laceration to the left upper eyelid. This incident was documented in an incident report and nursing documentation, and it was observed that the facility's campus consisted of two separate buildings connected by a long kitchen corridor, with ALF residents entering the Skilled Nursing Facility (SNF) through the front entrance. The courtyard was located in the center of the SNF building. Resident #8 was admitted to the facility with diagnoses including anxiety, depression, and non-Alzheimer's dementia. The care plan for Resident #8 included monitoring and documenting behaviors, not arguing with the resident, and talking in a calm voice when disruptive behaviors occurred. Despite these interventions, the altercation occurred, and staff interviews revealed that the residents were separated by staff members after the fight. Nurse Aide #5 and Nurse #4 provided details about the incident, including the treatment provided to Resident #8 and the notification of the Director of Nursing (DON). Interviews with other residents and staff members provided additional context to the altercation. Resident #25 and Resident #57 described the events leading up to the fight, indicating that Resident #8 was verbally loud and that the ALF resident responded aggressively. The ALF resident admitted to hitting Resident #8 after feeling threatened. The DON and the Administrator acknowledged the incident, with the Administrator stating that the altercation could be considered abuse if performed willfully. The DON explained that the facility was responsible for keeping all residents safe and that the ALF resident was not allowed to return to the SNF to visit after the incident.
Failure to Schedule Urology Consult as Ordered
Penalty
Summary
The facility failed to schedule a urology consult as ordered by the physician for a resident diagnosed with obstructive uropathy. The resident, who was moderately cognitively impaired and had an indwelling catheter, had a physician's order dated 1/23/24 for a follow-up with urology. However, a review of the resident's electronic medical record revealed no evidence of a urology appointment being scheduled after the order was placed. The Medical Records Coordinator, responsible for scheduling such appointments, admitted that the follow-up with urology was overlooked despite scheduling several other appointments for the resident. The Director of Nursing (DON) and the Administrator both stated that the appointment should have been scheduled when the order was placed. The DON explained that follow-up appointments are discussed in morning clinical meetings and recorded in a book accessible to the Medical Records Coordinator. The Physician confirmed that the urology appointment was for evaluating an enlarged prostate and stated that the delay did not cause any harm to the resident. The oversight was acknowledged by the Medical Records Coordinator, DON, and Administrator during their interviews.
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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