Linden Place Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 1201 Carolina Street, Greensboro, North Carolina 27401
- CMS Provider Number
- 345014
- Inspections on file
- 24
- Latest survey
- January 10, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Linden Place Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple failures in medication storage and labeling, including expired medications in the med storeroom refrigerator and on shelves (such as an RSV vaccine, a compounded IV antibiotic solution, hemorrhoidal suppositories, nicotine patches, Vitamin C tablets, and sore throat spray), as well as an opened multi‑dose vial of Tuberculin PPD without an open date to determine its 30‑day discard time. On a med cart, an opened sore throat spray lacked a resident name and was expired, and a bottle of lactulose for a resident remained on the cart past its labeled stop and discard‑after dates. Staff interviews confirmed that specific personnel had been designated to monitor medication expirations and that medication storage concerns had been discussed previously.
A resident’s room and bathroom were not maintained in good repair, resulting in a door that would not latch closed and a bathroom sink that repeatedly held one to two inches of standing water without draining. The Maintenance Director acknowledged prior unsuccessful repair attempts on the door and recognized that the sink required fixing to drain properly. Facility leadership later agreed that residents should be able to close their room doors and acknowledged that a non-draining sink did not support a homelike environment.
The facility failed to act upon and resolve group grievances raised in Resident Council meetings and did not consistently communicate follow-up to residents. Council minutes over several months documented repeated concerns about staff attitudes and foul language, medications left in rooms, call lights not in reach or not answered, staff voicing confidential information in public areas, unsanitary shower and bathroom conditions, poor communication about room changes, excessive staff noise, delayed staff responses, staff using personal phones while in rooms and on the hall, and staff rushing residents during meals. Although the Activities Director documented these concerns and forwarded them to the Administrator, grievance forms were incomplete, lacked evidence of investigation or resolution, and several issues were not addressed at subsequent meetings, leading residents to report that their grievances were repeatedly voiced without being fully resolved.
A resident with cancer, generalized muscle weakness, and moderately impaired cognition had conflicting code status documents maintained by the facility. A bright yellow/orange DNR form indicating no expiration date and a MOST form ordering CPR were both stored in the paper advance directive binder at the nursing station, while the EMR and care plan documented the resident as full code/CPR. The SW described a process in which she obtained and routed advance directives for provider review, after which nursing staff documented and retained the orders, and a nurse reported she would rely on either the binder or EMR in an emergency, creating potential confusion due to the contradictory documents.
Surveyors found that the facility did not accurately code MDS assessments for two residents. One resident had a documented PASRR Level II determination for serious mental illness and a care plan reflecting this status, yet the annual MDS indicated the resident was not considered to have a serious mental illness or related condition by the state PASRR process. Another resident with cerebrovascular disease had a terminal prognosis, active hospice enrollment, and current hospice certification and physician orders, but the quarterly MDS did not reflect hospice services, despite the DON confirming the resident was on hospice.
Surveyors found that the facility failed to develop comprehensive care plans for three residents’ identified needs. One resident admitted with a colostomy and indwelling urinary catheter had detailed MD orders and a triggered CAA for urinary incontinence and catheter use, yet no care plan addressed colostomy or catheter care. Another resident with ESRD had standing orders and a regular schedule for hemodialysis with AV shunt monitoring, and confirmed receiving dialysis three times weekly, but the care plan contained no dialysis-related goals or interventions. A third resident with metabolic encephalopathy had an MDS-documented goal to return to the community, social work notes describing plans for assisted living placement, and personal requests for help with community discharge, but the comprehensive care plan lacked any discharge planning focus or interventions.
A resident with systolic CHF and severely impaired cognition had PRN orders for supplemental O2 via nasal cannula at 2 L/min to maintain SpO2 above 90%. On multiple observations, the resident was in bed receiving O2, but no oxygen signage was posted on or near the room entrance, and only a general "No Smoking" sign was present at the main entrance. Interviews with the DON, Administrator, Regional Nurse Consultant, Medical Records/Central Supply clerk, a hall nurse, and a Unit Manager showed that staff had differing and unclear views about who was responsible for posting oxygen signage when a resident used supplemental O2, and no consistent process was identified.
A resident with metabolic encephalopathy, muscle weakness, and moderate cognitive impairment, care planned to receive supervision and assistance with personal hygiene, repeatedly requested that staff trim his mustache because it was curling into his mouth. Despite these requests over several weeks, observations showed his beard and mustache remained untrimmed. The assigned NA acknowledged the resident's need for assistance and his ongoing requests, believed the Transportation Aide was responsible due to the need for clippers, and stated she had reported the request, while the Transportation Aide reported never being informed. Nursing staff, the DON, and the Administrator each stated that NAs were responsible for facial hair care and that clippers were available, but none could explain why the grooming assistance was not provided.
A resident with severe cognitive impairment, multiple comorbidities, and documented stage 3 pressure ulcers on the sacrum and both buttocks did not have a physician order in place for treatment of the right buttock ulcer, even though the wound had been identified and was being treated by the wound care nurse. Treatment orders and TAR entries existed for the sacral and left buttock ulcers only, and the right buttock ulcer lacked an order until later, despite ongoing care. In addition, the resident’s pressure-relieving air mattress was repeatedly observed set to 350 lbs, while the resident weighed about 133 lbs, and nursing staff interviews showed a lack of awareness and clarity about responsibility for ensuring the mattress weight setting matched the resident’s actual weight.
Surveyors observed that a medication aide committed two medication administration errors, resulting in an 8% medication error rate. In one case, a resident receiving Breo Ellipta for reactive airway disease was given water to drink immediately after inhalation instead of being instructed to rinse and spit as ordered. In another case, a different resident ordered a daily multivitamin without minerals was instead given a multivitamin with minerals from a stock bottle on the med cart because the aide did not verify the correct product, leading to administration inconsistent with the physician’s order.
The facility failed to provide required written notification to the Ombudsman for emergency hospital transfers involving two residents who were sent out for evaluation and treatment of chest pain, seizures, and seizure-like activity, with one resident not returning after transfer. Record review showed no documentation of Ombudsman notification for any of these transfers, and interviews revealed that the Social Worker had not sent any emergency transfer notifications and was unclear about responsibility for this task, while the Ombudsman reported no such notifications had been received for several months and the Administrator believed the Social Worker was responsible.
The facility failed to transmit required MDS assessments within regulatory timeframes for two residents. For one resident with type 2 DM and HTN, a quarterly MDS was completed but not transmitted as expected, which the DON attributed to a system glitch that prevented automatic submission. For another resident who had been discharged, a discharge MDS was completed but not transmitted or accepted by the CMS system, and the DON acknowledged that the MDS nurse should have monitored transmission reports and ensured submission within the required 14-day window.
A resident with chronic obstructive pulmonary disease expressed concerns about receiving morning medications late, affecting his schedule. Despite being cognitively intact and having communicated his preference multiple times, the facility failed to honor his request. Nurse #4 admitted to running behind on the medication pass, resulting in late administration. The DON acknowledged the issue and indicated a willingness to adjust medication times.
A resident with multiple diagnoses, including atrial fibrillation on anticoagulant, showed neurological changes such as lethargy and sluggish pupil reaction. Nurse #1 documented these symptoms but failed to fully inform the on-call NP, only mentioning drowsiness. The NP, reliant on nurse reports due to lack of record access, was not aware of the full condition, leading to a deficiency in the facility's notification protocol.
A resident with a history of diabetes, atrial fibrillation, and end-stage renal disease experienced a change in condition that was not promptly identified by the facility staff. After undergoing dialysis, the resident showed signs of lethargy and unresponsiveness, which were initially attributed to fatigue. Despite elevated blood pressure and other symptoms, the staff delayed recognizing the severity of the situation, leading to the resident being sent to the hospital in critical condition.
The facility failed to maintain a clean and sanitary environment, with issues observed in resident rooms, a linen closet, and a dining room. Residents reported inadequate cleaning despite daily housekeeping, and staff interviews confirmed that deep cleaning was not consistently performed. An ongoing PIP aimed at improving environmental services was in place, but deficiencies persisted, indicating ineffective implementation.
The facility failed to maintain effective pest control, with pests observed in hallways and residents' rooms. Residents reported flies and bugs, while staff confirmed sightings of roaches in various areas. Despite an ongoing PIP and increased exterminator visits, pest issues persisted, indicating ineffective interventions.
The facility failed to develop a comprehensive care plan for a resident, missing care plans for cognitive loss/dementia, urinary incontinence, functional abilities, dehydration, dental care, pain, communication, nutritional status, and pressure ulcers. Staff interviews confirmed the oversight, and the DON acknowledged the care plans should have been completed within seven days of assessment.
The facility's QAPI Committee failed to maintain procedures and monitor interventions following previous surveys, leading to repeated deficiencies in developing comprehensive resident-centered care plans. The deficiencies included failure to address various needs such as cognitive loss, urinary incontinence, and nutritional status for a resident.
Expired, Unlabeled, and Undated Medications in Storeroom and Med Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management related to labeling, dating, and removal of expired drugs and biologicals. In the North Hall medication storeroom, an unopened single-use vial of Arexy RSV vaccine dispensed for a specific resident was found in the refrigerator with a manufacturer’s expiration date that had already passed, indicating it was kept beyond its expiration. A compounded IV bag of 0.9% sodium chloride with cefazolin for another resident was also stored past the pharmacy-labeled stop date and discard-after date. Additionally, a stock box of hemorrhoidal suppositories, a stock box of nicotine transdermal patches, two opened stock bottles of 500 mg Vitamin C tablets, and an unopened bottle of sore throat spray were all found on storeroom shelves with manufacturer expiration dates that had already passed. The surveyors further observed failures to properly date multi-dose medications to determine shortened expiration periods. In the medication storeroom refrigerator, one opened multi-dose vial of Tuberculin PPD injectable solution dispensed from the pharmacy had no label or box notation indicating the date it was opened, preventing determination of its 30‑day post‑opening discard date. A second opened multi-dose vial of Tuberculin PPD had an auxiliary pharmacy sticker indicating an open date and corresponding shortened expiration date, but the first vial lacked this required information. These findings showed inconsistent practices in documenting open dates for medications that require shortened beyond‑use dating. On North Hall Medication Cart #2, surveyors found an opened 6‑ounce bottle of sore throat spray that was not labeled with any resident’s name, and the med aide assigned to the cart could not identify which resident it belonged to; the bottle also bore a manufacturer’s expiration date that had passed. The same cart contained a bottle of lactulose solution dispensed for a resident, with pharmacy labeling that included a stop date and a “discard after” date that had already elapsed, indicating the medication was expired but still stored on the cart. During interviews, facility leadership acknowledged that responsibilities for monitoring expiration dates in the storeroom and on med carts had been assigned to specific staff, and that concerns about medication storage had been previously discussed.
Failure to Maintain Resident Room Door and Bathroom Sink in Good Repair
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s room door in good repair so that it would properly latch and remain closed. During an initial observation of the resident’s room, the door latch was found not to secure the door. In a subsequent observation with the Maintenance Director present, the door again failed to latch despite multiple attempts to close it. The Maintenance Director acknowledged he had previously worked on the door and that the repair had not resolved the problem, and he stated the door would likely need to be replaced. In a later interview, the Administrator and Regional Nurse Consultant agreed they would expect residents to be able to close the door to their room. The deficiency also includes the facility’s failure to maintain the resident’s bathroom sink in working order so that it would properly drain. An initial observation of the resident’s bathroom revealed one to two inches of standing water in the sink that was not draining. A follow-up observation several days later with the Maintenance Director present again showed one to two inches of standing water in the sink, indicating the problem persisted over time. When informed that the same issue had been observed earlier, the Maintenance Director stated the sink would need to be fixed to ensure proper drainage. In a subsequent interview, the Administrator acknowledged that a sink that failed to drain water did not create a homelike atmosphere.
Failure to Address and Resolve Resident Council Group Grievances
Penalty
Summary
The facility failed to honor residents' rights to have group grievances from Resident Council meetings acted upon, resolved, and communicated back to them. Resident Council minutes from 10/14/25 documented multiple grievances, including staff having poor attitudes and using foul language, medications being dropped off and left in resident rooms, call lights not in reach, staff voicing confidential resident information in public areas, unsanitary shower rooms and bathrooms, and lack of communication regarding room changes. Only one grievance form was completed by the Administrator for that date, and it did not address the concerns about staff voicing confidential information, unsanitary shower rooms and bathrooms, or lack of communication about room changes. Resident Council minutes from 11/18/25, completed by the current Activities Director, showed that old business and follow-up on grievances were reviewed and approved as corrected, but there was no evidence that the specific grievances from 10/14/25 regarding staff voicing confidential information, unsanitary shower rooms and bathrooms, and lack of communication about room changes were discussed, addressed, or resolved. The 11/18/25 minutes documented a repeat grievance about staff being rude and new grievances about call lights not being answered on 2nd and 3rd shifts, bugs being observed, staff turning off call lights and leaving without returning, residents not being told who their assigned nursing assistant was, and staff noise levels being too loud in the hallways. A grievance form completed by the Administrator on 11/18/25 listed some of these concerns, but there was no indication of investigation, interventions, or resolution for them. Resident Council minutes from 12/16/25 again indicated that old business and follow-up on grievances were reviewed and approved, but there was no evidence that the previously voiced concerns about staff turning off call lights and not returning, residents not being told their assigned nursing assistant, and excessive staff noise were addressed. The 12/16/25 minutes documented a repeat grievance about medications being left in residents' rooms and new grievances that staff were not responding to residents in a timely manner, staff were using personal phones in resident rooms and on the hall, and staff were rushing residents when eating. During a Resident Council meeting on 1/7/26, the Resident Council President and several other residents stated that grievances had been repeated month after month without being fully addressed or resolved. The Activities Director reported that she forwarded the minutes to the Administrator and relied on him for follow-up information, and the Administrator acknowledged that the process for documenting and resolving all Resident Council concerns had not been fully carried out, describing this as an oversight.
Conflicting Advance Directive Documents for a Resident’s Code Status
Penalty
Summary
The facility failed to maintain accurate and consistent advance directive information for one resident when conflicting code status documents were kept in the paper advance directive binder at the nursing station. The resident, who had cancer, generalized muscle weakness, and moderately impaired cognition, had a bright yellow/orange Do Not Resuscitate (DNR) form in the binder indicating DNR status with no expiration date. The same binder also contained a Medical Order for Scope of Treatment (MOST) form signed by the resident’s Nurse Practitioner that directed staff to attempt cardiopulmonary resuscitation (CPR) if the resident had no pulse and was not breathing. At the same time, the resident’s electronic medical record contained a physician’s order for full code/CPR, and the care plan documented the resident as a full code. The Social Worker reported that she was responsible for obtaining advance directives at or shortly after admission, reviewing them with the resident or family depending on cognition, and then placing the signed forms in the provider’s box for review, after which nursing staff were responsible for documenting and retaining the orders. The nurse assigned to the resident stated that in an emergency she would look for advance directive information either in the 3-ring binder at the nursing station or in the EMR, indicating reliance on both sources. During interviews, the Social Worker acknowledged the potential for confusion caused by having both the DNR and MOST forms in the binder, and the DON and Regional Nurse Consultant confirmed that the DNR form should not have been in the binder and likely came from the hospital, yet it remained stored with the resident’s advance directive documents, creating inconsistent and contradictory information regarding the resident’s code status.
Inaccurate MDS Coding for PASRR Level II Status and Hospice Services
Penalty
Summary
The facility failed to accurately code the MDS assessment for a resident with a documented PASRR Level II status. The resident’s EMR contained a PASRR Level II Determination Notification letter issued on 11/22/23 with no expiration date, and the resident’s diagnoses included schizophrenia and major depressive disorder. The resident’s care plan included a focus area indicating a Level II PASRR status related to serious mental illness due to schizophrenia, initiated on 3/25/25. Despite this, the resident’s most recent annual MDS dated 11/15/25 was coded to indicate that the resident was not considered by the state Level II PASRR process to have a serious mental illness or related condition. During interviews, the DON stated she believed a corporate MDS nurse had completed the assessment, and the social worker confirmed upon review that the resident did have a PASRR Level II status. The facility also failed to accurately code hospice services on the MDS for another resident. This resident was admitted with a diagnosis of cerebrovascular disease and had a care plan, last updated on 06/14/2024, that documented a terminal prognosis related to cerebrovascular disease and enrollment in hospice services. Physician orders dated 06/12/2024 confirmed hospice admission, and a hospice recertification dated 10/27/2025 documented a certification period from 11/25/2025 to 01/23/2026, with a corresponding hospice physician order reflecting the same certification period. However, the resident’s quarterly MDS assessment dated 11/02/2025 did not reflect hospice services. In an interview, the DON verified that the resident was receiving hospice care and that the MDS should have been coded to reflect hospice services.
Failure to Develop Comprehensive Care Plans for Specialized Treatments and Discharge Goals
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans addressing specific clinical needs and discharge goals for three residents. One resident was admitted with necrotizing fasciitis, soft tissue disorders, rectal hemorrhage, and had both a colostomy bag and an indwelling urinary catheter. Physician orders directed staff to check the catheter strap and monitor urinary output every shift, and to check, empty, and replace the colostomy bag as needed. The admission MDS documented that the resident was cognitively intact and had both an indwelling catheter and an ostomy bag, and the CAA summary showed that urinary incontinence and indwelling catheter triggered a care area to be addressed in the care plan. Despite this, the comprehensive care plan dated after admission contained no care plan for colostomy care or indwelling urinary catheter care, and the DON and Administrator acknowledged these areas should have been included but could not explain the omission. Another resident with end stage renal disease had physician orders for dialysis, including monitoring the AV shunt every shift for thrill, bruit, and signs of bleeding, and scheduled dialysis at a kidney center three times weekly. The admission MDS indicated the resident was cognitively intact and received dialysis treatment, and the resident confirmed in interview that he had been receiving dialysis three times a week since admission. However, the comprehensive care plan last reviewed in early October contained no goals or interventions related to dialysis treatment. The DON stated that the MDS nurse was responsible for developing care plans and that a dialysis care plan should have been added, describing the absence of such a plan as an oversight, and the Administrator agreed that a dialysis care plan should have been developed. A third resident, admitted with metabolic encephalopathy, had an admission MDS showing moderate cognitive impairment and participation in discharge planning with a goal to return to the community. A social work progress note documented that the social worker and the resident’s emergency contact discussed seeking placement at an assisted living facility. The resident reported requesting assistance from the social worker and his emergency contact for placement in an assisted living facility or return home. Despite this documented discharge goal and discussions, the comprehensive care plan contained no interventions or goals related to discharge planning. The social worker, identified as responsible for discharge planning and related care plans, acknowledged awareness of the resident’s discharge wishes and support from the emergency contact but stated she did not know why a discharge focus area was not included and characterized it as an oversight; the DON and Administrator also stated that a discharge care plan should have been added.
Failure to Post Oxygen Signage for Resident Receiving Supplemental Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to post cautionary oxygen signage at the entrance to a resident’s room while supplemental oxygen was in use. The resident had systolic congestive heart failure and severely impaired cognition, and had physician orders for PRN supplemental oxygen via nasal cannula at 2 L/min to maintain oxygen saturation above 90%. On multiple observations on one survey date, the resident was seen in bed receiving oxygen via nasal cannula, yet there was no oxygen signage on or near the room entrance. A general “No Smoking” sign was posted at the facility’s main entrance, but it did not indicate that supplemental oxygen was in use within the facility or specifically for this resident’s room. Further review of the electronic medical record showed the resident had been sent to the hospital and then readmitted, with new orders again for PRN supplemental oxygen at 2 L/min. On a subsequent observation date, the resident was again noted in bed with oxygen via nasal cannula and still no oxygen signage at the room entrance. Interviews with the DON, Administrator, Regional Nurse Consultant, Medical Records/Central Supply clerk, a hall nurse, and a Unit Manager revealed inconsistent and unclear understanding of who was responsible for ensuring oxygen signage was posted when a resident used supplemental oxygen. Staff members variously believed responsibility lay with Medical Records/Central Supply, nursing staff, the hall charge nurse, or the Unit Manager, and there was no clear process identified for residents who began oxygen use without advance notice or after new oxygen orders were written.
Failure to Assist Resident With Requested Facial Hair Grooming
Penalty
Summary
Failure to provide assistance with activities of daily living occurred when staff did not trim a resident's mustache despite multiple requests. The resident, admitted with metabolic encephalopathy, need for assistance with personal care, and muscle weakness, had an admission MDS showing moderate cognitive impairment and a need for supervision or touching assistance with personal hygiene. A care plan documented that the resident required staff supervision/touching assistance with personal hygiene and assistance by staff with personal hygiene. On two separate observations, the resident was noted to have a full beard about an inch long and a mustache about 1/2 inch long that covered the full top lip and curled inward toward the mouth. During interview, the resident stated he had repeatedly asked nursing assistants to have his mustache trimmed, was not concerned about the beard length, and was frustrated that no one had assisted him, despite being told someone would come to trim it and that several weeks had passed without this occurring. The assigned nursing assistant confirmed the resident required staff assistance for facial hair trimming, acknowledged he had requested mustache trimming "for a while," and stated she believed the Transportation Aide was responsible because clippers were needed; she reported having notified the Transportation Aide but could not recall when and did not know why it had not been done. The Transportation Aide, however, reported she was never informed of any request for this resident. The nurse on duty stated she was unaware of the resident's requests and that NAs normally shaved men's facial hair per preference, and the DON reported that NAs were responsible for facial hair trimming and that clippers were available to all nursing staff. The Administrator stated he did not know why the resident's facial hair had not been trimmed and that he expected staff to complete all ADL care for all residents.
Failure to Obtain Wound Treatment Order and Incorrect Pressure-Relieving Mattress Setting
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician order for treatment of a documented stage 3 pressure ulcer and failure to correctly set a pressure-relieving air mattress for a resident with multiple pressure ulcers. The resident was admitted with diagnoses including cerebrovascular disease, type 2 diabetes, hypertension, a sacral pressure ulcer, and peripheral vascular disease, and had severe cognitive impairment and dependence in ADLs. The care plan identified a coccyx pressure ulcer and risk for further breakdown, with goals for healing and interventions such as skin assessments and weekly wound documentation. Weekly skin reviews and wound measurements beginning on 12/23/25 showed stage 3 pressure ulcers on the sacrum and left buttock, and later documentation showed an additional stage 3 ulcer on the right buttock. Physician orders dated 12/24/25 were present for treatment of the sacral and left buttock stage 3 pressure ulcers, specifying cleansing with Dakin’s/normal saline, application of honey fiber, and coverage with a silicone super absorbent pad. However, there was no corresponding treatment order for the right buttock ulcer, despite the wound being identified on 12/23/25 and documented as a stage 3 pressure ulcer with specific measurements on 01/07/26. The Treatment Administration Records for December 2025 and January 2026 showed wound care being provided to the sacral area and left buttock starting 12/23/25, but no documented treatment order for the right buttock ulcer in December. The Wound Care Nurse reported that all three wounds (left buttock, right buttock, and sacrum) were identified on 12/23/25 and that she had been treating all of them, but she had not realized there was no physician order in place for the right buttock. A separate deficiency was identified regarding the pressure-relieving air mattress settings for the same resident. Observations on consecutive days showed the resident in bed with the air mattress set at 350 lbs, while the medical record documented the resident’s weight as 133.5 lbs. Nursing staff interviews revealed that the nurse assigned to the resident was not aware she was responsible for checking the weight setting on the pressure-relieving mattress. The Wound Care Nurse stated that it was the hall nurse’s responsibility to ensure the mattress weight setting was correct. These observations and interviews demonstrated that the mattress was not set according to the resident’s actual weight and that staff were unclear about their responsibility for verifying and adjusting the mattress settings.
Medication Administration Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 8% (2 errors out of 25 opportunities), exceeding the required rate of less than 5%. In the first instance, a medication aide administered Breo Ellipta 200-25 mcg inhalation powder as one puff by mouth to a resident with an order initiated on 12/24/25 for reactive airway disease. The physician’s order and the manufacturer’s prescribing information both specified that after inhalation the patient should rinse the mouth with water and spit it out to help reduce the risk of oropharyngeal candidiasis. During observation, after the resident inhaled one puff of Breo Ellipta, the medication aide offered water, which the resident drank and swallowed immediately. The aide did not prompt the resident to rinse and spit as required by the order. Subsequent review of the MAR and interview confirmed that the order included the rinse-and-spit notation and that the aide had allowed the resident to swallow the water instead. In the second instance, the same medication aide prepared and administered a multivitamin with minerals taken from a stock bottle on the medication cart to another resident. The current physician’s order for this resident, initiated on 7/17/24, specified a multivitamin without minerals to be given once daily for vitamin deficiency. During interview and review of the MAR, the nurse confirmed that the order was for a multivitamin only, without added minerals. The medication aide acknowledged uncertainty about whether a stock bottle containing only multivitamins (without minerals) was available on the cart, and the nurse indicated that such a bottle was present. The aide had not verified the stock bottle label closely enough and administered a multivitamin with minerals instead of the ordered multivitamin without minerals, constituting a second medication error contributing to the elevated error rate.
Failure to Notify Ombudsman of Emergency Hospital Transfers
Penalty
Summary
The facility failed to provide required written notification to the Ombudsman regarding residents’ emergency transfers to the hospital. For one resident, identified as Resident #99, nursing progress notes documented that the resident was out of the facility for an appointment and was transferred to the hospital for further evaluation due to chest pain. The medical record showed that this resident was discharged from the facility on the same day and did not return. The facility was unable to produce any documentation that the Ombudsman was notified in writing of this emergency transfer and discharge. For another resident, identified as Resident #88, nursing progress notes documented two separate emergency transfers to the hospital related to seizures and seizure-like activity, one initiated at the request of a family member. The medical record showed that the resident was discharged to the hospital on both occasions and later returned to the facility. In both instances, the facility could not provide documentation that the Ombudsman was notified of the emergency transfers. During interviews, the Social Worker stated she had not sent any Ombudsman notifications for emergency transfers since being hired and did not know who was responsible for doing so, while the interim Ombudsman reported that no emergency transfer notifications had been received from the facility since a prior month. The Administrator stated he was unaware that notifications had not been sent and believed it was the Social Worker’s responsibility to notify the Ombudsman of emergency hospital transfers.
Failure to Transmit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the State and CMS within the required timeframe for two residents. For Resident #1, who was admitted with diagnoses including type 2 diabetes and hypertension, a quarterly MDS with an Assessment Reference Date (ARD) of 11/14/25 was completed on 11/26/25 but had not been transmitted as of the time of review. The MDS coordinator was unavailable for interview, and the Director of Nursing (DON) verified that this quarterly MDS had not been transmitted, stating there was a system glitch and that it should have automatically transmitted when completed. The Administrator stated it was his expectation that all MDS assessments be transmitted on time. For Resident #30, the electronic medical record showed an admission and subsequent discharge on 9/18/25. A discharge MDS with an ARD of 9/18/25 was signed as completed by the facility’s MDS nurse on 10/3/25, but the record did not show that this discharge MDS had been transmitted to or accepted by the CMS system. During interviews, the DON and Administrator confirmed that the MDS nurse was unavailable and acknowledged that the 9/18/25 discharge MDS had not been transmitted. The DON further stated that the MDS nurse should have been monitoring a print-out that would indicate whether MDS assessments were successfully transmitted and accepted, and acknowledged that the discharge MDS should have been transmitted within 14 days of the ARD.
Failure to Honor Resident's Medication Timing Request
Penalty
Summary
The facility failed to honor a resident's request to have medications administered at a desired time, which is a violation of the resident's right to self-determination and choice. Resident #64, who was admitted with chronic obstructive pulmonary disease and was cognitively intact, expressed concerns about receiving morning medications late, sometimes close to lunchtime. Despite having communicated this issue multiple times, the resident's request was not addressed, as evidenced by interviews and a review of the electronic medication administration record showing scheduled times for morning medications. On one occasion, Resident #64 had not received his medications by 9:46 AM, and he had to approach the medication cart at 10:30 AM to request them. Nurse #4 admitted to running behind on the medication pass, which resulted in the late administration of medications. The resident expressed frustration as the delay affected his schedule, including making him late for bible study. The Director of Nursing acknowledged the issue and indicated a willingness to change the medication times to accommodate the resident's preference.
Failure to Notify On-Call NP of Neurological Change
Penalty
Summary
The facility failed to notify the on-call nurse practitioner when a resident experienced a change in neurological status. The resident, who was admitted with diagnoses including diabetes, atrial fibrillation on anticoagulant, and end-stage renal disease dependent on dialysis, showed signs of lethargy, sluggish pupil reaction, and lack of motor function in all extremities. Despite these symptoms being documented by Nurse #1 at 7:30 pm, the nurse did not communicate the full extent of the resident's condition to the on-call nurse practitioner at 11:30 pm, only mentioning the resident's drowsiness and sleepiness. The nurse practitioner's interview revealed that the on-call service providers rely solely on the information provided by the nurses, as they do not have access to the facility's records. The physician emphasized the importance of reporting any change in a resident's neurological status immediately. The failure to report the resident's complete condition, including the sluggishness of the eyes, lethargy, diaphoresis, and immobility of extremities, constituted a deficiency in the facility's protocol for notifying medical staff of significant changes in a resident's health status.
Failure to Identify Change in Condition
Penalty
Summary
The facility failed to identify a change in condition for a resident, leading to a deficiency in care. The resident, who had a history of diabetes, atrial fibrillation on anticoagulant therapy, and end-stage renal disease requiring dialysis, was admitted with specific medical orders, including a do-not-resuscitate directive and limited additional interventions. On the day of the incident, the resident underwent dialysis and was assessed by the Director of Nursing and a nurse, who noted no changes in her condition before dialysis. However, later that evening, the resident exhibited signs of lethargy, sluggish pupil response, and lack of motor function, which were not immediately recognized as a change in condition. Nurse #1, who was on duty during the night shift, documented the resident's deteriorating condition, including elevated blood pressure, lethargy, and unresponsiveness. Despite these observations, the nurse initially attributed the resident's symptoms to fatigue from dialysis and did not suspect a neurological change. The nurse held the resident's evening medications due to her inability to swallow and notified the on-call nurse practitioner, who advised holding the medications. The resident's condition continued to decline, with fixed pupils and unresponsiveness noted in the early morning hours. The nursing assistant assigned to the resident also observed the resident's drowsiness and quiet demeanor, attributing it to post-dialysis fatigue. It was not until the resident became unresponsive and exhibited severe symptoms, such as diaphoresis and fixed pupils, that the staff recognized the severity of the situation. The resident was eventually sent to the hospital by emergency medical services after the Director of Nursing was informed of the resident's critical status. The failure to promptly identify and respond to the resident's change in condition resulted in a deficiency in the care provided by the facility.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in several areas, including resident rooms, a linen closet, and a dining room. Observations revealed issues such as a sink pulling away from the wall, a light fixture filled with dead bugs, peeling baseboards, and debris on the bathroom floor in one room. Another room had dust and debris on the floor and broken vinyl tiles in the bathroom. The dining room had dust and cobwebs on the doors and vending machines, and a roach bait station was found covered in dust and debris. Interviews with residents indicated that while housekeepers cleaned daily, they did not perform thorough cleaning. One resident mentioned that dried bowel movement remained on the commode lid despite daily cleaning, and another resident noted difficulty in picking up belongings due to back pain, which hindered thorough cleaning. Staff interviews revealed that cleaning routines involved basic tasks like collecting trash and mopping floors, but deep cleaning was not consistently performed. The facility had an ongoing Performance Improvement Project (PIP) aimed at improving environmental services, including pest control. However, the PIP lacked a completion date, and the issues observed during the survey indicated that the interventions were not effectively implemented. The Administrator acknowledged the findings and stated that work orders were supposed to be submitted for repairs and pest sightings, but the deficiencies persisted, highlighting a gap in maintaining a clean and homelike environment for residents.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of pests in one of three hallways and two of three residents' rooms reviewed for pest activity. Observations revealed flies and brown bugs in residents' rooms, with one resident reporting flies around her face and dead flies in the light fixture since her admission. Another resident reported seeing bugs coming in and out of her bathroom, with the bathroom observed to have peeling baseboards and broken vinyl tiles. Common areas were also affected, with flies observed near the dining room door entrance. Interviews with staff members, including nurse aides and environmental specialists, confirmed sightings of roaches and other pests in various locations within the facility. Staff reported seeing roaches in linen closets, hallways, and residents' bathrooms, with some indicating that they had submitted work orders when pests were observed. The environmental specialist noted live baby roaches in a resident's room and flies in the break room, while a floor technician reported finding a roach in his mop bucket. The facility had an ongoing Performance Improvement Project (PIP) on environmental services, including pest control, which started in March 2024. The administrator stated that the exterminator was contracted monthly but changed to weekly visits in May 2024. Despite these efforts, pests continued to be reported by residents and staff, indicating that the interventions were not fully effective. The administrator acknowledged the presence of pests and stated that the facility was working on decluttering residents' rooms and sealing cracks in the walls.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed a resident's individual care needs. Specifically, for one resident, the facility did not create care plans for cognitive loss/dementia, urinary incontinence and indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. The resident was admitted with multiple fractures and pressure ulcers and was later discharged to the hospital without returning to the facility. The only care plan available for this resident was related to nutrition, dated 11/8/23. Interviews with staff revealed that the comprehensive care plans were not completed. MDS Nurse #1 and MDS Nurse #2 both confirmed that the care plans were missing and were unsure why this occurred. The Director of Nursing stated that comprehensive care plans should be based on the Care Area Assessments (CAAs) and completed within seven days from the resident assessment. However, this protocol was not followed in this case, leading to the deficiency.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put into place following previous surveys. This failure was evident during three federal surveys, including the most recent complaint investigation survey. The deficiency was specifically related to the development of comprehensive resident-centered care plans. The facility failed to develop care plans addressing various needs such as cognitive loss/dementia, urinary incontinence, indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury for one of the residents reviewed. During the recertification and complaint investigation surveys, the facility repeatedly failed to develop comprehensive care plans. In one instance, the facility did not include the daily use of antipsychotic and antianxiety medication in a resident's care plan. In another instance, the facility failed to create a care plan with measurable goals and objectives to address a resident's nutrition. An interview with the Administrator and the Director of Nursing revealed that the QAPI Committee was working on issues such as falls with injuries, pest control, and had recently added care plans to their focus areas. However, the continued failure to sustain an effective QAPI Program was evident in the repeated deficiencies.
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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