Litchford Falls Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Raleigh, North Carolina.
- Location
- 8200 Litchford Road, Raleigh, North Carolina 27615
- CMS Provider Number
- 345499
- Inspections on file
- 21
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Litchford Falls Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with complex medical history, recent spinal surgery, and high risk for skin breakdown developed multiple pressure ulcers to the buttocks, sacrum/coccyx, and gluteal folds while in the facility. Wound documentation repeatedly misidentified anatomical sites, and there were inconsistencies between wound assessments and the entry of treatment orders, leaving gaps where only one wound was treated despite multiple documented lesions. After hospitalization for a severe sacral/buttock ulcer and initiation of negative pressure wound therapy, the resident returned with orders to resume wound vac use, but no wound orders were entered for several days, staff did not apply the wound vac despite its availability, and only wet‑to‑dry dressings were used. Concurrently, the resident experienced significant weight loss and a drop in albumin, RD recommendations for high‑calorie supplements were not promptly converted into orders, and there was limited documented nutritional follow‑up, contributing to inadequate support for wound healing.
A resident with multiple chronic conditions and recent complex surgery was admitted with documented risk for weight loss and malnutrition. The RD later assessed that the resident’s oral intake (50–75% of meals) did not consistently meet estimated nutritional needs and recommended Med Plus 1.7 twice daily, but this supplement was not ordered for several weeks. The facility did not obtain weekly admission weights per its own system, and the first post-admission weight documented a significant loss that was not entered into the electronic record or evaluated, despite a concurrent drop in albumin and worsening skin breakdown from MASD to multiple pressure ulcers. There was no documented assessment of the causes of the weight loss and low albumin or related interventions during a critical period, and nutritional concerns were not recorded as discussed at a care conference, resulting in a deficiency for failure to provide adequate nutrition and monitoring.
A resident experiencing altered mental status was transferred to the hospital, but the RN completed a transfer form and SBAR using vital signs from the prior day and left the narrative section for additional change-in-condition information blank, with no progress note documenting the vital signs taken at the time of the change. In interview, the nurse reported taking the resident’s BP and pulse and writing them on a piece of paper that was never entered into the EMR. In addition, the wound nurse and wound NP documented an open area and subsequent Stage II pressure injury as being on the right buttock for several weeks when it was actually on the left buttock, resulting in inaccurate wound location documentation in the medical record.
Surveyors found that several resident rooms had unclean and poorly maintained conditions, including broken and dirty PTAC units, missing filters, damaged floor tiles, dirty flooring, and a broken electrical outlet cover. Both maintenance and housekeeping staff acknowledged the issues, and the Administrator confirmed that the rooms did not meet expected standards for cleanliness and repair.
Two residents did not have accurate MDS assessments completed: one was discharged without a required Discharge MDS, and another received an IV antibiotic that was not documented in the MDS despite administration during the look-back period. Staff interviews confirmed these omissions were due to oversight and failure to accurately reflect care provided.
A resident with a history of respiratory failure was identified as an independent smoker, but the care plan contained conflicting interventions regarding supervision and independence with smoking. Staff interviews and observations confirmed the resident smoked unsupervised, while documentation inconsistently required both supervision and independent smoking, resulting in an inaccurate care plan.
A medication cart was found with dried substances, powder, and several loose, partially dissolved pills in one of its drawers. Nursing staff and the Unit Manager confirmed that nurses were expected to keep medication carts clean and dispose of loose pills, while the DON and Administrator stated that staff were responsible for maintaining medication carts according to safety and regulatory standards.
A resident who was fully dependent on staff for personal hygiene did not receive regular fingernail care or shaving in accordance with his preference to be clean shaven. Observations showed the resident's fingernails were excessively long and dirty, and he had significant facial hair. Staff interviews revealed confusion about who was responsible for these grooming tasks, resulting in the resident's needs not being met until addressed by activities staff.
A resident with a DNR order was resuscitated after being found unresponsive due to a failure in verifying her code status. The facility lacked an effective system to ensure advance directives were honored, leading to the initiation of chest compressions before the DNR status was confirmed.
A resident with multiple health conditions experienced nausea, vomiting, and decreased urine output after an increase in diuretic medication. Despite these symptoms being observed by nurse aides, the physician was not notified, and there was no documentation of these changes. The resident was later hospitalized and diagnosed with severe conditions, ultimately leading to her death. The facility's failure to communicate and document the resident's symptoms resulted in a deficiency in care.
A facility failed to conduct ordered lab work and ensure effective communication regarding a resident's condition after an increase in diuretic medication. The resident, with multiple chronic conditions, experienced vomiting and decreased urine output, which were not adequately documented or communicated to the physician. This led to a lack of timely medical intervention, and the resident was later hospitalized with severe complications and expired.
A resident with multiple health issues developed a pressure sore, and the facility staff failed to follow the Wound NP's care plan. The NP recommended specific treatments and dressing change frequencies, but the staff did not update the orders accordingly, leading to daily dressing changes instead of the recommended three times per week. Miscommunication and misunderstanding of the treatment plan contributed to the worsening of the resident's condition, resulting in a hospital transfer and hospice care initiation.
A resident experienced a fall resulting in a head hematoma and pain, but the facility failed to document the incident and subsequent assessments in the medical record. The fall occurred in the early morning, and although the resident was transferred to the hospital, proper documentation was not made until two days later, lacking details about the fall and injury assessment.
A resident with a history of strokes and DVTs experienced a lapse in Eliquis coverage due to the facility's failure to consult with the MD for order clarification. The resident was hospitalized with a stroke after the medication was discontinued without consulting the physician. Interviews revealed a lack of process for addressing outside consultant recommendations.
A consultant pharmacist failed to urgently report the omission of Eliquis for a resident with a history of strokes and DVTs, leading to a 36-day lapse in anticoagulant therapy. The resident was subsequently hospitalized with an acute stroke. The pharmacist identified the omission during a monthly review but delayed communication to the facility, resulting in the resident not receiving the necessary medication.
A resident with a history of strokes and DVTs did not receive Eliquis for 36 days due to a failure to transcribe a physician's order after a vascular consultation. This oversight led to the resident's hospitalization with an acute stroke. The facility's process for reviewing and transcribing orders from outside consultations was not consistently followed, contributing to the medication error.
A resident with a history of DVTs, PE, and atrial fibrillation did not receive recommended compression stockings due to a failure in transcribing the order into the EMR after a vascular consultation. Interviews with facility staff revealed a lack of clarity and follow-through in the process of implementing external consultation recommendations, resulting in the resident not receiving the necessary treatment.
Failure to Coordinate Wound Care, Wound Vac Use, and Nutrition for Resident With Multiple Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent the development and worsening of multiple pressure sores for a resident with significant medical comorbidities and recent spinal surgery. The resident was admitted after a complicated hospitalization that included spinal decompression surgery, epidural hematoma, sepsis, and multiple chronic conditions such as COPD, diabetes, hypertension, obesity, neuropathy, and a history of alcoholism and drug use. On admission, the resident was identified as at risk for pressure sores and for weight loss/malnutrition, with an albumin of 3.5 and an admission weight of 226 pounds, down from 240 pounds at hospital discharge. Early documentation by the facility Wound Nurse misidentified the anatomical site of moisture-associated skin damage (MASD) and an open area, charting it as the right buttock when it was actually on the left, and subsequent orders and NP documentation continued to reference incorrect or inconsistent anatomical locations. As the stay progressed, the resident developed multiple pressure sores to the buttocks, sacrum/coccyx, and gluteal folds. There were repeated inconsistencies and gaps between wound assessments and the entry of corresponding treatment orders. On 11/3, a Stage II buttock pressure sore was documented and treated with collagen and a border gauze, but the site was again mis-labeled as the right buttock when the Wound Nurse later stated it was on the left. On 11/10, the Wound Nurse documented four pressure sore sites, including non‑stageable areas and a Stage II right buttock wound, but no new treatment orders were entered that day, and the November TAR showed only collagen treatment to the right buttock on 11/10 and 11/11. The Wound Nurse stated she would have used facility wound protocols on 11/10 and 11/11 but did not document this, and acknowledged that without orders, other nurses would not know the treatment plan. On 11/12, the Wound Nurse documented necrotic tissue, foul odor, and multiple pressure areas, while the Wound NP’s note the same day described several new unstageable wounds but did not mention the coccyx/sacrum wound or foul odor, and wound numbering and locations were inconsistent with prior documentation. The facility also failed to timely and consistently address the resident’s nutritional status and significant weight loss in relation to wound development and healing. The RD first recommended Med Plus 1.7 on 10/31 due to intake not consistently meeting estimated needs, but no physician order for this supplement was entered in October or November. The resident experienced a substantial weight loss from 226 pounds on admission to 197.2 pounds by mid‑November, with a drop in albumin from 3.5 to 3.0, and one weekly weight was missed. The RD did not document further follow‑up until 12/8, at which time a more than 30‑pound weight loss over two months and three pressure sores were noted, and supplements including Med Plus, multivitamin, vitamin C, and zinc were again recommended; these were not started until 12/10. After hospitalization for a worsening left‑sided sacral/buttock ulcer requiring sharp debridement and initiation of negative pressure wound therapy (wound vac), the resident returned to the facility on 12/5 with orders to resume wound vac therapy as soon as possible and to use a low air loss bed, strict turning, and activity restrictions. No pressure sore treatment orders were entered into the electronic record until 12/8, and there were no documented wound treatments on 12/6 and 12/7. A nurse who cared for the resident that weekend reported not knowing where to obtain a wound vac and believing it had to be specifically ordered, so she applied wet‑to‑dry dressings instead. The DON stated a wound vac was available in the treatment room and that multiple nurses were trained to apply it, and she had not been notified that staff could not locate or use it. When the Wound Nurse returned on 12/8, she found no wound orders in the system and no wound vac in place, only a clean wet‑to‑dry dressing, and then initiated wound vac and dressing orders. Throughout the stay, the care plan and documentation were updated intermittently, but the report describes failures in accurate wound site identification, timely order entry, consistent implementation of wound vac therapy, and systematic evaluation of the resident’s nutritional decline in relation to the development and worsening of multiple pressure sores.
Failure to Initiate RD-Recommended Supplements and Monitor Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutrition and monitoring for a resident with complex medical needs, including not initiating an RD-recommended supplement, not obtaining weekly admission weights per facility practice, and not evaluating significant weight loss and declining albumin. The resident was admitted after a complicated hospitalization that included spinal decompression surgery, an epidural hematoma requiring additional surgery, sepsis from hospital-acquired pneumonia, and multiple chronic conditions such as COPD, diabetes, hypertension, obesity, osteoarthritis, neuropathy, and a history of alcoholism and illegal drug use. The hospital discharge summary documented a last hospital weight of 240 pounds 4.8 ounces, while the facility admission weight on the same date was 226 pounds. On admission, the resident’s albumin was 3.5, within normal limits, and the care plan identified risk for weight loss or malnutrition related to recent acute illness, hospitalization, and chronic disease, with interventions including RD consult as needed, recording meal intake percentages, reviewing dietary preferences, and providing a therapeutic diet as ordered. On 10/31/25, the RD assessed the resident and documented that he had MASD to the buttocks, was on a diabetic diet, and was consuming 50–75% of his meals. The RD noted that his intake did not appear to consistently meet his estimated nutritional needs and recommended Med Plus 1.7, 90 ml twice daily with medications. However, review of physician orders for October and November showed that Med Plus was not ordered following this recommendation, and the RD later stated she did not know why nutritional support had not started at that time. The DON reported that residents were to be weighed weekly for four weeks after admission and then placed on an individualized schedule, and that the RD typically reviewed any abnormal weights. Nurse #1, who helped oversee weekly weights, reported that the facility missed weighing the resident during the first four weeks after admission as required by their system, and that the first weight she could find after admission was 197.2 pounds on 11/14/25, reflecting a significant loss from the 226-pound admission weight. This weight was not entered into the electronic record, and there was no documented assessment or follow-up of the weight loss at that time. During this same period, the resident’s skin condition worsened. On 10/24/25, the Wound Nurse documented MASD and an open area on the right buttock. By 11/10/25, the Wound Nurse documented four pressure sores, three unstageable and one Stage II, including one described as black and bleeding. On 11/12/25, the Wound Nurse documented multiple pressure sores, one necrotic with foul odor, and noted that the Wound NP planned to order labs. Labs on 11/13/25 showed the resident’s albumin had dropped to 3.0, an abnormally low level and a 0.5 decrease from 10/24/25. There was no documentation from 11/14/25 through 11/24/25 of an assessment of what was contributing to the resident’s weight loss and low albumin or of possible interventions. The RD did not evaluate the resident again until 12/8/25, after a hospitalization for worsening pressure sores and readmission on 12/5/25, at which time she documented that the resident had lost more than 30 pounds in two months, had three pressure sores present on admission, and had increased nutritional needs for wound healing. She again recommended Med Plus 1.7 and additional supplements, which were ordered and started on 12/10/25, marking the first time the Med Plus order appeared on the MAR since her initial recommendation on 10/31/25. Throughout this period, there was no documentation that weight loss or nutritional concerns were discussed at the 11/12/25 care conference, and key staff, including the MDS nurse, were not familiar with the resident’s weight loss or related interventions, contributing to the failure to timely address the resident’s nutritional decline. The deficiency also includes the facility’s failure to obtain admission weights per its stated system for another newly admitted resident, which prevented establishment of individualized weight monitoring timeframes. The DON stated that residents were to be weighed weekly for four weeks after admission, with the first four weights used to determine future monitoring schedules, and that Nurse #1 helped oversee weekly weights. However, Nurse #1 reported that the facility had missed weighing the resident during the first four weeks following initial admission, and that the 11/14/25 weight was the first weight she could locate after the 10/23/25 admission weight. This gap in weight monitoring, combined with the failure to act on the RD’s supplement recommendation and the lack of documented evaluation of significant weight loss and declining albumin, formed the basis of the cited deficiency for failure to provide sufficient food and fluids to maintain the resident’s health.
Incomplete and Inaccurate Medical Record Documentation for Change in Condition and Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and complete medical record for a resident experiencing a change in condition and for wound documentation. The resident was transferred to the hospital for altered mental status. On the date of transfer, Nurse #2 completed a transfer form and an SBAR form that were dated for that day but contained vital signs from the previous day. The SBAR form also had a designated area for additional nursing notes about the change in condition, which was left blank. Review of the medical record showed no narrative progress note documenting vital signs at the time the altered mental status was first observed. In interview, Nurse #2 stated she and the facility Wound Nurse noticed the resident was not responding at baseline, that she took the resident’s blood pressure and pulse, and that the resident was not having labored breathing, but she did not remember the vital sign values and did not enter them into the record, stating she had written them on a piece of paper that was later lost. The DON confirmed that the vital signs taken at the time of the altered mental status were not entered into the electronic medical record, leaving the record incomplete. The deficiency also includes inaccurate wound documentation for the same resident. On an admission skin observation assessment form, the facility Wound Nurse documented an open area on the right buttock. Later, on a skin assessment form, the Wound Nurse documented that the resident was seen by the Wound NP for a pressure sore to the right buttock, and the Wound NP documented a Stage II pressure sore to the right buttock. In a subsequent interview, the facility Wound Nurse confirmed that she had not documented the correct location of the open area on the initial skin observation assessment and that both she and the Wound NP had inaccurately documented the wound as being on the right buttock for several weeks when it was actually on the left buttock. The DON, present during the interview, stated that both the Wound Nurse and the Wound NP were newer to their roles, which may have contributed to the inaccurate documentation.
Failure to Maintain Clean and Safe Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment in five out of seven resident rooms on one hall. Specific deficiencies included broken and dirty PTAC (heating and air conditioning) units, missing filters, units detached from the wall, and visible debris such as rubber bands and unidentified substances inside the units. Additionally, there were damaged floor tiles, dirty baseboards and flooring, and a broken electrical outlet cover. These issues were directly observed during a tour with the Maintenance Director, who acknowledged the need for repairs and cleaning in the affected areas. Interviews with the Maintenance Director and Housekeeping Director revealed that responsibilities for cleaning and maintenance were divided between their departments, with housekeeping cleaning the outside of PTAC units and maintenance handling the inside. Despite daily cleaning routines described by the Housekeeping Director, the observed deficiencies indicated that these routines were not effectively ensuring cleanliness and repair in the resident rooms. The Administrator confirmed expectations for cleanliness and equipment maintenance, but the observed conditions did not meet these standards.
Failure to Accurately Complete and Document MDS Assessments
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for two residents. For one resident, the facility did not complete a Discharge MDS assessment upon the resident's discharge home with a family member, as confirmed by both the MDS Coordinator and the Administrator, who acknowledged the assessment was missed due to oversight. Review of the resident's records showed no Discharge MDS was present, despite the requirement to complete one at the time of discharge. For another resident with a history of non-Alzheimer's dementia and neurogenic bladder requiring a suprapubic catheter, the facility did not accurately document the administration of an intravenous antibiotic (ertapenem) in the MDS assessment. The resident received the antibiotic as ordered during the 7-day look back period, as evidenced by the Medication Administration Record (MAR), but the MDS did not reflect this. This omission was confirmed during interviews with the MDS Nurse and Regional MDS Nurse, who agreed the assessment should have indicated antibiotic use during the specified period.
Failure to Accurately Care Plan Smoking Interventions for Independent Smoker
Penalty
Summary
The facility failed to accurately care plan interventions related to smoking for a resident with a history of respiratory failure who was identified as an independent smoker. The resident's most recent Smoking Safety Screen indicated both that he could smoke independently and that he required supervision, creating conflicting information. The care plan included interventions stating the resident may smoke independently, required a smoking assessment as needed, and required supervision with smoking, but these interventions were not consistent with each other or with the resident's actual practice. Observations and interviews confirmed that the resident regularly smoked unsupervised and considered himself an independent smoker. Facility staff, including the Unit Manager and MDS nurses, acknowledged the inconsistency between the care plan and the resident's actual smoking status. The MDS nurses agreed that the care plan should clearly indicate whether the resident was a safe, independent smoker or required supervision, but at the time of the survey, the care plan remained inaccurate.
Medication Cart Not Maintained in Clean and Sanitary Condition
Penalty
Summary
Surveyors observed that the 100 [NAME] medication cart was not maintained in a clean and sanitary condition. Specifically, the second drawer of the cart contained red, clear, and white dried substances, as well as pink and white powder. Additionally, six loose, partially dissolved white pills were found at the bottom of the same drawer. During interviews, the Unit Manager acknowledged that nurses were expected to keep medication carts clean and to dispose of loose pills. The DON stated that nursing staff were responsible for maintaining medication carts according to safety and regulatory standards, with unit managers expected to monitor compliance. The Administrator confirmed that the DON was responsible for ensuring that staff maintained medication carts and areas in accordance with safety and regulatory requirements.
Failure to Provide Routine Fingernail Care and Shaving per Resident Preference
Penalty
Summary
A deficiency was identified when a dependent resident with non-Alzheimer's dementia and bilateral hand contractures did not receive routine fingernail care and was not shaved according to his stated preference. The resident was totally dependent on staff for bathing and personal hygiene, as documented in his care plan and most recent MDS assessment. Observations revealed that the resident's fingernails were approximately 1/2 inch long, discolored, and had a dark substance underneath. The resident also had facial hair about 1/2 inch long, despite expressing a preference to be clean shaven. The resident did not exhibit behaviors or reject care. Interviews with staff indicated confusion regarding responsibility for fingernail care and shaving. The activities staff member, prompted by a family request, ultimately trimmed the resident's fingernails, describing them as very long and dirty. The nurse aide assigned to the resident was unsure if she was permitted to trim fingernails and believed shaving male residents was the responsibility of the facility's Scheduler, who only shaved residents when cutting their hair. The Administrator confirmed that staff were expected to provide grooming care according to resident preferences, including fingernail care and shaving, typically on bath days and as needed.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to honor a resident's advance directive not to be resuscitated upon her death. The resident, who had multiple diagnoses including stroke, respiratory failure, and congestive heart failure, was admitted with a Do Not Resuscitate (DNR) order. Despite this, when the resident was found unresponsive, a code blue was called, and chest compressions were initiated by a nurse who was unaware of the resident's DNR status. The resuscitation efforts were stopped only after another nurse checked the resident's records and confirmed the DNR order. The incident revealed a lack of an effective system to ensure that the resident's advance directive was honored. The Director of Nursing and a corporate Nurse Consultant confirmed that the code status should be checked before initiating resuscitation. However, the nurse involved in the incident did not verify the resident's code status before starting chest compressions. This deficiency highlights a failure in the facility's protocol to quickly verify and respect residents' advance directives during emergency situations.
Failure to Notify Physician of Resident's Symptoms
Penalty
Summary
The facility failed to notify the physician when a resident experienced nausea, vomiting, and decreased urine output following an increase in her diuretic medication. The resident, who had a history of congestive heart failure, stroke, hypertension, diabetes, and other conditions, was on a furosemide regimen that was increased by the physician due to observed swelling. Despite the resident's symptoms of vomiting and decreased urination, which were noted by nurse aides, there was no documentation or physician notification regarding these changes. Interviews with staff revealed that nurse aides observed the resident vomiting brown emesis and having decreased urine output over several days, but this information was not communicated to the physician. The resident's condition was not adequately monitored, and the physician was not informed of the significant changes in the resident's health status. The resident was later found to be clinically dehydrated upon hospital admission, where she was diagnosed with multiple severe conditions, including sepsis and cirrhosis. The resident's physician indicated that had he been informed of the vomiting and decreased urine output, he would have continued the diuretic treatment but with closer monitoring. The resident eventually transitioned to hospice care and passed away due to multiple organ failure. The lack of communication and documentation regarding the resident's symptoms contributed to the deficiency in care provided by the facility.
Failure to Conduct Ordered Lab Work and Communicate Resident's Condition
Penalty
Summary
The facility failed to ensure that labs were drawn as ordered for a resident whose diuretic medication was increased. This oversight occurred despite the resident being at risk for complications due to diuretic use, as noted in her care plan. The lab work, which was ordered to monitor the resident's condition after an increase in furosemide dosage, was not completed because the order was not entered into the lab draw book, leading to a lack of communication with the phlebotomist. Additionally, there was a failure in effective communication between nurse aides and nurses regarding the resident's symptoms of vomiting and decreased urine output. The resident experienced vomiting and a significant decrease in urine output, which were not adequately documented or communicated to the physician. This lack of communication resulted in the resident not receiving nausea medication as prescribed and the physician not being informed of the resident's lower urine output after the diuretic dosage was increased. The resident, who had multiple chronic conditions including congestive heart failure, stroke, and diabetes, was eventually referred to hospice care. Despite the resident's transition to hospice, the facility's failure to complete the ordered lab work and communicate critical changes in the resident's condition contributed to a lack of timely medical intervention. The resident was later hospitalized with severe complications, including dehydration, acute kidney injury, and sepsis, and subsequently expired in the hospital.
Failure to Follow Wound Care Plan for Resident with Pressure Sore
Penalty
Summary
The facility staff failed to effectively communicate with the Wound Nurse Practitioner (NP) regarding the care plan for a resident with a pressure sore. The resident, who had a history of stroke, hypertension, diabetes, pelvic fracture, and congestive heart failure, was admitted to the facility and later developed a pressure sore. The Wound NP recommended a specific treatment plan, including cleansing the wound with a wound cleanser, applying silver alginate, and changing the dressing three times per week. However, the facility staff did not update the orders to reflect these recommendations, and the dressing changes continued to be performed daily. The situation worsened when the Wound NP assessed the resident again and noted a significant deterioration in the pressure sore, recommending a new treatment plan involving Dakin's solution for cleansing, Santyl, and calcium alginate, with dressing changes every three days. Despite these recommendations, the facility staff did not follow the updated treatment plan, as the orders were entered incorrectly, omitting the use of Dakin's solution and continuing daily dressing changes. The Facility Wound Nurse misunderstood the instructions, believing that Dakin's and Santyl could not be used together, and did not realize the frequency of dressing changes should have been reduced. The resident's condition continued to decline, with the pressure sore worsening and the resident becoming resistive to care. The Wound NP suspected a terminal condition might be contributing to the rapid deterioration. The resident was eventually transferred to the hospital after a fall, and hospice services were initiated. The lack of adherence to the Wound NP's treatment recommendations and the miscommunication between the facility staff and the Wound NP contributed to the deficiency in care for the resident's pressure sore.
Incomplete Documentation of Resident Fall and Injury
Penalty
Summary
The facility failed to maintain complete medical records for a resident who experienced a fall and subsequent injury. The resident, who stayed at the facility from January 27 to February 8, was found on the floor with a hematoma on his head and complained of pain on the morning of February 8. Despite being transferred to the hospital for evaluation, there was no documentation of the fall or any assessment of injuries in the resident's medical record prior to a note made on February 10. This note, made by the Minimum Data Set assessment nurse, mentioned a review by the interdisciplinary team but lacked details about the timing of the fall or the assessment of injuries. Interviews with staff confirmed the absence of proper documentation regarding the circumstances of the fall and the resident's condition following the incident.
Failure to Consult MD Leads to Lapse in Anticoagulant Medication
Penalty
Summary
The facility failed to immediately consult with a resident's Medical Doctor (MD) for order clarification when there was a lapse in the resident's coverage of an oral anticoagulant medication, Eliquis. This medication is crucial for reducing the risk of stroke and blood clots in individuals with atrial fibrillation. The resident, who had a history of strokes, deep vein thrombosis (DVTs), pulmonary embolism (PE), and atrial fibrillation, was admitted to the hospital due to a change in mental status and was diagnosed with an acute middle cerebral artery (MCA) stroke. The lapse in medication coverage occurred because the facility did not clarify with the Vascular consultant or the resident's physician whether Eliquis needed to be continued until the next Vascular consult. The resident had been receiving Eliquis as part of her medication regimen from February 2024 until September 2024. However, after a Vascular consultation on September 27, 2024, the resident's Eliquis was discontinued, and enoxaparin was initiated. Upon returning to the facility, the order to restart Eliquis was transcribed with a start date of September 28, 2024, and an end date of October 28, 2024. The facility did not consult the physician when the Eliquis was discontinued on October 28, 2024, leading to an 11-day lapse in administration until the next Vascular consultation on November 8, 2024. Interviews with facility staff revealed a lack of a set process to address recommendations from outside consultants. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were unaware of the lapse in medication coverage and did not consult the physician when the medication ran out. The resident's Medical Doctor stated that if he had been informed, he would have recommended consulting the Vascular consultant. The lapse in medication coverage was not intentional, but it resulted in the resident being hospitalized with a stroke.
Removal Plan
- 100% audit of all current residents discontinued/stopped medication in the last 30 days by the Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinator to identify any other medication that was discontinued/stopped/ran-out without consultation with an attending physician.
- Facility employees will ensure any changes in medication or treatment, to include discontinuation of medication such as Eliquis, will be reported to the physician prior to the discontinuation to ensure appropriate medical intervention/assessment is implemented.
- Licensed nurse on duty will inform the resident; consult with the resident's physician; and notify the resident representative when there is a significant change in the resident's physical, mental, or psychosocial status, a need to alter treatment significantly.
- The facility's clinical team initiated a process for reviewing clinical documentation for the last 24 hours and physician orders written in the last 24 hours to ensure any needed notification of changes to the physician, and/or responsible party was done in a timely manner.
- 100% education of all licensed nurses to include full time, part time, and as needed licensed nurses will be completed by the Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, and/or Unit Coordinators.
- 100% education of all current clinical leadership team members to include Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator and/or Admission nurse completed by the Regional Director of Clinical services.
Failure to Urgently Report Medication Omission
Penalty
Summary
The deficiency involved a failure by the consultant pharmacist to urgently report a significant medication irregularity for a resident with a history of strokes, deep vein thrombosis (DVTs), pulmonary embolism (PE), and atrial fibrillation. The resident was prescribed Eliquis, an oral anticoagulant, to reduce the risk of stroke and blood clots. However, after a vascular consultation recommended the continuation of Eliquis, the medication was not administered from the end of October to early December, despite the pharmacist identifying the lapse during a monthly Medication Regimen Review (MRR) on November 13th. The consultant pharmacist identified the omission of Eliquis but failed to notify the facility or the attending physician urgently. The pharmacist's recommendation to restart Eliquis was not communicated to the facility until November 20th, a week after the MRR. This delay in communication resulted in the resident not receiving the anticoagulant for 36 days, leading to the resident being admitted to the hospital with an acute middle cerebral artery (MCA) stroke on December 3rd. Interviews with facility staff, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), revealed that the report from the pharmacist was not timely and did not highlight the urgency of the situation. The facility's medical director and the resident's attending physician both acknowledged the importance of continuing anticoagulant therapy and expressed that the pharmacist should have alerted the facility immediately upon identifying the medication omission.
Removal Plan
- 100% audit of current residents who have had medical appointments to validate any orders/recommendations from the consulting physician were transcribed to the facility electronic health records and implemented as ordered.
- 100% of all consulting pharmacist nursing recommendations and MD recommendations for current residents were audited to identify any other recommendations that were not transcribed/implemented/acted upon correctly in the facility.
- The licensed pharmacist will review each resident drug regimen monthly and report any irregularities to the attending physician and the Director of Nursing to be acted upon in a timely manner.
- The facility's clinical team initiated a process for reviewing pharmacy recommendations completed by the licensed pharmacist to ensure the recommendations to include any irregularities on drug regimen are reported to the attending physician and acted upon in a timely manner.
- 100% education of all current clinical leadership team members to include Director of Nursing, Assistant Director of Nursing, Medical records coordinator, Unit coordinator #1, Unit coordinator #2 and/or Admission nurse completed by the facility administrator.
- The facility Administrator conducted a phone Inservice education to the facility medical director, attending physician, and the licensed pharmacist who provide services to the facility on the importance of ensuring any medication irregularity is communicated to the attending physician timely for proper follow through.
Failure to Administer Anticoagulant Leads to Hospitalization
Penalty
Summary
The facility failed to provide an uninterrupted course of Eliquis, an oral anticoagulant, for a resident with a history of strokes, deep vein thrombosis (DVT), pulmonary embolism (PE), and atrial fibrillation. The medication was discontinued 11 days before the resident's follow-up from an outside vascular consultation, resulting in the resident missing the medication for 36 days until she was discharged to the hospital. This lapse occurred because the facility did not transcribe an order for Eliquis into the resident's electronic medical record (EMR) after her vascular consultation. The resident was admitted to the hospital due to a change in mental status and was diagnosed with an acute middle cerebral artery (MCA) stroke. The facility's failure to transcribe the order for Eliquis after the resident's vascular consultation on 11/8/24 was a significant medication error. The resident's medical history included chronic anticoagulation due to atrial fibrillation and a history of DVT and PE, making the continuation of Eliquis critical. Interviews with facility staff revealed that the process for reviewing and transcribing orders from outside consultations was not consistently followed. The hall nurse was initially responsible for transcribing orders, but the Unit Manager was supposed to ensure the task was completed. However, the consultation paperwork was not always reviewed or followed up on, leading to the oversight in the resident's medication regimen.
Removal Plan
- 100% audit of current residents who have had medical appointments to validate any orders/recommendation from the consulting physician were transcribed to the facility electronic health records and implemented as ordered.
- 100% audit of current residents' medication discontinues to validate any discontinued medication that was done based on the physician orders to ensure such actions are done based on the medical guidance to prevent significant medication error.
- A licensed nurse on duty will review a consultation report for any resident who returned from medical appointment while on duty and transcribe any orders in facility electronic health records.
- Employees will administer medication based on physician orders, to include Eliquis, to treat a specific condition as diagnosed, and document the administration of such medication in each resident's clinical record.
- The facility's clinical team initiated a process for reviewing clinical documentation to include the review of medical appointments ordered and/or scheduled to ensure the appointment is scheduled and take place as ordered.
- 100% education of all current clinical leadership team members to ensure residents' medical appointments are reviewed in the daily clinical meeting to ensure ordered appointments are scheduled, completed, and the consultation forms from the completed appointments are reviewed for any new orders and recommendations.
- Assistant Director of Nursing will provide 100% education of all licensed nurses and Medication aides, to include full time, part time, and as needed nursing employees, on the importance of administering medication per physician order, consulting the attending physician before medication stopped/discontinued, and ensuring consultation forms for residents who returned from the medical appointment are reviewed for any new orders/recommendation.
Failure to Implement Compression Stockings for Resident with DVTs
Penalty
Summary
The facility failed to initiate the use of compression stockings for a resident with a history of deep vein thrombosis (DVTs), pulmonary embolism (PE), and atrial fibrillation. The resident was admitted to the facility after a hospital stay for a left distal fibular fracture. Despite recommendations from a vascular consultation to use compression stockings daily, this order was not transcribed into the resident's electronic medical record (EMR) upon her return to the facility. Interviews with facility staff revealed that the nurse on duty at the time of the resident's return from the vascular consultation did not recall seeing an order for compression stockings. Subsequent reviews of the resident's physician's orders, Medication Administration Record (MAR), and Treatment Administration Record (TAR) confirmed the absence of orders for compression stockings. The resident's care plan and Kardex also did not include instructions for the use of compression stockings, indicating a breakdown in communication and documentation processes. Further interviews with the facility's staff, including the Unit Manager and Assistant Director of Nursing (ADON), highlighted a lack of clarity and follow-through in the process of transcribing and implementing external consultation recommendations. The ADON explained that the nurse should have reviewed the new orders, obtained provider approval, and transcribed the order into the EMR, which did not occur. This oversight resulted in the resident not receiving the recommended compression stockings, which were intended to manage her chronic bilateral lower extremity DVTs.
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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