Magnolia Lane Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Morganton, North Carolina.
- Location
- 107 Magnolia Drive, Morganton, North Carolina 28655
- CMS Provider Number
- 345219
- Inspections on file
- 22
- Latest survey
- December 19, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Magnolia Lane Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not consistently document or communicate its responses and rationales to concerns raised by residents during multiple Resident Council meetings, particularly regarding food services and care practices. Despite residents voicing ongoing issues, there was a lack of written follow-up or formal documentation of actions taken, and residents reported rarely receiving updates about how their concerns were addressed.
The facility did not submit required Level II PASRR evaluations for four residents admitted with serious mental health disorders, despite documented diagnoses and ongoing treatment with psychotropic medications. Staff interviews and record reviews confirmed that the process for requesting Level II PASRR evaluations was not followed, resulting in the absence of necessary screenings for these individuals.
Surveyors found expired lemon-flavored thickener in the walk-in cooler and observed boxes of frozen turkeys and french toast sticks stored directly on the floor in the walk-in freezer. Interviews with the Dietary Manager and Administrator confirmed that staff did not follow procedures for discarding expired food or storing food off the floor.
A resident with advanced cancer and severe cognitive impairment was admitted to hospice care with a physician's order for Do Not Resuscitate (DNR) status. Despite this, the required DNR form was not completed or signed by the physician and was missing from the medical record, as confirmed by record review and staff interviews.
The facility did not provide a SNF ABN to three residents whose Medicare Part A skilled services were ending, even though continued services might not be covered. While a NOMNC was discussed and signed, there was no evidence that the required SNF ABN was reviewed with or given to the residents before their skilled coverage ended. Miscommunication between the therapy team and business office led to this deficiency.
A medication aide, not licensed or qualified to perform IV insertions, attempted to insert a peripheral IV catheter into a resident with multiple medical conditions after a nurse was unsuccessful and left the room. The aide, who was attending nursing school, made one attempt and was witnessed by another aide. The incident was not immediately reported to the nurse, and staff confirmed the aide acted outside her scope of practice.
Three residents' discontinued narcotic medications were not properly returned to the pharmacy due to breakdowns in the facility's medication return process. Medications were placed in an unsealed bag with incomplete or unclear documentation, and the pharmacy did not receive the drugs or the required forms. Staff interviews and record reviews revealed confusion over responsibilities and a forged courier signature, resulting in unaccounted-for controlled substances.
A resident with severe cognitive impairment, malnutrition, and a pressure ulcer did not receive the physician-ordered double portions and enriched meal program at breakfast. The breakfast tray was missing required items such as oatmeal and chocolate milk, did not provide the correct double portions, and included a disliked food item without the appropriate substitute. Staff interviews revealed confusion about the enriched meal program and a lack of adherence to the diet card instructions.
A nurse did not wear a protective gown while administering a nutritional supplement and water flushes through a feeding tube for a resident with an implanted medical device, despite facility policy and posted instructions requiring Enhanced Barrier Precautions (EBP) for such high-contact care activities. Gowns were available and an EBP sign was posted, but the nurse was unaware that precautions were still in place.
A resident with severe cognitive and physical impairments, fully dependent on staff for oral hygiene, was found to have persistent buildup of debris on their teeth and gums over several days. Staff interviews and observations confirmed that oral care was not routinely provided, despite care plans and dental recommendations indicating the need for daily assistance.
A resident admitted with multiple pain management needs did not receive prescribed as-needed controlled pain medication because the emergency kit supply was depleted and the facility failed to follow proper procedures for reordering through the pharmacy. Staff were unable to provide the required medication, leading the resident to call 911 for hospital transfer. Interviews and record reviews revealed inconsistent inventory checks, improper handling of DEA 222 forms, and a lack of timely communication with the pharmacy, resulting in the deficiency.
The facility failed to maintain cleanliness around a trash dumpster and grease trap, potentially impacting sanitary conditions and attracting pests. Observations revealed various discarded items, including a recliner, wheelchairs, and plastic containers, around the dumpster. The grease trap area was littered with debris. The Dietary Manager was aware of the issue but did not know the reporting process or his responsibility. The Administrator acknowledged the oversight, noting the DM's recent employment.
A survey identified multiple deficiencies in food safety and hygiene at an LTC facility. Wet dishware was improperly stacked, perishable food was stored on the floor, and expired or spoiled food was found in storage areas. Staff failed to follow hygiene protocols, with some not wearing beard guards or hair nets during food preparation. These practices potentially compromised the safety and quality of food served to residents.
A facility failed to maintain resident privacy when a medication cart laptop was left unattended with health information exposed. The laptop, displaying resident details, was in a public area, and Nurse #2 did not minimize or lock the screen when leaving the cart. The DON confirmed the need to hide such information when unattended.
A facility failed to label a resident's tube feeding formula with necessary details, including the time and flow rate, as observed over two days. Staff interviews revealed that nurses were responsible for labeling, but complacency may have led to the oversight, despite training during orientation.
A resident with ESRD did not receive appropriate dialysis care due to the facility's failure to obtain necessary physician orders for dialysis frequency and access site monitoring. Additionally, the facility did not enforce the resident's fluid restrictions, as there was no order in place despite the care plan indicating a 1200 cc/day limit. Staff interviews revealed communication and documentation issues, contributing to the oversight in the resident's care.
A resident was admitted without a completed food preference form, leading to frequent serving of disliked meals. Despite expressing a dislike for chicken, no alternative was offered, and dietary staff were not informed. Staff interviews revealed a lack of communication and understanding of the process for documenting and addressing food preferences.
A resident's Oxycodone medication was misappropriated due to discrepancies in medication administration records and controlled substance counts. Despite receiving routine pain medication, 19 tablets were missing, leading to an investigation involving the ADON, local police, and suspension of a nurse. The facility failed to maintain accurate records, resulting in a deficiency in protecting the resident's medication rights.
A resident with hemiplegia and chronic pain required assistance with oral care, but the facility failed to provide adequate support. Despite being cognitively intact, the resident's oral hygiene was poor, with cavities and inflamed gums. Observations showed thick plaque on teeth, and staff interviews revealed inconsistent assistance and documentation of care refusals. The facility's documentation practices were lacking, and oral care was not prioritized, leading to inadequate care for the resident.
The facility failed to post required contact information for State agencies and advocacy groups, including the State Survey Agency and the Long-Term Care Ombudsman program, during a recertification survey. Observations revealed missing postings in key areas, and the Administrator confirmed the information was not reposted after renovations.
The facility did not post signage for the location of survey results for three out of four days during a recertification survey. Observations and interviews revealed that residents were unaware of where to find the survey results, which were kept in an unlabeled grey binder on a low shelf in the front lobby. The Administrator acknowledged the absence of signage, attributing it to possible removal during renovations.
The facility failed to post accurate RN staffing information for eight days, with missing RN hours on several dates. The Receptionist, responsible for daily postings, was on medical leave, leading to inconsistent completion of the task by various staff. Despite payroll records showing RNs worked the required hours, the postings were inaccurate due to lack of consistent process and communication.
Failure to Document and Communicate Responses to Resident Council Concerns
Penalty
Summary
The facility failed to adequately communicate and document its responses and rationales to concerns raised during Resident Council meetings for five out of ten meetings reviewed. Resident Council minutes from several months indicated that residents repeatedly voiced concerns regarding food variety, menu postings, consistency of dietary staff, and issues with nurse aides not making beds or turning off lights after care. Despite these ongoing concerns, the minutes lacked documentation of the facility's responses, actions taken, or rationales for addressing or not addressing the issues raised. Interviews with residents confirmed that they rarely received communication from facility staff regarding what was done to address their concerns voiced during meetings. Residents expressed a desire for more transparency and involvement in the resolution process. The Activity Director, who had recently assumed her role, acknowledged that while she shared concerns with the Administrator and department managers, she did not document these concerns on grievance forms nor consistently provide written resolutions to the Resident Council. Instead, resolutions were often communicated verbally to individual residents, if at all. The Administrator confirmed that concerns raised during Resident Council meetings were assigned to department managers for investigation and written response, but was unable to provide documentation of such investigations or resolutions since his employment began. The facility's grievance logs did not reflect any concerns filed on behalf of the Resident Council during the review period, further indicating a lack of formal documentation and follow-up regarding resident concerns.
Failure to Submit Level II PASRR Evaluations for Residents with Serious Mental Illness
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for four residents who were admitted with serious mental health disorders. Each of these residents had a Level I PASRR determination and documented diagnoses such as bipolar disorder, post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety. Despite these diagnoses and the use of psychotropic medications including antipsychotics, anticonvulsants, and antidepressants, there was no evidence in the medical records that a Level II PASRR evaluation was requested or completed for any of the residents reviewed. Staff interviews revealed that the admissions process involved verifying the presence of a PASRR determination, but the responsibility for requesting a Level II evaluation was not consistently executed. The Admission Coordinator stated that she ensured residents had a PASRR and would request one if missing, but had not submitted any Level II requests since starting her position. The Social Worker confirmed that she was not informed by the clinical team to submit Level II requests and acknowledged that such requests should have been made for residents admitted with mental health diagnoses. The Administrator also confirmed that the process required the Social Worker to submit Level II requests when indicated, but these were overlooked for the residents in question. Documentation in the residents' records, including care plans, physician and psychiatric notes, and medication administration records, consistently showed ongoing treatment for serious mental illnesses. However, the absence of Level II PASRR evaluations meant that the required federal and state screening process for individuals with serious mental illness or intellectual disability was not followed for these residents. This deficiency was identified through record review and staff interviews, with all involved parties acknowledging that the necessary requests for Level II PASRR evaluations were not made.
Expired Food and Improper Storage in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to discard food items past their use-by date and did not store food off the floor in the walk-in freezer. Specifically, two one-quart containers of lemon-flavored thickener with a use-by date that had already passed were found in the walk-in cooler. Additionally, three boxes of frozen turkeys and one box of french toast sticks were found placed directly on the floor in the walk-in freezer. These findings were made during an initial observation of the kitchen with the Dietary Manager present. Interviews with the Dietary Manager and the Administrator confirmed that dietary staff were responsible for checking use-by dates on food items and ensuring that expired items were discarded. Both also acknowledged that food should not be stored on the floor of the freezer. The Dietary Manager explained that the extra turkeys were due to holiday distribution to staff and that limited freezer space contributed to the improper storage. The improper storage and failure to discard expired food items were not reported or corrected by staff prior to the surveyor's observation.
Failure to Complete and File Physician-Signed DNR Form
Penalty
Summary
The facility failed to ensure that a Do Not Resuscitate (DNR) form was completed and signed by a physician and included in the medical record after a physician ordered DNR status for a resident. The resident, who was admitted with a diagnosis of malignant neoplasm of the gallbladder and was on hospice care, had a physician's order for DNR documented in the medical record. However, upon review, there was no evidence that the required DNR form had been completed or signed by the physician. The resident was severely cognitively impaired and had a condition with a life expectancy of less than six months. The care plan documented the resident as DNR, with goals and interventions reflecting this status. Despite this, the necessary DNR documentation was missing from the medical record. Staff interviews revealed that the process for completing and signing DNR forms was not followed in this case, and an audit of advanced directives had overlooked this resident.
Failure to Provide SNF ABN to Residents Ending Medicare Part A Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to residents whose Medicare Part A skilled services were ending, despite the facility's belief that continued services might not be covered by Medicare. For three residents reviewed, documentation showed that while a Notice of Medicare Non-Coverage (NOMNC) was discussed and signed, there was no evidence that a SNF ABN was reviewed with or provided to the residents prior to the end of their Medicare Part A coverage. Each resident remained in the facility after their skilled services ended, but their records lacked the required SNF ABN documentation. Interviews with the Business Office Manager revealed that the therapy team was responsible for reviewing the NOMNC with residents or their responsible parties and returning the signed forms to the business office. However, due to miscommunication between the therapy team and the business office, SNF ABNs were not being provided alongside the NOMNCs. The deficiency was confirmed by both the Business Office Manager and the Administrator, who acknowledged that the SNF ABN should have been issued to the residents prior to the end of their Medicare Part A skilled services.
Unqualified Staff Attempted IV Insertion
Penalty
Summary
A deficiency occurred when a medication aide, who was not licensed or qualified to perform intravenous (IV) catheter insertions, attempted to insert a peripheral IV catheter into a resident's arm. The resident involved had significant medical conditions, including arthritis, dementia, Alzheimer's disease, and diabetes mellitus, and was severely cognitively impaired and dependent on assistance for daily living activities. The resident had a physician's order for IV fluids, and the assigned nurse was unable to establish IV access after an attempt. After the nurse left the room, the medication aide, who was present to assist and calm the resident, asked the resident for permission to attempt the IV insertion. The aide proceeded to use the needle from an IV catheter kit and made one attempt to insert the catheter, achieving blood return but failing to maintain IV access due to vein collapse. This action was witnessed by another medication aide, who assisted in covering the site and later reported the incident to nursing leadership. The medication aide who attempted the procedure was attending nursing school and had practiced IV insertions but was not authorized or competent to perform this task in the facility. Multiple staff interviews and written statements confirmed that the medication aide acted outside her scope of practice by attempting the IV insertion. The incident was not immediately reported to the nurse who had left the room, and the nurse only became aware of the event the following day. The facility's staff, including medication aides and nurse aides, were not licensed or trained to perform IV insertions, and this incident represented a failure to ensure that only qualified personnel provided care according to each resident's written plan of care.
Failure to Ensure Proper Return and Accountability of Controlled Substances
Penalty
Summary
The facility failed to maintain effective systems for the return of controlled medications to the pharmacy for three residents who had discontinued narcotic prescriptions. For each resident, there were discrepancies between the controlled substance count records and the medication administration records (MARs), as well as inconsistencies in the documentation of medication returns. In one case, a resident prescribed hydrocodone-acetaminophen had 10 tablets remaining after discontinuation, and the return of drugs form was completed, but the medication was not received by the pharmacy. Similarly, another resident prescribed oxycodone had 17 tablets left, and a third resident prescribed oxycodone-acetaminophen had 30 tablets remaining; both medications were documented as prepared for return, but the pharmacy did not receive them. The investigation revealed that the process for returning controlled substances involved placing discontinued medications in an unsealed bag in the narcotic drawer, completing a return of drug form, and faxing the form to the pharmacy. However, there was confusion and lack of clarity among staff regarding who completed the forms and who was responsible for ensuring the medications were picked up by the pharmacy courier. The return of drug form for the missing medications was found with a courier signature that was later determined not to be authentic. Staff interviews indicated that while the medications were prepared for return and placed in the appropriate location, there was no confirmation that the pharmacy courier actually picked up the medications, and the medications were ultimately unaccounted for. The pharmacy manager confirmed that the pharmacy had no record of receiving the medications or the return of drug form, and the courier verified that the signature on the form was not hers. The facility's internal investigation, including interviews with nursing staff and audits of medication carts, was unable to determine the exact circumstances of the missing medications. The deficiency was attributed to the facility's failure to have a reliable system for verifying and documenting the return of controlled substances, resulting in unaccounted-for narcotic medications.
Failure to Provide Physician-Ordered Therapeutic Diet
Penalty
Summary
The facility failed to follow the physician's diet order for a resident who was admitted with adult failure to thrive, moderate protein-calorie malnutrition, and a stage two pressure ulcer. The resident was assessed as severely cognitively impaired, required assistance with eating, and was at risk for weight changes. The registered dietitian recommended, and the physician ordered, double portions at breakfast and participation in the enriched meal program, which included specific items such as oatmeal and chocolate milk. However, during observation, the resident's breakfast tray did not include all items listed on the diet card, specifically missing oatmeal and chocolate milk, and did not provide the correct double portions of bacon and French toast sticks. Additionally, the tray included cheese grits, which was a documented dislike for the resident, and did not provide the appropriate substitute for the enriched meal program. Interviews with staff revealed a lack of understanding of the enriched meal program and a failure to ensure that the food served matched the diet card instructions. The dietary manager confirmed that the resident should have received different items and substitutions based on the resident's preferences and the diet order. The registered dietitian also confirmed that the meals served should match the diet card, and the administrator acknowledged that the food served should align with the physician's order and diet card. These findings indicate that the facility did not ensure the resident received the prescribed therapeutic diet as ordered by the physician and recommended by the dietitian.
Failure to Implement Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
Nurse #2 failed to follow the facility's infection control policy and procedures for Enhanced Barrier Precautions (EBP) during the administration of a nutritional supplement and water flushes through a feeding tube for Resident #45. The facility's policy, last revised on 6/13/24, required staff to wear a protective gown when providing high-contact care activities, including care involving a feeding tube for residents with an implanted medical device. During a continuous observation, an EBP sign was posted on the resident's door with instructions to wear a gown, and gowns were available in an over-the-door storage bin. Despite these measures, Nurse #2 did not wear a protective gown while performing the high-contact care activity. During interviews, Nurse #2 stated she believed the resident was no longer under any type of precautions and was unaware that EBP was still required at the time of care. The Staff Development Coordinator/Infection Preventionist and the Director of Nursing both confirmed that Nurse #2 should have worn a protective gown during the procedure. Resident #45 had a feeding tube, which is considered an implanted medical device, and was subject to EBP according to facility policy.
Failure to Provide Oral Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, upper extremity contractures, and visual impairment, who was fully dependent on staff for oral hygiene, did not receive adequate oral care. Record review showed the resident had poor oral hygiene documented by a dental visit, with heavy plaque and calculus buildup and red tissue. The care plan indicated the resident required total assistance with activities of daily living, including oral hygiene. Multiple observations over three consecutive days revealed a persistent white buildup of debris on the resident's upper front teeth and gums, indicating oral care was not being provided as required. Interviews with staff and the responsible party confirmed that oral hygiene was not routinely performed for the resident. The responsible party reported that family members often found the resident's teeth unclean and provided oral care themselves. Nurse aides acknowledged not offering or providing oral hygiene care, and the DON confirmed that oral hygiene should be performed at least daily. The buildup was only removed after a nurse aide brushed the resident's teeth during an observed visit, further confirming the lack of routine oral care.
Failure to Maintain Controlled Medication Supply in Emergency Kit
Penalty
Summary
A deficiency occurred when the facility failed to maintain an effective system for acquiring and maintaining the supply of controlled medications in the emergency kit, resulting in a resident not having access to prescribed as-needed pain medication upon admission. The resident, who had recently undergone joint replacement surgery and had a history of hypertension and type 2 diabetes, was admitted late in the evening and was informed that his medications would not be available for at least 12 hours. Despite staff responding to his requests, the specific pain medication that was effective for him was not available, leading the resident to call 911 and request transport to the hospital for pain management. The physician's orders for the resident included multiple controlled pain medications, such as oxycodone, tramadol, acetaminophen, and hydromorphone. Upon review, it was found that while some medications were administered from the emergency kit, oxycodone was not available as it had run out, and hydromorphone was not stocked in the kit. Staff interviews revealed that the process for reordering controlled medications for the emergency kit was not consistently followed, with confusion over the correct procedure for submitting DEA 222 forms to the pharmacy. The DON admitted to changing dates on the form and faxing it instead of sending the original, contrary to pharmacy policy, and there was a lack of documentation regarding inventory checks and declining count sheets for the controlled medications. Further interviews with pharmacy staff confirmed that the pharmacy only dispensed controlled medications upon receipt of the original DEA 222 form and did not have records of emergency requests or faxes from the facility during the relevant period. The pharmacy manager and president both stated that the process required the original form to be placed in the pharmacy tote for courier pickup, and that medications could be ordered for replacement seven days a week. The lack of adherence to these procedures resulted in the emergency kit not being restocked in a timely manner, directly impacting the resident's access to necessary pain medication.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the grounds surrounding one of two trash dumpsters and the grease trap area, which had the potential to impact sanitary conditions and attract pests and rodents. During an observation conducted with the Dietary Manager (DM), various items were found around the dumpster, including a dirty linen/cart with cardboard boxes, plastic bags, a rinse aid pail, a recliner, folded wheelchairs, plastic containers, wooden pallets, a stainless steel rack, and wooden planks. Additionally, the grease trap area was littered with old cardboard, paper towels, cellophane wrappers, plastic lids, pine straw, cigarette butts, and food scraps. In an interview, the DM acknowledged awareness of the items but was unsure of the reporting process or his responsibility in maintaining the area. The Administrator later explained that the DM was relatively new to the facility and admitted that the oversight was due to a lack of awareness about the broken equipment being present.
Food Safety and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility was found to have several deficiencies related to food storage, preparation, and safety during a survey. Observations revealed that insulated bases, lids, pans, and baking sheets were stacked while still wet, which is against professional standards for food safety. Additionally, perishable food items were improperly stored, with a box of potatoes found on the floor and a dented can of beef stew stored for use. Expired and spoiled food items were also found in the walk-in cooler and main dining room refrigerator, including a bag of shredded cheese, sour cream, pimiento spread, and Italian pasta salad, all of which were either not dated or past their expiration dates. The facility's policy on outside foods was not adhered to, as evidenced by expired mayonnaise and thousand island dressing found in the dining room refrigerator, which was not monitored by dietary staff. Furthermore, staff members were observed not following proper hygiene protocols during food preparation. Specifically, a nutrition consultant and the dietary manager were seen without beard guards, and the dietary manager was also without a hair net, despite being near food preparation areas. These practices were noted to potentially affect the safety and quality of food served to residents. Interviews with staff revealed a lack of awareness and adherence to food safety protocols, with the dietary manager acknowledging his unfamiliarity with certain responsibilities due to his recent employment at the facility.
Resident Information Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy of a resident's medical records by leaving a medication cart laptop unattended with resident health information exposed. During an observation of the Main Hall, a medication cart was left unattended with the laptop screen open, displaying resident information such as names, medications, and diagnoses. This occurred in an area accessible and visible to the public, with several staff members and two visitors passing by. Nurse #2, who was responsible for the medication cart, was observed returning from the nurse's desk, approximately 20 feet away, without having minimized or locked the laptop screen. In an interview, Nurse #2 acknowledged that she usually minimizes the screen to hide resident information but failed to do so on this occasion. The Director of Nursing confirmed that the laptop screen should have been hidden to protect resident information whenever the nurse or medication aide walked away from the cart.
Failure to Properly Label Tube Feeding Formula
Penalty
Summary
The facility failed to properly label the tube feeding formula for a resident who was dependent on a gastrostomy tube for nutrition. The resident, who was admitted with severe protein-calorie malnutrition and gastrostomy status, was observed to have a tube feeding formula bag that was not labeled with the required information, including the resident's name, date, time it was hung, and flow rate. This deficiency was noted during observations on two consecutive days, where the formula bag was either missing the time and rate or not labeled at all. Interviews with staff revealed a lack of adherence to labeling protocols. A Med Aide stated that only nurses were responsible for certain tasks related to tube feeding, including labeling. A nurse confirmed that the night shift nurse was responsible for labeling the tube feeding, and the label should include specific details such as the resident's name, rate, time, date, and the nurse's initials. The Director of Nursing acknowledged that nurses received training during orientation and were expected to perform demonstrations, but suggested that complacency might have led to the oversight in labeling.
Deficiency in Dialysis Care and Fluid Restriction Management
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with End Stage Renal Disease (ESRD) who required dialysis services. The resident, who had moderate cognitive impairment, was admitted with a diagnosis of ESRD and dependence on renal dialysis. The facility did not have a physician's order for the resident's dialysis frequency or for monitoring the dialysis access site. Additionally, there was no documentation in the resident's medical records regarding dialysis visits or access port care. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's dialysis care, with the Director of Nursing acknowledging that dialysis orders should have been reinstated after the resident's hospital stay. The facility also failed to implement fluid restrictions for the resident, who was on a renal diet with a 1200 cc/day fluid restriction. Despite the care plan indicating these restrictions, there was no physician's order in place to enforce them. Observations of the resident's meal tickets showed discrepancies in fluid amounts provided, and staff interviews indicated a lack of awareness about the absence of fluid restriction orders. The facility's Corporate Dietitian and the Dialysis Center Registered Dietitian both confirmed that there should have been an order for fluid restrictions, but communication issues between the facility and the dialysis center contributed to the oversight. Interviews with various staff members, including the Medical Director and the Facility Administrator, highlighted a systemic issue in maintaining and updating orders for residents requiring dialysis. The Medical Director did not see the necessity for specific dialysis orders if a diagnosis of ESRD was present, while the Administrator admitted that orders for dialysis and access site care were not restarted after the resident's hospital discharge. The lack of communication and documentation, as well as the failure to update and maintain necessary medical orders, led to deficiencies in the resident's care.
Failure to Determine and Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to determine and accommodate a resident's food preferences, resulting in a deficiency. Resident #23, who was cognitively intact, was admitted to the facility without a completed food preference form. The resident expressed a dislike for chicken, which was served frequently, but was not aware that an alternative could be requested. Despite communicating this dislike to staff, no alternative was offered, and the resident continued to receive chicken meals. Observations and interviews revealed that staff, including Nurse Aides and nurses, did not follow up on the resident's food preferences or offer alternatives when food was left untouched. The dietary staff was not informed of the resident's dislike for chicken, and the food preference form was not completed in a timely manner. The Admissions Coordinator acknowledged the delay in completing the new food preference form, which was introduced after the resident's admission. Interviews with various staff members, including the Nutrition Consultant and Dietary Manager, highlighted a lack of communication and understanding of the process for documenting and addressing food preferences. The Dietary Manager and Nutrition Consultant were unaware of when food preferences should be completed, and the Administrator expected dietary staff to know a resident's preferences within the first week of admission. However, the resident's preferences were not documented or communicated effectively, leading to the deficiency.
Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to protect a resident's rights by not preventing the misappropriation of controlled substances. A resident, who was cognitively intact and required routine pain medication for chronic pain syndrome and phantom limb syndrome, was prescribed Oxycodone 10 mg to be administered three times daily. However, discrepancies were found in the medication administration records and controlled substance count records, indicating that 19 tablets of Oxycodone were missing. The issue was discovered when the Assistant Director of Nursing (ADON) attempted to refill the medication and found that the resident was not eligible for a refill due to a recent delivery of 60 tablets. The investigation revealed that Nurse #7 had signed for the delivery of the Oxycodone and had been involved in the medication count process. However, there were missing entries in the shift change controlled substance count check sheets, and Nurse #7 could not recall administering the medication or disposing of the empty medication card. The ADON, upon discovering the discrepancy, conducted an audit of the medication sign-in and count sheets, which were found to be incomplete or missing. The local police and the facility's corporate team were notified, and Nurse #7 was suspended pending further investigation. Interviews with the Pharmacy Consultant and Medical Director highlighted concerns about the significance of the missing narcotic tablets. The Medical Director emphasized that the loss of 19 tablets was significant and should have been reported to appropriate authorities. Despite the resident not missing any doses due to backup medication, the facility's failure to maintain accurate records and prevent the diversion of controlled substances constituted a deficiency in protecting the resident's property and medication rights.
Inadequate Assistance with Oral Care for Resident
Penalty
Summary
The facility failed to provide adequate assistance with oral care for a resident who was dependent on staff for activities of daily living. The resident, who was admitted with a history of hemiplegia, muscle weakness, and chronic pain, required set-up assistance for oral hygiene. Despite being cognitively intact and not exhibiting any behavioral symptoms or rejection of care, the resident's oral health was in poor condition, with obvious cavities, broken teeth, and inflamed gums. The care plan aimed to prevent infection in the oral cavity, but interventions were insufficient as the resident's oral hygiene remained poor. Observations and interviews revealed that the resident's teeth were coated with a thick yellowish substance, indicating a lack of proper oral care. Staff interviews indicated that the resident sometimes brushed his teeth independently but required assistance to ensure thorough cleaning. However, there was no documentation of any refusals of care, and staff were not consistently providing the necessary assistance, such as applying toothpaste and positioning the resident for effective oral hygiene. The Director of Nursing and other staff members acknowledged the deficiency in oral care, noting that recommendations from a dental hygienist were not adequately followed. The facility's documentation practices were also lacking, as refusals of care were not consistently recorded, and there was confusion among staff about the resident's need for assistance. The administrator admitted that oral care was not prioritized as much as other ADL care, leading to inconsistent care for the resident.
Failure to Post Required State Agency and Advocacy Group Information
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the State Survey Agency, adult protective services, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community-based service programs, and the Medicaid Fraud Control Unit. This deficiency was observed during a recertification survey conducted over four days, with the absence of required postings noted on three of those days. Observations conducted on different days revealed that there were no postings in various areas of the facility, including the main hallway, dining room, main entrance, lobby, central hallway, Magnolia Hall, and the front lobby area. During an observation with the Administrator, it was confirmed that the postings were missing throughout the facility. The Administrator acknowledged that the information should have been posted and explained that it had been removed during building renovations and not reposted. The absence of these postings was consistent across multiple areas of the facility, and an enclosed signage station near the nurse's station was found to be empty, further indicating the lack of required information being displayed for residents and staff.
Failure to Post Survey Results Signage
Penalty
Summary
The facility failed to post signage about the availability of the most recent survey results for three out of four days during the recertification survey. Observations conducted on multiple days revealed that there was no signage in the front lobby indicating the location of the survey results. During a Resident Council group meeting, all five residents in attendance stated they were unaware of where the survey results were located. Additionally, during a tour with the Administrator, it was noted that the survey results were kept in a grey binder on the bottom shelf of a brown side table in the front lobby, with no visible labeling or signage. Interviews with staff further highlighted the deficiency. The Receptionist was unaware of any signage for the survey results and only directed people to the binder if asked. The Administrator acknowledged that there used to be signage but was unsure why it was removed, suggesting it might have been taken down during renovations. The Administrator agreed that the signage should be visible and accessible to residents and visitors to ensure the survey results are easy to locate.
Inaccurate RN Staffing Information Posted
Penalty
Summary
The facility failed to post accurate Registered Nurse (RN) staffing information for eight days over a period of 205 days. The daily posted staffing sheets were missing RN hours for all three shifts on several specific dates, and in one instance, the RN hours were partially recorded. Interviews with staff revealed that the Receptionist was responsible for completing the daily staff postings based on information received from the Medical Records/Scheduler. However, during the Receptionist's unexpected medical leave, the responsibility for completing the postings was inconsistent, leading to errors in the recorded RN hours. The Medical Records/Scheduler and the Director of Nursing (DON) both stated that they were unaware of any days without an RN working for at least eight hours. The Administrator confirmed that payroll documents showed RNs had worked the required hours on the dates in question, despite the inaccuracies in the daily postings. The discrepancies were attributed to the lack of a consistent process for completing the postings during the Receptionist's absence, as several individuals were involved in the task without clear communication or verification of the information being posted.
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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