Mill Creek Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Winston-salem, North Carolina.
- Location
- 4911 Brian Center Lane, Winston-salem, North Carolina 27106
- CMS Provider Number
- 345149
- Inspections on file
- 24
- Latest survey
- April 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mill Creek Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not provide or document information to several residents or their responsible parties about the right to accept or refuse medical or surgical treatment when making decisions about advance directives, such as Full Code or Do Not Resuscitate status. This deficiency was confirmed by staff interviews and affected both cognitively intact and impaired residents.
The facility did not offer the Prevnar 20 (PCV20) pneumococcal vaccine to residents as required by updated CDC and ACIP guidelines. Instead, only the PPSV23 vaccine was offered, and documentation did not reflect that PCV20 was presented as an option, even when residents declined PPSV23. Staff interviews confirmed a lack of awareness regarding the need to offer PCV20, and the facility's immunization policy did not specify the required vaccine brands.
A resident was found self-administering a nasal spray medication at bedside without a physician's order, assessment, or care plan in place. Nursing staff and the DON were unaware of the resident's self-administration, and no evaluation of the resident's ability to manage their own medication had been conducted.
A resident who was totally dependent on staff and a mechanical lift for transfers did not have access to their wheelchair for an extended period after returning from the hospital. Staff did not ask if the resident wanted to get out of bed and were unaware the wheelchair was missing, resulting in the resident being unable to attend group activities or leave their room.
Confidential medical information, including names and dialysis schedules, was posted in public view near nurses' stations, making it accessible to residents and visitors. The DON confirmed that this information should not have been displayed where unauthorized individuals could see it.
A resident with dementia and COPD was admitted to hospice care for late-onset Alzheimer's disease, but the facility did not complete the required Significant Change in Status MDS assessment following the hospice admission. The Administrator confirmed that this assessment should have been completed within the specified timeframe.
A housekeeping cart containing a spray cleaner and a flammable spray deodorizer was left unlocked and unattended outside a resident's room, with several residents nearby. The cart's lock had been broken for several days, and although the issue was reported to management, it had not been addressed. The chemicals inside the cart could cause irritation or were flammable, according to their SDS.
A resident with chronic lung disease was found receiving continuous oxygen therapy without a cautionary oxygen sign posted outside the room and without an active physician order for the therapy. Staff interviews revealed the sign was not moved when the resident changed rooms, and the DON confirmed the lack of a current order for continuous oxygen use.
The facility did not consistently maintain or document communication with the dialysis center for two residents with ESRD, resulting in missing and incomplete dialysis communication forms. Nursing staff sent forms with residents and received post-dialysis information from the dialysis center, but gaps in documentation and scanning into the electronic medical record were identified, with the DON unable to account for the missing records.
A resident with multiple chronic conditions and documented oral health issues did not receive dental services as ordered by the physician. Despite orders for a dental referral following findings of cavities and oral pain, the referral was not processed due to a breakdown in the facility's order handling process, resulting in the resident not being seen by a dentist.
A resident who was dependent on staff for toileting and mobility was left in soiled briefs from the overnight shift through breakfast service, despite requesting incontinence care. Staff delayed care, citing meal tray delivery procedures, and the resident declined to eat until cleaned. The DON confirmed residents should be clean before meals and that this practice was unacceptable, highlighting a lapse in maintaining resident dignity.
Surveyors found that an electrical outlet cover in a resident's room was partially detached and not reported for repair, despite staff awareness. Additionally, two residents' clothing was observed to be dirty and improperly stored in overflowing bags and piles, rather than in appropriate containers or laundry bags, indicating lapses in maintaining a clean and homelike environment.
A resident who was dependent on staff for all ADLs and required a mechanical lift for transfers was not provided timely incontinence care despite requesting assistance before daylight. The resident remained in a soiled brief with a large amount of stool until after breakfast trays were passed, as staff reported they were not to perform care during meal service. The DON confirmed that residents should not be left in soiled briefs for extended periods.
Survey results were placed in a lobby area that was secured by a locked door, requiring staff assistance for residents to access. Multiple residents reported being unaware of the survey results' location or unable to access them, and the Administrator confirmed that the lobby was always locked and required staff to unlock it for resident entry.
A resident with a seizure disorder did not receive scheduled doses of Valproic Acid due to being at dialysis, and the facility failed to notify the physician of these missed doses. Nursing staff either did not recall the resident or assumed the physician was aware, while the Unit Manager and NP were unaware of the issue. The physician knew about the scheduling conflict, but the facility's leadership expected proper notification and administration of medications.
A resident with a seizure disorder missed five doses of Valproic Acid due to being at dialysis during scheduled administration times. Nurses documented the absence but did not notify the physician. The physician was aware of the scheduling conflict but did not consider the missed doses harmful. The facility expected medications to be given as ordered and deviations to be communicated.
A resident was not assessed by a medical professional before being repositioned after falling out of a wheelchair in a transportation van. The driver moved the resident despite instructions not to, leading to a serious injury. The resident had multiple diagnoses and required full assistance with transfers.
A facility failed to use an occupant restraint system correctly during transport, leading to a resident's severe injury and subsequent death. The driver did not follow the manufacturer's instructions, resulting in the resident sliding out of the wheelchair when the brakes were applied suddenly.
Failure to Inform Residents of Rights Regarding Advance Directives
Penalty
Summary
The facility failed to provide information to residents or their responsible parties regarding the right to accept or refuse medical or surgical treatment when formulating advance directives. This deficiency was identified for four out of six sampled residents. For each of these residents, there was no documentation in the medical record indicating that information about the right to accept or decline treatment was provided prior to making decisions about advance directives, such as Full Code or Do Not Resuscitate status. Interviews with the Social Worker confirmed that the facility did not inform or document informing the residents or their responsible parties of these rights. The affected residents included both cognitively intact and severely cognitively impaired individuals, with some decisions made by responsible parties. The lack of documentation and communication was consistent across all reviewed cases, regardless of the resident's cognitive status or advance directive choice.
Failure to Offer Prevnar 20 Vaccine per Updated Guidelines
Penalty
Summary
The facility failed to offer the Prevnar 20 (PCV20) pneumococcal conjugate vaccine to residents in accordance with the most recent recommendations from the CDC and ACIP. Record reviews for four residents revealed that while the facility either administered or offered the PPSV23 vaccine, there was no documentation that the PCV20 vaccine was offered or administered, nor was there evidence that residents had received PCV20 prior to admission. In cases where residents declined the PPSV23 vaccine, the declination forms did not indicate that PCV20 was also offered as an option. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the facility's practice was to offer only the PPSV23 vaccine to residents and that staff were unaware of the requirement to offer PCV20 in accordance with updated ACIP guidelines. The facility's immunization policy, last revised in 2019, did not specify the brand of pneumococcal vaccine to be offered, and staff reported that Prevnar 20 had never been offered to residents.
Failure to Assess and Document Resident's Ability to Self-Administer Medication
Penalty
Summary
A cognitively intact resident was observed with fluticasone propionate nasal spray on their bedside table, which they reported using independently for nasal congestion over the past month or two. There was no documentation of a physician's order for the nasal spray, nor was there an assessment or care plan addressing the resident's ability to self-administer medications. Nursing staff were unaware of the resident's use of the medication at bedside, and the DON confirmed that no assessment for self-administration had been completed for this resident.
Failure to Ensure Wheelchair Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure the accessibility of a wheelchair for a resident who was totally dependent on staff and a mechanical lift for transfers. The resident, who had diagnoses including osteomyelitis, cerebral infarction, and diabetes mellitus, was cognitively intact and previously used a wheelchair to attend group activities. After returning from a hospital stay, the resident reported not having access to his wheelchair and had not attended out-of-room activities since his return. Multiple observations confirmed that the wheelchair was not present in the resident's room or bathroom over several days. Interviews with nursing assistants revealed that none of them had asked the resident if he wanted to get out of bed, and they were unaware that the wheelchair was missing from the room. The resident's wheelchair was eventually found in a storage room, labeled with his name, after the issue was brought to the attention of the Interim Rehabilitation Director. The lack of staff awareness and failure to ensure the resident's wheelchair was accessible resulted in the resident not being reasonably accommodated for his needs and preferences.
Confidential Medical Information Posted in Public Areas
Penalty
Summary
Surveyors observed that confidential medical information for three residents was posted on 8.5 x 11-inch sheets of paper on the walls behind and next to both nurses' stations in the 100 and 200 halls. The posted documents, dated 3/12/25, included the residents' names, details about their dialysis treatments, scheduled days, departure times, and procedure times, all in large, typed print with additional handwritten notes. These signs were visible and readable to both residents and visitors from the front of the nurses' station countertops. During an interview, the Director of Nursing confirmed that the medical information was displayed in public view and acknowledged that it should not have been accessible to anyone other than nursing staff due to HIPAA regulations.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for a resident who was admitted to hospice services. The resident, who had diagnoses including dementia and chronic obstructive pulmonary disorder, was admitted to hospice with Alzheimer's disease with late onset. Record review showed that after the resident's admission to hospice, the required Significant Change in Status MDS assessment was not completed. During an interview, the facility's Administrator confirmed that the assessment should have been completed within fourteen days of the resident's admission to hospice, but it was not done.
Unsecured Housekeeping Cart with Chemicals Left Accessible
Penalty
Summary
A housekeeping cart on the second floor was observed with its side door partially ajar and lacking a working lock, positioned outside a resident's room with three residents nearby and no staff present. The cart contained a spray cleaner and a spray deodorizer. The housekeeper responsible for the cart confirmed that the lock had broken over the weekend and, although she had reported the issue to the Environmental Manager, it had not yet been repaired. She stated she was aware of the requirement for a working lock but continued to use the cart as it was the only one available on the floor, keeping it close as she moved between rooms. Review of the Safety Data Sheets for the products inside the cart revealed that the spray cleaner could cause eye irritation, while the spray deodorizer contained flammable propanol and could cause irritation to the eyes, nose, and throat. The Housekeeping Manager, who had been at the facility for two weeks, acknowledged being informed of the broken lock but had not yet notified maintenance. The Administrator emphasized the importance of having a working lock on all housekeeping carts due to the chemicals stored inside.
Failure to Post Oxygen Signage and Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with chronic lung disease and hypertension by not posting cautionary signage outside the resident's room to indicate that supplemental oxygen was in use. During an observation, the resident was found receiving continuous oxygen via nasal cannula from an oxygen concentrator, but there was no sign outside the room to alert staff and visitors to the presence of oxygen. Staff interviews revealed that the resident had recently moved rooms and the oxygen in use sign was not transferred with him. Additionally, the facility did not have an active physician order for the resident's continuous oxygen therapy, despite the care plan specifying oxygen administration at 3 liters per minute and the resident reporting ongoing use of oxygen. The DON confirmed that the previous order for as-needed oxygen had been discontinued and acknowledged that a new order for continuous oxygen should have been entered into the facility's system, including instructions for the flowrate. The DON also stated that the facility physician needed to be notified to write an order when continuous oxygen therapy was initiated based on an outside physician's recommendation.
Failure to Maintain Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis treatment center for two residents with end stage renal disease who required regular dialysis. For both residents, there were active physician orders and care plans specifying the need for communication with the dialysis center using a designated form. However, record reviews revealed significant gaps and incomplete documentation of dialysis communication forms. For one resident, only 23 forms were located over several months, with 5 incomplete and none available for an entire month. For the other resident, only a few completed forms were found for two months, and the last scanned forms in the electronic medical record were from several months prior. Nursing staff reported that they completed the top portion of the dialysis communication form and sent it with the resident, while the dialysis center typically returned their own printed post-dialysis information instead of completing the facility's form. Both sets of documents were sent to medical records, but there was no process for retaining copies on the unit. The Director of Nursing confirmed the facility's responsibility for ensuring completion and proper documentation of dialysis communication forms, but was unable to explain the missing or incomplete records, noting that scanning into the electronic medical record was the responsibility of medical records staff, who were unavailable for interview.
Failure to Provide Dental Services as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to provide dental services as ordered by the physician for a resident with multiple medical diagnoses, including COPD, diabetes, and Crohn's disease. The resident's oral evaluation revealed red and inflamed oral tissue, heavy plaque buildup, and cavities, with recommendations for dental cleaning and assistance with oral hygiene. Despite a dental referral order being placed by the physician due to cavities and subsequent oral pain, there was no documentation that the resident was referred to or seen by a dentist as ordered. The process for handling referral orders required the nurse to confirm the physician's order in the electronic health record, print it, and deliver it to the Appointment Scheduler. However, due to the physician confirming the order directly, the nursing staff were unaware of the referral, and it was not processed as required. The Appointment Scheduler confirmed that no dental referrals for the resident were received or scheduled during the relevant period, despite the presence of orders and ongoing oral health concerns. Interviews with staff and the resident confirmed that the resident had not received the necessary dental follow-up after the initial evaluation and subsequent complaints of oral pain. The facility had not provided onsite dental services for several months, and the breakdown in communication and order processing led to the failure to obtain timely dental care for the resident, as documented in the clinical record and staff interviews.
Failure to Provide Timely Incontinence Care Prior to Meals
Penalty
Summary
A deficiency occurred when a resident with bowel and bladder incontinence, who was cognitively intact and dependent on staff for all activities of daily living, was not provided timely incontinence care. The resident reported needing to be changed before daylight and had requested assistance from the overnight nurse aide, who acknowledged the request but did not return to provide care. The resident remained in soiled briefs into the morning, resulting in a strong odor in the room. When the day shift arrived, the resident was given a breakfast tray but declined to eat until he was cleaned, stating he could not eat in that condition. The nurse aides on the morning shift indicated they could not provide incontinence care while meal trays were being passed and believed the overnight shift should have ensured the resident was clean before breakfast. Staff interviews confirmed that it was expected for residents to be clean and dry before breakfast, and the DON stated it was unacceptable for residents to be left in soiled briefs while being served meals. The resident expressed ongoing dissatisfaction with this pattern of care since admission, feeling neglected and undignified. The failure to provide timely incontinence care resulted in the resident being left in an unclean state during mealtime, directly impacting his dignity and comfort.
Unsecured Electrical Outlet and Improper Clothing Storage
Penalty
Summary
A deficiency was identified when an electrical outlet cover in a resident's room was observed to be partially separated from the wall, with two electrical cords plugged in and both devices functioning. The resident occupying the room had not left since returning from the hospital and was unaware of the outlet's condition. Despite the outlet's visible state, it was not reported to the maintenance department by staff, although a nursing assistant stated she had informed a staff nurse about the issue in February. The facility's protocol required staff to report such maintenance needs through a designated program, but this was not followed, resulting in the outlet remaining unrepaired during multiple observations. Additionally, the facility failed to ensure that residents' clothing was clean and stored properly for two residents on the 200 hall. Observations revealed large, clear plastic bags of dirty clothing overflowing and stored on the floor beneath vanities, as well as piles of clothing on top of vanities. One resident expressed a preference for dirty clothes to be placed in a container or laundry bag. The Environmental Services Director confirmed that laundry was done twice weekly and as needed, but indicated that dirty clothes would not accumulate if nursing assistants brought them to the laundry room as required. Nursing assistants were expected to participate in a shower assistant team responsible for transporting dirty laundry, but the observed conditions indicated this process was not consistently followed.
Failure to Provide Timely Incontinence Care Upon Resident Request
Penalty
Summary
A resident with osteomyelitis and bowel and bladder incontinence, who was cognitively intact and dependent on staff for all activities of daily living, was not provided timely incontinence care upon request. The resident required a mechanical lift for transfers and was frequently incontinent, as documented in the care plan. On the morning of the survey, a strong odor of feces was noted coming from the resident's room. The resident reported having requested to be changed before daylight, but staff did not respond to his request in a timely manner. When incontinence care was finally provided, the resident was found with a saturated brief containing a large amount of soft stool, and the bottom sheet was soiled. The resident's skin was pink and intact, and the stool was not dried or stuck to the skin. Nurse aides interviewed stated that the resident was often left in this condition by the previous shift and that they were instructed not to perform patient care while breakfast trays were being distributed. The resident confirmed that he had asked the night shift aide for assistance, who acknowledged the request but did not return. The resident remained in a soiled brief until after breakfast trays were passed by the day shift. The Director of Nursing confirmed that residents should be clean and dry before the first shift and that it was unacceptable for residents to remain in soiled briefs for extended periods.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to make survey results easily accessible to residents, as required. On observation, the survey results binder was located in the lobby, which was secured by a locked door requiring a code for entry. During a Resident Council meeting, several residents stated they were unaware of the location of the survey results or that they were posted, and all reported being unable to access the lobby to review the binder. The Resident Council President was aware of the binder's location but also confirmed that residents could not access the lobby without staff assistance. An interview with the Administrator confirmed that the lobby door was always locked and residents needed staff to unlock it in order to view the survey results.
Failure to Notify Physician of Missed Anticonvulsant Doses
Penalty
Summary
The facility failed to notify the physician when an anticonvulsant medication, Valproic Acid, was not administered to a resident with a seizure disorder. The resident was admitted with diagnoses including stroke and epilepsy, and had a physician's order for Valproic Acid to be given every 8 hours. However, the medication was not administered on multiple occasions due to the resident being at dialysis during the scheduled administration times. Specifically, the medication was not given on five separate dates, and there was no documentation indicating that the physician was notified of these missed doses. Interviews with nursing staff revealed a lack of recollection regarding the resident and the missed doses. The nurses involved either did not remember the resident or assumed that the physician was aware of the situation. The Unit Manager and Nurse Practitioner were also unaware of the missed doses, while the physician was aware of the scheduling conflict with dialysis. The Interim Director of Nursing and the Administrator both stated that they expected medications to be administered as ordered and for the physician to be notified if they were not.
Failure to Administer Antiseizure Medication as Prescribed
Penalty
Summary
The facility failed to prevent a significant medication error by not administering antiseizure medication as prescribed to a resident with a seizure disorder. The resident, who had a history of stroke and epilepsy, missed five doses of Valproic Acid due to being at dialysis during the scheduled administration times. The medication was not given on multiple occasions, and the reasons documented included the resident being on leave of absence or at dialysis. Nurses involved did not recall the resident or the specific circumstances, and there was no evidence that the physician was notified of the missed doses. Interviews with the nursing staff, unit manager, nurse practitioner, physician, and pharmacist revealed a lack of communication and documentation regarding the missed doses. The physician was aware of the scheduling conflict with dialysis but did not believe the missed doses were harmful, as the resident did not experience seizures at the facility. The pharmacist indicated that missing a single dose would not have made the resident subtherapeutic. Despite this, the facility's expectation was that medications should be administered as ordered, and any deviations should be communicated to the physician.
Failure to Assess Resident by Medical Professional Before Repositioning After Fall
Penalty
Summary
The facility failed to have a resident assessed by a medical professional before repositioning the resident after he was thrown forward out of his wheelchair while inside a contracted transportation van. The incident occurred when the van driver applied the brakes suddenly to avoid a collision, causing the resident to slide out of his wheelchair onto the floor of the van. Despite instructions from her supervisor not to move the resident and to call 911, the driver repositioned the resident back into his wheelchair before emergency medical services arrived. The resident complained of significant pain and was later diagnosed with an acute impacted oblique left femoral fracture with edema and bleeding around the left knee at the hospital. The resident involved had multiple diagnoses, including end-stage renal disease, diabetes mellitus, and cerebrovascular accident, and required 100% assistance with transfers using a mechanical lift. The resident was non-ambulatory, unable to stand, non-weight bearing, and unable to sit without full back and head support. On the day of the incident, the resident was being transported back to the facility from a dialysis appointment when the accident occurred. The driver initially reported that she did not move the resident, but later admitted to repositioning him due to his complaints of pain and panic. Interviews with the driver, supervisors, and facility staff revealed that the driver moved the resident despite being instructed not to do so. The facility was not aware that the resident had been moved before EMS arrived, and the medical director confirmed that the resident should have remained in place to avoid the risk of further injury. The facility's failure to ensure that the resident was assessed by a medical professional before being moved led to the resident suffering a serious injury, highlighting a significant deficiency in the facility's handling of the situation.
Removal Plan
- The involved contracted transportation company contract was terminated in writing by the facility administrator.
- Education was provided in person by the Director of Plant Operations to the facility van driver and provided the education to the company-contracted van drivers to pull over, not move a resident if he/she slides down or falls out of their wheelchair, call 911, and wait for paramedics to assess the resident, as well as the risks of moving a resident prior to EMS arrival.
- A reiteration of education and return demonstration was completed again in the presence of the Director of Plant Operations.
- Drivers will not be allowed to transport any resident until education has been completed.
- Education will be tracked by the Director of Plant Operations or Maintenance Director with documented signatures.
- Newly hired transportation drivers will be required to receive the same education in orientation prior to any transportation.
Failure to Properly Secure Resident During Transport
Penalty
Summary
The facility failed to utilize an occupant restraint system according to the manufacturer's instructions for a resident during transport in a contracted transportation van. The driver applied a shoulder restraint under the armrest of the wheelchair and across the lap of the resident but did not apply a lap restraint. When the driver applied brakes to avoid hitting a car, the resident slid out of his wheelchair, resulting in severe pain and subsequent hospitalization. The resident was diagnosed with an acute impacted oblique left femoral fracture with edema and bleeding around the left knee, which later led to complications causing the resident's death. The incident occurred when the driver, who had been trained to use both a shoulder restraint and a lap belt, did not have a lap belt available in the van and used the shoulder restraint incorrectly. The driver stated that she secured the shoulder restraint under both armrests and across the lap of the resident because she thought it would be a choking hazard to use it across the shoulder. The driver also mentioned that the resident usually leaned forward during transport, which influenced her decision. The manufacturer's instructions clearly stated that both a shoulder belt and a lap belt should be used to secure the occupant properly. Interviews with the driver, supervisors, and facility staff revealed that the driver did not follow the manufacturer's guidelines for securing the resident. The contracted transportation van used for the transport did not come equipped with a lap belt, and the driver did not obtain one from another source. The facility's failure to ensure the proper use of the restraint system led to the resident's injury and subsequent death. The incident highlighted a significant lapse in adherence to safety protocols and proper training for transportation staff.
Removal Plan
- The involved contracted transportation company contract was terminated by the facility for noncompliance with not using an effective restraint system to safely secure a resident.
- Education of proper securement per manufacturer guidelines was provided to the one facility van driver by the Director of Plant Operations who is knowledgeable of the manufacturer guidelines for the single facility vehicle.
- A return demonstration was also completed to show full compliance and understanding.
- Other contracted van drivers will be educated by their company management who is knowledgeable on their specific vehicle's manufacturing guidelines.
- Re-education and return demonstration was completed by the facility and contracted van drivers by the Director of Plant Operations.
- Education included following the manufacturer's guidelines for the specific vehicle being used to prevent this event from reoccurring.
- Drivers will not be allowed to transport any resident until education has been completed.
- Newly hired transportation drivers will be required to receive the same education provided by the Director Plant Operations or Maintenance Director during orientation.
- The Administrator will be responsible for tracking the education.
- Facility will require return demonstrations of correct securement per the manufacturer's guidelines before transport and monitored by the Maintenance Director or designee.
- If stretcher transport is required, the facility will utilize the services of a medical transport company that specializes in stretcher transport.
- Residents with poor center of gravity will utilize the appropriate equipment for safe securement following the manufacturer guidelines.
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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