Monroe Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monroe, North Carolina.
- Location
- 1212 Sunset Drive East, Monroe, North Carolina 28112
- CMS Provider Number
- 345254
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Monroe Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to document and communicate its response to repeated Resident Council complaints about cold meals, particularly breakfast items, over several months. Multiple cognitively intact residents reported voicing concerns about cold food and late meal service during Resident Council meetings, and being told by the Activities Director that the issues would be addressed, but they did not receive written grievance responses or follow-up. Meeting minutes for the relevant period reflected only general discussion and did not record these concerns, and there was no evidence of completed Resident Council grievance forms. The Activities Assistant and Activities Director confirmed that concerns were handled verbally, with the Activities Director unaware that documentation of Resident Council grievances and follow-up was required, and the Administrator acknowledged that concerns from these meetings were addressed verbally rather than in writing.
A nurse aide used a personal cell phone to record a video of a resident during personal care without consent, exposing the resident's chest and capturing the resident verbally and physically resisting care. The aide continued providing care despite the resident's objections and later admitted to recording the video for personal reasons, violating facility policy and the resident's right to privacy. The incident was discovered when the video was shared by a third party, leading to distress for the resident's representative.
The facility did not maintain an effective pest control program after several snakes were observed inside the building, with entry points identified at the front entrance and under office doors. Staff reported the incidents inconsistently, and the contracted pest control company was not promptly notified. Structural gaps and vegetation touching the building contributed to the issue, and the facility lacked immediate access to snake deterrent materials.
A resident with cognitive impairment and mobility needs experienced difficulty self-transferring and possible hip pain, as reported by a nurse aide and the resident's roommate. Despite these reports, nursing staff did not perform a physical assessment or document the change in condition, instead deferring evaluation until the next day. The resident was later found to have a left hip fracture requiring hospitalization.
A resident with severe cognitive and mobility impairments was injured during van transport when the facility's driver failed to properly secure the wheelchair and occupant according to manufacturer instructions. The driver did not tighten tie-down straps or verify that the lap and shoulder belts were fully engaged, leading to the resident and wheelchair tipping over during transit. The resident sustained a head laceration, finger fracture, and cervical spine fracture as a result.
A resident with dementia and Parkinson's disease was injured during care when a nurse aide failed to manage the resident's combative behavior properly. The resident sustained multiple injuries, including a bruise, a bloody nose, and a skin tear, during a hard transfer from a wheelchair to a bed. The nurse aide did not seek assistance or stop care despite the resident's aggression, leading to the deficiency.
The facility failed to properly label and manage medications on two medication carts, leading to deficiencies. On the 3W cart, several medications were improperly labeled or expired, including a Lantus Solostar insulin pen without a resident's name and expired insulin pens and vials. On the 3E cart, an expired CO Q-10 50 bottle was found. Nurses and the DON acknowledged responsibility for checking and discarding expired medications, but the facility did not ensure proper labeling and timely removal of expired medications.
The facility was found deficient in maintaining a clean and sanitary environment, with multiple resident rooms and common areas exhibiting stains, grime buildup, and unclean conditions. Residents expressed dissatisfaction, and staff interviews revealed inconsistencies in cleaning protocols, contributing to the unsanitary conditions.
A resident with severe cognitive impairment and no order to self-administer medications was found with amantadine left at the bedside. Nurse #1, who was training, forgot to administer the medication after setting it down to give other medications. The DON confirmed that medications should not be left at the bedside, and the NP noted that missing the dose was not a significant error as the medication was given three times daily.
A resident with a gastrostomy tube was at risk of bacterial growth due to improper storage of a feeding tube syringe. The syringe was observed with the plunger inside and liquid at the tip, contrary to protocol. Nurse #3 was unaware of the correct storage procedure, and the Director of Nursing expected compliance with the protocol.
A resident with dementia and Alzheimer's, requiring substantial assistance with eating, was not provided a dignified dining experience. A nursing assistant fed the resident while standing, without making eye contact, despite available seating. The facility's protocols require staff to assist residents at eye level to ensure dignity, which was not followed in this instance.
The facility failed to maintain a pest-free environment, with roaches observed in resident rooms and a community restroom. Residents reported frequent sightings, and staff confirmed regular roach presence despite monthly pest control treatments. The Maintenance Director acknowledged the issue, but the Administrator was unaware of recent complaints.
The facility did not post required contact information for State agencies and advocacy groups, including the State Survey Agency and Adult Protective Services, during a recertification survey. Observations over several days confirmed the absence of necessary postings, and the Administrator acknowledged the oversight.
The facility failed to provide written notification of hospital transfers for two residents, one cognitively intact and the other severely impaired. Both residents were transferred due to changes in condition without their representatives receiving the required notifications. The Social Worker did not complete the notifications, and the Administrator was unaware of the lapse, leading to a deficiency in communication and regulatory compliance.
Failure to Document and Follow Up on Resident Council Food Temperature Complaints
Penalty
Summary
The deficiency involves the facility’s failure to document and communicate its efforts to address concerns raised in Resident Council meetings, specifically regarding repeated complaints of cold food. Review of Resident Council minutes from three meetings showed only "open discussion" with no recorded concerns about cold food, despite multiple residents reporting that such concerns were voiced. There was no written evidence from December 2025 through February 2026 demonstrating the facility’s response to grievances or recommendations made by the Resident Council. One cognitively intact resident, serving as Resident Council President, reported that during the February Resident Council meeting she complained about cold food, specifically grits that were not warm enough for cheese to melt. She stated the Activities Director told her the concern would be addressed with the Dietary Manager but did not specify when, and the Resident Council never received any follow-up from either the Dietary Manager or the Activities Director. Another cognitively intact resident reported attending Resident Council meetings regularly and stated she had voiced concerns on several occasions, including during the January meeting, about cold food at breakfast and dinner. She reported submitting a verbal complaint to the Activities Director and was told the concern would be looked into, but she did not receive any grievance response or follow-up. A third cognitively intact resident reported regularly receiving cold breakfast meals and that breakfast was often served late, and stated these concerns were discussed during the December, January, and February Resident Council meetings. The Activities Assistant, who supported Resident Council meetings, stated the Activities Director was responsible for documenting resident concerns and acknowledged hearing concerns about cold coffee and food months earlier, but was unsure if they were documented or if a Resident Council grievance form was completed. The Activities Director confirmed she led the meetings and was responsible for the minutes, acknowledged hearing occasional concerns about cold food, and stated she verbally notified department heads and the Administrator but did not document concerns in the minutes or through the grievance process because she was unaware documentation was required. The Administrator stated he was aware of cold food concerns the prior year and that concerns after Resident Council meetings were addressed verbally, not in writing.
Unauthorized Video Recording and Privacy Violation During Personal Care
Penalty
Summary
A nurse aide (NA) used her personal cellular phone to record a video of a resident while providing personal care, without the resident's consent. During the recording, the resident's chest area was exposed, and the resident was observed holding a pink baby doll for comfort. The video captured the resident verbally and physically resisting care, including swinging her arm at the NA and verbally asking to be left alone. Despite the resident's resistance and request, the NA continued to provide care and record the incident. The NA later admitted to recording the video to capture the resident's combative behaviors, which she found amusing, and acknowledged she had been trained not to record residents or use personal devices in care areas. The resident involved had a history of dementia, was moderately cognitively impaired, and was care-planned for resisting care. The care plan included interventions such as providing choices during personal care. The resident's representative expressed distress upon learning of the video, stating that the resident's right to privacy had been violated and that the video was distributed without consent. The video was discovered by a third party who accessed the NA's phone and subsequently shared it with another individual, leading to the facility being notified of the incident. Interviews with facility staff and other caregivers indicated that the resident was dependent on staff for most activities of daily living and that her response to care depended on the approach used by staff. The DON and other staff confirmed that the NA had received training on abuse prevention and the prohibition of recording residents. The NA's actions were found to be in violation of facility policy and the resident's rights, resulting in the exposure of the resident's nudity and humiliation through the unauthorized recording and sharing of the video.
Failure to Maintain Effective Pest Control Program Following Multiple Snake Sightings
Penalty
Summary
The facility failed to implement an effective pest control program to maintain a pest-free environment after multiple sightings of snakes within the building. The initial incident involved a small snake entering through a gap at the bottom of the front entrance doors and subsequently being observed in the admissions office. The gap between the doors, as well as a one-inch space under the admissions office door, provided easy access for pests. Staff members, including a nurse and a housekeeper, observed and reported the presence of snakes, but the maintenance logs did not reflect these sightings, and the maintenance director was not immediately notified after the first incident. Communication regarding the pest issue was inconsistent, with notifications being sent via group text to the Administrator and DON, but not to the Maintenance Director in a timely manner. The Administrator and DON did not become aware of the initial snake sighting until hours after it was reported. Subsequent sightings of snakes occurred in other areas of the building, including a resident bathroom in a hall that was closed for renovations and near the dining room. The contracted pest control company was not notified until after the second snake was found, and their technician reported that their contract did not cover snake removal or treatment, only visual inspection. The wildlife department was eventually contacted to address the issue. Structural issues, such as the open space at the bottom of the front entrance doors and vegetation touching the building exterior, were identified as contributing factors to the pest problem. The facility did not have snake repellent materials on hand and relied on external sources to obtain them, which were not immediately available. The contracted pest control company and wildlife department both conducted inspections, but no further snakes were found during their visits. The wildlife department applied snake deterrent material around the exterior doors, but the structural gap at the front entrance remained unaddressed at the time of the last observation.
Failure to Assess Resident After Reported Change in Mobility and Possible Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to perform a physical assessment of a resident after a change in the resident's ability to self-transfer was reported. The resident, who had a history of dementia, stroke, and legal blindness, was known to require supervision for all mobility tasks and had a care plan focused on fall prevention. On the evening in question, a nurse aide observed the resident having difficulty transferring from a wheelchair to bed and reported that the resident mentioned possible hip pain. Additionally, the resident's roommate reported that the resident had fallen a couple of nights prior. Despite these reports, neither the assigned nurse nor other nurses on duty conducted a physical assessment of the resident at that time. Multiple staff interviews confirmed that the nurse aide communicated the resident's difficulty and the roommate's report of a fall to the nursing staff. However, the nurses involved reviewed the electronic medical record and found no documentation of a recent fall, and after consulting with each other, did not proceed with a physical assessment. The resident was observed sleeping and did not verbalize pain during subsequent checks, leading staff to defer assessment and instead make a note in the physician communication book for evaluation the following day. No immediate nursing documentation or assessment was completed regarding the reported change in the resident's condition. The following morning, the resident was found to have increased pain and physical signs consistent with a left hip injury, including the left leg being rotated inward. Upon assessment by the DON and a nurse, the resident was sent to the hospital, where a left hip fracture was diagnosed and surgically treated. Interviews with staff and the resident confirmed that the resident did not initially report pain or the fall to staff, but did experience difficulty with mobility and later reported pain. The failure to assess the resident promptly after a change in condition and reports of a possible fall constituted the deficiency.
Failure to Secure Wheelchair and Resident During Transport Results in Serious Injury
Penalty
Summary
A facility failed to ensure the safe transport of a resident with severe cognitive impairment and mobility limitations following an orthopedic appointment. The designated van driver did not properly secure the resident's wheelchair to the van floor or ensure that the resident was restrained according to the manufacturer's instructions. Specifically, the driver did not tighten the tie-down straps, did not verify that the lap and shoulder belts were fully engaged, and did not check the security of the wheelchair or restraints before departure. The driver later admitted to rushing and skipping these safety checks due to time constraints. During transport, after making a right turn onto a main road, the resident and her wheelchair tipped over, resulting in the resident falling onto the van floor. The driver found the resident with a bleeding head laceration, the wheelchair tipped on its side, the seat and lap belt disconnected, and one of the front tie-down straps unhooked. Emergency medical services were called, and the resident was transported to the emergency department, where she was diagnosed with a frontal scalp laceration, a left middle finger fracture, and a cervical spine fracture. The incident was directly attributed to the failure to secure the wheelchair and occupant per the manufacturer's guidelines. Interviews and reenactments with facility staff and the van driver confirmed that the required safety procedures were not followed. The driver demonstrated during reenactments that she did not tighten the tie-downs or check the restraints for proper engagement. Staff interviews and medical records indicated that the resident was unable to stand or transfer independently, further emphasizing the necessity of proper securement during transport. The facility's failure to ensure adherence to safety protocols resulted in significant injury to the resident.
Removal Plan
- Resident was assessed and transported to the emergency department for evaluation and treatment after the incident.
- The Van Driver was suspended pending the results of the investigation.
- The facility notified the resident’s legal guardian and Medical Director of the incident.
- A reenactment of the incident was conducted with facility leadership to determine how the wheelchair was secured.
- The facility’s van driver education records were audited to ensure the Van Driver received necessary education and training.
- The Director of Nursing reviewed facility incidents and accidents to ensure no other falls/incidents had occurred related to van transport.
- An audit of all appointments via van transport was completed to ensure residents were rescheduled with a contracted wheelchair transport company and that residents and/or responsible parties were notified.
- All appointments requiring van transportation were reviewed during the center’s morning clinical meeting to verify transfer vehicle and resident/responsible party notification.
- An audit was completed to identify any interviewable residents that were transferred to ensure no incident or accident occurred during their van transport.
- The contracted wheelchair transport company’s staff training and certification were reviewed and validated to be in place before use.
- The facility van was sent to the wheelchair transport van service center for inspection; no problems were found.
- All transport appointments requiring the facility van were scheduled through a contracted wheelchair transport company.
- The facility contracted all resident van transports with a contracted wheelchair transport company.
- All appointments requiring van transportation were reviewed in the morning clinical meeting to determine if additional assistance was necessary.
- The Administrator received education on checking the locking mechanisms/restraints on the van for the wheelchair and seatbelt prior to transporting residents per manufacturer’s instructions.
- The Administrator provided education to the Maintenance Director and Director of Nursing regarding van safety and checking locking mechanisms/restraints per manufacturer’s instructions.
- The facility will continue to use the contracted wheelchair transport company instead of transporting residents in the facility van.
- An ADHOC quality assurance (QA) meeting was held to review the incident and identify the root cause.
- An audit will be completed of two residents receiving transport services by the Administrator twice a week to ensure the contracted wheelchair transport company is compliant with safety guidelines.
- Once a new van driver is identified, they will go through the facility’s motor vehicle and driver safety program, including a return demonstration and education/training by the Administrator and President of Operations.
- The Quality Assurance Improvement committee will review the results of the weekly audits during monthly QA meetings to determine if further actions are needed.
- The Administrator and Director of Nursing are responsible for ensuring implementation of the immediate jeopardy removal and that education and training are provided.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
The facility failed to protect a resident from abuse by a nurse aide during care. The resident, who was diagnosed with dementia and Parkinson's disease, was severely cognitively impaired and required assistance with daily activities. During an incident, the resident sustained multiple injuries, including a bruise to the left eye, a bloody nose, a skin tear to the left elbow, and a scratch on the left cheek. The nurse aide involved stated that the resident was combative and resistive to care, which led to a hard transfer from the wheelchair to the bed. The resident's care plan indicated that he was resistive to care due to dementia and required specific interventions to manage his behavior. However, during the incident, the nurse aide continued to provide care despite the resident's aggression, resulting in the resident falling onto the bed and sustaining injuries. The nurse aide did not call for assistance or stop the care when the resident became combative, which contributed to the deficiency. Interviews with staff and the resident's family member revealed that the resident was known to be aggressive during care, and the nurse aide was aware of this behavior. Despite this knowledge, the nurse aide proceeded with the transfer and care without seeking help, leading to the resident's injuries. The facility's investigation concluded that the injuries were likely caused by the resident hitting the headboard during the transfer.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to properly label and manage medications on two of its medication carts, leading to deficiencies in medication storage and labeling. On the 3W medication cart, several medications were found improperly labeled or expired. A Lantus Solostar insulin pen was not labeled with the resident's name, and an Insulin lispro pen, a Novolog vial, and an Insulin glargine injector were all past their manufacturer-recommended discard dates. Additionally, an Albuterol sulfate nebulizer was stored beyond its recommended usage period. Nurse #5 confirmed the lack of labeling and was unaware of the missing label, while the Director of Nursing (DON) and the Administrator acknowledged that nurses were responsible for checking and discarding expired medications. On the 3E medication cart, a CO Q-10 50 multidose bottle was found expired. Nurse #4 and the DON both stated that the Unit Manager and nurses were responsible for ensuring expired medications were removed. The DON also mentioned that the pharmacy and Unit Manager were supposed to check the medication carts regularly. Despite these protocols, the facility failed to ensure proper labeling and timely removal of expired medications, leading to the observed deficiencies.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment across multiple resident rooms and common areas, as observed during a survey. Specifically, 16 rooms on the 200 hall, 4 rooms on the 300 hall, 8 rooms on the 100 hall, 3 community restrooms, and 1 shower room were found to have significant cleanliness issues. These included dark brown and black stains on walls, grime buildup around baseboards, and thick substances on commode seats. Residents expressed dissatisfaction with the cleanliness of their rooms, indicating that the lack of proper cleaning was a persistent issue. Interviews with residents revealed that the unclean conditions were distressing to them. One resident mentioned that the Maintenance Director attempted to cover grime with grout instead of cleaning it, and another resident expressed a desire to clean the room herself if she were able. These statements highlight the residents' awareness and concern about the inadequate cleaning practices in their living spaces. Staff interviews indicated a breakdown in the facility's cleaning protocols. Housekeeping staff claimed to perform daily cleaning tasks and monthly deep cleans, but the observed conditions contradicted these claims. The Housekeeping Manager and Administrator acknowledged the deficiencies, noting that the rooms should be cleaned daily and deep cleaned monthly. However, the Floor Technician admitted that he was unable to perform his duties due to staff shortages, which contributed to the failure to maintain a sanitary environment.
Failure to Administer Amantadine to Cognitively Impaired Resident
Penalty
Summary
The facility failed to administer amantadine to a resident who was observed with medications at the bedside. The resident, admitted with diagnoses including nontraumatic intracerebral hemorrhage and hypertension, was severely cognitively impaired and had no physician order to self-administer medications. A physician order required the administration of amantadine three times per day. During an observation, a medication cup containing 20 milliliters of clear liquid was found on the resident's bedside table, which the resident identified as his medication. Nurse #1, who was training, admitted to setting the amantadine down on the bedside table while administering other medications and forgetting to administer it to the resident. The Director of Nursing confirmed that no medication should be left at a resident's bedside and that all medications should be administered before leaving the room. The Nurse Practitioner stated that the resident was not capable of self-administering medications and missing the dose would not have been a significant medication error since the medication was administered three times daily.
Improper Storage of Feeding Tube Syringe
Penalty
Summary
The facility failed to properly store a tube feeding syringe for a resident with a gastrostomy tube, which created a potential for bacterial growth. The resident, who was admitted with diagnoses of stroke and difficulty swallowing, was receiving tube feedings and water flushes as per physician's orders. During observations, the syringe was found with the plunger inside and clear liquid at the tip, stored in a plastic bag hanging from the feeding pole. This improper storage was noted on two separate occasions. Nurse #3, responsible for the resident's care, was unaware of the requirement to separate the plunger from the syringe to prevent bacterial contamination. The Director of Nursing expected the nurses to follow this protocol, but it was not being adhered to. The facility's Administrator did not provide a qualified statement on the matter but acknowledged that the nurse should follow the correct protocol to prevent bacterial growth in the syringe.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident diagnosed with vascular dementia and Alzheimer's disease, who required substantial assistance with eating. During an observation, the resident was in bed with the meal tray positioned across his lap. A nursing assistant (NA) entered the room and fed the resident while standing, without making eye contact, despite the availability of chairs in the room. The resident expressed a preference for staff to sit while assisting with meals, indicating a lack of adherence to the facility's training and protocols for maintaining resident dignity during meal assistance. The Director of Nursing (DON), Administrator, and Regional Clinical Director confirmed that staff were trained to assist residents at eye level to ensure dignity. The DON stated that staff should be seated when assisting residents with meals in their rooms, aligning with the resident's care plan and facility protocols. The failure to adhere to these protocols resulted in a deficiency in providing a dignified dining experience for the resident.
Pest Control Deficiency in Resident Rooms and Restroom
Penalty
Summary
The facility failed to maintain an environment free of pests, specifically roaches, in several resident rooms and a community restroom. Observations revealed dead roaches in the room of a cognitively intact resident, who reported that roaches frequently appeared at night and disturbed her sleep by crawling on her bed. Another resident occasionally observed roaches on the floor of her room, while a third resident frequently saw roaches in her bathroom. Additionally, a live roach was observed in a community restroom on the 300-hall. Interviews with staff indicated that roaches were seen in the building once or twice a week, with the 100-hall being particularly affected. Despite the facility's pest control company conducting monthly treatments and responding to reports of roaches, the issue persisted. The Maintenance Director acknowledged the presence of roaches but denied an infestation, while the Administrator was unaware of recent resident complaints. Pest Control Reports from July to November indicated no observed pest activity during treatments, suggesting a disconnect between reported sightings and documented pest control efforts.
Failure to Post Required Contact Information for State Agencies
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, Complaint Intake, Adult Protective Services, the Office of the State Long-Term Care Ombudsman program, and the Protection and Advocacy network. This deficiency was observed during an onsite recertification survey conducted over four days. Specifically, on three of these days, surveyors noted the absence of required signage or postings that would provide residents, families, or visitors with the necessary contact information to file concerns or complaints. Observations were made on multiple occasions, including a tour of the facility with the Administrator, which confirmed the lack of appropriate postings. During an interview, the Administrator acknowledged that such information should be accessible to residents and their families. However, the facility did not have the required postings in place, leading to the deficiency noted in the survey report.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to the hospital for two residents, leading to a deficiency in communication and compliance with regulatory requirements. Resident #29, who was cognitively intact, was transferred to the hospital twice due to a change in condition, but neither she nor her representative received written notification of these transfers. Interviews with the resident and her representative confirmed the lack of notification, and the Social Worker (SW) admitted to not completing the notifications, citing a lack of clarity on responsibility. Similarly, Resident #19, who was severely cognitively impaired, was transferred to the hospital without written notification being provided to their representative. The SW again acknowledged not completing the notifications, and the Administrator expressed an expectation that the SW should handle these notifications but was unaware of why they were not being done. This lack of communication and procedural clarity resulted in a failure to meet the regulatory requirement for notifying residents and their representatives of hospital transfers.
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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