Mount Olive Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Olive, North Carolina.
- Location
- 228 Smith Chapel Road, Mount Olive, North Carolina 28365
- CMS Provider Number
- 345126
- Inspections on file
- 29
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Mount Olive Center during CMS and state inspections, most recent first.
A cognitively intact resident used a nurse aide’s money transfer account to pay $120 for groceries, then accidentally sent an additional $300 intended for a relative. The resident promptly informed the aide of the mistake and repeatedly requested repayment, including partial amounts, but the aide did not return the funds and did not immediately report the situation to facility leadership. The resident later informed the Social Worker, who doubted the account and delayed notifying the Administrator, and an initial misappropriation report was not submitted to the State Agency as required.
A cognitively intact resident reported to a Social Worker that $300 had been inadvertently sent to a CNA via a money transfer app, with a promise of repayment that did not occur. The Social Worker, doubting the account, did not immediately notify the Administrator as required by the abuse and misappropriation policy, and the CNA continued to work assigned shifts during this period. The Administrator and DON later acknowledged that both the Social Worker and the CNA should have promptly reported the situation. When the Administrator eventually attempted to file the initial allegation report with the State Agency, an error in the email address prevented receipt, and this failure went unnoticed until identified by surveyors, leaving the allegation unreported to the State Agency for an extended period.
A resident with cognitive impairment and no opioid prescription was mistakenly given 60 mg of oxycodone intended for another patient after a nurse in training administered the medication without proper verification. The error occurred when a nurse handed the medication to the trainee, who failed to confirm the resident's identity according to policy. The incident was recognized and reported after administration, and the resident was monitored and treated for potential adverse effects.
A resident with chronic pain and fibromyalgia received oxycodone-acetaminophen as ordered, but staff failed to document the administration on the MAR, despite recording it on the narcotic sheet. Interviews confirmed this documentation error, and facility leadership stated that both records should be completed for narcotic administration.
A resident with vascular dementia and NPO status was repeatedly observed self-administering enteral feedings, using unidentified liquids in her g-tube, rummaging through trash for food and liquids, and disconnecting her tube feeding pump. Staff were aware of these behaviors but did not consistently assess the resident for self-administration, communicate with the physician or dietician, or implement effective interventions. The care plan relied on education and reminders, which were inconsistently provided, and there was a lack of supervision and monitoring, resulting in ongoing unsafe behaviors.
A resident with hypertension, heart failure, and orthostatic hypotension was repeatedly administered Coreg despite physician orders to hold the medication if systolic blood pressure was below 150 mmHg. Documentation and staff interviews revealed that the medication was given on numerous occasions when the resident's blood pressure was below the specified threshold, and staff were either unaware of or did not follow the hold parameters. The error was identified through MAR review, therapy notes, and pharmacy consultant findings, with no evidence that recommendations to address the issue were acted upon.
The facility did not maintain accurate medical records for three residents, including incorrect documentation of medication administration for a resident with hypertension and heart failure, and discrepancies between physician orders, MAR entries, and observed oxygen flow rates for two residents with respiratory conditions. Staff interviews confirmed that documentation did not reflect actual care provided, and the DON acknowledged the need for accurate verification and recording.
Two residents receiving antipsychotic medications did not receive ongoing Abnormal Involuntary Movement Scale (AIMS) assessments as required by protocol. Although care plans identified the need for regular AIMS testing due to the risk of complications from psychotropic medications, only a single assessment was documented for each resident. Staff interviews revealed that the EMR system may not have been set to trigger reminders for these assessments, and some staff were unaware of the requirement for ongoing AIMS evaluations.
Three residents did not receive supplemental oxygen as prescribed, with two receiving higher oxygen flow rates than ordered and one lacking required 'No Smoking - Oxygen in Use' signage. Staff interviews revealed inconsistent monitoring of oxygen concentrator settings and failure to ensure proper signage, despite clear physician orders and care plans.
The facility did not address or document pharmacist recommendations from monthly medication regimen reviews, resulting in missed assessments and medication administration errors for several residents with complex medical needs. Staff were unclear about their responsibilities for receiving, acting on, and storing these recommendations, and required documentation was often missing or unavailable.
Surveyors found that a medication cart was left unlocked and unattended, allowing access to various medications and supplies. An opened vial of insulin was discovered in a medication refrigerator without proper labeling, including missing open and discard dates and illegible resident information. Additionally, locked boxes containing refrigerated controlled drugs were not secured to permanent structures, making them removable from the medication rooms. Staff interviews confirmed these lapses in medication security and labeling.
A nurse failed to set an enteral feeding pump to the physician-ordered rate for a resident with a feeding tube, initially programming the formula and water flushes incorrectly. The error was discovered during observation and subsequently corrected after verification of the physician's order by the nurse and confirmation by the DON.
Two residents transferred to the hospital did not receive the required written notice of transfer/discharge, and the Ombudsman was not notified of these transfers. Staff interviews confirmed that while clinical documents were sent with the residents, the mandated notices were not provided, and social services staff did not complete or send the necessary notifications.
The facility did not consistently post accurate or complete daily nurse staffing information, with missing or outdated postings and incomplete details for several days. This occurred because the weekend Nurse Supervisor had not been assigned or trained to maintain the postings, and facility leadership was unclear about responsibility for this task.
A resident at an LTC facility did not receive the required bowel preparation for a scheduled colonoscopy and subsequent surgery, leading to the cancellation of both procedures. The facility failed to administer the bowel preparation as ordered, resulting in the resident undergoing unnecessary anesthesia and surgical preparation without the intended procedure being completed. Communication and documentation issues among staff contributed to the oversight.
Two residents assessed as unsafe smokers were found smoking unsupervised, leading to incidents where one resident's pants caught fire and another's bandage was burnt. Despite facility policies requiring supervision and secure storage of smoking materials, these protocols were not followed, allowing residents to access and use smoking materials unsupervised.
The facility failed to notify a physician of a significant change in condition for a resident who later expired from septic shock. Additionally, the facility did not inform the responsible party of a medication change for another resident, leading to a deficiency citation.
A resident in an LTC facility exhibited a rash and changes in mental status, but staff failed to communicate and act, delaying medical intervention. The resident was later found unresponsive and diagnosed with septic shock, leading to his death. Another resident with a head injury was moved without proper assessment.
Two residents in an LTC facility suffered injuries due to staff not following care plans. One resident, with osteoporosis, was improperly transferred without a mechanical lift, resulting in a femur fracture. Another resident, at risk for falls, was found on the floor with a fractured nose and no fall mats in place. These incidents highlight the facility's failure to adhere to care plans designed to prevent such injuries.
A resident with cognitive impairment and hearing loss did not receive necessary follow-up for malfunctioning hearing aids. Despite an audiologist's recommendation, the facility failed to act on warranty and repair information, leaving the resident without functional hearing aids. Staff were unaware of the issue until a surveyor highlighted it.
A resident with multiple health issues fell and sustained a head injury in a LTC facility. Due to insufficient staffing, the resident was moved back to bed by a nurse aide without an assessment. The facility was understaffed that night, with only five nurse aides on duty, leading to a delay in medical evaluation. The resident was later sent to the ER with significant facial trauma.
The facility failed to accurately document health status information for two residents. One resident's record inaccurately showed assessments after they had been transferred to a hospital, while another resident's record incorrectly maintained an order for a catheter that had been removed. Additionally, a rash observed on the second resident was not documented. These inaccuracies were acknowledged by the staff involved.
The facility failed to maintain the dignity and rights of residents, including unnecessary 1:1 observation for a resident cleared by an NP, a resident's urinal not being emptied before meals, and an uncovered urinary drainage bag visible from the hallway. These incidents highlight communication and procedural failures among staff.
The facility failed to ensure proper drying of kitchenware, as observed with wet meal trays and dinner plates stacked for reuse. The RD confirmed the need for air drying, and the Administrator acknowledged the oversight.
The facility's pest control program was ineffective, leading to fly infestations in the kitchen, resident rooms, and hallways. Despite recommendations from the pest control provider, fly trapping machines were not activated, and staff left doors open, allowing flies to enter. Residents and staff reported persistent fly issues, with residents using fly swatters and staff swatting flies during medication administration. The Maintenance Director implemented some measures, but fly activity remained significant.
Three residents were not involved in their care planning process due to administrative oversights. One resident, assessed as severely cognitively intact, was not invited to a care plan meeting, and documentation was missing. Another resident, also cognitively intact, was not present at his care plan meeting due to care being provided at the time, and his POA did not receive a message about the meeting. A third resident was not invited to a care plan meeting, and there was no documentation of such a meeting. The Social Service Director and Assistant Administrator acknowledged these oversights.
A resident was observed with a wander guard despite a physician's order to discontinue its use. The resident's care plan initially included the device due to an elopement risk, but an assessment later indicated no risk. Staff interviews revealed a lack of awareness about the need for the wander guard, and there was no documentation of its monitoring. The DON acknowledged the need for reassessment and a physician order.
A resident admitted with stroke-related conditions and a risk for aspiration did not receive ordered speech therapy services. Despite a physician's order for evaluation and treatment, the facility lacked documentation of a speech therapy screen or services. The absence of a speech therapist and the Rehabilitation Director's medical leave contributed to the oversight, with key staff unaware of the lapse.
The facility failed to post nurse staffing information at the beginning of each shift for several days. Observations revealed outdated postings, and interviews with the DON and Administrator indicated that responsibilities were not consistently fulfilled due to a new scheduler being in training and the DON assisting another building.
The facility did not ensure residents received their mail on Saturdays, affecting all residents. Interviews revealed that mail was only delivered if the Activities Director or front office staff were present. The Business Office Manager confirmed that mail was left at the front desk until Monday unless it appeared special. The Administrator stated the weekend receptionist was responsible for mail delivery, but this was not consistently done.
Failure to Protect Resident from Misappropriation of Personal Funds
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from misappropriation of personal funds after a cognitively intact resident mistakenly transferred $300.00 to a nurse aide via a money transfer application. The resident, who had been admitted earlier and assessed as cognitively intact on a quarterly MDS, initially used the aide’s account to send $120.00 for groceries, which the aide purchased and delivered with a receipt. The following day, the resident accidentally transferred an additional $300.00 intended for a relative’s rent to the same aide’s account. When the aide next worked, the resident informed her of the mistake and requested the $300.00 be returned, explaining his hand coordination issues and shaky hands caused the error. The aide acknowledged to the resident that the $300.00 had already been withdrawn due to her overdrawn account and told him she would repay him when she received her paycheck. Despite the resident’s repeated requests, including attempts to negotiate partial repayment of $200.00 and then $150.00 through the money transfer application and in person, the aide did not return any of the funds during this period. The aide did not immediately notify the Director of Nursing or the Administrator when she became aware of the mistaken transfer, even though she had been educated not to take money from residents for any reason. The resident’s transaction history on the money transfer application corroborated the payments and multiple unfulfilled requests for repayment. The deficiency was further compounded when the resident reported the issue to the Social Worker, who did not act promptly on the allegation. The resident informed the Social Worker that he had inadvertently sent $300.00 to the aide and that the aide’s account was negative, with a promise of repayment after the aide’s paycheck. The Social Worker doubted the resident’s account and chose to wait to see if the aide would return the money, delaying notification to the Administrator until several days later. Additionally, as of a later date, the State Agency had not received an initial report from the facility regarding the allegation of misappropriation involving this resident and the aide, despite the incident meeting the criteria for such reporting.
Failure to Timely Report and Act on Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to implement its abuse, neglect, and misappropriation policy when an allegation of misappropriation of funds involving a cognitively intact resident was not immediately reported to the Administrator. The abuse policy required any staff who witnessed or became aware of suspected abuse, neglect, or misappropriation of patient property to report it immediately to a supervisor, who in turn was to immediately notify the Administrator or designee so that an investigation could be initiated within 24 hours and residents protected from further harm. The resident told the Social Worker that he had inadvertently sent $300 to a nurse aide via a money transfer application around Christmas, that the aide’s account was negative, and that she had promised to repay him after receiving her paycheck. The Social Worker doubted the truthfulness of the account and chose to wait to see if the funds would be returned instead of immediately reporting the allegation as required by policy. From the time the Social Worker was informed of the $300 transfer until several days later, the Administrator was not notified, and the nurse aide remained on the work schedule and had nurse aide assignments. The Administrator later confirmed that she was not informed of the situation until several days after the Social Worker first learned of it, and that the aide should have been removed from duty earlier to protect residents. The DON also stated that the aide should have immediately notified management when she became aware that the resident’s $300 had been transferred into her account. Additionally, when the Administrator attempted to submit the initial allegation report to the State Agency, she transposed letters in the State Agency’s email address, resulting in the report not being received, and she did not detect this failure until informed by the surveyor. As of a later survey date, the State Agency had not received the initial allegation report, and the facility’s corrective action plan inaccurately stated that the report had been sent on an earlier date.
Medication Error: Oxycodone Administered to Wrong Resident Due to Verification Failures
Penalty
Summary
A significant medication error occurred when a resident with diagnoses including Parkinson's disease, dementia, and palliative care, who was cognitively impaired and had no opioid prescription, was administered 60 mg of oxycodone intended for another resident. The error took place during a medication pass when a nurse in training (Nurse #1) was handed the medication by another nurse (Nurse #2), who had pulled the medication for the resident's roommate. Nurse #1 mistakenly believed the medication was for the resident and administered it without proper verification. Interviews and documentation revealed that Nurse #1 stated she thought she had verified the resident's name, but Nurse #2 reported not witnessing any confirmation of identity. Nurse #2 realized the error upon entering the room and immediately reported it. Both nurses notified the Unit Manager, who then informed the Nurse Practitioner and Director of Nursing. The resident was closely monitored and received naloxone and IV fluids after becoming sleepy, but remained stable throughout the monitoring period. The investigation identified that both nurses failed to follow the facility's medication administration policy, specifically the 5 rights of medication administration and the use of two resident identifiers. Additionally, it was found that the orientation and competency validation for the nurses involved was incomplete at the time of the incident, and there was inadequate supervision during the orientation process. The pharmacy consultant was not notified of the error, and the medication administration error was not discovered until after the event had occurred.
Failure to Accurately Document Narcotic Administration
Penalty
Summary
The facility failed to maintain accurate medical records for one resident with chronic pain syndrome and fibromyalgia. The resident had a physician's order for oxycodone-acetaminophen 5-325 mg to be administered every six hours as needed for pain. On a specific date, the resident's individual narcotic record sheet indicated that the medication was administered at two separate times. However, the December Medication Administration Record (MAR) did not reflect documentation of the medication being given at either time. During interviews, one nurse confirmed she had signed the narcotic record sheet but had not documented the administration on the MAR, acknowledging this as an error. The other nurse involved was no longer employed and could not be reached for comment. Both the DON and the Administrator confirmed that facility policy requires narcotics to be documented on both the narcotic sheet and the MAR when administered.
Failure to Assess and Supervise Resident with G-Tube Leading to Unsafe Self-Administration and Ingestion Behaviors
Penalty
Summary
The facility failed to assess a resident with vascular dementia, dysphagia, and NPO status for self-administration of enteral feedings and did not implement effective interventions after repeated observations of unsafe behaviors. The resident was observed multiple times by staff and surveyors self-administering tube feedings, using unidentified liquids in her gastrostomy tube, rummaging through trash for food and liquids, chewing and spitting out food, obtaining food as bingo prizes, and disconnecting herself from her g-tube pump during continuous feedings. Despite these behaviors, there was no documented assessment or physician order for self-administration of tube feedings, and the care plan interventions were limited to education and reminders, which were inconsistently provided and documented. Staff interviews revealed that the resident frequently disconnected her tube feeding, used items from the trash, and attempted to self-administer both water and tube feeding formula, sometimes using bottles she had taken from the trash or her room. Several staff members, including nurses and the NP, were aware of these behaviors but did not consistently communicate them to the physician, Registered Dietician, or other relevant team members. The Medical Director and Psychiatric NP were not made aware of the full extent of the resident's behaviors, and the Registered Dietician was not informed about deviations in the resident's tube feeding regimen. The Activities Director was also unaware of the resident's NPO status and provided food prizes for bingo, despite the resident's inability to swallow. Observations and record reviews indicated a lack of effective supervision and monitoring, as the resident was able to access and use potentially contaminated items for her tube feedings and was not prevented from obtaining or attempting to consume food and liquids orally. Documentation was inconsistent, and there was no system in place to ensure that all staff, including agency staff, were aware of and followed the resident's care plan. The facility's failure to assess the resident's capacity for self-administration and to implement and communicate effective interventions resulted in ongoing unsafe behaviors and placed the resident at risk.
Failure to Prevent Significant Medication Error Related to Blood Pressure Parameters
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension, heart failure, and orthostatic hypotension was administered Coreg (carvedilol) despite physician orders to hold the medication if the systolic blood pressure was less than 150 mmHg. The resident's blood pressure readings frequently fell below this threshold, yet Coreg was administered on numerous occasions as documented in the Medication Administration Records (MAR) for July, August, and September. The error was identified through record review, interviews with nursing staff, pharmacy consultant, nurse practitioner, and cardiologist, and was corroborated by therapy notes documenting episodes of dizziness and low blood pressure during therapy sessions. The resident's care plan included interventions to administer medications as ordered, assess for effectiveness, and report abnormalities to the physician. Despite these interventions, the MAR showed that Coreg was given when the resident's systolic blood pressure was below the ordered parameter on multiple dates. Interviews with nursing staff and medication aides revealed a lack of awareness or understanding of the hold parameters in the physician's order, with some staff admitting they did not read the full order or did not realize the medication should have been held. The Director of Nursing noted that the electronic MAR required scrolling to see the full order, which may have contributed to the oversight. Pharmacy consultant reviews also identified the error and documented that Coreg was administered contrary to the hold parameters, but there was no evidence that these recommendations were addressed by medical providers or nursing staff. The nurse practitioner and cardiologist were not aware that the medication had been administered outside of the prescribed parameters. The resident experienced symptoms consistent with orthostatic hypotension, including dizziness and low blood pressure during therapy, which were documented in therapy and nursing notes.
Inaccurate Documentation of Medication and Oxygen Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents regarding the administration of medications and oxygen therapy. For one resident with hypertension and heart failure, the Medication Administration Records (MAR) for July and August documented that Coreg was administered even when the resident's blood pressure was below the physician-ordered threshold of 150 mmHg. The nurse responsible for the documentation admitted that the records were incorrect and could not explain the discrepancies, confirming that the medication was not administered as recorded and that the MAR did not accurately reflect the resident's medication administration. Additionally, two residents with respiratory conditions requiring oxygen therapy had discrepancies between the physician's orders, the MAR, and actual observations. One resident with acute respiratory failure and asthma had a physician order for 3 liters per minute of oxygen, but was observed receiving 4 liters per minute, while the MAR reflected the ordered amount. Another resident with COPD and heart failure had a physician order for 2 liters per minute of oxygen, but was observed receiving 6 liters per minute, despite the MAR indicating the ordered amount. Staff interviews confirmed that the documentation did not match the observed oxygen settings, and the Director of Nursing acknowledged that staff should be verifying and documenting the correct oxygen flow rates each shift.
Failure to Complete Ongoing AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to provide ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for residents receiving antipsychotic medications, as required by protocol. For two residents with diagnoses including depression with psychosis and bipolar disorder, medical records showed that only one AIMS assessment was completed for each resident, with significant lapses in subsequent assessments. Care plans for both residents indicated a risk for complications related to psychotropic and antipsychotic medications and included interventions for AIMS testing per protocol, but these interventions were not consistently implemented. Interviews with facility staff, including the DON and the pharmacy consultant, confirmed that AIMS assessments were to be conducted every six months for residents on antipsychotics. However, the DON stated that the electronic medical record (EMR) system may not have been properly set to trigger reminders for these assessments, resulting in missed assessments. Unit management staff were unaware of the need for ongoing AIMS assessments for the affected residents, and the pharmacy consultant could not recall discussing the assessments with the DON. The administrator confirmed that the DON was responsible for ensuring completion of AIMS assessments.
Failure to Administer Oxygen as Prescribed and Post Required Oxygen Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not administering supplemental oxygen as prescribed by the physician and by failing to post required cautionary signage indicating oxygen use. For one resident with chronic obstructive pulmonary disease, although the care plan and physician orders specified oxygen at three liters per minute via nasal cannula, there was no 'No Smoking - Oxygen in Use' signage posted outside the resident's door. Multiple staff interviews confirmed that both nursing and respiratory therapy staff were responsible for ensuring signage was in place, but the signage was missing and not checked during rounds. Another resident with acute respiratory failure, severe persistent asthma, and hypoxemia had a physician order for oxygen at three liters per minute to maintain oxygen saturation above 90%. However, the resident was observed receiving oxygen at four liters per minute, and the medication aide on duty documented this higher setting but was unable to adjust the concentrator. The resident was capable of changing the setting independently. Staff interviews revealed that nursing staff were expected to check and set the oxygen concentrator according to physician orders every shift, but this was not consistently done. A third resident with COPD, altered mental status, and heart failure had a physician order for oxygen at two liters per minute via nasal cannula for hypoxia. Observations showed the resident receiving oxygen at six liters per minute, while the medication administration record indicated two liters per minute was documented. Nursing staff admitted they did not check the oxygen concentrator settings during their shifts, despite expectations from the DON and administration that these checks should occur every shift.
Failure to Address and Document Pharmacist Recommendations in Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that irregularities identified by the Consultant Pharmacist during monthly drug regimen reviews were addressed and that documentation of these reviews was maintained and readily available. Multiple residents receiving antipsychotic and other high-risk medications did not have required assessments, such as the Abnormal Involuntary Movement Scale (AIMS), completed at the recommended intervals. For example, one resident on antipsychotic medication had only one AIMS assessment on file, despite repeated pharmacist recommendations for ongoing assessments, and there was no evidence that these recommendations were acknowledged or acted upon by staff. Additionally, recommendations regarding medication administration timing, such as separating psyllium from other medications to avoid absorption issues, were not communicated or implemented, and staff were unaware of these recommendations. The report also documents that medication regimen review reports and pharmacy recommendations were not consistently maintained or accessible in the facility. In several cases, the facility was unable to provide copies of pharmacy recommendations for extended periods, and staff interviews revealed confusion about who was responsible for receiving, addressing, and storing these recommendations. The Director of Nursing (DON), Nurse Practitioner (NP), and Administrator each described different processes and responsibilities, leading to a lack of clarity and follow-through. In some instances, recommendations to hold medications based on clinical parameters, such as blood pressure, were not followed, and there was no documentation that these issues were addressed by nursing or medical staff. Residents affected by these deficiencies included individuals with complex medical histories, such as those with bipolar disorder, anxiety, depression, hypertension, and heart failure, who were prescribed multiple medications requiring careful monitoring. The lack of proper documentation, communication, and follow-up on pharmacist recommendations resulted in repeated medication administration errors and missed assessments. Staff interviews confirmed that recommendations were often not received, acknowledged, or acted upon, and there was no established system for ensuring that pharmacy recommendations were addressed and retained in the residents' records.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications. One medication cart was observed unlocked and unattended at a nursing station, with several residents and staff passing by. The lock on the cart was only partially engaged, allowing access to over-the-counter medications, respiratory inhalers, ear and eye medications, diabetic supplies, and a locked narcotic box. The nurse responsible for the cart admitted to not fully locking it to allow nurse aides access to blood pressure supplies, and both the Regional Nurse Consultant and Director of Nursing confirmed that the cart should have been completely locked when unattended. In a separate incident, an opened vial of Lispro insulin was found in a medication refrigerator without an open date, discard date, or legible resident information on the label. The manufacturer’s guidelines require the insulin to be discarded 28 days after opening, and both the unit manager and Director of Nursing acknowledged that the vial should have been properly labeled and not used for any resident. The vial was subsequently discarded after being identified as non-compliant. Additionally, locked black boxes used to store refrigerated controlled medications were found unsecured to permanent structures in two medication rooms. These black boxes, although locked and kept in locked medication rooms, could be removed from the refrigerators, which themselves were not locked. Staff interviews confirmed that the black boxes were not secured to prevent removal, and the Director of Nursing stated that the controlled medications were considered secure due to being behind two locking mechanisms, despite the lack of physical attachment to a permanent structure.
Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when a nurse failed to administer enteral feeding formula at the correct rate as ordered by the physician for a resident with dysphagia, gastrostomy for enteral feedings, malnutrition, and vascular dementia. The resident's physician order specified continuous enteral feeding via a pump at 130 ml per hour for 12 hours overnight, with water flushes of 50 ml every 4 hours. During an observation, the nurse programmed the feeding pump incorrectly, setting the formula to infuse at 50 ml per hour and the water flushes at 130 ml every 4 hours, contrary to the physician's orders. The error was identified when the nurse was asked to verify the physician's order and realized the settings were incorrect. The nurse then re-entered the resident's room and adjusted the pump to the correct settings as per the physician's order. The Director of Nursing confirmed that the enteral feeding pump should have been set according to the physician's instructions. The deficiency was based on the failure to follow the prescribed enteral feeding and water flush rates for the resident.
Failure to Provide Required Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to residents and to notify the Ombudsman when residents were transferred from the facility to the hospital. Specifically, two residents who were hospitalized did not receive the required written notice of transfer/discharge, and there was no evidence that the Ombudsman was informed of these transfers. Record reviews showed that neither resident had documentation of receiving the notice, and interviews with the residents confirmed they did not recall receiving such notification. One resident was cognitively intact at the time of transfer, while the other was severely cognitively impaired. Staff interviews revealed that nursing staff sent clinical documents such as face sheets, order summaries, and medication administration records with the residents during transfer, but did not include the required notice of transfer. Social services staff, who were responsible for providing these notices, confirmed that the notices were not completed or sent for the two residents in question. Additionally, the Ombudsman was not notified of the transfers, as the process relied on having a copy of the notice, which was not available for these cases.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post accurate and complete daily nurse staffing information for three out of six days reviewed. On one occasion, the posted staffing information was outdated, and on another, the posting was incomplete, lacking details for certain shifts and missing required information such as census and licensed nurse staffing. For one day, there was no staffing posting at all. Interviews revealed that the weekend Nurse Supervisor, who was supposed to be responsible for maintaining the daily staffing postings on weekends, had not been assigned or trained to perform this duty, resulting in the postings not being completed. The Director of Nurses and the Administrator both indicated uncertainty regarding who was responsible for the postings on weekends.
Failure to Administer Bowel Preparation Leads to Procedure Cancellations
Penalty
Summary
The facility failed to administer the necessary bowel preparation for a resident on two separate occasions, leading to the cancellation of medical procedures. The first incident occurred when the resident was scheduled for a colonoscopy. Despite having clear orders for bowel preparation, the medication administration record showed that the preparation was not administered as required. The resident consumed a soda and did not complete the bowel preparation, resulting in the cancellation of the colonoscopy. The second incident involved a scheduled surgery for a limited sigmoid colon resection. The resident was supposed to undergo surgery to remove a suspicious colon polyp. However, the surgery was aborted after the surgeon discovered that the colon was full of stool, indicating that the bowel preparation had not been completed. The facility did not have any record of receiving bowel preparation orders from the surgeon's office, and there was a lack of follow-up to ensure the resident received the necessary instructions. Interviews with staff revealed a breakdown in communication and documentation. The Nurse Practitioner and other staff members did not verify or follow up on the bowel preparation orders, and there was confusion about whether the resident received the necessary instructions. The facility's failure to administer the bowel preparation as ordered resulted in the resident undergoing unnecessary anesthesia and surgical preparation without the intended procedure being completed.
Inadequate Supervision of Unsafe Smokers
Penalty
Summary
The facility failed to ensure adequate supervision for two residents who were assessed as unsafe smokers, leading to incidents where they were found smoking unsupervised. Resident #1, diagnosed with Huntington's disease and ataxia, was identified as requiring supervision while smoking due to unsafe habits, including sharing and selling smoking materials. Despite this, he was found alone in the smoking area with his pants on fire, having inappropriately extinguished a cigarette with his shoe. Staff discovered approximately 30 lighters in his room, indicating he had access to smoking materials despite the facility's policy that these should be kept at the nurses' station. Resident #2, who had chronic obstructive pulmonary disease and no fingers on either hand, was also identified as an unsafe smoker requiring supervision. However, he was found with a burnt bandage on his hand after smoking unsupervised. Despite being reminded of the smoking policy, Resident #2 claimed he was outside with staff, although no staff were present to supervise him at the time of the incident. The facility's policy required that smoking materials be stored at the nurses' station and that residents be supervised while smoking, but these protocols were not followed. Both incidents highlight a failure in the facility's supervision and management of smoking materials for residents assessed as unsafe smokers. The lack of adherence to the smoking policy and inadequate supervision allowed residents to access and use smoking materials unsupervised, leading to potentially dangerous situations. The facility's staff were either unaware of the residents' smoking status or failed to enforce the necessary precautions, resulting in these deficiencies.
Failure to Notify Physician and Responsible Party of Changes in Condition and Medication
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident, identified as Resident #13, who was observed by nurse aides to be in an altered mental state, not eating, and having a rash on multiple areas of his body. Despite these observations, the physician was not notified, and the resident was not assessed for further medical intervention. The following day, the resident was found to be in septic shock and was transferred to the hospital, where he later expired. The lack of communication and failure to act on the resident's change in condition contributed to the deficiency. Additionally, the facility failed to notify the responsible party of a medication change for another resident, identified as Resident #6. The resident's narcotic medication was changed from Oxycodone ER to Morphine ER without informing the responsible party. This oversight was discovered only after the responsible party inquired about the resident's increased drowsiness. The failure to communicate medication changes to the responsible party was another aspect of the deficiency. The report highlights the facility's failure to have effective systems in place for notifying physicians and responsible parties of significant changes in residents' conditions and treatment orders. This lack of communication and documentation led to immediate jeopardy for Resident #13 and a deficiency citation for the facility.
Failure to Recognize and Act on Resident's Change in Condition
Penalty
Summary
The facility failed to ensure proper communication and action among staff and with the physician, resulting in a resident not receiving timely medical services during an emergency situation. A resident exhibited a rash, described by staff as a 'death rash,' along with changes in mental status and eating habits. Despite these observations, no immediate action was taken to provide medical care. The following morning, the resident was found unresponsive with mottled skin and was transferred to the hospital, where he was diagnosed with septic shock and later expired. The resident had a complex medical history, including severe malnutrition, chronic alcoholism, and multiple health conditions such as emphysema and an abdominal aortic aneurysm. Upon admission to the facility, he was noted to be cognitively intact and was receiving rehabilitation. However, staff failed to recognize the significance of the rash and changes in the resident's condition, leading to a delay in emergency medical intervention. Additionally, the facility failed to assess another resident who sustained a head injury following a fall before moving them. This lack of adherence to professional standards of practice was identified for two of the five residents reviewed. The facility's inaction and lack of communication among staff contributed to the adverse outcomes observed in these cases.
Failure to Follow Care Plans Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that staff provided transfer assistance as care planned for a resident with osteoporosis, leading to a fracture. The resident, who was severely cognitively impaired and dependent on staff for mobility, was supposed to be transferred using a mechanical lift with a full body sling. However, staff members were found to have been transferring the resident by standing and pivoting, contrary to the care plan. This improper transfer method likely contributed to the resident's acute fracture of the left distal femur, which was discovered after the resident was sent to the hospital for evaluation of increased knee pain. Another resident, with a history of falls and osteoporosis, was found on the floor with a large hematoma and a fractured nose, indicating a failure to ensure fall mats were in place as per the care plan. The resident, who was totally dependent on staff for mobility and had contractures, was supposed to have fall mats on both sides of the bed. However, at the time of the fall, no fall mats were present, and the resident sustained significant facial trauma. The incident occurred when a CNA found the resident on the floor during rounds, and the resident was subsequently sent to the hospital for evaluation. The deficiencies in care for both residents highlight a lack of adherence to established care plans, which were designed to prevent injuries due to the residents' medical conditions. The failure to use a mechanical lift for transfers and the absence of fall mats as required by the care plans directly contributed to the injuries sustained by the residents. These incidents underscore the importance of following individualized care plans to ensure resident safety and prevent accidents.
Failure to Address Resident's Hearing Aid Needs
Penalty
Summary
The facility failed to follow up on an audiologist's recommendation regarding a resident's hearing aids, resulting in a deficiency. The resident, who was admitted with diagnoses including stroke and dementia, was cognitively impaired and had impaired hearing. The resident's care plan noted that the hearing aids were not working, but no interventions were documented to address the malfunctioning devices. An audiology report indicated that one hearing aid was lost and the other was damaged, with a recommendation to follow up on warranty and repair information. However, there was no documentation of any follow-up actions taken by the facility. Interviews with the resident's Responsible Party (RP) and facility staff revealed a lack of communication and awareness regarding the resident's hearing aid issues. The RP reported that the facility was supposed to check on obtaining new hearing aids, but no progress had been made. The Assistant Director of Nursing (ADON) and the facility's social worker were unaware of the necessary steps to address the missing and damaged hearing aids. The Administrator and Director of Nursing were also unaware of the problem until it was brought to their attention by a surveyor. The audiologist's consult had been filed in the electronic record without notifying the staff, leading to the oversight.
Insufficient Staffing Leads to Delayed Assessment After Resident Fall
Penalty
Summary
The facility failed to provide sufficient staff to ensure a resident received an assessment prior to being moved following a fall with a head injury. The incident involved a resident with multiple diagnoses, including stroke, heart disease, osteoporosis, and dementia, who was found on the floor with a head injury and skin tears. The resident was discovered by a nurse aide who, due to a lack of available staff, moved the resident back to bed without an assessment. The nurse aide was unable to find immediate assistance, as there were only five nurse aides on duty that night due to call-outs. The medication aide assigned to the resident was busy administering medications to other residents and was not present at the time of the fall. The nurse covering for the medication aide was also occupied with other duties and did not assess the resident until later. The nurse documented the fall and notified the provider, who ordered the resident to be sent to the emergency room. The emergency room records indicated significant facial trauma, including a nasal bone fracture, but no other traumatic injuries. The staffing sheets revealed that the facility was understaffed on the night of the incident, with two nurse aides assigned to the resident's station. The night shift nursing supervisor was also serving as a floor nurse and was occupied with another resident who required continuous monitoring. Interviews with staff indicated that the lack of sufficient staffing contributed to the delay in assessing the resident after the fall, as the available staff were overwhelmed with their responsibilities.
Inaccurate Documentation of Resident Health Status
Penalty
Summary
The facility failed to accurately document health status information in the medical records of two residents, leading to deficiencies in record-keeping. For Resident #3, the documentation indicated that the resident was assessed at the facility at a time when they had already been transferred to the hospital. The skilled nursing evaluation recorded vital signs and health assessments that could not have been conducted as the resident was not present at the facility. This discrepancy was acknowledged by Nurse #11, who admitted the documentation was made in error, as she was a travel nurse and did not recall the resident. For Resident #13, the medical record inaccurately maintained an order for a catheter that had been removed and not reinserted prior to the resident's discharge. Despite the resident voiding without a catheter, the electronic medical record still reflected the presence of a catheter. Additionally, Nurse #8's documentation failed to mention a rash observed on the resident and inaccurately noted the presence of a catheter. The Nurse Practitioner relied on these nursing notes for evaluating residents, highlighting the importance of accurate and complete documentation.
Failure to Maintain Resident Dignity and Rights
Penalty
Summary
The facility failed to uphold the dignity and rights of several residents, as evidenced by multiple incidents. One resident, who had been admitted with a history of stroke and depression, was placed on a 1:1 observation following a threat to self-harm after receiving a 30-day discharge notice. Despite being cleared by a Nurse Practitioner the following day, the facility continued the 1:1 observation for 30 days, which the resident felt was punitive and retaliatory. The resident expressed frustration and a lack of privacy, and the Ombudsman confirmed the resident's increased depression due to the observation. The facility's administration and medical staff failed to communicate effectively, resulting in the unnecessary continuation of the observation. Another resident, who was cognitively intact and required assistance for mobility, experienced a lack of dignity when a half-full urinal was left on their bedrail during meal times. The resident reported that the urinal was not emptied as often as needed, leading to an unpleasant smell during meals. Staff interviews revealed a lack of awareness and responsibility for ensuring the urinal was emptied before meal delivery, indicating a breakdown in communication and procedure adherence among the facility staff. A third resident, who was severely cognitively impaired and had an indwelling urinary catheter, was observed with an uncovered urinary drainage bag visible from the hallway. This lack of privacy was noted over several days, and staff interviews revealed uncertainty about the requirement for privacy covers for residents confined to bed. The Director of Nursing confirmed that catheter bags should be covered for all residents, highlighting a failure in maintaining resident dignity and privacy.
Improper Drying of Kitchenware
Penalty
Summary
The facility failed to adhere to proper food safety protocols by not allowing cooking pans and dome lids to completely dry before stacking them for reuse. During an observation of the kitchen, it was noted that thirty-three meal trays were stacked wet and ready for reuse on a cart next to the tray line. The Registered Dietitian (RD) confirmed that the meal trays should be air dried before meal service and instructed the kitchen staff to rewash and air dry the trays. In a subsequent observation, twenty dinner plates were also found stacked wet and ready for reuse. The RD acknowledged that the plates should have been air dried. The Administrator later confirmed that the kitchen staff should have ensured the meal trays and dinner plates were air dried.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by fly activity observed in the kitchen, resident rooms, and hallways. The pest control service provider had made recommendations to prevent recurring pest activity, including repairing cracks and sealing gaps, but these were not fully implemented. Observations revealed that fly trapping machines in the kitchen were not turned on, and there was an open cereal bag in the dry storage area, which could attract pests. Additionally, the kitchen staff left the back door open, which could allow flies to enter. Multiple residents reported issues with flies in their rooms. Resident #113 and Resident #24, both cognitively intact, were observed with fly swatters and reported having to kill flies frequently. During medication administration, flies were observed around food and medication carts, and staff were seen swatting at them. Nurse #4, who had been working at the facility for a few weeks, noted that the flies had been a persistent issue since she started. The Maintenance Director had installed blue lights in the halls and air curtains at entrance doors, but issues such as worn-out gaskets on lobby doors may have allowed flies to enter. Despite these efforts, staff and residents continued to report significant fly activity. The Administrator acknowledged the need to relocate fly trapping machines due to a lack of nearby outlets and believed the pest control program was effective due to perceived improvements.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to involve residents and their representatives in the care planning process, as evidenced by the cases of three residents. Resident #69, who was assessed as severely cognitively intact, was not invited to participate in the care plan meeting after admission. The Assistant Administrator, who was covering social services duties at the time, could not find documentation of the care plan meeting, attributing the oversight to human error. Both the Director of Nursing and the Administrator confirmed that the resident and her representative should have been invited to the meeting. Resident #125, who was cognitively intact, also did not participate in his care plan meeting. The Social Service Director noted that the resident was unable to attend due to care being provided at the time, and a message was reportedly left for the resident's Power of Attorney, who later stated she did not receive any such message. The Social Service Director admitted she could have waited to conduct the meeting after care was completed but did not, and she was new to the position and still learning the process. Resident #108, also cognitively intact, was not invited to a care plan meeting, and there was no documentation of such a meeting in the resident's electronic medical record. The Social Worker Director, who started after the resident's admission, and the Assistant Administrator, who was responsible for scheduling meetings at the time, both confirmed that there was no record of an interdisciplinary care plan meeting being scheduled or held for the resident. The Social Worker Director acknowledged that the resident and her representative should have been invited to a care plan meeting.
Failure to Discontinue Wander Guard as Ordered
Penalty
Summary
The facility failed to discontinue the use of a wander guard for a resident based on a physician's order and an elopement assessment. The resident, who was admitted with diagnoses including hypertension and heart failure, was observed with a wander guard on the left ankle despite a physician's order to discontinue its use. The resident's care plan initially included the use of a wander guard due to a risk for elopement, but an elopement evaluation later indicated the resident was not at risk. There was no current physician order for the wander guard, and no documentation of monitoring its use was found in the resident's records. Interviews with staff revealed a lack of awareness and understanding regarding the resident's need for the wander guard. The resident expressed discomfort with the device and was unable to explain its presence. Staff, including a nurse and the unit manager, were unaware of any incidents of attempted elopement by the resident and did not know why the wander guard was still in use. The Director of Nursing acknowledged that the resident should have been reassessed for elopement risk upon readmission and that a physician order should have been obtained for the wander guard's use.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The facility failed to provide speech therapy services as ordered for a resident who was reviewed for therapy services. The resident, who was admitted with a diagnosis of stroke with left side hemiplegia and dysarthria, was assessed at the hospital to be at moderate risk for aspiration and recommended for a puree diet with moderately thick liquids. A physician ordered a speech therapy evaluation and treatment, as well as a puree diet with honey thick liquids. However, the resident did not receive the speech therapy services as ordered. Interviews with the Rehabilitation Director revealed that although the normal process would include a speech therapy screen or evaluation for a newly admitted resident with such diagnoses, there was no documentation that the resident received a speech therapy screen or services. The facility was without a speech therapist for a period, and the Rehabilitation Director was on medical leave during that time. The Director of Nursing and the Nurse Practitioner were not aware that the resident did not receive speech therapy services. The Administrator acknowledged the absence of a speech therapist but did not recall the specific resident's case.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information at the beginning of each shift for two out of four days during the survey and for 47 out of 57 days reviewed from May 1, 2024, through June 26, 2024. On June 26, 2024, it was observed that the nurse staffing information posted in the lobby was dated June 24, 2024. The Director of Nursing (DON) admitted that she and the Administrator were responsible for posting the information, but due to the new scheduler being in training, the posting for June 25, 2024, was completed but not displayed, and the posting for June 26, 2024, was forgotten. Further review revealed that there was no documentation of staff postings from May 1, 2024, to June 16, 2024. The DON explained that during May 2024, she was assisting another building and was unaware that the postings were not being completed. The Administrator confirmed that the scheduler at that time did not consistently complete the task, and the DON was attempting to keep them current. However, the staff postings were not completed in a timely manner.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received their mail on Saturdays, impacting all 127 residents. Resident interviews revealed that mail was not consistently delivered on Saturdays unless the Activities Director or front office staff were present. The Business Office Manager confirmed that the receptionist was responsible for sorting mail, but resident mail was often left at the front desk until Monday unless it appeared to be a special item like a birthday card. The Administrator stated that the weekend receptionist was supposed to deliver mail on Saturdays, but this was not consistently happening.
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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