Nc State Veterans Home - Black Mountain
Inspection history, citations, penalties and survey trends for this long-term care facility in Black Mountain, North Carolina.
- Location
- 62 Lake Eden Road, Black Mountain, North Carolina 28711
- CMS Provider Number
- 345558
- Inspections on file
- 21
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Nc State Veterans Home - Black Mountain during CMS and state inspections, most recent first.
The facility did not submit required Level II PASRR evaluation requests for four residents with serious mental health disorders, despite documented diagnoses such as PTSD, major depressive disorder, and bipolar disorder, and ongoing use of psychotropic medications. Medical records and care plans reflected active psychiatric conditions, but no evidence of Level II PASRR referrals was found. Interviews with the SW and Administrator revealed a lack of training and understanding of the PASRR process, resulting in no evaluations being requested for affected residents.
A Nurse Aide failed to follow droplet-contact isolation precautions for a resident with influenza, entering the room without cleaning hands or wearing a gown and gloves as required by posted instructions. The NA acknowledged the oversight, and facility leadership confirmed staff are expected to adhere to these infection control measures.
A facility failed to follow its abuse policy when a Nurse Aide observed a bed sheet used as a restraint on a resident's feet and wheelchair. The incident was not immediately reported to the Administrator, delaying investigation and reporting to the State Agency. Both nurses involved did not escalate the issue, despite discussing the inappropriateness of using a bed sheet as a restraint.
Two residents with severe cognitive impairments were involved in physical altercations, leading to one resident sustaining a hip fracture. The incidents occurred in a memory support unit, where staff were not present to intervene. The first altercation involved one resident intentionally bumping his walker into the other's chair, leading to a fall. In the second incident, the same resident fell after the other tripped over his walker, causing a serious injury. The lack of supervision and staff presence contributed to the deficiency.
The facility failed to secure medications and adhere to storage guidelines, resulting in deficiencies. A resident's zinc oxide ointment was left unattended by a nurse, and expired medications, including Latanoprost eye drops and Mucinex tablets, were found in medication carts. Nurses acknowledged the errors, citing distractions and unclear responsibilities.
The facility failed to discard spoiled and expired food items in the walk-in refrigerator and freezer, including lettuce with browning leaves, celery with a white fuzzy substance, and expired cinnamon rolls. The Dietary Manager acknowledged that these items should have been discarded during routine checks, but they were overlooked. The Interim Administrator expected adherence to regulatory standards for food storage.
The facility failed to effectively address and communicate resolutions to concerns raised by residents during Resident Council meetings over several months. Issues such as speeding vehicles, medication delivery times, and maintenance problems were not adequately followed up on, leading to resident dissatisfaction. Despite attempts to reassure residents, the facility lacked a structured plan for ensuring residents were informed about the status of their concerns.
The facility failed to provide SNF ABN notices to two residents before the end of their Medicare Part A skilled services. NOMNCs were discussed with the responsible parties, but SNF ABNs were not issued due to a lack of awareness and process oversight by the Business Office Manager and MDS Coordinators.
A nurse aide in an LTC facility took an unauthorized video of a resident with severe cognitive impairment interacting with a Santa Claus mannequin and sent it to a nurse via a cellphone messenger app. Both staff members acknowledged the violation of privacy policy, stating there was no intent to harm or share the video beyond their communication. The facility's investigation confirmed the breach of privacy, and the incident was reported to the State Agency and Ethics Committee.
A facility failed to obtain an x-ray for a resident with non-pressure skin conditions as ordered by the Wound Care NP. The resident had increased tenderness and redness in the right foot, and the NP instructed the Wound Care Nurse to order an x-ray, but it was not entered into the system. The NP did not know how to enter the order, and the Wound Care Nurse did not verify its placement. The x-ray was performed later, showing no fracture or osteomyelitis.
The facility did not provide ongoing communication about resident rights, as revealed by a review of Resident Council meeting minutes and interviews. Residents confirmed that rights were not discussed during meetings, and the Activities Director, unaware of her responsibility, had not reviewed them since taking over. The Interim Administrator noted that reviewing rights was standard practice in her previous roles.
Failure to Submit Level II PASRR Evaluations for Residents with Serious Mental Health Disorders
Penalty
Summary
The facility failed to submit requests for Level II Preadmission Screening and Resident Review (PASRR) evaluations for four residents who had serious mental health disorders. Each of these residents had a Level I PASRR determination with no expiration date and were admitted with diagnoses such as PTSD, major depressive disorder, bipolar disorder, delusional disorder, and anxiety. Despite having active psychiatric diagnoses and receiving psychotropic medications, there was no documentation in their medical records that a Level II PASRR evaluation had been requested or completed for any of these residents. For each resident, medical records and care plans indicated ongoing mental health concerns and the use of medications such as antidepressants, anticonvulsants, and antianxiety agents. Psychiatric and physician progress notes documented the presence and management of these mental health conditions, including follow-up visits and medication adjustments. However, the facility was unable to provide evidence that the required Level II PASRR evaluations had been initiated, even when new or ongoing mental health diagnoses were identified after admission. Interviews with the Social Worker (SW) and Administrator revealed a lack of knowledge and training regarding the PASRR process. The SW, who took over the PASRR responsibilities in April, stated she had not been shown what to do or what to look for regarding Level II PASRR referrals and had not submitted any requests for evaluations. The Administrator, who also started in April, confirmed uncertainty about whether any Level II PASRR requests had been made and was unable to locate any documentation to that effect. Both indicated an expectation that referrals should be made when residents are admitted with mental health diagnoses or when new diagnoses are identified, but this was not occurring in practice.
Failure to Follow Droplet-Contact Isolation Precautions for Resident with Influenza
Penalty
Summary
A deficiency occurred when a Nurse Aide (NA) failed to follow the facility's infection control policy and procedures regarding droplet-contact isolation precautions for a resident who had tested positive for influenza A. The facility's policy required that residents with influenza be placed on droplet-contact precautions for seven days, with specific instructions posted on the resident's door. These instructions included cleaning hands before entering and when leaving, and wearing a gown, face mask, and gloves upon entry, with removal of PPE before exiting. During a meal tray service observation, the NA entered the resident's room wearing only a face mask, without cleaning her hands or donning a gown and gloves as required by the posted instructions. The NA acknowledged awareness of the infection control training and the posted precaution sign but stated she had forgotten to follow the instructions before entering the room. Interviews with the Infection Preventionist, DON, and Administrator confirmed that the expectation was for staff to read and adhere to the posted droplet-contact precaution instructions before entering the room of a resident on isolation. The failure to follow these procedures was directly observed and confirmed through staff interviews.
Failure to Report Alleged Restraint Use
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding the immediate reporting of an alleged use of physical restraint on a resident. A Nurse Aide observed a bed sheet wrapped around a resident's feet and wheelchair, which restricted the resident's movement. The Nurse Aide removed the sheet and informed a nurse, but did not immediately report the incident to the Administrator as required by the facility's policy. The incident was not promptly communicated to the Director of Nursing (DON) or the Administrator, resulting in a delay in the investigation and reporting to the State Agency. Nurse #1, who was informed of the incident by Nurse #2, did not report it to the Administrator or DON. Nurse #2, who discussed the incident with the staff, also failed to report it to the higher authorities, despite acknowledging that the use of a bed sheet as a restraint was unacceptable. The Director of Nursing and the Interim Administrator were unaware of the incident until it was brought to their attention by the surveyor. The facility's policy mandates that any concerns of abuse, even if uncertain, should be reported immediately to the Administrator or DON for investigation. The delay in reporting and investigating the incident highlights a breakdown in communication and adherence to the facility's abuse prevention policies.
Failure to Prevent Resident Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when two residents were involved in physical altercations, resulting in one resident sustaining a serious injury. Resident #33, who had severe cognitive impairment and used a walker for mobility, was involved in two incidents with Resident #324, who also had severe cognitive impairment and a history of behavioral issues. During the first altercation, Resident #33 intentionally bumped his walker into Resident #324's chair, prompting Resident #324 to pull Resident #33 to the floor. Resident #33 was able to get up and walk away after this incident. In the second altercation, Resident #33 was banging his walker into a door when Resident #324 approached him again. As Resident #324 attempted to engage with Resident #33, he tripped over the wheel of the walker, causing Resident #33 to fall and sustain a left hip fracture. The fall was unwitnessed, and staff were not present in the area to intervene or prevent the altercation. The incident was captured on video footage, which was later reviewed by the facility's former Administrator and Director of Nursing. The facility's staff, including nurses and nurse aides, were not adequately monitoring the residents, particularly in the memory support unit where the altercations occurred. The lack of staff presence and supervision in the area where the incidents took place contributed to the deficiency, as staff were unable to prevent or deescalate the situation between the two residents. The facility's failure to ensure proper supervision and intervention led to the serious injury of Resident #33.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to secure medications properly and adhere to storage guidelines, leading to several deficiencies. In one instance, zinc oxide ointment was left unattended in a resident's room. The resident, who had dermatitis and was not approved for self-administration of medication, found the ointment left by a nurse who was distracted by another resident's call for help. The nurse acknowledged leaving the ointment unattended, which was against the facility's protocol. Additionally, the facility did not remove expired medications from the medication carts. An opened bottle of Latanoprost eye drops was found in a medication cart, stored at room temperature beyond the manufacturer's recommended period. A nurse admitted to not knowing the specific storage guidelines for the eye drops. Furthermore, expired Mucinex tablets were found in another medication cart, with the nurse attributing the oversight to the night shift's responsibility and the consultant pharmacist's monthly checks. Both nurses acknowledged the expired medications should have been discarded.
Failure to Discard Spoiled and Expired Food
Penalty
Summary
The facility failed to properly manage food storage in both the walk-in refrigerator and freezer, leading to the presence of potentially hazardous and expired food items. During an observation of the walk-in refrigerator, surveyors found two unopened bags of green leaf lettuce with browning leaves and brown liquid, as well as a box of celery with a white fuzzy substance, indicating spoilage. Additionally, an open box of cinnamon rolls with an expired date was found in the walk-in freezer. Interviews with the Dietary Manager revealed that a dietary staff member was responsible for checking expiration dates and spoiled food weekly, but these items were overlooked. The Interim Administrator expressed that her expectation was for kitchen food storage to adhere to regulatory standards, ensuring expired or moldy foods are removed and disposed of.
Deficiency in Addressing Resident Council Concerns
Penalty
Summary
The facility failed to effectively address and communicate resolutions to concerns raised by residents during Resident Council meetings over a period of several months. The Resident Council minutes from August 2023 to June 2024 revealed that residents consistently expressed doubts about the facility's responsiveness to their concerns, such as speeding vehicles around the facility, medication delivery times, and maintenance issues like the stabilization of a birdhouse. Despite the facility's attempts to reassure residents and propose resolutions, there was a lack of follow-up communication to confirm whether these issues were resolved, as indicated by the incomplete sections on the Resident Council Response Forms. Interviews with residents and staff highlighted the ongoing dissatisfaction with the facility's communication process. Residents expressed that they often received vague responses such as "we are working on it" or "we can't do that," without any satisfactory resolution or feedback on the actions taken. The Resident Council President acknowledged that while some issues might take time to resolve, clear communication about the steps being taken would be appreciated. The Activity Director, responsible for recording meeting minutes, confirmed that resolutions were typically reported back at the next meeting, but the documentation of these follow-ups was lacking. The Interim Administrator, who had previously served in the facility, noted that during her tenure, Town Hall meetings were used to discuss concerns and communicate the facility's responses. However, the current process seemed to lack a structured plan for ensuring residents were informed about the status of their concerns. This deficiency in communication and follow-up contributed to the residents' perception that their issues were not being adequately addressed.
Failure to Issue SNF ABN Notices
Penalty
Summary
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF ABN) to two residents prior to the termination of their Medicare Part A skilled services. For Resident #12, the Notice of Medicare Non-Coverage (NOMNC) was discussed with the responsible party on April 2, 2024, indicating that Medicare Part A coverage would end on April 4, 2024. However, there was no evidence in the medical record that a SNF ABN was reviewed with or provided to Resident #12 or their responsible party. The Business Office Manager confirmed that a SNF ABN was not issued because the Minimum Data Set (MDS) Coordinators did not forward it along with the NOMNC, and she was unaware that both notices were required. Similarly, for Resident #70, the NOMNC was discussed with the responsible party on May 16, 2024, indicating that Medicare Part A coverage would end on May 20, 2024. Again, there was no evidence that a SNF ABN was reviewed with or provided to Resident #70 or their responsible party. The Business Office Manager confirmed that a SNF ABN was not issued due to the same oversight. The Interim Administrator acknowledged that the process for issuing the required notices had changed, which led to the SNF ABN not being issued, as the MDS Coordinators were responsible for forwarding both the NOMNC and SNF ABN to the Business Office Manager for review with the resident or their responsible party.
Unauthorized Video Recording of Resident
Penalty
Summary
The facility failed to protect a resident's right to privacy when a nurse aide used her cellphone to take an unauthorized video of a resident displaying behaviors and sent the video to a nurse via a cellphone messenger application. The resident involved, who had severe cognitive impairment due to Alzheimer's disease and dementia, was observed by the nurse aide engaging with a Santa Claus mannequin in a tender manner. The nurse aide, who was aware of the facility's policy against using cellphones to record residents, took the video to show the nurse the resident's behavior, which she had not seen before. The incident was reported to the facility on the same day it occurred, and an investigation was initiated. Both the nurse aide and the nurse confirmed the video was taken and shared, but they stated there was no intent to harm or share the video beyond their communication. The video was not posted on social media and was deleted from their devices. The facility's investigation found no malicious intent, but it was acknowledged that the action violated the resident's privacy rights. The former Director of Nursing confirmed the facility's policy prohibits staff from taking photographs or videos of residents. The incident was reported to the State Agency and the facility's Ethics Committee. The interim administrator emphasized that communication about residents should be verbal and that taking videos of residents is unacceptable.
Failure to Obtain Timely X-ray for Resident
Penalty
Summary
The facility failed to obtain an x-ray as ordered by the Wound Care Nurse Practitioner (NP) for a resident with non-pressure skin conditions, specifically to rule out a possible fracture and osteomyelitis. The resident, who had diagnoses including peripheral vascular disease and cellulitis of the right toe, was noted to have increased tenderness and redness in the right foot. The Wound Care NP had instructed the Wound Care Nurse to order an x-ray, but the order was not entered into the system, and the x-ray was not performed until several days later. Interviews revealed that the Wound Care NP did not know how to enter orders for diagnostic x-rays into the electronic medical record, and assumed the x-ray had been refused by the resident. The Wound Care Nurse uploaded the NP's progress note but did not verify that the x-ray order was in place. The Director of Nursing (DON) and the Interim Administrator expected the NP to enter the order, but it was not done until the deficiency was identified. The x-ray was eventually performed, showing no fracture or osteomyelitis.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to provide ongoing communication to residents regarding their rights in a nursing home setting. This deficiency was identified through a review of Resident Council meeting minutes and interviews with residents and staff. The review of meeting minutes from May 11, 2023, through August 15, 2024, showed no evidence that resident rights were discussed. During a group interview, several residents confirmed that resident rights were not discussed during or outside of the Resident Council meetings. One resident mentioned that while he could access the posted resident rights, not all residents had the same ability. The Activities Director, who took over the position in May 2024, admitted to not reviewing resident rights during the meetings, as she was unaware it was part of her responsibilities. The Interim Administrator noted that in her previous experience, resident rights were typically reviewed during these meetings.
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.
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.
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.
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.
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.
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 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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