Nc State Veterans Home - Salisbury
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, North Carolina.
- Location
- 1601 Brenner Ave., Building #10, Salisbury, North Carolina 28145
- CMS Provider Number
- 345531
- Inspections on file
- 16
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Nc State Veterans Home - Salisbury during CMS and state inspections, most recent first.
Staff failed to properly disinfect shared blood glucose meters before and after each use, using alcohol wipes instead of EPA-registered disinfectant wipes, and sometimes not disinfecting at all. This occurred during blood glucose checks for two residents with bloodborne pathogens, with staff demonstrating lack of knowledge about correct procedures despite prior training. The meters were not individually labeled or stored, leading to potential cross-contamination.
Two residents experienced a lack of dignity and respect for their rights when one was subjected to rough handling during bathing despite asking for it to stop, and another had their urine collection bag left uncovered and visible from the hallway after a medical procedure. Staff did not respond to resident requests or ensure privacy measures were maintained.
Two residents were administered antipsychotic and antidepressant medications without appropriate mental health diagnoses, and a PRN antipsychotic was ordered for longer than regulations allow. Staff, including the DON and Consultant Pharmacist, did not verify medication orders for compliance, relying instead on pharmacy review and assuming hospice orders were exempt from certain requirements.
A resident with dementia and chronic conditions reported being roughly handled by a nursing assistant during a shower, repeatedly asking for the care to stop. Despite the resident's complaints, neither the involved NA nor another NA who overheard the allegation reported it to administration or the charge nurse, allowing the accused NA to continue working. The incident was only reported days later by the resident's representative, resulting in delayed assessment and documentation, and a failure to follow the facility's abuse reporting policy.
A resident with chronic pain did not receive lidocaine patches as ordered by the physician, with nurses administering fewer patches than prescribed and failing to seek clarification or update the order. Both the DON and physician confirmed the order was not followed or clarified by staff.
A resident with an indwelling urinary catheter was observed on two occasions with their catheter collection bag lying on the floor, despite staff knowledge that the bag should be hung below the bladder and off the floor. Staff interviews confirmed awareness of proper catheter care, but the training materials did not specifically address bag placement. The deficiency was identified through direct observation and staff interviews.
Two residents received antipsychotic and antidepressant medications without appropriate diagnoses or correct PRN stop dates, and the Consultant Pharmacist failed to identify or report these drug regimen irregularities during monthly reviews. Facility staff were unaware of regulatory requirements for PRN antipsychotic duration and did not question physician orders, resulting in continued inappropriate medication use.
Nursing staff failed to accurately document and administer lidocaine patches as ordered for a resident with pain management needs. Nurses applied fewer patches than prescribed and signed the MAR as if the full dose was given, resulting in inaccurate medical records. The DON and ADON confirmed that the documentation did not reflect actual practice.
Two residents did not have proper documentation related to influenza vaccination: one did not have evidence of receiving vaccine education or a Vaccine Information Statement (VIS) prior to consenting, and another received the vaccine without a signed consent form, with only staff witness signatures indicating verbal consent. Facility staff acknowledged missing documentation and inconsistent practices, despite policy requirements for providing the VIS and documenting education and consent.
A resident with a history of tobacco use, stroke, and vascular dementia did not receive a required quarterly smoking safety screen, as mandated by facility policy. The resident, who required supervision while smoking, continued to participate in supervised smoking sessions. The DON confirmed that the assessment was not completed and that there was no system in place to ensure these evaluations were done on schedule.
The facility did not post a complete and current list of required state agency and advocacy group contact information, including the State Survey Agency, Adult Protective Services, Ombudsman Program, and others. Observations showed missing or outdated postings in key areas, and staff interviews revealed confusion about responsibility for maintaining these postings.
Two residents' representatives signed arbitration agreements without adequate explanation from facility staff. In one case, a representative was present with the Admissions Coordinator but was not given an explanation of the forms. In another, the representative received the paperwork electronically and had no verbal communication with staff, leading to confusion about the agreement's content.
Unlabeled items were found in nourishment rooms on both floors of the facility, including lactose-free milk, Gatorade, cherry coke, ice cream cones, and containers of ice cream. Dietary staff were unsure of ownership, and it was noted that nursing staff were responsible for labeling residents' items, while staff items were not allowed in these rooms.
A resident who was alert and independent expressed a preference to eat in the dining room during evening meals but was repeatedly denied this choice due to staff shortages. Staff interviews confirmed that residents were often unable to use the dining room for supper because staff were too busy assisting others. The DON and Administrator were unaware of the specific complaints, although the expectation was for residents to have dining choices.
A resident dependent on staff for personal hygiene due to a stroke and hemiplegia was not shaved as per their care plan. Despite the resident's preference for being shaved, staff did not fulfill this need due to time constraints and other priorities. Interviews with staff and administration confirmed the oversight in providing necessary personal hygiene care.
Failure to Properly Disinfect Shared Blood Glucose Meters
Penalty
Summary
Facility staff failed to properly clean and disinfect shared blood glucose meters before and after each use, as required by both facility policy and the manufacturer's instructions. Observations revealed that staff used alcohol wipes instead of EPA-registered disinfectant wipes, and in some cases, did not disinfect the meters at all prior to use. This practice was observed during blood glucose checks for two residents, both of whom were identified as having bloodborne pathogens, including hepatitis C. The blood glucose meters were not labeled for individual resident use and were stored in a manner that allowed for potential cross-contamination. Nursing staff, including a nurse and the Assistant Director of Nursing (ADON), demonstrated a lack of knowledge regarding the correct disinfection procedures. The nurse stated he was trained to use alcohol for cleaning, and the ADON admitted she was unaware that the meter needed to be cleaned both before and after each use. Both staff members had previously received training on blood glucose meter disinfection, but failed to follow the correct procedures during observed care. The facility's policy and the manufacturer's guidelines both specified the use of EPA-registered disinfectant wipes with a required contact time, which was not followed. The deficiency was identified during direct observation and interviews, which confirmed that the improper cleaning and disinfection of blood glucose meters occurred while caring for residents with known bloodborne pathogens. The facility's monitoring systems failed to detect or correct these lapses in infection control, and staff continued to use shared meters without proper disinfection, increasing the risk of cross-contamination and exposure to bloodborne infections among residents.
Removal Plan
- Removed and discarded prior blood glucose meters that were being utilized for multi-resident use.
- Placed individual blood glucose meters in a zipped plastic bag with resident's name identifier to prevent cross contamination.
- Blood glucose meters are removed from the zipped plastic bag prior to entering the resident room, then cleaned, disinfected, and air-dried per EPA-registered disinfectant wipe manufacturer's recommendation before and after use.
- Blood glucose meters are stored in each resident's respective medication cart.
- Applied residents' names to the individual blood glucose meters.
- Upon resident discharge, blood glucose meter is disinfected with EPA-registered disinfectant wipe and stored in medication room.
- All new admissions and residents with new blood glucose meter testing orders will be given a new blood glucose meter by the nurse receiving the order and/or admitting nurse.
- Nurse and/or admitting nurse will label the blood glucose meter and baggy with resident's name and place it in their respective medication cart.
- Education provided to all Licensed Nurses on the specific resident use of blood glucose meters, storage, cleaning, and disinfecting using proper EPA-disinfecting wipe.
- Licensed Nurses who have not received the education will be removed from the schedule until the education has been completed.
- Education related to cleaning, disinfecting, and storage of individual blood glucose meters will be added to the general orientation of newly hired Licensed Nurses.
- Administrator and/or Director of Health Services is responsible for ensuring all Licensed Nurses are educated.
- Licensed nurses who are scheduled to work will receive in-person education and complete return demonstration of cleaning and disinfecting blood glucose meters.
- Licensed Nurses who are not scheduled to work will receive over the phone education with return demonstration review by Director of Health Services prior to next scheduled shift.
- Administrator and/or Director of Health Services maintains the employee roster of those who have been educated and who require review.
- Facility contacted the local health department regarding the infection control breach.
- Medical Director was notified of the infection control breach.
Failure to Honor Resident Dignity and Rights
Penalty
Summary
The facility failed to honor a resident's right to dignity and self-determination in two separate incidents. In the first incident, a resident with chronic pain and dementia, who was moderately cognitively impaired and dependent on staff for bathing and toileting, requested that a nursing assistant stop a shower due to being handled roughly. Despite the resident's repeated requests to stop and expressions of discomfort, the nursing assistant continued with the shower and did not report the incident to supervisory staff. The resident later expressed fear of the nursing assistant and felt that his concerns were not being heard by staff. In the second incident, another resident with severe cognitive impairment and an indwelling catheter was observed multiple times with his urine collection bag visible from the hallway, lacking a privacy or dignity cover. The urine in the collection bag was visible to staff, visitors, and other residents passing by. Staff interviews confirmed that the privacy cover was not in place following the resident's return from a urology procedure, and that staff had not noticed or addressed the missing cover during their shifts. Both incidents demonstrate failures to maintain resident dignity and respect resident rights, as staff did not respond appropriately to resident requests or ensure privacy measures were in place. These deficiencies were identified through observations, record reviews, and interviews with residents, staff, and family members.
Failure to Ensure Proper Diagnosis and Regulatory Compliance for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents had appropriate diagnoses for the use of antipsychotic and antidepressant medications, and did not comply with regulations regarding the duration of PRN antipsychotic orders. For one resident with mild dementia, agitation, and brief psychotic disorder, a PRN order for Haldol was written for 60 days to manage agitation, without a proper diagnosis justifying its use for agitation and without adhering to the required 14-day stop date for PRN antipsychotics. The order was written by a Physician Assistant and hospice Physician, both of whom were unaware of the 14-day regulatory limit. The Consultant Pharmacist, who reviewed the order, did not question the extended duration or the diagnosis, assuming hospice orders were exempt, and the Director of Nursing stated that staff did not verify medication orders for accuracy or compliance with regulations. For another resident with unspecified dementia and no documented behavioral or psychotic disturbances, antipsychotic (olanzapine) and antidepressant (sertraline) medications were ordered and administered without a supporting mental health diagnosis. The resident's records and progress notes did not indicate behaviors or symptoms that would justify the use of these medications. The Physician Assistant and Assistant Director of Nursing confirmed that the medications were ordered for dementia without behaviors, and that no mental health diagnosis was present until after the deficiency was identified. The Director of Nursing acknowledged that the facility relied solely on pharmacy review for medication order accuracy and was unaware of the missing diagnoses until it was brought to their attention. These deficiencies were identified through record review and interviews with facility staff, the Consultant Pharmacist, and the prescribing clinicians. The facility's process lacked adequate checks to ensure that medication orders were supported by appropriate diagnoses and that regulatory requirements for PRN antipsychotic medications were followed.
Failure to Immediately Report and Protect Resident Following Allegation of Rough Handling
Penalty
Summary
The facility failed to follow and implement its abuse policy and procedures in the case of a resident with multiple diagnoses, including unspecified dementia, chronic obstructive pulmonary disease, and chronic pain. The resident reported that a nursing assistant (NA) was rough and manhandled him during a shower, and despite the resident's repeated requests for the NA to stop, the care continued. The resident expressed fear and distress, stating that staff did not listen when he tried to report the incident after returning to his room. Two nursing assistants were aware of the resident's allegations: one directly involved in the incident and another who overheard the resident's complaints. Neither assistant reported the incident to administration or the charge nurse as required by facility policy, allowing the NA in question to complete the shift and return to work the following day. The charge nurse on duty did not recall being informed of the incident, and the resident's representative did not immediately report the allegation to staff, only doing so during a subsequent visit after the resident repeated his account and appeared upset. The facility's policy required immediate reporting of any abuse allegations to the Administrator and safeguarding of the resident. However, the delay in reporting resulted in the accused NA continuing to work and potentially exposed other residents to risk. The initial assessment and documentation of the resident's condition were also delayed, with the skin and pain assessment not documented until days after the incident. Staff interviews revealed a lack of awareness or recall regarding the reporting of the incident, and the facility's investigation confirmed that the abuse allegation was not reported promptly as required by policy.
Failure to Administer Lidocaine Patches per Physician Order
Penalty
Summary
The facility failed to administer lidocaine 4% external pain patches according to the physician's order for one resident with diagnoses of right hip and low back pain. The physician's order specified that four lidocaine patches were to be applied daily to the resident's bilateral hips and bilateral lower back. However, review of the Medication Administration Record (MAR) and staff interviews revealed that nurses consistently failed to apply the prescribed number of patches. One nurse admitted to applying only two patches on the dates she worked, choosing either the hips or the lower back, and stated she did not seek clarification or a new order from the physician despite her belief that the resident no longer needed four patches. Another nurse reported only applying one patch on the dates she worked, acknowledging awareness of the order but unable to explain why she did not follow it, nor did she request clarification from the physician. The physician confirmed that the order was for four patches daily and stated that no staff had contacted him for clarification or to change the order. The Director of Nursing and Assistant Director of Nursing also confirmed that the nurses should have either followed the physician's order or sought clarification if there were questions. The failure to administer the medication as ordered was identified through observations, record reviews, and staff and physician interviews.
Catheter Collection Bag Found on Floor
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and an indwelling urinary catheter was observed on two separate occasions with their urinary catheter collection bag lying on the floor, both in the dining area and in bed. The bag was covered for privacy, but its placement on the floor was directly observed by surveyors. Staff interviews revealed that nursing assistants and nurses were aware that catheter bags should not be on the floor and should be hung below the bladder, but none reported seeing the bag on the floor during their shifts. The Assistant Director of Nursing and the Physician Assistant both confirmed that it was unacceptable for the catheter bag to be on the floor due to the increased risk of infection. Record review indicated that the resident's care plan included a goal to prevent complications or injury related to catheter use. Training records showed that staff had received education on catheter care, but the provided training materials did not specifically address the proper placement of the catheter collection bag. Despite staff knowledge and training, the deficiency occurred due to the failure to ensure the catheter bag was consistently kept off the floor, as required for infection prevention.
Failure to Identify and Report Drug Regimen Irregularities During Monthly Pharmacist Reviews
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report drug regimen irregularities for two residents during monthly medication reviews. For one resident with mild dementia, brief psychotic disorder, and anxiety, a PRN order for Haldol (haloperidol) was written for 60 days for agitation, with the diagnosis listed as dementia with agitation. The Consultant Pharmacist did not document any recommendations or irregularities regarding the inappropriate duration of the PRN antipsychotic order, which should have been limited to 14 days, nor did she question the diagnosis or the order, assuming it was acceptable due to the resident's hospice status. Interviews with facility staff revealed a lack of awareness about the 14-day limit for PRN antipsychotic medications and a reluctance to question hospice physician orders, even when the diagnosis or duration was incorrect. For another resident with unspecified dementia without behavioral or psychotic disturbances, physician orders were in place for olanzapine (an antipsychotic) and sertraline (an antidepressant), both prescribed for dementia without behaviors. The Consultant Pharmacist's monthly reviews did not document any recommendations or irregularities regarding the lack of appropriate diagnoses for these medications. Although the Pharmacist stated that a message was sent to the physician to review the diagnosis for sertraline, there was no documentation of this notification, and the issue with olanzapine was not addressed in a timely manner. The Physician Assistant confirmed that there were no current diagnoses of depression or psychosis for this resident, and the Assistant Director of Nursing acknowledged that the medications were prescribed without a mental health diagnosis. Throughout the review period, the Consultant Pharmacist did not consistently identify or report medication irregularities related to the indicated use and scheduled stop dates of antipsychotic and antidepressant medications for the two residents. Facility staff, including the DON and ADON, confirmed that medication orders were only checked monthly by the Consultant Pharmacist and that no recommendations or notifications regarding these irregularities were received. This lack of identification and reporting of drug regimen irregularities resulted in the continuation of inappropriate medication orders for both residents.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain accurate medical records and ensure proper documentation of medication administration for a resident with orders for lidocaine adhesive patches. The resident had a physician's order specifying the application of four 4% lidocaine patches daily to bilateral hips and lower back. However, observations and interviews revealed that nursing staff did not follow the order as written. One nurse consistently applied only two patches, either to the resident's low back or hips, and documented in the Medication Administration Record (MAR) as if all four patches were administered. Another nurse admitted to applying only one patch per administration, despite signing the MAR for four patches, and could not provide a reason for not following the order. Both nurses acknowledged that their documentation on the MAR was inaccurate, as it did not reflect the actual number of patches applied. The Director of Nursing and Assistant Director of Nursing confirmed that the nurses should have clarified the order if they were not administering the medication as prescribed, and agreed that the documentation was not accurate. The deficiency was identified through observations, record reviews, and staff interviews, which demonstrated a pattern of inaccurate documentation and failure to follow physician orders for medication administration.
Failure to Document Vaccine Education and Obtain Proper Consent for Influenza Vaccination
Penalty
Summary
The facility failed to properly document education regarding the influenza vaccine for one resident and failed to obtain a required signature on the influenza vaccine consent/refusal form for another resident. In the first instance, a resident who was cognitively intact consented to receive the influenza vaccine and signed the consent form, but there was no Vaccine Information Statement (VIS) attached, nor was there documentation in the electronic medical record (EMR) indicating that education about the vaccine was provided to the resident or their representative. The Infection Preventionist confirmed that she did not always bring a VIS form when discussing vaccination and that documentation of education was missing from the EMR. Both the Director of Nursing (DON) and the Administrator were unable to explain why the VIS was not provided or why education was not documented, despite facility policy requiring that the VIS be provided and education documented prior to vaccine administration. In the second case, another resident with moderate cognitive impairment had a consent form marked as consenting to the influenza vaccine, but neither the resident nor their representative had signed the form. The form was witnessed by two staff members, including the Infection Preventionist, who stated that she witnessed verbal consent but did not document this on the form. The vaccine was administered without a resident or representative signature, and the VIS form attached also lacked the required signature. The DON stated that the resident likely refused to sign but gave verbal consent, yet there was no documentation of verbal or telephone consent as required. Interviews with staff revealed inconsistent practices regarding the provision and documentation of vaccine education and consent. The Infection Preventionist, DON, and Administrator all acknowledged gaps in documentation and were unable to provide reasons for the missing information. Facility policy required that the VIS be provided and education documented prior to vaccine administration, but these steps were not consistently followed or recorded for the residents involved.
Failure to Complete Required Smoking Safety Screen for Resident
Penalty
Summary
The facility failed to complete a required quarterly smoking safety screen for a resident with a history of tobacco use, cerebral vascular accident, and vascular dementia. According to the facility's policy, staff are required to evaluate each resident's ability to safely use smoking materials and determine the level of supervision needed. The resident's previous assessment indicated the need for supervision while smoking, as the resident was unable to hold or extinguish cigarettes independently. However, the August 2025 Nursing Quarterly Assessment did not include the mandated smoking safety screen for this resident. Interviews with the resident confirmed ongoing participation in supervised smoking during designated times. The DON acknowledged that quarterly smoking safety screens are required and that staff nurses are responsible for completing these assessments. Upon review, the DON was unable to provide documentation of the August 2025 assessment and confirmed there was no system in place to ensure timely completion of these required evaluations.
Failure to Post Required State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to post a complete and up-to-date list of names, addresses (including mailing and email), and telephone numbers of all required state agencies and advocacy groups, such as the State Survey Agency, Adult Protective Services, State Long-Term Care Ombudsman Program, Resident Advocacy Network, Home and Community Based Service Programs, and the Medicaid Fraud Control Unit. Observations conducted over four days revealed that the front hallway bulletin board lacked this required signage. While Resident Rights posters with the local Ombudsman's contact information were present at the first-floor nurses station and the second-floor nurses station, the latter displayed outdated information. No other postings for the required agencies or advocacy groups were observed in the facility. Interviews with facility staff, including the Recreation Director, Social Worker, and Administrator, confirmed that the responsibility for maintaining these postings was unclear and that the required information had not been posted for over three years. The Recreation Director updated the Ombudsman's contact information when notified of changes but was not involved with other postings. The Social Worker was unaware of the status of the postings, and the Administrator believed the postings were current but later acknowledged the required information had not been posted during his tenure.
Failure to Explain Arbitration Agreement to Resident Representatives
Penalty
Summary
The facility failed to adequately inform resident representatives about the arbitration agreement prior to obtaining their signatures. For two residents reviewed, the representatives either did not have the agreement explained to them or were not given the opportunity for verbal communication regarding the content of the agreement. In one case, the representative sat with the Admissions Coordinator during the pre-admission meeting, but reported that the Coordinator did not explain any of the forms and only indicated where to sign. The arbitration agreement for this resident was signed without either the acceptance or declination box being checked. In another instance, the representative received the admission paperwork, including the arbitration agreement, via email and was instructed to sign without any verbal explanation or communication from the Admissions Coordinator. The representative had to interpret the paperwork independently and later expressed a lack of understanding about the agreement. Interviews with facility staff confirmed that forms were sent electronically with an offer to answer questions if contacted, but no proactive explanation was provided. The DON acknowledged that forms should be explained if not understood, but this was not done in these cases.
Unlabeled Items Found in Nourishment Rooms
Penalty
Summary
The facility failed to remove unlabeled items from nourishment rooms on both the first and second floors, as observed during a survey. On the second floor, a bottle of lactose-free milk, a bottle of orange Gatorade, and an opened bottle of cherry coke were found in the refrigerator without labels. Dietary staff were unsure if these items belonged to residents or nursing staff, but acknowledged that they should not have been in the refrigerator unlabeled. It was noted that nursing staff were responsible for labeling items belonging to residents, and staff items were not permitted in the nourishment rooms. On the first floor, two push-up ice cream cones and two open containers of ice cream were also found unlabeled. Dietary staff and a nurse indicated that these items belonged to a resident, but they could not recall which resident. The Director of Nursing and the Administrator confirmed that nursing staff had been educated to label residents' items and that dietary staff were expected to check nourishment rooms daily for unlabeled items. However, the Dietary Manager was unavailable for an interview during the survey.
Failure to Honor Resident Dining Preferences
Penalty
Summary
The facility failed to honor a resident's preference for dining in the dining room during evening meals. The resident, who was alert, oriented, and independent but required setup for eating, expressed a desire to eat in the dining room with friends. However, the resident was repeatedly told by staff that dining in the dining room was not possible due to staff shortages, particularly on weekends and sometimes during the week. Interviews with staff members confirmed that residents were often unable to use the dining room for supper because staff were too busy assisting residents who required help, leaving no time to accommodate those who wanted to dine in the dining room. The Director of Nursing acknowledged that there were instances when dining in the dining room was not allowed and stated that staff had been educated to permit residents to choose their dining preferences. However, the Director of Nursing and the Administrator were not aware of the specific complaints from the resident about being unable to eat in the dining room. The Administrator expected residents to have a choice in dining but was unaware that nursing staff were not following this expectation.
Failure to Provide Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident who was dependent on staff assistance due to a stroke and hemiplegia. The resident was admitted with these conditions and required moderate assistance with personal hygiene, including shaving. Despite the care plan indicating the need for staff assistance with personal hygiene, the resident was observed with a full beard, approximately 1/2 inch long, and expressed a preference for being shaved, which was not fulfilled by the staff. The deficiency was further highlighted during interviews with staff members. Nurse Aide #2 admitted to not shaving the resident during a shower session due to time constraints and other residents needing showers. The Assistant Director of Nursing confirmed that shaving should be provided during shower times, and the Administrator acknowledged that while the resident sometimes refused shaving, staff should ensure it is done. This indicates a lapse in following the care plan and ensuring the resident's personal hygiene needs were met.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
