Northchase Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, North Carolina.
- Location
- 3015 Enterprise Drive, Wilmington, North Carolina 28405
- CMS Provider Number
- 345119
- Inspections on file
- 28
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Northchase Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found expired medications and multiple instances of opened medications lacking proper labeling or dating on several med carts. Expired inhaled medications and supplements were present, and opened inhalers and nebulizer vials were not dated, making it impossible to determine if they were still safe for use. Nursing staff and leadership confirmed that medications should be labeled and discarded per manufacturer instructions.
Surveyors found that expired food items were not removed and opened or leftover food was not properly labeled or dated in both the walk-in refrigerator and a nourishment room. The Dietary Manager and Administrator both confirmed that all food items should be labeled and expired items discarded, but these practices were not consistently followed, leading to the presence of expired and unlabeled food in storage areas.
A resident with moderate cognitive impairment and significant ADL needs was not offered or provided scheduled showers, despite a posted shower schedule and family requests. Documentation showed only bed baths were given, with no evidence of showers being offered or refusals recorded. Staff interviews confirmed the expectation to offer and document showers, but this was not done.
Two residents with mental health diagnoses and completed Level II PASRR screenings were not accurately coded as Level II PASRR on their annual MDS assessments, despite care plans reflecting their PASRR status. The social worker responsible for MDS coding could not explain the omissions, and the administrator confirmed that accurate MDS completion, including PASRR coding, was expected.
A resident who was cognitively intact and independent with eating repeatedly requested grits for breakfast and no orange juice, but continued to receive orange juice and was not served grits as requested for several weeks. Despite dietary communication slips and verbal reminders from staff, the resident's preferences were not updated in the dietary system, resulting in ongoing frustration and unmet requests until the issue was finally addressed.
A nurse neglected to read and act upon a severe drug-to-drug interaction alert for a resident with multiple cardiac and respiratory conditions, administering a newly prescribed antibiotic alongside an existing heart medication without notifying the provider. The nurse assumed it was the NP's responsibility to check for interactions, despite facility policy requiring nurses to review and communicate pharmacy alerts.
A resident with dementia and on hospice care did not receive proper protection of their controlled pain medications, as hydrocodone/acetaminophen and oxycodone pills went missing without proper documentation or accountability. Pharmacy records, medication administration records, and staff interviews revealed missing count sheets and unaccounted-for blister packs, with two nurses last in possession of the medications. The facility could not determine the root cause or responsible party for the misappropriation, though the resident did not miss any scheduled doses.
A resident with multiple chronic conditions and documented allergies received ceftriaxone despite an allergy listed in the EMR, due to failures by both nursing and provider staff to verify allergies before administration. Additionally, the resident was given azithromycin while on amiodarone, despite a severe drug interaction alert from the pharmacy, which was acknowledged but not acted upon by nursing staff. These actions resulted in the administration of unnecessary and contraindicated medications.
The facility failed to accurately code MDS assessments for nutrition, affecting four residents. One resident with adult failure to thrive and diabetes lost 47.1 pounds over 180 days, but this was not reflected in the MDS. Another resident with end-stage renal disease lost 23 pounds in 30 days, yet the MDS did not document this. A third resident gained 43 pounds in 30 days, and a fourth gained 24.91% of their weight over six months, but these changes were not recorded. The MDS Coordinator cited a lack of computer warnings and failure to manually calculate weight changes.
The facility failed to update care plans for three residents, reflecting changes in mobility and nutrition interventions. One resident experienced significant weight loss, yet their care plan was not revised to include current interventions. Another resident's care plan did not reflect their actual weight loss or dietary needs due to dialysis. A third resident's care plan was outdated, focusing on obesity despite significant weight fluctuations. Staff interviews revealed these oversights were due to errors and lack of involvement in care planning.
The facility failed to monitor vital signs before administering Metoprolol to a resident with hypertension and end-stage renal disease, and did not perform weekly weight checks for another resident with congestive heart failure, as ordered by physicians. These deficiencies were due to a lack of adherence to medical directives and an error in the electronic medical record system.
Two residents in an LTC facility did not receive physician-ordered nutritional supplements and had inconsistent weight monitoring, leading to deficiencies in their nutritional care. One resident with a history of stroke and malnutrition experienced significant weight loss due to not receiving Mighty Shake supplements and weekly weights as ordered. Another resident with diabetes and hypertension did not receive the Magic Cup supplement and had fluctuating weights. Staff interviews revealed issues with oversight, staff turnover, and training, contributing to these deficiencies.
A resident with a history of left breast keloid and cognitive intactness did not have a physician-ordered mammogram scheduled, despite filing a grievance and repeated requests. The facility's failure was due to communication breakdowns and process issues, as revealed in interviews with the resident, staff, and NP. The Transportation Specialist was aware of the need but had not scheduled the appointment, and the Unit Manager was unaware of the referral. The Administrator acknowledged the grievance but was unaware of the delay reasons.
A resident undergoing hemodialysis did not receive multiple doses of prescribed medications, including Metoprolol, Tradjenta, Sevelamer, and Cymbalta, due to scheduling conflicts with dialysis times. Additionally, the resident did not receive the full course of Diflucan for vaginitis, as the medication was marked unavailable despite being in the facility's emergency kit. The MAR was not adjusted to account for these missed doses, leading to significant medication administration failures.
The facility failed to provide palatable and appropriately heated meals to residents, leading to dissatisfaction and reliance on external nutritional supplements. Several residents reported receiving cold and unappetizing meals, with some resorting to family-provided snacks. Despite grievances and ongoing Resident Council concerns, the Dietary Manager was unaware of these issues, citing staff turnover and training challenges. The DON acknowledged the need for improvement in meal service, while the Administrator's expectations for meal quality were not met.
The facility failed to provide alternative meals and honor resident preferences, leading to dissatisfaction among residents. Several residents reported receiving meals that were cold, unappetizing, or not aligned with their dietary needs, and they were not consistently informed about alternative options. The process for obtaining meal preferences was inconsistent, with staff interviews revealing that menus were not always provided in time, and receptionists struggled to interview all residents. This resulted in unmet nutritional needs and reliance on external food sources.
A resident with CHF experienced significant weight gains, but the facility failed to notify the provider as required by the physician's order. Despite a 7.5-pound gain in one day and a 5.3-pound gain over three days, the staff did not report these changes, which were crucial for managing the resident's condition. The DON acknowledged the oversight, but no adverse health outcomes were reported.
The facility failed to provide the required CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to two residents before their discharge from Medicare Part A skilled services. Despite having remaining benefit days, the residents did not receive the necessary SNF-ABN forms, as confirmed by staff interviews and record reviews. The Social Services Director acknowledged the oversight, and the Administrator expected that appropriate notices should have been given.
Three residents in an LTC facility did not receive necessary meal tray setup and assistance, impacting their ability to perform activities of daily living. One resident with cognitive impairments and another with physical limitations struggled to eat due to lack of setup, while a third resident with hemiplegia was unable to open containers or cut food. Staff interviews confirmed the need for assistance, but it was not consistently provided.
A medication cart was left unattended and unlocked with keys in the lock in a hallway near resident rooms. A visitor was nearby, and the nurse responsible was not in sight, returning a few minutes later. The nurse admitted to being distracted by a resident, leading to the oversight.
The facility failed to implement its Enhanced Barrier Precautions policy, as two nurse aides did not wear gowns while providing care to a resident with a dialysis catheter and wound care needs. Despite being trained, the aides acknowledged their mistakes. The resident had recently transitioned from Contact Precautions for C. difficile to Enhanced Barrier Precautions due to the presence of a dialysis access device and ongoing wound care.
A resident with cataracts and diabetes did not receive a timely ophthalmology appointment despite multiple requests and a grievance. The facility's staff, including the Transportation Specialist and Social Workers, were unaware of a physician's referral order, leading to a lack of follow-through. The DON and Administrator cited issues with the resident's payor source and insurance, but the resident's request remained unfulfilled, highlighting a deficiency in addressing healthcare needs.
Expired and Unlabeled Medications Found on Multiple Med Carts
Penalty
Summary
Surveyors observed that staff failed to discard expired medications and did not consistently label or date medications when opened on multiple medication carts. Specifically, opened boxes of ipratropium bromide and albuterol sulfate intended for residents with COPD were found on two medication carts with opened dates far exceeding the manufacturer's recommended two-week discard period. Additionally, a bottle of zinc sulfate tablets was found with a manufacturer's expiration date that had already passed. These expired and improperly stored medications were accessible on the 100 and 200 hall medication carts. Further observations revealed that several opened inhalers and nebulizer vials were not labeled with the date they were opened, making it impossible to determine if they were still within the manufacturer's recommended usage period. This issue was noted on the 100, 200, and 400 hall medication carts. In some cases, medications were found outside of their original packaging and without any identifying information or opened dates. Interviews with the DON and Administrator confirmed that the expectation was for staff to label and date medications upon opening and to discard them before expiration, in accordance with manufacturer instructions.
Failure to Remove Expired Food and Label Opened Items in Food Storage Areas
Penalty
Summary
The facility failed to remove expired food items and properly label and date opened or leftover food in both the walk-in refrigerator and the Rehabilitation Hall nourishment room. During an observation in the kitchen, multiple food items were found without opened dates, including Swiss cheese, deli meats, muffins, and beverages. Some items, such as stewed tomatoes and honey thick orange juice, were found past their use-by dates. The Dietary Manager acknowledged that all items should be labeled and expired items discarded, but cited challenges in maintaining this standard due to frequent staff turnover and falling behind on audits. In the Rehabilitation Hall nourishment room, additional issues were observed, including opened nutritional supplements and leftover food items without dates or labels, as well as expired food items that had not been discarded. The Dietary Manager confirmed that dietary staff were responsible for checking and stocking the nourishment room refrigerators daily, but expired and unlabeled items were still present. The Administrator stated that all food items should be properly labeled with resident names and dates, and expired items should be discarded immediately, but these expectations were not met.
Failure to Honor Resident's Choice for Shower
Penalty
Summary
A deficiency was identified when a resident with vascular dementia, anxiety, depression, and insomnia was not provided with the opportunity to receive a shower as per her care plan and posted shower schedule. The resident was assessed as moderately cognitively impaired, requiring substantial to maximal assistance with personal hygiene, and was frequently incontinent. Her care plan specified that activities of daily living, including personal care, would be completed with staff support to maintain her highest practical functioning. The posted shower schedule indicated she was to be offered a shower on Wednesdays and Sundays during the night shift. A review of the resident's activity of daily living (ADL) shower sheet and nursing progress notes for the first week after admission revealed no documentation that the resident had received a shower, nor was there evidence that she was offered a shower and refused. The only documented hygiene provided was a bed bath on two occasions, with no record of showers being offered or given. The resident's family member, who was present daily, confirmed that the resident had not received a shower since admission and had specifically requested one from staff, but was repeatedly told it would occur on scheduled days, which did not happen. Interviews with nurse aides and the Director of Nursing confirmed that showers were to be offered according to the posted schedule, and refusals were to be documented and reported to nursing staff. However, the nurse aides could not recall providing a shower or documenting any refusals, and the records supported that no showers were given or offered. The Director of Nursing stated the expectation that showers be offered and refusals documented, but this was not reflected in the resident's records or staff recollections.
Inaccurate PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of Preadmission Screening and Resident Review (PASRR) for two residents. For one resident with diagnoses of anxiety, depression, and bipolar disorder, the electronic health record showed a completed Level II PASRR, and the care plan included interventions and goals based on this status. However, the annual MDS assessment did not reflect the resident's Level II PASRR status. The social worker, responsible for coding PASRR status on the MDS, stated she had a list of Level II PASRR residents but could not explain why the resident was not coded correctly, attributing it to an oversight. The administrator confirmed the expectation that MDS assessments, including PASRR coding, be completed accurately. Similarly, another resident with diagnoses of psychosis and hallucinations had a completed Level II PASRR and a care plan addressing the associated needs and interventions. Despite this, the annual MDS assessment did not indicate the resident's Level II PASRR status. The social worker again acknowledged responsibility for coding but could not account for the omission, stating it was likely missed. The administrator reiterated the expectation for accurate completion of MDS assessments, including PASRR status.
Failure to Honor Resident Food Preferences
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's documented food preferences over a period of several weeks. The resident, who was cognitively intact and independent with eating, had a physician order for a regular diet and had specifically requested grits for breakfast and no orange juice. Despite multiple dietary communication slips and verbal reminders from both the resident and nursing staff, the resident continued to receive orange juice and was not served grits as requested. Observations confirmed that the resident's breakfast trays repeatedly included orange juice and omitted grits, requiring the resident to ask staff each morning to correct her meal. Interviews with the resident, nursing staff, and the Dietary Manager revealed that the communication slips indicating the resident's preferences were overlooked and not entered into the electronic record. The Dietary Manager acknowledged that she had discontinued her previous system of initialing slips after updating preferences, which contributed to the oversight. The resident expressed frustration at having to repeatedly request her preferred breakfast items, and the issue persisted until it was finally addressed after several weeks of noncompliance.
Failure to Address Severe Drug Interaction Alert for Resident
Penalty
Summary
A nurse failed to protect a resident's right to be free from neglect by disregarding a severe drug-to-drug interaction alert sent from the pharmacy. The alert, which was triggered when a new antibiotic (azithromycin) was prescribed for a resident already taking amiodarone for abnormal heart rhythm, indicated a severe interaction risk due to additive QT interval prolongation. The nurse acknowledged the alert in the electronic medical record but did not read its contents or notify the physician about the potential interaction before administering the antibiotic. The resident involved had multiple significant medical conditions, including congestive heart failure, chronic obstructive pulmonary disease, lymphedema, kidney disease, paroxysmal atrial fibrillation, hypertension, and a history of transient ischemic attacks. The resident was cognitively intact and receiving oxygen therapy as needed. The new antibiotic was prescribed following an acute episode of dyspnea and a diagnosis of right lower lobe pneumonia. Interviews with facility staff, including the nurse, consultant pharmacist, DON, and medical director, confirmed that the nurse did not follow protocol for handling pharmacy alerts. The nurse believed it was the nurse practitioner's responsibility to check for allergies and contraindications and admitted to acknowledging the alert without reading it. The facility's policy, as described by the consultant pharmacist and DON, required nurses to read pharmacy alerts and notify the provider of any drug interactions before administering medications.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
A facility failed to prevent the misappropriation of a resident's controlled medications, specifically hydrocodone/acetaminophen and oxycodone, which were prescribed for pain management. The resident involved had dementia, a history of falls, atrial fibrillation, and was receiving hospice care at the time of the incident. Pharmacy records showed multiple deliveries of controlled substances, and medication administration records indicated that doses were given as ordered. However, discrepancies were found between the number of doses administered and the available count sheets, with missing declining count sheets and unaccounted-for medication blister packs. The investigation revealed that early refill requests were made for the resident's medications, and the pharmacy notified the facility that it was too soon to dispense additional medication. Despite this, the facility reordered the medication at its own expense to ensure the resident did not miss any doses. During the review, it was discovered that there were missing count sheets for both hydrocodone/acetaminophen and oxycodone, and at least 30 pills of each medication were unaccounted for. Staff interviews and record reviews indicated that two nurses were last in possession of the medications, but one nurse could not be reached for follow-up, and the other denied involvement. There was no evidence that the missing medications were returned to the pharmacy or that the required documentation was completed. The facility's internal investigation included audits of controlled substance count sheets, packing slips, and return forms, as well as interviews with staff. The Director of Nursing confirmed that the root cause of the missing medications could not be determined, but drug diversion was substantiated for the resident's narcotic medications. The resident did not miss any scheduled doses, and pain assessments were conducted to ensure effective pain management. The incident was reported to regulatory agencies, but the facility was unable to identify the individual responsible for the misappropriation.
Failure to Prevent Administration of Unnecessary and Contraindicated Medications
Penalty
Summary
A resident with multiple chronic conditions, including congestive heart failure, COPD, kidney disease, and paroxysmal atrial fibrillation, was admitted to the facility with documented allergies to several medications, including ceftriaxone and sulfa drugs. The allergy to ceftriaxone was noted in the electronic medical record (EMR), but the nurse entering the information did not review the specific reactions associated with each allergy, as these were listed on a different page of the hospital discharge summary. Subsequently, the nurse relied only on the top section of the summary and did not include the detailed reactions. The allergy information was transmitted to the pharmacy and appeared in the medication administration record (MAR), but the process for verifying and acting on this information was inconsistent among staff. During an acute episode of dyspnea, the nurse practitioner (NP) evaluated the resident and ordered ceftriaxone and azithromycin for pneumonia. The NP did not check the resident's allergies in the EMR before placing the order, and the nurse who signed off on the order also failed to verify allergies prior to obtaining and preparing the medication from the emergency kit. The pharmacy sent an alert regarding the ceftriaxone allergy, but because the medication was taken from the emergency kit, the alert did not prevent administration. The resident ultimately received the ceftriaxone injection from a different nurse, who also did not check the allergy information before administration. Interviews revealed that both the NP and nursing staff expected the other party to verify allergies, leading to a breakdown in the process. Additionally, the resident was prescribed azithromycin while already receiving amiodarone, a combination known to have a severe drug-to-drug interaction risk due to additive QT interval prolongation. The pharmacy sent an electronic alert about this interaction, which was acknowledged by the nurse without being read or acted upon. The nurse did not notify the provider or obtain a baseline EKG as would have been appropriate given the risk. The NP later confirmed that the combination was contraindicated and that she would have taken additional precautions if notified. The failure to read and respond to pharmacy alerts and to verify allergies before medication administration resulted in the resident receiving unnecessary and potentially harmful medications.
Inaccurate MDS Coding for Resident Nutrition
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments in the area of nutrition for four residents, leading to significant discrepancies in recorded weight changes. Resident #107, who was admitted with diagnoses including adult failure to thrive and diabetes, experienced a 47.1-pound weight loss over 180 days, yet the MDS assessment did not reflect this significant weight change. The MDS Coordinator acknowledged the error, attributing it to a lack of computer-generated warnings and a failure to manually calculate the weight change as per the Resident Assessment Instrument (RAI) manual. Similarly, Resident #12, with end-stage renal disease, lost 23 pounds in 30 days and 25 pounds over 180 days, but the MDS assessment failed to document this significant weight loss. The MDS Coordinator again cited the absence of computer warnings and admitted to not manually calculating the weight change. The Director of Nursing (DON) and the Administrator both expressed expectations for accurate MDS coding to ensure resident care plans accurately reflect current conditions. Resident #19, diagnosed with diabetes and hypertension, showed a 43-pound weight gain in 30 days and a 21.5-pound gain over 180 days, yet the MDS assessment did not indicate any significant weight change. The MDS Coordinator admitted to not questioning the computer-populated weight and failing to review the weights carefully. Resident #69, with diagnoses including end-stage renal disease and mild protein-calorie malnutrition, gained 24.91% of his weight over six months, but this was not reflected in the MDS assessment. The DON and Administrator reiterated their expectations for accurate coding, while the MDS Nurse acknowledged the incorrect coding without understanding the reason for the error.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the comprehensive care plans for three residents, reflecting changes in care interventions related to mobility and nutrition. Resident #107, who was admitted with diagnoses including stroke with hemiparesis and diabetes, experienced significant weight loss over several months. Despite this, the nutrition care plan was not updated to include a goal for desired weight or reflect the current interventions, such as the prescription of a nutritional supplement. Additionally, the mobility care plan for Resident #107 was not revised to reflect her non-ambulatory status, despite her lack of progress in therapy and non-compliance with splints. Resident #12, diagnosed with end-stage renal disease and dependent on dialysis, also had an outdated nutrition care plan. The plan did not reflect the resident's actual weight loss or the current dietary orders for a renal carbohydrate-controlled diet. The resident experienced a significant weight loss over a period of 30 days, yet the care plan remained unchanged, failing to address the resident's current nutritional needs and status. Resident #19, with a diagnosis of diabetes, had a nutrition care plan that was not updated to reflect a significant weight gain followed by weight loss. The care plan continued to focus on issues related to obesity and excessive appetite, despite the resident's fluctuating weight. The care plan did not incorporate the new dietary orders or the resident's current nutritional status, leading to a lack of accurate and person-centered care planning. Interviews with staff, including the MDS Coordinator and the Registered Dietitian, revealed that these oversights were due to errors and a lack of involvement in the care planning process.
Failure to Monitor Vital Signs and Weights as Ordered
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to deficiencies in care. For one resident with hypertension and end-stage renal disease, the facility did not obtain blood pressure readings or heart rate measurements before administering the antihypertensive medication Metoprolol. The medication had specific parameters to hold administration if the systolic blood pressure was less than 110 mmHg or the heart rate was less than 60 beats per minute. Despite these parameters, the medication was administered on multiple occasions without the required vital sign checks, as evidenced by the Medication Administration Record and progress notes. Another resident with congestive heart failure did not receive physician-ordered weekly weight checks. The resident's electronic medical record showed weights recorded on only a few occasions over a two-month period, rather than weekly as ordered. This oversight was attributed to an error in how the order was entered into the electronic medical record, preventing it from appearing on the Medication Administration Record for weekly weight monitoring. Both residents were observed to be alert and oriented during interviews, with no immediate changes in condition reported. However, the lack of adherence to physician orders for monitoring vital signs and weights represents a failure in providing appropriate treatment and care according to the residents' needs and medical directives.
Failure to Provide Nutritional Supplements and Monitor Weights
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplements and obtain physician-ordered weights for two residents, leading to deficiencies in their nutritional care. Resident #107, who had a medical history of stroke, failure to thrive, protein-calorie malnutrition, and diabetes, experienced significant weight loss over several months. Despite a physician's order for Mighty Shake nutritional supplements three times a day and weekly weight monitoring, the resident did not receive the supplements as ordered, and weights were not consistently recorded. Observations on multiple occasions revealed that the resident's meal trays lacked the prescribed nutritional supplements and other dietary items, contributing to the resident's continued weight loss. Interviews with facility staff, including the Registered Dietitian, Nurse Practitioner, and Dietary Manager, highlighted a lack of awareness and oversight regarding the resident's nutritional needs. The Registered Dietitian admitted to not routinely observing or interviewing residents, while the Dietary Manager acknowledged issues with staff turnover and training, which led to the oversight of not providing the required supplements. The Nurse Practitioner and Administrator both expressed expectations that residents should receive nutritional supplements and have their weights monitored as ordered, indicating a disconnect between expectations and actual practice. Similarly, Resident #19, who had diagnoses of diabetes and hypertension, also experienced issues with weight monitoring and nutritional supplementation. The resident's electronic health record showed significant fluctuations in weight, and a physician order was in place for daily weights and a Magic Cup supplement for additional calories and protein. However, observations revealed that the resident did not receive the Magic Cup on multiple occasions, and weights were not consistently recorded. Interviews with the Registered Dietitian and Dietary Manager again pointed to issues with staff training and oversight, resulting in the resident not receiving the necessary nutritional support.
Failure to Schedule Physician-Ordered Mammogram
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively intact and had a history of left breast keloid, had an appointment scheduled for a physician-ordered mammogram. The resident had filed a grievance in December 2023, requesting a referral for a mammogram, which was acknowledged by the Director of Nursing/Assistant Administrator. Despite the grievance resolution indicating that follow-up would be made with the provider, the appointment was not scheduled. A physician order to schedule the mammogram was written in February 2024, but the resident continued to request the appointment in subsequent months, indicating that it had not been scheduled. Interviews with the resident, staff, and Nurse Practitioner revealed a breakdown in communication and process. The Transportation Specialist, responsible for scheduling appointments, was aware of the need for a mammogram but had not scheduled it, citing difficulties in arranging transportation. The Unit Manager was unaware of the referral, and the Nurse Practitioner expected to be notified of any delays. The Administrator acknowledged the grievance and expected the appointment to be made promptly, but was unaware of the reasons for the delay. This series of inactions and miscommunications led to the deficiency in providing the necessary medically-related social services to the resident.
Medication Administration Failures for Dialysis Resident
Penalty
Summary
The facility failed to administer prescribed medications to a resident who was undergoing hemodialysis, resulting in multiple missed doses of critical medications. The resident, who had diagnoses including hypertension, diabetes, end-stage renal disease, and neuropathy, did not receive 15 doses of Metoprolol, 15 doses of Tradjenta, 15 doses of Sevelamer, and 8 doses of Cymbalta. This occurred because the medications were scheduled for administration at times when the resident was out of the facility for dialysis, and the medication administration record (MAR) was not adjusted to administer the medications upon the resident's return. Additionally, the facility failed to administer the full course of the antifungal medication Diflucan as prescribed for the treatment of vaginitis. The resident was supposed to receive three doses of Diflucan, but only one dose was administered. The MAR indicated that the medication was not available for the first two scheduled doses, despite the medication being available in the facility's emergency kit. The failure to administer the full course of Diflucan was not addressed in a timely manner, and the MAR was not updated to reflect the missed doses once the medication became available. Interviews with facility staff, including a medication aide and the Director of Nursing, revealed that the medication administration process was not properly managed, leading to these deficiencies. The Nurse Practitioner, who routinely evaluated the resident, was unaware of the missed doses and indicated that the medication times should have been adjusted to account for the resident's dialysis schedule. The Consultant Pharmacist confirmed that the Diflucan was available in the facility's emergency kit, but it was not utilized, resulting in the resident not receiving the full prescribed treatment.
Deficiency in Food Service Quality
Penalty
Summary
The facility failed to ensure that food was palatable and served at an appetizing temperature for several residents. Resident #22, who was cognitively intact and had diabetes, reported that the food was often cold, unappetizing, and not cooked well. Despite expressing a preference for grilled cheese sandwiches, the resident frequently received meals that were not to her liking, such as cold chicken tenders and dry macaroni and cheese. The Dietary Manager and Administrator were unaware of these complaints, indicating a lack of communication and awareness of resident preferences and concerns. Resident #116, also cognitively intact, frequently found the meals unappetizing and cold, leading her to rely on nutritional supplements provided by her family. Despite significant weight loss, the Registered Dietitian was not aware of the resident's issues with food temperature and palatability, nor was there any follow-up with the Dietary Manager. Similarly, Resident #107 expressed dissatisfaction with the meals, often resorting to snacks provided by her family. The resident's meal preferences were not consistently met, and the food was described as cold and unpalatable. The Resident Council meeting minutes revealed ongoing concerns about food quality, including cold meals and repetitive menus. Despite grievances being filed, the Dietary Manager was not informed of these issues and cited challenges with staff turnover and training. The Director of Nursing acknowledged the need for a better system to ensure residents received hot, palatable meals. The Administrator expected staff to offer alternate meals and reheat cold food, but these expectations were not met, contributing to the deficiency in food service quality.
Failure to Provide Alternative Meals and Honor Resident Preferences
Penalty
Summary
The facility failed to provide alternative meals for six out of eight residents reviewed for nutrition, leading to dissatisfaction and unmet dietary needs. Residents reported receiving meals that were cold, unappetizing, or not in line with their preferences, and they were not consistently informed about the availability of alternative meal options. For instance, one resident expressed that they were not aware they could request an alternate meal and often received food they disliked or that was cold. Another resident, who disliked seafood, was served fried shrimp and was not offered an alternative, leading them to rely on food brought in by their roommate's family. The process for obtaining meal preferences was inconsistent and ineffective. The facility had a system where receptionists were supposed to interview residents about their meal preferences for the week, but this was not consistently executed. Interviews with staff revealed that the menus were not always provided in a timely manner, and the receptionists often did not have enough time to interview all residents. As a result, residents were not asked about their meal preferences on several days, and the kitchen did not receive the necessary information to adjust meal tickets accordingly. Several residents, including those with specific dietary needs such as diabetes, reported dissatisfaction with the meals provided. They were often unaware of the available alternatives and resorted to consuming food brought in by family members or nutritional supplements. The dietary manager and administrator acknowledged the issues but were unsure why the process was not working effectively. The lack of a reliable system for offering and documenting meal preferences contributed to the deficiency in meeting residents' nutritional needs and preferences.
Failure to Notify Provider of Significant Weight Gain in CHF Resident
Penalty
Summary
The facility failed to notify the provider of significant weight gain for a resident with a history of Congestive Heart Failure (CHF), as required by the physician's order. The order specified that the provider should be notified of a weight gain greater than 3 pounds in 24 hours or 5 pounds in a week. Despite this, the medical record review showed that the resident experienced a 7.5-pound weight gain in one day and a 5.3-pound gain over three days, without any notification to the physician. The Nurse Practitioner confirmed that neither she nor the MD was informed of these significant weight changes, which were crucial for managing the resident's CHF. Interviews with the Nurse Practitioner and the Director of Nursing revealed that the staff did not report the weight concerns, contrary to the expectations set by the physician's order. The Director of Nursing acknowledged that the MD should have been notified of the weight gains, as per the order, but was unaware of why this did not occur. The failure to notify the physician could have impacted the resident's treatment plan, although no adverse health outcomes were reported at the time.
Failure to Provide SNF-ABN Forms to Residents
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to two residents prior to their discharge from Medicare Part A skilled services. Resident #126 and Resident #129, who were both reviewed for beneficiary protection notification, did not receive the SNF-ABN form, which is necessary to inform them of their potential liability for services not covered by Medicare. Both residents had remaining benefit days, as indicated by the Notice of Medicare Non-Coverage (NOMNC, Form CMS-10123), but the facility did not provide the CMS-10555 SNF-ABN form to them. Interviews with facility staff revealed that the Social Services Director (SW#1) acknowledged the oversight, stating that either she or a new social worker (SW #2) should have provided the SNF-ABN forms to the residents. However, there was no documentation available to confirm that the forms were given. The facility's Administrator also expressed that it was her expectation for residents or their Responsible Party (RP) to receive appropriate notices before being discharged from Medicare services.
Failure to Provide Meal Tray Setup and Assistance
Penalty
Summary
The facility failed to provide necessary assistance with meal tray setup and feeding for three residents, leading to a deficiency in maintaining their ability to perform activities of daily living. Resident #112, who was receiving palliative care through hospice services, had moderate to severe cognitive impairments and required supervision and setup for meals. Despite this, observations revealed that her meal trays were not set up, and she struggled to open containers and cut her food. Interviews with staff confirmed that meal trays should be set up for residents who are not independent, but this was not consistently done for Resident #112. Resident #126, who had no cognitive impairments but required supervision with eating, also experienced a lack of meal tray setup. She was observed struggling to eat her breakfast due to the absence of setup assistance, which was necessary due to her physical limitations. Staff interviews indicated that Resident #126 was receiving physical therapy and needed tray setup assistance, but this was not provided consistently. Similarly, Resident #131, who had hemiplegia and required supervision with eating, did not receive the necessary meal tray setup. She was unable to open containers or cut her food with one hand, as her left side was affected by a stroke. Staff interviews confirmed that Resident #131 needed assistance with her meals, but the nursing aides did not consistently provide this support. The deficiency was further highlighted by the lack of communication among staff regarding which residents required meal tray setup and assistance.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to secure a medication cart, which was left unattended and unlocked with the keys in the lock, in the hallway near resident rooms. This incident was observed with one of the four medication carts reviewed for medication storage. During an observation, the medication cart on the 400 hallway was found unattended and unlocked, with the cart keys left in the lock. A visitor was standing three feet away from the cart, and the nurse responsible was not in sight, returning approximately 2-3 minutes later from a resident's room down the hallway. In an interview, the nurse admitted to being distracted when called away by a resident, acknowledging that she left the cart unlocked and the keys in the lock in error. The Director of Nursing confirmed that the nurse reported the error, explaining that she was called into a resident's room in a hurry, leading to the oversight.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy, which requires the use of both gloves and gowns during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms. Observations revealed that two nurse aides did not adhere to this policy while providing care to a resident with an indwelling central venous catheter for dialysis and who required wound care. Specifically, Nurse Aide #3 was seen changing bed linens without wearing a gown, despite being aware of the EBP requirements and having received training. Similarly, Nurse Aide #4 provided incontinence care without a gown, acknowledging the mistake and the need to wear appropriate PPE. The resident involved was alert and oriented, with a medical history that included a dialysis port and a wound on the leg. The resident had recently transitioned from Contact Precautions for Clostridium difficile to Enhanced Barrier Precautions due to the presence of a dialysis access device and ongoing wound care. Interviews with the Infection Control Nurse and the Director of Nursing confirmed that the staff had been trained on the EBP policy and should have worn gowns along with gloves during direct care activities. The failure to consistently implement the EBP policy was identified as a deficiency in the facility's infection prevention and control program.
Failure to Schedule Ophthalmology Appointment for Resident
Penalty
Summary
The facility failed to obtain an ophthalmologist appointment for a resident with cataracts and diabetes, despite multiple requests and a grievance filed by the resident. The resident, who was cognitively intact and had impaired vision, had requested a referral to an eye doctor for cataracts as early as December 2023. The grievance was acknowledged by the Director of Nursing and the Assistant Administrator, who indicated that the resident would be placed on a list for the next in-house eye care visit or an outside referral would be discussed if the resident did not want to wait. However, the resident continued to express concerns about her worsening eyesight and the lack of an appointment. Interviews with facility staff revealed a lack of communication and follow-through regarding the resident's request for an ophthalmology appointment. The Transportation Specialist, responsible for scheduling appointments, acknowledged being informed of the need for an appointment but had not recently attempted to schedule it. The Social Workers, who were involved in arranging in-house ophthalmologist visits, were not aware of the physician's order for a referral written in February 2024. The Unit Manager and the Nurse Practitioner were also unaware of the referral order and the grievance filed by the resident. The Director of Nursing and the Administrator acknowledged the delay in scheduling the appointment, citing issues with the resident's payor source and insurance acceptance by providers. Despite these challenges, the resident had not seen an eye doctor in over a year, and the facility had not made sufficient efforts to secure an appointment with an outside provider. The resident's request for an ophthalmology appointment remained unfulfilled, highlighting a deficiency in the facility's process for addressing residents' healthcare needs.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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