O'berry Neuro-medical Treatment Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Goldsboro, North Carolina.
- Location
- 400 Old Smithfield Road, Goldsboro, North Carolina 27533
- CMS Provider Number
- 34A002
- Inspections on file
- 21
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at O'berry Neuro-medical Treatment Center during CMS and state inspections, most recent first.
Two residents with severe cognitive and physical impairments experienced deficiencies in care when staff failed to follow required transfer and supervision protocols. In one case, a resident dependent on two-person transfers was moved by a single staff member, resulting in an unsafe transfer. In another, a resident was left unattended on the toilet for an extended period, leading to a fall. Both incidents were confirmed through staff statements, video review, and internal investigations.
A resident with a tracheostomy experienced a medical emergency when her oxygen saturation levels dropped to a life-threatening level. Despite the critical situation, the physician and EMS were not notified immediately, resulting in a delay in the resident's transfer to the hospital. The resident was later diagnosed with acute hypoxia respiratory failure and a heart attack related to the lack of oxygen.
A resident with a history of respiratory issues experienced an acute change of condition, showing signs of pain and low oxygen levels. A nurse administered 20 mg of morphine instead of the prescribed 2 mg, and the resident was not monitored adequately afterward. This led to a significant drop in oxygen saturation and respiratory distress, resulting in a hospital diagnosis of acute hypoxia respiratory failure and a heart attack.
A resident with respiratory failure and severe cognitive impairment received ten times the prescribed morphine dose due to a nurse's error in dosage calculation. The nurse did not write down the physician's order, preventing proper verification. This led to the resident's oxygen saturation dropping significantly, resulting in hospitalization for acute hypoxia respiratory failure and a heart attack.
A facility failed to maintain an accurate MAR for a resident who was prescribed Tramadol after surgery. The resident's MAR did not document a midnight dose, although a nursing note confirmed it was administered. A nurse admitted forgetting to sign the MAR, and the DON stated that nurses had been trained to complete the MAR accurately.
A nurse failed to notify a physician when a resident was not provided with bolus tube feedings as ordered, believing the resident was full. The nurse independently made this decision without notifying the physician, despite being aware of the orders. The resident had a history of esophageal dysmotility, recurrent aspiration pneumonia, dysphagia, a gastric tube, and weight loss. The nurse admitted to using her judgment to hold feedings without consulting the physician, which was a deviation from protocol.
A nurse in a LTC facility failed to administer a resident's bolus tube feeding as ordered by the physician, believing the resident was full. The resident, who was non-verbal and relied entirely on a gastric tube for nutrition, showed signs of hunger and discomfort. The nurse admitted to withholding feedings on multiple occasions without assessing the resident or consulting the physician, leading to a substantiated neglect allegation.
The facility failed to document advance directive information and opportunities for 16 residents, despite policy requirements. Residents with severe cognitive impairments and various diagnoses lacked documentation of advance directive discussions. Staff interviews revealed a lack of awareness and adherence to documentation requirements.
The facility failed to document controlled medication reconciliation on a medication cart, as required by policy. Nurses either did not sign or signed incorrectly, with one nurse often signing for both shifts due to staffing issues. Management acknowledged the lack of proper monitoring and documentation.
A facility failed to accurately code the MDS assessment for a resident receiving Apixaban, an anticoagulant, due to a data entry error. The resident, with coronary artery disease, was documented as receiving an antiplatelet instead. Staff interviews confirmed the miscoding and clarified that Apixaban is an anticoagulant.
The facility failed to develop comprehensive care plans for two residents, one receiving anticoagulants and the other anti-seizure medication. Despite being prescribed Apixaban and Lacosamide, their care plans did not address these medications. Interviews with staff confirmed the oversight, but no explanation was provided for the omissions.
The facility failed to secure medications in Building 1 Hall 4, where both the medication room and cart were left unlocked by a nurse. In Building 2 Hall 2, an expired medication was found, and medication refrigerators in Building 2 Hall 2 and Building 4 Hall 3 had improper temperature logs, with one refrigerator exceeding the required temperature range. Nurses were unsure of who was responsible for monitoring these temperatures.
A resident with severe cognitive impairment and a gastrostomy tube did not receive scheduled tube feedings as ordered by the physician. Nurse #1 admitted to skipping feedings without a doctor's order, believing the resident was full. The resident's care plan required all nutrition through the tube due to aspiration risks. The RD was unaware of the missed feedings, which could have affected the resident's nutritional intake and weight stability.
A facility failed to maintain accurate medication and treatment records for a resident who was to receive a 2-Calorie formula bolus via gastric tube four times daily. The resident's TAR showed that a nurse signed off on providing feedings without noting any holds, despite admitting to withholding feedings without documentation. Attempts to interview the nurse were unsuccessful, but her supervisor confirmed the nurse's admission.
The facility failed to maintain accurate nurse staffing records for three buildings, with missing or incomplete forms due to lack of awareness and inconsistent processes. Building 1 had no forms for over a month, while Buildings 2 and 4 had incomplete or missing forms due to absent supervisors and untrained secretaries. The DON admitted to not monitoring the process.
A facility failed to credit interest on a resident's trust fund account with a balance over $100. The Business Manager stated that residents' funds were pooled, and no interest was credited due to bank fees exceeding the interest earned. The Administrator confirmed that trust fund statements lacked interest information for the same reason.
The facility failed to document grievances properly for four residents, leaving critical sections of grievance forms incomplete. This included missing documentation of investigation findings and communication of results to residents' representatives, as required by the facility's grievance policy.
A resident with a known diagnosis of PICA disorder repeatedly ingested medical examination gloves due to inadequate supervision and ineffective interventions. The resident was found vomiting gloves on multiple occasions, including an incident where a glove was discovered under her pillow. Investigations revealed that staff failed to prevent access to gloves, despite the high risk of serious harm such as airway blockage and aspiration. The facility's response was inconclusive, with no clear trigger event identified and staff denying leaving gloves within reach. The deficiency highlights a systemic failure in protecting residents with complex behavioral conditions.
A resident with intellectual disability and PICA disorder ingested medical examination gloves on multiple occasions due to inadequate supervision. Despite a care plan requiring close monitoring to prevent ingestion of inedible objects, the resident accessed and ingested gloves, resulting in risks such as choking and aspiration. Staff interviews revealed lapses in supervision, with the resident self-propelling her wheelchair and accessing gloves. The facility's investigation highlighted the need for enhanced supervision and a glove-free environment, but incidents continued to occur.
The facility failed to report multiple allegations of neglect involving a resident to the state agency, APS, and local law enforcement within the required timeframe. Incidents included a piece of a glove found in the resident's gastric fluid and another glove found in the resident's vomit. The administration stated that neglect was generally not reported unless there was a suspicion of a crime.
The facility's QAA Committee failed to maintain and monitor interventions for abuse and neglect, leading to repeated incidents of a resident with PICA disorder ingesting medical gloves. The facility was also cited for failing to protect residents from verbal and physical abuse by staff, with the QAPI committee not meeting since the last survey.
Failure to Provide Safe Transfers and Adequate Supervision
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with severe cognitive impairment, hemiparesis, and total dependence on staff for transfers. The resident's care plan required two staff members and the use of a gait belt for all transfers. However, a contract health care technician (HCT) performed a stand/pivot transfer alone, without assistance, and allowed the resident to fall hard into a recliner instead of assisting him down. This action was witnessed by another staff member and confirmed by video review. The staff member involved admitted to transferring the resident alone, acknowledging it was against protocol. Another deficiency was identified when a resident with profound intellectual disabilities, seizure disorder, and a high risk for falls was left unattended on the toilet by a health care technician. The resident's care plan specified that staff must remain close by during toileting to prevent falls or injury. Instead, the staff member left the resident alone in the bathroom for an extended period, during which the resident fell and was found on the floor by another staff member. The staff member responsible was found to have been away from the resident for approximately 44 minutes, during which time she was observed in the breakroom. Both incidents were corroborated by staff interviews, written statements, video surveillance, and internal investigation reports. In both cases, the residents were assessed after the incidents, with one sustaining a small bruise and the other showing no signs of injury or distress. The failures to follow established care plans and supervision protocols directly led to the deficiencies cited in the report.
Failure to Notify Physician During Medical Emergency
Penalty
Summary
The facility failed to immediately notify the physician when a resident with a tracheostomy experienced a medical emergency. The resident, who had severe cognitive impairment and a history of respiratory failure with hypoxia, showed signs of distress when her oxygen saturation levels dropped to 69% on room air. Nurse #1 managed to stabilize the resident temporarily by administering oxygen and pain medication. However, later in the shift, the resident's condition worsened, with oxygen saturation levels dropping to a life-threatening 55%, and she exhibited signs of cyanosis. Despite the critical nature of the situation, the physician and Emergency Medical Services (EMS) were not notified immediately. Nurse #1 was informed by a nurse aide about the resident's deteriorating condition, and although the nurse increased the oxygen supply, the physician was only contacted after a significant delay. The resident was eventually transferred to the hospital, where she was diagnosed with acute hypoxia respiratory failure and a heart attack related to the lack of oxygen. The delay in notifying the physician and EMS resulted in a delay in the resident's transfer to the hospital, which could have exacerbated her condition. The facility's failure to act promptly during the medical emergency was identified as a deficiency affecting the resident's care. The report highlights the importance of immediate communication with medical professionals during emergencies to ensure timely and appropriate interventions.
Removal Plan
- The Director of Nursing educated the Unit Nurse Managers and Nurse Educators that immediately upon being notified of a significant change of status for a resident, the doctor is to be notified.
- Provided the emergency number (Code Blue number) for the doctor to ensure expedient responses by the doctor.
- Programmed the doctor's telephone numbers into the residential unit cellphone to contact doctors during non-emergent times and to call 911 immediately in case of an emergency followed by a call to the doctor.
- Nurses not present will be in-serviced upon return to work by the Unit Nurse Manager, Floor Shift Nurse Supervisor, Nurse Educator, or any lead nurse who has been previously in-serviced.
- New Hires will be educated on this during their orientation period by the Nurse Educator.
- All nursing department staff will be in-serviced on the Code Blue Policy to ensure activation for life-threatening emergencies to include notification of EMS and the doctor.
- Sent an all nursing department staff notification through CareTracker Electronic Data collection and messaging system to report all changes in condition to nurse immediately or activate the Code Blue Policy.
- Staff must read and acknowledge the message in CareTracker prior to being able to complete any documentation in the CareTracker system.
- Direct Care and nursing staff not receiving the message will be in-serviced in person upon return to duty.
- The Unit Nurse Managers, Floor Shift Nurse Supervisors, and the Facility Support Specialist are responsible for tracking the receipt of message and/or in-services and ensure that no nursing staff work until completed.
- The Floor Shift Nurse Supervisor, Unit Nurse Manager, or the Facility Support Specialist and the Home Life Support Assistant (Charge CNA) will in-service the Home Life Support Assistants and all CNAs on the importance of reporting all change in conditions, behaviors, or appearance immediately to the nurse assigned to the resident's living area.
- This information will be discussed during their shift exchange daily and added to the 24-hour shift report.
- A CareTracker message was sent out with a read receipt inclusive of this information for repetitive learning.
- Any staff not trained will be in-serviced prior to resident contact by the nurse manager or designee.
- The Unit Nurse Managers, Floor Shift Nurse Supervisors, and the Facility Support Specialists are responsible for tracking the in-services and ensuring no nursing staff work until completed.
Failure to Monitor Resident After Medication Error
Penalty
Summary
The facility failed to provide adequate nursing assessments and monitoring for a resident following an acute change of condition. The resident, who had a history of respiratory failure with hypoxia and a tracheotomy, exhibited signs of pain and had critically low oxygen saturation levels. Despite the physician's order for close monitoring after administering morphine, the resident was not adequately monitored by the nursing staff, leading to a significant drop in oxygen saturation and subsequent respiratory distress. Nurse #1 administered an incorrect dose of morphine, giving 20 mg instead of the prescribed 2 mg. This error was compounded by the lack of monitoring, as neither Nurse #1 nor Nurse #2 checked on the resident for nearly an hour after the medication was given. The resident's condition deteriorated, with oxygen saturation levels dropping to 55%, and emergency medical services were not contacted until much later, resulting in the resident being diagnosed with acute hypoxia respiratory failure and a heart attack. The deficiency was identified as immediate jeopardy due to the facility's failure to ensure proper nursing assessments and monitoring, which placed the resident at significant risk. The lack of timely intervention and communication with emergency services further exacerbated the situation, highlighting critical lapses in the facility's response to the resident's acute change of condition.
Removal Plan
- The Director of Nursing in-serviced the Unit Nurse Managers and Nurse Educator to ensure that when medication or treatment is given for an acute condition, the nurse will monitor every 15 minutes for 2 hours and document all findings to include vital signs and reactions to treatment/medication in a progress note.
- If a decision is made to transport a resident to the emergency department, a nurse will remain with the resident until care is transferred to EMS.
- All nurses present were in-serviced, and all other nurses will be in-serviced upon return to duty by the Unit Nurse Manager, Nurse Educator, or the Director of Nursing.
- All nursing department staff will be in-serviced prior to start of shift on the Code Blue Policy to ensure activation for life-threatening emergencies to include notification of EMS and the doctor.
- The Unit Nurse Manager sent an all nursing department staff notification through CareTracker Electronic Data collection and messaging system to report all changes in condition to a nurse immediately or activate the Code Blue Policy by calling #4545.
- The Floor Shift Nurse Supervisor, Unit Nurse Manager, or the Facility Support Specialist and the Home Life Support Assistant (Charge CNA) will in-service the Home Life Support Assistants and all CNAs on the importance of reporting all change in conditions, behaviors, or appearance immediately to the nurse assigned to the resident's living area.
- The Floor Shift Nurse Supervisor, Unit Nurse Manager, or the Facility Support Specialist and the Home Life Support Assistant (Charge CNA) will in-service the Home Life Support Assistants and all CNAs on the understanding of oxygen saturation levels and their impact on sustaining life.
- Just Culture Review was conducted by the Unit Nurse Manager for both nurses involved in this deficient practice regarding their failure to respond appropriately to get the resident needed care with appropriate actions to be taken.
Significant Medication Error Due to Incorrect Morphine Dosage
Penalty
Summary
The facility failed to prevent a significant medication error when a nurse administered ten times the ordered amount of morphine to a resident. The resident, who had a history of respiratory failure with hypoxia and severe cognitive impairment, was experiencing pain and low oxygen saturation levels. The physician ordered a 2 mg dose of morphine to be administered subcutaneously. However, the nurse mistakenly believed each vial contained 1 mg of morphine, leading to the administration of 20 mg instead of the prescribed 2 mg. The error occurred because the nurse did not write down the physician's order, which prevented proper verification of the dosage by a second nurse. The nurse drew morphine from two vials, each containing 10 mg, and administered the entire amount to the resident. This resulted in the resident's oxygen saturation levels dropping significantly, and she was subsequently transferred to the hospital with acute hypoxia respiratory failure and a heart attack related to a lack of oxygen. The incident highlighted a breakdown in the facility's medication administration process, particularly in the verification of verbal orders and dosage calculations. The nurse involved did not ensure the order was transcribed and verified by a second nurse, leading to the overdose. The facility's failure to adhere to proper medication administration protocols resulted in immediate jeopardy for the resident involved.
Removal Plan
- Just Culture Algorithm performed for staff involved to determine appropriate outcomes.
- Medication dose calculation test implemented by nurse educators and approved by the Director of Nursing.
- Competency of Nurse #1 verified by a floor shift nurse supervisor using the Medication Administration Evaluation tool.
- All Nurses re-inserviced on medication night cabinet policy and procedure.
- Unit Nurse Managers and Nurse Educator inserviced to ensure verbal orders are transcribed and verified by a second nurse.
- Pharmacy Director exchanged Morphine in the night cabinet from 10 mg vial to 5 mg vial.
- Nurses receiving training on medication administration best practices and competencies.
- All nurses will take the state approved medication administration written test during written competencies.
Incomplete Medication Administration Record
Penalty
Summary
The facility failed to maintain a complete and accurate medication administration record (MAR) for a resident who was reviewed for medical record accuracy. The resident was admitted with diagnoses including respiratory failure with hypoxia and had undergone surgery to remove kidney stones and place an indwelling ureteral stent. Following the surgery, the resident was prescribed Tramadol, a narcotic pain medication, to be administered every 8 hours for 3 days. However, the MAR for January 2025 did not document the administration of Tramadol at midnight, despite a nursing progress note indicating that the medication was given at that time. Nurse #1 admitted in an interview that she forgot to sign the MAR after administering the medication. The Director of Nursing confirmed that nurses had been trained to complete the MAR accurately when medications and treatments were given.
Failure to Notify Physician of Deviations in Tube Feeding Orders
Penalty
Summary
The facility failed to notify the primary care physician when a resident was not provided with bolus tube feedings as per the physician's order. Nurse #1 did not administer the bolus tube feeding to Resident #103, believing the resident was full, despite being aware of the physician's orders. This decision was made independently without notifying the physician, and Nurse #1 confirmed that this was not a new practice for her, having done it previously without notifying the physician. Resident #103 was readmitted to the facility with diagnoses including esophageal dysmotility, recurrent aspiration pneumonia, dysphagia, a gastric tube, and a history of weight loss. The physician's order required the resident to receive a 2-Calorie formula bolus four times a day. However, Nurse #1 did not provide the midnight and 6:00 AM feedings on multiple occasions, as indicated by the Treatment Administration Record and nursing progress notes, which lacked documentation of any reasons for holding the feedings. The issue was reported by Nurse Aid #1, who observed that Nurse #1 did not provide the feedings and was not present on the unit during the night shift. An investigation revealed that Nurse #1 had not been following the physician's orders and had not assessed the resident for residual formula or the functionality of the feeding tube. Nurse #1 admitted to using her nursing judgment to hold the feedings without consulting the physician, which was a deviation from the expected protocol.
Removal Plan
- Nurse #1 was removed from duty.
- The Director of Nursing notified Resident #103's physician of Nurse #1's failure to administer the tube feeding as ordered.
- The DON reviewed weight information, provider's, and nurse's notes on all 43 residents who had orders for tube feeding and found no discrepancies with their feedings and no expressed concerns by their treating physicians.
- The Director of Nursing met with the physicians during morning rounds and inquired if they had concerns regarding tube feedings. No concerns were expressed.
- All nurses were inserviced by the Director of Nursing and the Unit Nurse Managers on giving tube feedings, medications, and treatment as ordered by the physician and if there were any changes needed to that, it would require an assessment and a new provider order obtained.
- All medical staff (nurses and physicians) were re-inserviced on: If changes are needed to an existing order or a new order is needed, communicate the concerns with the physician. It is never ok to disregard a physician's order. You can get clarification on an order, provide feedback regarding orders and voice concerns you have regarding orders to include significant changes.
- The Medical Director and Director of Nursing will track education to ensure no staff will work on the floor until the education is received.
- The Unit Nurse Managers and Floor Shift Nurse Supervisors will provide the training to those reporting to work.
- Newly hired staff will be educated by their direct supervisors and training rosters will be submitted to Staff Development to be entered into their training records.
Neglect Due to Nurse's Failure to Administer Tube Feeding
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when a nurse did not provide the necessary care and services as ordered by the physician. The nurse, aware of the physician's orders, deliberately disregarded them and independently decided not to administer the resident's bolus tube feeding, believing the resident was full. This practice was not isolated, as the nurse admitted to having done this previously for the resident an undetermined number of times. This action placed the resident at risk of serious harm and/or death. The resident involved was non-verbal, vulnerable, and relied entirely on a gastric tube for nutrition due to conditions such as esophageal dysmotility, recurrent aspiration pneumonia, and dysphagia. The physician's orders specified a 2-Calorie formula bolus to be administered four times a day. However, the nurse failed to provide the midnight and 6:00 AM feedings on multiple occasions, as evidenced by the lack of documentation in the Treatment Administration Record and nursing progress notes. The nurse's actions were reported by a nurse aide who witnessed the resident showing signs of hunger and discomfort during the night shift. The facility's investigation revealed that the nurse did not assess the resident for residual formula or consult with the physician before withholding the feedings. The nurse's account of the events changed multiple times during interviews with management, and she admitted to not following the proper protocol for holding feedings. The facility substantiated the neglect allegation, and the nurse was removed from duty. The incident highlighted a failure to follow physician orders and a lack of communication with the medical team regarding the resident's care.
Removal Plan
- All nurses were in-serviced by the Director of Nursing and the Unit Nurse Managers on giving tube feedings, medications, and treatment as ordered by the physician and if there were any changes needed to that, it would require an assessment and a new provider order obtained.
- Certified Nursing Assistants were educated on the importance of reporting their concerns and ensuring it gets to the appropriate people to assist with resolving issues/concerns. This was completed by the floor shift nurse supervisors and Unit Nurse Managers.
- All medical staff (nurses and physicians) were re-inserviced on: If changes are needed to an existing order or a new order is needed, communicate the concerns with the physician. It is never ok to disregard a physician's order. You can get clarification on an order, provide feedback regarding orders and voice concerns you have regarding orders to include significant changes. This was completed by the Medical Director and the Unit Nurse Managers. The Medical Director and Director of Nursing will track education to ensure no staff will work on the floor until the education is received. The Unit Nurse Managers and Floor Shift Nurse Supervisors will provide the training to those reporting to work.
- All staff were in serviced on abuse, neglect, exploitation, and rights infringements with emphasis on Neglect to include a failure to follow a physician's order is neglect, a failure to report that meals are withheld to include tube feedings from an individual without a physician's order to hold the meal is neglect, and if you witness, hear or suspect that it has occurred and fail to report, you are as guilty as the person committing the act and will be held accountable through the Just Culture Process. Training was conducted by Standards Director, Chief Financial Officer, Unit Nurse Managers, Floor Shift Nurse Supervisors and Department Supervisors campus wide. Each manager and supervisor will track education to ensure no staff will work on the floor until the education is received. The Managers, Supervisors and designee will provide the training to those reporting to work. Once training is complete, rosters will be turned into Staff Development to be added to their training record. Newly hired staff will be educated by their direct supervisors.
Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to document written advance directive information and/or provide an opportunity to formulate an advance directive for 16 out of 19 residents reviewed. The facility's policy required that residents who have the capacity to receive advance care directive information be given this information upon admission or when they regain capacity. However, the facility did not adhere to this policy, as evidenced by the lack of documentation in the medical records of the residents reviewed. The report highlights several residents who were severely cognitively impaired, as indicated by their Minimum Data Set (MDS) assessments. Despite their cognitive impairments, there was no documentation that these residents or their responsible parties were educated about advance directives or given the opportunity to formulate one. This includes residents with various diagnoses such as seizures, hypertension, diabetes, and depression, among others. The absence of documentation was consistent across multiple residents, regardless of their code status, whether it was full code or do not resuscitate (DNR). Interviews with facility staff, including a floor shift supervisor, the Director of Standards, a medical doctor, and the Administrator, revealed a lack of awareness and adherence to the documentation requirements for advance directives. The medical doctor admitted to being unaware of the need to document discussions about advance directives in the medical records. The Administrator acknowledged that while advance directives were supposed to be addressed during care plan meetings, the facility had not consistently documented these discussions, especially when responsible parties were not present at the meetings.
Failure to Document Controlled Medication Reconciliation
Penalty
Summary
The facility failed to properly document the reconciliation and accounting of controlled medications on the Cluster 1 Hall 2 medication cart. The facility's Diversion Prevention Policy requires that both the off-going and oncoming nurses perform a count of controlled medications and document this on a controlled substance shift change accountability record. However, a review of the controlled medication records revealed that there were missing nurse signatures for both oncoming and off-going shifts, or the same nurse signed for both roles, on multiple dates for several residents' controlled medication records. This indicates a failure to adhere to the policy of having two different nurses verify the count of controlled medications. Interviews with nursing staff and management revealed confusion and procedural issues contributing to the deficiency. Nurse #10 admitted to signing the controlled medication record incorrectly due to confusion about where to sign on the new form. Nurse #11, the only night nurse for Cluster 1, stated she often signed as both the oncoming and off-going nurse due to a lack of available staff to perform the count with her. The Unit Manager and Director of Nursing confirmed that the policy requires two different nurses to verify the count, but acknowledged that monitoring and documentation were not being properly conducted, leading to incomplete and inaccurate records.
MDS Assessment Miscoding for Anticoagulant Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident's use of anticoagulants. Resident #63, who was admitted with a diagnosis of coronary artery disease, had physician orders for Apixaban, an anticoagulant, to be administered every twelve hours. The Medication Administration Records for October and November 2024 confirmed that the resident received Apixaban as prescribed. However, the quarterly MDS assessment incorrectly indicated that the resident was receiving an antiplatelet medication instead of an anticoagulant. Interviews with MDS Nurse #1, Unit Manager #1, and the Director of Nursing confirmed that Apixaban is an anticoagulant and not an antiplatelet, and the miscoding was identified as a data entry error.
Failure to Develop Comprehensive Care Plans for Anticoagulant and Anti-Seizure Medications
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident #63, who was admitted with coronary artery disease, was prescribed Apixaban, an anticoagulant, to reduce the risk of blood clots. Despite receiving this medication consistently from October to December 2024, the resident's care plan did not include a focus on the use of blood thinners or anticoagulants. Interviews with the MDS Nurse, Unit Manager, and Director of Nursing confirmed that the care plan should have addressed the use of anticoagulants, but no explanation was provided for the omission. Similarly, Resident #101, who was readmitted with a diagnosis of seizures, was prescribed Lacosamide, an anti-seizure medication. Despite being severely cognitively impaired and receiving this medication, the resident's care plan lacked a focus on seizures or the use of anti-seizure medication. Interviews with the Unit Manager, Director of Nursing, and Director of Standards revealed that the resident should have had a care plan for seizures, but no reason was given for the absence of such a plan. The facility's expectation was that all residents have person-centered care plans to guide service provision and ensure their wellbeing.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to secure medications properly in Building 1 Hall 4, where both the medication room and the medication cart were left unlocked. Nurse #12 admitted to leaving the medication room and cart unlocked when she went to collect laboratory tests for a resident, which left the residents' medications unsecured. The Unit Manager and the Director of Nursing confirmed that the medication room and cart should have been locked to ensure the security of the medications, especially controlled substances that require a double locking system. In Building 2 Hall 2, an expired medication was found on the medication cart, and the nurse acknowledged it should have been removed. Additionally, the facility failed to maintain proper temperature logs for medication refrigerators in Building 2 Hall 2 and Building 4 Hall 3. The temperature in one refrigerator was found to be 50F, above the required range, and temperature logs were incomplete or missing. Nurses were unsure of who was responsible for monitoring and recording the refrigerator temperatures, and the Director of Nursing stated that temperature checks should be done daily.
Failure to Administer Tube Feedings as Ordered
Penalty
Summary
The facility failed to administer tube feedings as ordered by the physician for a resident with a gastrostomy tube. The resident, who had severe cognitive impairment and required tube feeding for nutrition, did not receive his scheduled feedings on multiple occasions. Specifically, Nurse #1 did not provide the resident with his midnight or 6:00 AM formula feeding on certain dates, and there were allegations that this had happened several times in the past. Nurse #1 admitted to not administering the feedings because she believed the resident was full and thought she could hold the feeding without a doctor's order. The resident had a history of esophageal dysmotility, recurrent aspiration pneumonia, dysphagia, and weight loss, necessitating the use of a feeding tube. His care plan required that he receive all nutrition and hydration through the gastric tube due to aspiration risks. Despite this, Nurse #1 did not assess the resident's condition before deciding to skip feedings, and there were no documented signs of distress or behaviors that would justify holding the feedings. The resident's weight was being monitored by the Registered Dietician (RD), who was unaware of the missed feedings and noted that the resident's nutritional needs were being met according to the tube feeding orders. The RD's assessments indicated that the resident's tube feeding order was designed to exceed his estimated nutritional needs to promote weight stability and gradual weight gain. However, the RD was not informed of the missed feedings, which could have impacted the resident's caloric intake and weight stability. The RD noted that the resident's weight fluctuated due to various factors, but the tube feeding was intended to provide sufficient calories and protein. The failure to administer the feedings as ordered compromised the resident's nutritional care plan and was not communicated to the RD or medical team for further evaluation.
Inaccurate Medication and Treatment Record for Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medication and treatment administration record for a resident, identified as Resident #103, who was supposed to receive a 2-Calorie formula bolus via gastric tube four times a day. According to the physician's order dated April 11, 2024, the resident's feeding schedule was set for midnight, 6:00 AM, noon, and 6:00 PM, with instructions to check residuals before each feeding and hold the bolus for one hour if residuals exceeded 30 cc. However, the Treatment Administration Record (TAR) for September 28-30, 2024, showed that Nurse #1 signed off on providing the tube feeding at midnight and 6:00 AM, with no notes indicating any feeding was held. In a written statement, Nurse #1 admitted to not administering the midnight feeding on September 29, 2024, because she believed the resident was full, and she occasionally withheld feedings without documenting specific dates. Attempts to interview Nurse #1 were unsuccessful, but her supervisor, Unit Manager #2, confirmed that Nurse #1 admitted to signing the TAR for a feeding that was not given.
Inaccurate and Incomplete Nurse Staffing Documentation
Penalty
Summary
The facility failed to maintain accurate and complete nurse staffing information for three resident buildings, leading to a deficiency in the documentation of staffing hours. In Building 1, there were no census daily staffing forms completed for the entire month of November and the first nine days of December 2024. The Unit Manager of Building 1 was unaware of the requirement to complete these forms until informed by the Director of Nursing on December 11, 2024. In Building 2, the census daily staffing forms were either incomplete or missing for several days in November and December 2024. The Unit Manager of Building 2 stated that the responsibility for completing these forms fell to the floor shift supervisor, home life specialist, or the secretary. However, due to the absence of a floor shift supervisor, the home life specialist was supposed to complete the forms, but this was not consistently done. The secretary, who was responsible for checking the forms for accuracy, was not aware of the need to ensure their completion and accuracy before filing. Building 4 also experienced issues with incomplete or missing census daily staffing forms. The Unit Manager of Building 4 noted that the forms were not always completed due to the absence of a floor shift supervisor or the supervisor forgetting to complete them. The secretary in Building 4 was responsible for storing the forms but had not received instructions on how to ensure their completion. The Director of Nursing admitted to not monitoring the completion of these forms and acknowledged that each building was handling the process differently, leading to inconsistencies in the documentation of staffing hours.
Failure to Credit Interest on Resident Trust Fund Accounts
Penalty
Summary
The facility failed to manage a resident trust fund account by not crediting interest earned on accounts with a balance over $100, specifically for one resident. The resident was readmitted to the facility on March 17, 2024, and a review of their trust fund statement dated December 12, 2024, showed a balance exceeding $100 without any information about interest payments or bank fees. During an interview, the Business Manager explained that the residents' trust funds were pooled into one account, and no interest was credited to individual accounts because the bank fees typically exceeded the interest accrued. The Administrator confirmed that the trust fund statements did not include interest information due to the fees surpassing the interest earned, leaving no funds to distribute to the residents.
Failure to Document Grievances Properly
Penalty
Summary
The facility failed to maintain proper documentation of grievances for four residents, as required by their grievance policy. The policy mandates that grievances be documented with details of the investigation, findings, and communication of results to the resident's representative. However, for all four residents reviewed, the facility did not complete the grievance forms, leaving sections blank that should have contained critical information about the investigation and resolution of the grievances. For Resident #125, the grievance form was incomplete, lacking documentation of the department the grievance was referred to, findings from the investigation, and actions taken. The resident's representative was not informed of the results, and the administrator admitted to not having reviewed or discussed the evaluation with physical therapy. Similarly, for Resident #8, the grievance form was incomplete, with no documentation of the investigation findings or communication of results to the guardian. The Director of Standards confirmed that the forms should have been fully completed. Resident #46's grievance form also lacked documentation of the investigation and communication of results. The nurse involved did not document the conversation with the representative, and the grievance form was left incomplete. For Resident #33, the grievance form was missing documentation of actions taken and communication of results, despite the unit manager having investigated the incident. The consistent failure to document grievances properly indicates a systemic issue in the facility's grievance handling process.
Neglect in Managing PICA Disorder Leads to Repeated Ingestion of Medical Gloves
Penalty
Summary
The facility failed to protect Resident #1 from neglect by not implementing effective interventions to prevent a resident with a known diagnosis of PICA disorder from accessing and ingesting medical examination gloves. Resident #1, who had a history of PICA behaviors, was found to have ingested and vomited medical examination gloves multiple times, posing a high risk of serious harm such as airway blockage and aspiration. Despite being aware of the resident's condition, the facility did not provide adequate supervision to prevent these incidents, leading to repeated episodes of glove ingestion. The deficiency was identified through a series of incidents where Resident #1 was observed vomiting gloves, with one incident involving a glove found under her pillow. Investigations conducted by the facility revealed that staff failed to ensure Resident #1's safety by leaving gloves within her reach, despite the known risks associated with her condition. The facility's initial response to the incidents was inconclusive, with no clear trigger event identified, and staff denying leaving gloves in proximity to the resident. The lack of effective interventions and supervision to prevent Resident #1 from accessing and ingesting gloves ultimately led to the facility being cited for neglect in their care of the resident with PICA disorder. The immediate jeopardy began when the facility neglected to implement interventions to prevent Resident #1 from accessing gloves, resulting in the resident repeatedly ingesting them. Despite attempts to address the issue through enhanced supervision and staff training, the deficiency persisted, highlighting a systemic failure in protecting residents with complex behavioral conditions.
Supervision Lapses Lead to PICA Incidents Involving Ingestion of Medical Gloves
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with a known diagnosis of PICA disorder from engaging in PICA behaviors, resulting in multiple incidents of ingesting medical examination gloves. Resident #1, admitted with diagnoses of intellectual disability and PICA disorder, exhibited behaviors such as wandering and PICA. Despite the care plan indicating the need for close supervision and interventions to prevent ingestion of inedible objects, Resident #1 managed to ingest gloves on multiple occasions, leading to risks of serious harm such as airway blockage, choking, and aspiration. Incidents on 2/21/2024, 2/24/2024, and 3/24/2024 involved Resident #1 vomiting gloves, with one incident resulting in a dime-sized glove fragment found in the enteral feeding residual. Staff interviews revealed lapses in supervision, with Resident #1 being able to self-propel her wheelchair and access gloves despite the prescribed supervision levels. Despite training on PICA behaviors and enhanced supervision orders, Resident #1 continued to exhibit PICA behaviors, leading to concerns about choking hazards and the need for continuous monitoring. The facility's investigation reports highlighted the need for re-inservicing staff on PICA behaviors, enhancing supervision levels, and ensuring the environment was free of items Resident #1 could ingest. Despite these actions, subsequent incidents occurred, indicating ongoing challenges in preventing Resident #1 from accessing and ingesting inedible objects. The deficiency in providing adequate supervision to prevent PICA behaviors in a resident with a history of such behaviors led to repeated incidents of ingesting gloves, posing significant risks to Resident #1's health and safety.
Failure to Report Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect to the state agency, Adult Protective Services (APS), and local law enforcement within the required timeframe. This deficiency was identified for one resident who experienced multiple incidents of neglect. The facility became aware of an incident on 2/21/2024 involving Resident #1 but did not notify APS or law enforcement. Similarly, another incident on 2/24/2024 involving a small piece of a glove found in the resident's gastric fluid was not reported to the state agency, APS, or law enforcement. The Director of Nursing (DON) confirmed that the incident was not reported because it was believed the glove piece could have been from a previous incident or torn from a nurse's glove during care. Further incidents on 3/24/2024 and 4/5/2024 involving the same resident were also not reported to the appropriate authorities. The facility's administration stated that neglect was generally not reported to APS or the police unless there was a suspicion of a crime. During a complaint investigation and revisit survey, the Administrator was officially notified of neglect related to these incidents, but there was no documentation of initial or investigation reports sent to the state agency, APS, or law enforcement. The DON verified that the 4/5/2024 incident was not reported because it was not communicated that the resident ingested the glove found on the bed.
Failure to Prevent Abuse and Neglect
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain and monitor interventions for abuse and neglect, as evidenced by repeated deficiencies cited during three federal surveys. Specifically, the facility did not implement effective interventions to prevent a resident with PICA disorder from ingesting medical examination gloves. This resident experienced multiple incidents of glove ingestion, including vomiting gloves on several occasions and finding a glove in their enteral feeding residual. These incidents occurred despite the facility being previously cited for similar issues, indicating a failure to sustain an effective Quality Assurance Program. During the complaint investigation surveys, the facility was cited for failing to protect residents from both verbal and physical abuse by staff. The Administrator admitted that the QAPI committee had not met since the last survey, which was related to physical abuse. This lack of consistent monitoring and intervention by the QAA Committee contributed to the ongoing deficiencies in protecting residents from abuse and neglect.
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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