Oak Forest Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Winston Salem, North Carolina.
- Location
- 5680 Windy Hill Drive, Winston Salem, North Carolina 27105
- CMS Provider Number
- 345443
- Inspections on file
- 30
- Latest survey
- June 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Oak Forest Health And Rehabilitation during CMS and state inspections, most recent first.
Two residents experienced deficiencies in care: one was injured after being rolled out of bed by a single staff member despite requiring two-person assist for bed mobility, resulting in multiple fractures and a hematoma; another resident, identified as a smoker, did not receive timely quarterly smoking assessments as required by facility policy, though was observed to smoke safely and independently.
Two residents with nicotine dependence and hypertension were observed smoking independently without any corresponding care plan interventions or goals addressing their smoking behaviors. Staff interviews confirmed that these residents should have been care planned for smoking, but this was not done.
A resident with a history of stroke and hypertension, dependent on staff for ADLs and not ambulatory, was found to have overgrown, thick, and yellow toenails, including an ingrown toenail causing discomfort and inability to wear shoes or socks. Despite being on the list for podiatry, the resident was not seen by the podiatrist since admission, and staff were unaware of the missed visit, resulting in a lack of appropriate foot care.
Two residents' narcotic medications, totaling 75 doses of Oxycodone 5 mg, were unaccounted for after being left unsecured following discharge and death. Nursing staff placed the medications in a pharmacy tote and an unlocked desk drawer, both accessible to multiple staff members, without ensuring double-lock security. The medications were missing when the pharmacy and facility later attempted to reconcile them.
Unused narcotic medications for two residents were not stored in double-locked, permanently affixed compartments as required. Instead, the medications were placed in a pharmacy tote and an unlocked desk drawer in an office accessible to multiple staff. As a result, significant quantities of Oxycodone were found missing when the medications were to be returned to the pharmacy, with staff interviews confirming lapses in following proper storage procedures.
Two residents who were assessed as safe, independent smokers and had intact cognition were not allowed to smoke outside of designated hours due to a facility policy limiting smoking times. Both residents expressed dissatisfaction with the restriction, and staff confirmed that multiple complaints had been made about the inability to smoke after certain hours. Facility leadership stated the policy was a department head decision and were unaware of resident complaints.
Two residents with chronic pain and cognitive impairment were not protected from the misappropriation of their prescribed Oxycodone when 84 tablets and related documentation went missing from a medication cart. Despite required narcotic counts and no reported pain issues or suspicious behavior, the loss was only discovered during an audit, and staff were unable to account for the missing medications.
A resident with significant physical limitations and a need for staff assistance with ADLs was not provided with regular facial shaving, despite a care plan specifying this need and the resident's stated preference for a clean-shaven face. Staff interviews confirmed awareness of the resident's grooming preferences, but the lapse in care was not explained by the assigned nurse aide, nurse, or facility leadership.
A resident with an indwelling suprapubic catheter, who was fully dependent on staff for care, was observed on multiple occasions with their urinary catheter drainage bag resting on the floor while the bed was in a low position. Staff interviews confirmed knowledge of the requirement to keep catheter bags off the floor, but the deficiency persisted over several days.
The facility failed to accurately code the MDS assessments for two residents using CPAP machines. Despite having care plans and physician's orders for CPAP use, the MDS assessments did not reflect this, as the MDS nurse was unaware of the need to code CPAP usage as non-invasive mechanical ventilation. The administrator expected accurate coding by the MDS nurses.
An agency nurse in a LTC facility administered the wrong medications to a resident, leading to a significant medication error. The resident, with a history of bipolar disorder and chronic kidney disease, received medications intended for another resident, including psychotropic and anticonvulsant drugs. The error was identified by the nurse, who reported it immediately. Despite monitoring and interventions, the resident's condition worsened, resulting in hospitalization for acute kidney injury and other complications.
A medication administration error occurred when an agency nurse misidentified a resident and administered another resident's medications. The resident, who was moderately cognitively impaired, received medications not prescribed to them, including metformin and aspirin. The error was realized shortly after, and the resident was monitored for adverse effects, with no immediate distress observed.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, limited mobility, and contractures was not provided care in accordance with her care plan, which required two-person assistance for bed mobility and use of a mechanical lift for transfers. During incontinent care, a nursing assistant attempted to reposition the resident alone, resulting in the resident rolling off the bed and sustaining significant injuries, including a fractured clavicle, a rib fracture, and a large scalp hematoma. The resident was on blood thinning medication due to a history of pulmonary embolism, further complicating her condition. The nursing assistant admitted to being aware of the two-person assist requirement but did not request help, and the posted note indicating this requirement was not noticed by the assistant at the time of the incident. Additionally, the facility failed to conduct timely smoking assessments for another resident with a diagnosis of tobacco use. The resident's care plan identified a risk for injury related to smoking, and facility policy required quarterly smoking assessments. However, there was a lapse of several months between assessments, exceeding the expected quarterly interval. Despite this, the resident was observed to smoke independently and safely during the survey, with no evidence of burns or injury at the time of observation. Both deficiencies were identified through observation, record review, and staff interviews. The first involved a failure to follow established care protocols for a resident with significant physical and cognitive impairments, resulting in a serious fall and injury. The second involved a failure to adhere to the facility's policy for regular smoking assessments, which are intended to minimize the risk of smoking-related injuries.
Failure to Develop and Implement Smoking Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement care plan interventions for two residents with nicotine dependence who were observed smoking independently. Both residents had documented diagnoses including hypertension and nicotine dependence, and their most recent smoking assessments were completed. However, review of their care plans revealed no goals or interventions addressing their smoking behaviors. Despite being cognitively intact, one resident required limited assistance with activities of daily living (ADL), while the other required extensive assistance. Both residents reported smoking since admission or shortly thereafter. Interviews with the MDS Coordinators, Director of Nursing (DON), and Administrator confirmed that they were unaware these residents had not been care planned for smoking. The staff acknowledged that all residents who smoke are expected to have care plans with specific goals and interventions, but this was not done for the two residents in question. The deficiency was identified through record review, observation, and staff interviews.
Failure to Coordinate Podiatry Care for Dependent Resident
Penalty
Summary
A resident with a history of stroke and hypertension, who was dependent on staff for activities of daily living and not ambulatory, was observed to have overgrown, thick, and yellow toenails, including an ingrown toenail that caused discomfort and prevented her from wearing shoes or socks. The resident reported that a nurse aide had trimmed some of her smaller toenails a few days prior, but she had not been seen by a podiatrist, despite her ongoing discomfort and request for podiatry care. Interviews with nursing staff and the Director of Nursing (DON) revealed that the resident was supposed to be seen by the facility's podiatrist during a recent visit but was not, and there was uncertainty as to why she had been missed. The DON confirmed that the resident had not been assessed by podiatry since admission, despite being on the list for the previous podiatry visit. The facility expected residents' toenails to remain trimmed and for podiatry to be consulted if issues arose, but this did not occur for the resident in question.
Failure to Secure and Account for Narcotic Medications After Resident Discharge or Death
Penalty
Summary
The facility failed to maintain effective systems and safeguards to prevent drug diversion, specifically regarding the handling and security of narcotic medications for two residents. In the first case, a resident with diabetes and diabetic neuropathy, who was cognitively intact and receiving opioid medications, was discharged to the hospital. After discharge, 45 doses of Oxycodone 5 mg prescribed to the resident were found to be missing. Nursing staff reported counting and placing the medication in a pharmacy tote, sealing it, and leaving it in the Unit Manager's office for pharmacy pickup. However, the medication was not present when the pharmacy received the tote, despite the correct documentation and seals being in place. The tote had been left in an office accessible to multiple staff members, and it was unclear how long it remained there before being sent to the pharmacy. In the second case, another cognitively intact resident with lung cancer, who was also receiving opioid medications, died in the facility. After the resident's death, a medication card containing 30 doses of Oxycodone 5 mg was placed in an unlocked desk drawer in the Unit Manager's office by the night shift supervisor. The office was locked, but several staff members had access to it. The medication was not secured under double lock as required, and the doses were later found to be missing. The narcotic count form for the medication was discovered in the unlocked drawer, but the medication itself was unaccounted for. Interviews with nursing staff and the pharmacist confirmed that the medications were not properly secured and that staff were unaware of the requirement to keep narcotic medications double locked until returned to the pharmacy. The facility's failure to ensure the security of these medications resulted in a total of 75 doses of Oxycodone being unaccounted for, with the medications left in areas accessible to multiple staff members and not properly safeguarded against diversion.
Failure to Secure and Store Narcotics Results in Missing Medications
Penalty
Summary
The facility failed to store unused narcotic medications in accordance with its own policy and accepted professional standards, resulting in the loss of controlled substances prescribed to two residents. For one resident, a physician had ordered Oxycodone 5 mg every four hours as needed for pain, and after the resident was discharged to the hospital, the remaining doses were counted by two nurses and placed in a pharmacy tote with a numbered zip lock tag. This tote was then stored in the Unit Manager's office, which was not always locked and accessible to several staff members. The exact duration the tote remained in the office before being sent to the pharmacy was unknown, and when the pharmacy received the tote, the medication was missing, though the seals were intact. For another resident, who had a physician's order for Oxycodone 5 mg three times daily for pain, the remaining medication was placed by the night shift supervisor in an unlocked desk drawer in the same office. The office was sometimes locked, but multiple staff had keys, and the medication was not secured in a double-locked compartment as required. During an investigation into the missing narcotics for the first resident, it was discovered that the medication for the second resident was also missing, with only the narcotic count form found in the unlocked drawer. Interviews with nursing staff and the DON confirmed that the process for storing and returning narcotics was not consistently followed, and staff were unaware that medications should not be left in unsecured locations. The facility's policy required all narcotic medications to be stored under double lock in a designated cabinet or safe, but this was not adhered to, resulting in the loss of a significant number of controlled medication doses for both residents.
Failure to Support Resident Choice for Independent Smoking
Penalty
Summary
The facility failed to honor the rights of residents to self-determination and choice by restricting the smoking times for residents who had been assessed as safe, independent smokers. Two residents with intact cognition and a history of tobacco use were care planned and assessed as able to smoke independently and safely. Despite this, the facility implemented a policy limiting smoking in the designated area to between 8:00 AM and 8:00 PM, as indicated by posted signage and confirmed through staff and resident interviews. Both residents expressed dissatisfaction with the imposed smoking schedule, stating their preference to smoke outside of the designated hours, including late evenings and early mornings. Staff interviews confirmed that multiple residents had complained about the restricted smoking times, and that these concerns had been communicated to nursing staff. The decision to restrict smoking hours was made by department heads, and facility leadership reported being unaware of resident complaints regarding the policy.
Failure to Safeguard Residents' Narcotic Medications
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed narcotic medications, specifically Oxycodone. Both residents had chronic pain and were moderately cognitively impaired, with physician orders for Oxycodone—one as needed and one scheduled via feeding tube. During a routine audit, it was discovered that two cards of Oxycodone, totaling 84 tablets, and the second page of the narcotic count sheet were missing from a medication administration cart assigned to a specific hall. The discrepancy was identified during a narcotic process audit by the DON, who found that the medications and documentation were not present as required. The investigation revealed that the last nurse assigned to the cart did not notice any discrepancies during the shift change narcotic count, which was conducted and signed off by both the outgoing and incoming nurses. No pain issues were reported for the residents during the relevant shifts, and the medication administration records indicated that one resident did not require PRN Oxycodone, while the other received her scheduled dose. Despite the required procedures for narcotic counts and documentation at each shift change, the missing medications were not detected until the audit, and no staff reported any issues or suspicious behavior prior to the discovery. Interviews with nursing staff, the pharmacy consultant, and the medical director confirmed that the narcotic count was believed to be correct at the time of shift changes, and no one could account for the missing medications. The facility's process required two nurses to complete narcotic counts at each shift change and to report any discrepancies immediately, but the loss of the narcotics and documentation was not identified until after the fact. The investigation was unable to determine how the medications were removed or by whom, resulting in a failure to safeguard the residents' property as required.
Failure to Provide Grooming Assistance for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, muscle weakness, left side hemiplegia, post-polio syndrome, and dysphagia, who was cognitively intact but required extensive assistance with activities of daily living (ADLs), was not provided with appropriate grooming care. The resident's care plan specified a need for total assistance with bathing and staff assistance with grooming and personal hygiene, including shaving facial hair. During an observation, the resident was found to have several chin hairs approximately one inch in length and expressed a preference for a clean-shaven face, stating she often had to request staff assistance for shaving. Interviews with staff revealed that the nurse aide assigned to the resident was aware of the resident's grooming preferences and confirmed that the resident rarely refused care. However, the aide was unsure why the resident's face had not been shaved. The nurse assigned to the resident was not aware of the facial hair and did not recall any resistance to personal care from the resident. Both the administrator and the DON were also unaware of the reason for the lapse in grooming and stated that residents were expected to be kept clean and shaved as preferred.
Catheter Drainage Bag Found Resting on Floor for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of hydronephrosis, urogenital implants, and neuromuscular dysfunction of the bladder, who was dependent on staff for all activities of daily living and had an indwelling suprapubic catheter, was observed multiple times with their urinary catheter drainage bag resting on the floor. The resident's care plan included interventions to keep the urinary collection bag below the level of the bladder, but did not specify that the bag should not touch the floor. During three separate observations over consecutive days, the catheter bag was seen hanging from the bedframe with the entire bottom of the bag in contact with the floor while the bed was in a low position. Staff interviews confirmed awareness of the requirement to keep catheter bags off the floor to prevent infection. A nurse aide reported having noticed the bag on the floor several times and repositioning it, while the DON stated that staff had been educated on this practice and that hooks were available for proper placement. The unit manager also acknowledged the expectation that the drainage bag should not touch the floor and described a temporary measure taken to prevent contact with the floor.
Inaccurate MDS Coding for CPAP Usage
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in relation to the use of continuous positive airway pressure (CPAP) machines. Resident #1, who was admitted with diagnoses including obstructive sleep apnea and acute respiratory failure with hypoxia, had a care plan indicating the use of a CPAP machine. Despite having an active physician's order for CPAP use and documented usage with occasional refusals, the Quarterly MDS assessment did not reflect the use of a CPAP machine. During an interview, MDS Nurse #1 admitted to not being aware of the need to code the CPAP usage as non-invasive mechanical ventilation. Similarly, Resident #2, admitted with obstructive sleep apnea, also had a care plan and physician's order for CPAP use. The resident's Significant Change MDS assessment failed to code the use of the CPAP machine, despite documented compliance with the physician's order. MDS Nurse #1 again acknowledged the oversight in coding, indicating a lack of awareness regarding the requirement to code CPAP usage as non-invasive mechanical ventilation. The facility's administrator expected the MDS nurses to ensure accurate coding of the residents' MDS assessments.
Significant Medication Error Due to Agency Nurse's Mistake
Penalty
Summary
The facility failed to protect a resident from a significant medication error when an agency nurse, Nurse #1, administered the wrong medications to Resident #1. On the morning of the incident, Nurse #1 gave Resident #1 his prescribed medications and later mistakenly administered medications intended for another resident, Resident #2, to Resident #1. The wrongly administered medications included several psychotropic and anticonvulsant drugs, which were not prescribed for Resident #1. Nurse #1 realized the error after returning to her medication cart and immediately reported it to the Unit Manager and the Nurse Practitioner (NP). Following the medication error, Resident #1 was monitored for any adverse effects. Initially, his vital signs were within normal limits, but later in the day, his blood pressure dropped, prompting the NP to order intravenous fluids. Despite these interventions, Resident #1's condition worsened, and he became lethargic and unresponsive. By the following day, his altered mental status necessitated a transfer to the Emergency Department for further evaluation. In the hospital, Resident #1 was diagnosed with acute kidney injury, potentially due to medication side effects, and was treated with intravenous fluids and antibiotics. Resident #1 had a medical history that included bipolar disorder, dementia, anxiety disorder, heart failure, and chronic kidney disease, which may have contributed to his vulnerability to the medication error. The facility's failure to ensure proper medication administration procedures, particularly by an agency nurse unfamiliar with the residents, led to this significant medication error. The incident highlights the importance of adhering to medication administration protocols to prevent such errors, especially when agency staff are involved.
Removal Plan
- The Director of Nursing completed a 100% audit on all current alert and oriented residents with brief interviews for mental status of 13 or greater to ensure there were no issues with medication administration.
- A body audit was completed by the DON, Assistant DON, and Unit Managers on all non-verbal, non-alert residents with BIMS of 12 or lower to ensure there were no issues related to medication administration.
- The DON, ADON, unit managers, and Staff Development Coordinator began interviewing nurses and medication aids during med pass observations to check if they had performed medication errors.
- The DON reviewed all incident reports to identify any recent medication errors.
- The Staff Development Clinician began in-servicing all Registered Nurses, Licensed Practical Nurses, and medication aides, including agency staff, on Preventing Medication Error policy.
- The Director of Nursing ensured that any staff who did not complete the in-service training would not be allowed to work until the training was completed.
- The DON, Assistant DON, unit managers, and SDC will monitor medication administration passes using the Quality Assurance monitoring tool Med Pass Audit.
- Reports will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is initiated as appropriate.
- The decision was made to initiate this into the QA process and to review it in QA.
Medication Administration Error Due to Resident Misidentification
Penalty
Summary
The facility failed to protect a resident from non-significant medication errors, as evidenced by an incident involving a medication administration error. A resident, who was moderately cognitively impaired and had multiple diagnoses including bipolar disorder, dementia, anxiety disorder, heart failure, and chronic kidney disease, was mistakenly given another resident's medications. This error occurred when an agency nurse, who was on her second day at the facility, addressed the resident by the wrong name, and the resident confirmed the incorrect identity. The nurse administered medications intended for another resident, including metformin, aspirin, levocarnitine, and baclofen, to the wrong resident. Upon realizing the mistake, the nurse immediately notified the Unit Manager, the Nurse Practitioner, and the resident's family. The resident was assessed and found to be stable, with vital signs within normal limits, and was monitored for any adverse effects such as hypotension and bradycardia. Interviews with the involved staff, including the nurse, Unit Manager, and Nurse Practitioner, confirmed the sequence of events and the immediate actions taken following the error. The Medical Director was also informed and did not anticipate any negative outcomes from the non-significant medications administered. The incident highlighted a lapse in the medication administration process, specifically in verifying the correct resident before administering medications.
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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