Orchard Valley Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Hendersonville, North Carolina.
- Location
- 200 Heritage Circle, Hendersonville, North Carolina 28791
- CMS Provider Number
- 345285
- Inspections on file
- 28
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Orchard Valley Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to accurately code MDS assessments for hospice and PASRR status for multiple residents. Several residents who had elected or been admitted to hospice, and who had current hospice recertifications, were not coded on their quarterly or significant change MDS assessments as receiving hospice care or as having a condition with a life expectancy of less than six months. Another resident with a documented Level II PASRR determination was not coded on the annual MDS as having a serious mental illness and/or intellectual disability or related condition. Facility MDS staff acknowledged these omissions as oversights, while leadership stated they expected accurate MDS coding.
Surveyors found that quarterly MDS assessments were not completed within the required timeframe for three residents, with each assessment finalized more than 14 days after the ARD. Review of electronic records showed delayed completion dates for these quarterly assessments, and during interviews the MDS RN and regional clinical staff confirmed the assessments were late. Staff reported that a high volume of new admissions contributed to falling behind on required MDS work, and leadership acknowledged that additional improvement was needed to ensure timely completion.
A resident admitted with multiple mental health diagnoses, including schizoaffective disorder, anxiety, depression, bipolar disorder, schizophrenia, OCD, and insomnia, and receiving antianxiety medications, did not receive a requested Level II PASRR evaluation. The admission MDS reflected active psychiatric/mood disorder diagnoses, and psychiatric NP notes documented ongoing treatment for anxiety, depression, and bipolar disorder. The SW reported that her usual practice was to review diagnoses and medications and submit PASRR requests through NCMUST for residents with mental health diagnoses, but acknowledged that this resident was overlooked during an audit. The Administrator stated that the expectation was for the SW to review all residents admitted with a Level I PASRR and mental health diagnoses and submit them for Level II re-evaluation, which did not occur in this case.
The facility failed to request Level II PASRR reevaluations for two residents with serious mental illness after significant changes in condition were identified on MDS significant change assessments. Both residents had existing Level II PASRR determinations with no expiration date and were receiving psychotropic medications, yet NC MUST records showed no reevaluation requests following the documented changes. The SW, who was responsible for PASRR submissions, reported being unaware that a significant change in condition required a Level II PASRR reevaluation, and the Administrator confirmed that the SW was designated to review diagnoses and request reevaluations per regulatory guidelines.
Surveyors found that the facility failed to complete current bed rail assessments and obtain informed consent before installing and using bed grab bars for two residents with chronic pain, mobility limitations, and range of motion impairments. In both cases, quarterly MDS assessments documented specific assistance needs with bed mobility and indicated that bed rails were not used as restraints, yet observations showed bed grab bars in upright positions being used either for independent repositioning or to assist staff during care. Electronic records lacked informed consent for bed grab bar use, and the most recent bed rail assessments were months old, documented no expressed desire for assistive devices, and did not reflect the actual use of the grab bars. Interviews with CNAs, the DON, the Unit Manager, and the Administrator confirmed the residents’ use of the devices and revealed confusion about assessment frequency and unawareness of the requirement to obtain informed consent prior to installation.
A resident with incomplete quadriplegia, chronic pain, and a height of 73 inches was repeatedly observed in bed with the head elevated, legs straight, and feet pressed against the footboard, causing discomfort. The resident, who was cognitively intact and dependent on staff for bed mobility and self-care, reported that his feet hurt and stated he had requested a longer bed multiple times, as well as asking staff to place pillows under his feet. A NA and a medical assistant confirmed the resident’s ongoing complaints and their use of pillows to relieve pressure when the head of the bed was raised. During an observation with the DON, the resident again stated the bed was too small, and the DON acknowledged the bed appeared too small and that the resident’s feet were pressed against the footboard. The DON also noted the resident had previously been in a longer bed before a room change but could not explain why he was later placed in a shorter bed, and a work order for a longer bed was not initiated until the surveyor’s inquiry.
A resident with vascular dementia and severe protein-calorie malnutrition experienced significant weight loss while under orders for fortified pudding, frozen nutritional cups, and a house supplement for weight stability. Despite these physician and RD-directed orders, surveyors observed that the resident’s lunch trays did not include the fortified pudding or frozen nutritional cups, and meal tickets lacked these items. A CNA confirmed the supplements were not being served, the Dietary Manager acknowledged the orders but reported no recollection of receiving diet requisition forms needed to enter them into the Meal Tracker system, and the nourishment room did not contain the ordered products. The MD, RD, DON, and Administrator all stated they expected ordered nutritional supplements to be provided.
A resident with vascular dementia and dysphagia was not provided with an updated care plan reflecting physician-ordered changes to a mechanical soft diet with nectar thick liquids and pureed meats. Despite recommendations from the Speech Therapist and new physician orders, the care plan continued to list a regular diet with thin liquids, and staff responsible for updating care plans were unaware of the changes.
A resident with dementia and dysphagia, who required nectar thick liquids due to aspiration risk, was served thin liquid hot tea instead of the ordered consistency. The error was identified by a nurse aide after reviewing the meal card, and confirmed by dietary and therapy staff as a failure to follow the physician's order for nectar thick liquids.
The facility failed to provide meals according to the approved menu, affecting residents on regular, mechanical soft, and puree diets. Observations revealed missing ingredients in shepherd's pie and incorrect portion sizes during breakfast service. Dietary staff did not follow the approved menu or seek necessary approvals for substitutions, leading to deficiencies in meal service.
The facility failed to maintain cleanliness and proper food handling procedures, with observations revealing dried stains on floors and improper food labeling and storage. Expired food items were found, and open food items were not labeled, dated, or covered. The Dietary Manager cited staff shortages as a contributing factor, while the Administrator expected cleanliness and proper food handling.
The facility did not notify the Regional Ombudsman of resident discharges or transfers for six months, affecting 150 residents. The responsibility for notifications was in transition between staff members who subsequently left, leading to the oversight. The Administrator and DON attempted to cover the roles but failed to send the required notifications.
The facility failed to ensure timely physician visits every 30 days for the first 90 days of admission for four residents with various medical conditions. The deficiency was due to an unreliable system for tracking regulatory visits, exacerbated by staff turnover. The DON was temporarily managing the process, but oversight occurred, and the MD was unaware of the missed visits.
The facility failed to maintain a safe and clean environment, with unsecured and non-functional overbed lights, unsanitary bathroom conditions, and furniture in disrepair. The maintenance manager was unaware of many issues due to a lack of communication, and the housekeeping supervisor admitted to not consistently verifying staff work. The administrator and DON expected a clean environment, but the survey revealed significant deficiencies.
The facility failed to complete MDS assessments within the required timeframe for several residents due to staff turnover and increased workload. Additionally, a resident's CAA was submitted without necessary analysis for a triggered care area. The issues were acknowledged by the MDS Coordinator and the Director of Nursing.
The facility failed to complete quarterly MDS assessments within the required timeframe for several residents due to high turnover in MDS staff positions. This led to significant delays in completing assessments, as MDS Nurses had to cover additional responsibilities typically handled by other team members. The Administrator confirmed that the backlog was present upon his arrival and was worsened by further staff departures.
The facility failed to involve two residents in their care planning process. One resident with intact cognition and another with moderate cognitive impairment were not invited to participate in care plan meetings following their MDS assessments. The facility's administrator noted that the social worker responsible for scheduling these meetings had left, and the schedule had not been updated, leading to undocumented meetings.
A resident with diabetes and renal dialysis dependence did not receive the prescribed renal diet due to a failure in the facility's meal tracking system. The resident was served restricted items like potatoes and orange juice, which were not listed on the meal tray ticket due to a system error. Staff interviews confirmed the oversight, and the resident expressed dissatisfaction with the meals provided.
A resident with severe cognitive impairment and bedridden status was unable to access a light switch due to a broken cord, which was not reported or repaired in a timely manner. Staff were aware of the issue but failed to notify maintenance, relying instead on a wall switch. The DON expected staff to report such issues promptly to ensure resident accessibility.
A resident's advanced directives were inconsistent across their care plan and medical records. Despite having a DNR status on the MOST form and electronic health record, the care plan listed the resident as Full Code. Staff interviews revealed confusion over responsibility for updating directives, with the DON assuming the role due to a vacant social worker position.
A resident with bacteremia had a UA ordered, but the results were not obtained due to a failure in communication and process. The nurse collected the specimen but did not ensure it was processed, and the NP was not informed of the missing results. The DON and Administrator acknowledged the communication breakdown, but the resident did not suffer harm.
A resident reported inappropriate touching by another resident, but the incident was not immediately reported to the Administrator as required by the facility's abuse policy. The nurse documented the incident in a progress note but failed to notify the DON or Administrator promptly, leading to a delay in reporting to the State Agency and law enforcement.
The facility failed to renew PASRR evaluations and update care plans for two residents with mental health diagnoses. A resident with schizoaffective disorder and another with schizophrenia had expired PASRR Level II determinations, and their care plans did not reflect these determinations. The Social Worker responsible for PASRR oversight had left, and the RDCS was unaware of the expired evaluations.
Two residents with intact cognition and a desire to return to the community were not provided with adequate discharge planning due to the absence of a Social Worker. Despite being approved for Medicaid programs to assist with their transition, no discharge care plans were developed, and the residents did not receive the necessary support to complete applications or set up appointments. The facility's Administrator and DON attempted to fill the gap but failed to document conversations or update the residents on their discharge plans.
A resident with diabetes mellitus and moderately impaired cognition experienced increased confusion and weakness. Despite guidance to check blood sugar, Nurse #5 did not do so, nor did they report the resident's use of hypoglycemic medication to the on-call MD. The resident was later found to have hypoglycemia at the hospital. Interviews with facility staff revealed an expectation that blood sugar should have been checked as part of the assessment.
A resident requiring a mechanical lift and two-person assistance for transfers was manually transferred by a single NA without assistance, contrary to the care plan. The NA, an agency staff member, was misinformed by another NA and did not receive proper orientation, leading to the unsafe transfer.
A resident with an indwelling urinary catheter was found to have the catheter tubing unsecured, despite a physician's order to use an anchoring device every shift. The resident confirmed the device was not routinely applied, and although nurses documented it as secure, it was revealed that the resident often removed it. This inconsistency led to the identification of a deficiency during a survey.
A resident with chronic conjunctivitis missed five doses of prescribed Moxifloxacin eye drops due to a delay in pharmacy delivery. The delay was caused by a refill request being too soon for insurance coverage, and the necessary payment authorization form was not submitted in time. The resident's eye condition worsened during this period, although it was not painful or itchy.
A resident with chronic conjunctivitis missed five doses of prescribed Moxifloxacin eye drops due to a delay in pharmacy delivery. Despite the nurse's efforts to refill the medication promptly, it was not included in shipments, leading to missed doses. The DON was not informed in time to address the issue.
A resident's urinalysis was not completed due to a nurse failing to fill out the necessary requisition form, resulting in the specimen not being collected by the lab. The DON found the uncollected specimen in the refrigerator, and the NP was not informed about the missing lab results. The Administrator expected proper documentation and communication to ensure lab orders are processed.
A resident in an LTC facility, who was cognitively intact, had a care plan indicating a preference for double protein portions. Despite this, the resident reported not receiving the larger portions requested. The Dietary Manager was aware of the request but failed to update the meal ticket, resulting in the resident receiving standard portions. The Regional Director of Operations and the Director of Nursing were unaware of the issue, and the Administrator expected staff to honor residents' preferences, highlighting a communication breakdown.
A resident with a right-hand muscle contracture did not have a splint applied as required by a physician's order, despite documentation indicating otherwise. Observations on two days showed the absence of the splint, and a nurse admitted to possibly signing off on the MAR by accident. The DON and Administrator expected accurate documentation and explanations if the splint was not applied.
The facility lacked a qualified Activity Director, affecting all 106 residents. The Assistant Activity Director and Activity Assistant, both without formal training or degrees, were unaware of the requirements. The Administrator confirmed the absence of a qualified AD since August, with temporary roles filled by untrained staff. Interviews for a new AD were ongoing.
The facility failed to complete MDS assessments and entry tracking records within the required timeframes for two residents due to significant staff turnover. The deficiency was confirmed by MDS nurses and the Administrator, who noted that the assessments were already behind when he started, and further staff departures worsened the situation.
The facility failed to ensure privacy for residents in two semi-private rooms. In one room, there was no track for a privacy curtain, preventing its installation. In another, the curtain did not fully extend due to incorrect installation of track wheels. Both issues were confirmed by staff and acknowledged by the Administrator as communication and reporting failures.
A resident with severe cognitive impairment was not protected from sexual abuse by another resident with moderate cognitive impairment. The male resident was found in bed with the female resident, with clothing displaced, indicating an intention to engage in sexual activity. The male resident's known wandering behavior was not adequately supervised, contributing to the incident. The facility staff intervened after the incident, but the deficiency highlights a failure to protect residents from abuse.
A LTC facility failed to preserve evidence in a potential sexual assault case involving two residents with cognitive impairments. Staff provided incontinence care and discarded potential evidence, focusing on maintaining the dignity of the female resident. The facility's policy on abuse and evidence preservation was not followed, affecting the investigation's integrity.
A facility with 134 certified beds failed to employ a qualified full-time Social Worker (SW) as required. The SW hired did not have the necessary bachelor's degree in social work or a related field, holding only an associate's degree in medical billing and coding. The Administrator, new to the facility, was aware of the regulation but had not addressed the issue. The Vice President of Operations cited recruitment challenges and noted that the Administrator and a SW at a nearby facility could provide support.
Inaccurate MDS Coding for Hospice and PASRR Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately code Minimum Data Set (MDS) assessments for hospice status and PASRR Level II determinations for four residents. One resident who had been initially admitted to hospice and recertified for continued hospice services did not have hospice services reflected on a quarterly MDS assessment. Another resident, admitted to hospice several months earlier and recertified for hospice services, had a quarterly MDS that did not indicate a condition or chronic disease with a life expectancy of less than six months and did not show that hospice care was being received. A third resident elected hospice services, as documented in a hospice agreement, and a significant change MDS was completed due to this election; however, the MDS did not indicate that the resident was receiving hospice care. The facility also failed to accurately code PASRR information for a fourth resident. This resident had a Level II PASRR determination letter with no expiration date, but the annual MDS assessment did not reflect that the resident was currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. In interviews, the Regional MDS Consultant, MDS Coordinator, and MDS RN acknowledged that each of these MDS assessments should have reflected the residents’ hospice status or Level II PASRR status and characterized the errors as oversights. The DON and Administrator each stated they expected MDS assessments to be coded accurately.
Untimely Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for three of thirty sampled residents. For one resident, the electronic medical record showed a quarterly MDS with an ARD of 09/29/25 that was not marked as completed until 10/22/25. For a second resident, the quarterly MDS had an ARD of 11/15/25 and was not completed until 12/04/25. For a third resident, the quarterly MDS had an ARD of 11/07/25 and was not completed until 12/02/25. These completion dates exceeded the regulatory timeframe tied to the ARD for quarterly assessments. During a joint interview on 02/19/26, the MDS RN and Regional MDS Consultant confirmed that the quarterly MDS assessments for these three residents were not completed within the required regulatory timeframe. The MDS RN stated that the facility had experienced a high volume of new admissions and that staff had fallen behind on the number of MDS assessments needing completion. In a subsequent interview on 02/20/26 with the Administrator present, the Regional Director of Clinical Operations acknowledged that, despite good-faith efforts to address MDS issues, further improvement was still needed in completing assessments within regulatory timeframes.
Failure to Request Level II PASRR Evaluation for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident admitted with multiple mental health diagnoses. Documentation showed the resident had a Level I PASRR determination with no expiration date and was admitted with schizoaffective disorder, anxiety, depression, and bipolar disorder. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, yet listed active psychiatric/mood disorder diagnoses including anxiety, depression, bipolar disorder, and schizophrenia, and the resident was receiving antianxiety medications. Subsequent psychiatric nurse practitioner notes documented a history of obsessive compulsive disorder (OCD), schizophrenia, bipolar disorder, major depressive disorder, schizoaffective disorder, anxiety, and insomnia, and ongoing treatment for anxiety, depression, and bipolar disorder. Despite these documented mental health conditions and ongoing psychiatric treatment, there was no evidence that the facility submitted a request for an updated Level II PASRR evaluation for this resident. The social worker reported that her process was to review diagnoses and medications for new admissions and submit to the North Carolina Medicaid Uniform Screening Tool (NCMUST) when a resident had a mental health diagnosis, and that she had many Level II PASRRs at the facility and a PASRR office contact for questions. She stated she had conducted an audit when she started in August 2025 and acknowledged that this resident was overlooked. The administrator stated that the expectation was for the social worker to review all residents admitted with a Level I PASRR and a mental health diagnosis and submit them for re-evaluation for a Level II PASRR, which did not occur for this resident.
Failure to Request PASRR Level II Reevaluations After Significant Changes in Condition
Penalty
Summary
The facility failed to request Level II PASRR reevaluations after significant changes in condition for residents already determined to have Level II PASRR status. One resident with schizoaffective disorder, bipolar type, and anxiety disorder had a Level II PASRR determination with no expiration date and was identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and schizophrenia, and receiving antipsychotic and antidepressant medications. Despite this significant change assessment, a review of the NC Medicaid Uniform Screening Tool (NC MUST) showed that no PASRR reevaluation request had been submitted following the significant change. Another resident with major depressive disorder and anxiety disorder also had a Level II PASRR determination with no expiration date and was similarly identified on a significant change MDS assessment as having a serious mental illness, with active anxiety disorder and depression and receiving antianxiety and antidepressant medications. NC MUST records again showed no PASRR reevaluation request after the significant change assessment. During interviews, the Social Worker, who was responsible for submitting Level II PASRR reevaluation requests, stated she was still learning the PASRR process and was not aware that a reevaluation request was required when a resident had a significant change in condition. The Administrator confirmed that the Social Worker was responsible for reviewing diagnoses and requesting Level II PASRR reevaluations when residents experienced significant changes in condition per regulatory guidelines.
Failure to Complete Bed Rail Assessments and Obtain Informed Consent for Bed Grab Bars
Penalty
Summary
The deficiency involves the facility’s failure to complete required bed rail assessments and obtain informed consent prior to installing and using bed grab bars for two residents. Facility policy required that different approaches be tried before using a bed rail and, if a bed rail was needed, that the resident be assessed for safety risk, risks and benefits be reviewed with the resident or representative, informed consent be obtained, and the bed rail be correctly installed and maintained. For both residents cited, surveyors found bed grab bars in use without documentation of informed consent in the electronic medical record and with outdated bed rail assessments that did not support the current use of the devices. One resident had chronic respiratory failure with hypoxia, muscle weakness, chronic pain, intact cognition, and lower extremity range of motion impairment. A quarterly MDS showed he required supervision or touching assistance with bed mobility, was independent with moving from sitting to lying, and did not use bed rails as a physical restraint. During observations, a bed grab bar was seen secured in the upright position on the right side of his bed while he was sleeping and later while he was sitting up eating breakfast. The last bed rail assessment, dated many months earlier, documented that neither the resident nor his representative expressed a desire for an assistive device, that he could independently reposition in bed, and that alternatives to bed rails had not been attempted because a bed rail would promote mobility and transfers. Staff interviews confirmed he used the bed grab bar independently for repositioning and bed mobility, yet no informed consent for its use was found in his record. The second resident had rheumatoid arthritis and lumbar intervertebral disc degeneration with discogenic back and lower extremity pain, intact cognition, and range of motion impairment in both upper and lower extremities. A quarterly MDS indicated he was always incontinent of bowel and bladder, dependent on staff for toileting hygiene, required supervision or touching assistance with rolling, and partial to moderate assistance with position changes, with bed rails not used as a physical restraint. Observations showed bilateral bed grab bars in the upright position, which the resident and staff reported he used only to hold onto while staff rolled him for care, not for independent repositioning. The last bed rail assessment, completed months earlier, documented that neither the resident nor his representative expressed a desire for an assistive device, that he could not rise independently from a supine position, could not reposition himself in bed, had balance and trunk control problems, and that a PT consult had been attempted as an alternative. However, there was no evidence of informed consent for the bed grab bars, and interviews with the DON, Unit Manager, and Administrator revealed uncertainty and lack of awareness regarding assessment frequency and the requirement to obtain informed consent before installation.
Failure to Provide Properly Sized Bed to Accommodate Resident Needs
Penalty
Summary
The facility failed to reasonably accommodate a resident’s need for an appropriately sized bed, resulting in the resident’s feet pressing against the footboard whenever he was in his usual position. The resident, who was 73 inches tall and had incomplete quadriplegia at C5–C7 with chronic pain due to trauma, was cognitively intact and dependent on staff for self-care, bed mobility, and transfers. On multiple observations, the resident was seen in bed with the head of the bed elevated about 30 degrees, his head positioned approximately two inches below the top of the bed, and his legs straight with his feet pressed against the footboard. The resident reported that his feet hurt when they pressed against the footboard and stated he had requested a longer bed multiple times, as well as asking NAs to elevate his feet on pillows to relieve the discomfort. Staff interviews confirmed that the resident had repeatedly expressed discomfort and requested pillows under his feet because of the pressure against the footboard. A NA and a medical assistant both stated that when the head of the bed was raised, the resident’s feet pressed into the footboard and that they used pillows to elevate his feet at his request. During an observation with the DON, the resident again stated the bed was too small, and the DON acknowledged that his feet were pressed against the footboard, that the bed appeared too small, and that he could be at risk for skin breakdown. The DON also stated the resident had previously been in a longer bed before a room transfer but could not explain why he received a shorter bed afterward. The Maintenance Director reported that nursing staff were responsible for assessing bed size and entering work orders for larger beds, and confirmed that a work order for a longer bed for this resident was not received until the date of the survey interview, indicating that prior requests and observations had not resulted in timely accommodation.
Failure to Provide Ordered Nutritional Supplements for Weight-Stable Care
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nutritional supplements to a resident with vascular dementia and severe protein-calorie malnutrition who was experiencing significant weight loss. The resident had physician orders for fortified pudding after lunch beginning in June and frozen nutritional cups twice daily beginning in December for weight stability, and later an order for a house supplement (fortified shake) four times daily. Weight records showed a decline from approximately 154 pounds in early December to 133.8 pounds in early February, and the RD documented an 11.9% weight loss over three months. The RD and Medical Director both stated they expected the resident to receive all ordered supplements, and the RD noted the resident was usually consuming 51–75% of meals and was to receive fortified pudding once daily, house supplement three times daily, and frozen nutritional cups twice daily. Surveyor observations and staff interviews showed that the ordered fortified pudding and frozen nutritional cups were not being provided with the resident’s meals. On multiple observed lunch trays, the resident received a mechanically altered meal with nectar thick liquids but did not receive fortified pudding or a frozen nutritional cup, and a nurse aide confirmed these items were not on the lunch tray despite the resident eating about 75% of meals over the prior two weeks. Review of the meal ticket confirmed the supplements were not listed. The Dietary Manager acknowledged the resident had physician orders for fortified pudding and frozen nutritional cups and that these should have been on the tray, but stated she had no recollection of receiving a diet requisition form from nursing to add them to the Meal Tracker system. The Unit Manager could not recall whether diet requisition forms had been submitted for these supplements, and an observation of the nourishment room showed no stock of fortified pudding or frozen nutritional cups. The Medical Director, DON, and Administrator each stated they expected residents to receive nutritional supplements as ordered.
Failure to Update Care Plan for Physician-Ordered Diet Changes
Penalty
Summary
The facility failed to update the care plan to reflect the current diet as ordered by the physician for a resident with vascular dementia and dysphagia. The resident was admitted with moderate cognitive impairment and required partial to moderate assistance with eating. The care plan, last revised on 4/23/25, indicated a regular diet with thin liquids, but did not reflect subsequent changes in the physician's orders. On 05/27/25, the physician ordered a mechanical soft diet with nectar thick liquids due to overt signs and symptoms of aspiration, and on 05/28/25, pureed meats were added to the diet order. Despite these changes, the care plan was not updated to reflect the new dietary orders. The Speech Therapist evaluated the resident and recommended the diet downgrade due to high risk for aspiration, and both the MDS Coordinator and DON confirmed that the care plan should have been updated. The MDS Coordinator was unaware of the changes to the diet orders and acknowledged responsibility for updating care plans, indicating a lapse in communication and care plan revision processes.
Failure to Provide Ordered Nectar Thick Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with vascular dementia and dysphagia, who was assessed as moderately cognitively impaired and at high risk for aspiration, was not provided with fluids consistent with the physician's order. The resident's care plan and physician's order specified a mechanical soft diet with nectar thick liquids due to overt signs and symptoms of aspiration. However, during a lunch observation, the resident's meal tray included a cup of thin liquid hot tea instead of the required nectar thick consistency. The nurse aide delivering the tray did not initially notice the inconsistency and only realized the error after reading the meal card, which specified nectar thick hot tea. The resident did not consume the tea, and it was removed from the tray. Interviews with dietary staff and the speech therapist confirmed that the resident's order was for nectar thick liquids and that the thin liquid tea was an oversight by dietary staff. The facility used pre-thickened fluids to avoid such errors, but in this instance, the correct consistency was not provided. The speech therapist had previously evaluated the resident and recommended nectar thick liquids due to a high risk of aspiration. Both the DON and the Administrator acknowledged that the resident should have been served nectar thick liquids as per the physician's order.
Deficiency in Meal Service and Menu Adherence
Penalty
Summary
The facility failed to provide all food items as specified by the approved menu and did not ensure residents received the correct portion sizes based on the approved menu. During an observation of the lunch meal tray line, it was noted that the shepherd's pie served to residents on regular and mechanical soft diets lacked mixed vegetables and onions, which were part of the approved recipe. The dietary staff member responsible for preparing the meal stated that he did not include these ingredients because they were unavailable and followed guidance from a former Regional Director of Operations (RDO) who did not include them in the recipe. The Dietary Manager and current RDO confirmed that the shepherd's pie should have contained all the items called for in the recipe, or the Dietary Manager should have been notified to obtain approval for appropriate substitutions. Additionally, during the breakfast meal service, the facility did not follow the approved menu for both regular and puree diets. The regular diet menu called for two slices of French toast, one sausage patty, and six ounces of oatmeal, while the puree diet menu specified pureed French toast, pureed sausage, and pureed oatmeal. However, observations revealed that residents on regular diets received only one piece of French toast, scrambled eggs, and grits instead of oatmeal, without proper approval for these substitutions. Similarly, residents on puree diets did not receive pureed French toast or sausage, and the pureed eggs served did not contain cheese as approved by the Registered Dietician (RD). Interviews with dietary staff and the RDO indicated a lack of communication and adherence to the approved menu and portion sizes. The RD confirmed that a contract company handled food preparation and she was not involved in day-to-day kitchen operations. The facility's Administrator expressed an expectation that dietary staff follow approved recipes and notify supervisors if ingredients are unavailable to allow for appropriate substitutions. However, the failure to adhere to these expectations resulted in deficiencies in meal service for residents on regular, mechanical soft, and puree diets.
Deficiencies in Cleanliness and Food Handling Procedures
Penalty
Summary
The facility failed to maintain cleanliness and proper food handling procedures in various areas, including the walk-in cooler, walk-in freezer, dry storage room, kitchen, and nourishment rooms. Observations revealed multiple dried stains on the floors of these areas, and the Dietary Manager attributed the lack of cleanliness to the absence of two staff members due to illness. The Administrator expressed an expectation for all kitchen floors to be clean and free of stains. Additionally, the facility did not adhere to proper food labeling, dating, and storage practices. Expired food items, such as pasteurized eggs and bread, were found in the walk-in cooler and kitchen, respectively. Open food items in the walk-in freezer and reach-in coolers were not labeled, dated, or covered, and milkshakes lacked use-by dates. The Dietary Manager acknowledged these issues and cited staff shortages as a contributing factor. The facility also failed to maintain clean food preparation areas and equipment. The bottom shelves of food preparation tables were found with scattered food crumbs and dried stains, and the reach-in coolers had dried and smeared stains on their doors. The nourishment room refrigerators and freezers contained dried stains, and the Dietary Manager confirmed that it was the dietary department's responsibility to clean these areas. The Administrator expected all food preparation areas and equipment to be clean and free of debris.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the Regional Ombudsman of resident discharges or transfers for six consecutive months, from April to November 2024. This deficiency was identified through a review of the facility's Admission/Discharge reports, which showed that a total of 150 residents were discharged or transferred during this period. The Administrator admitted that there was no documentation of notifications being sent to the Regional Ombudsman. The responsibility for sending these notifications was in transition from the Admissions Director to the Social Worker, but both individuals left their positions, leaving the Administrator and the Director of Nursing to cover these roles. This oversight resulted in the failure to notify the Ombudsman as required.
Failure to Ensure Timely Physician Visits for New Admissions
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first 90 days of admission for four residents. Resident #21, with diagnoses including chronic obstructive pulmonary disease and heart failure, was only seen by the MD twice during the first 90 days. Resident #31, who had diabetes and chronic kidney disease, was also seen only twice in the same period. Resident #41, with conditions such as chronic obstructive pulmonary disease and dementia, was seen once during the first 90 days and not again until after the 90-day period. Resident #55, with hemiplegia and diabetes, was seen twice during the first 90 days. The deficiency was attributed to a lack of a reliable system to track and ensure compliance with regulatory visit requirements. The Director of Nursing (DON) was temporarily managing the tracking of MD visits due to turnover in the Medical Records and Social Worker positions. The DON provided the MD with weekly reports of admissions and discharges, but the system was not foolproof, leading to oversight of required visits. The MD confirmed that he relied on the facility's list of admissions to determine which residents needed to be seen and was unaware that the required visits for the four residents had not been completed as per regulations.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple deficiencies observed during the survey. In several rooms, overbed light fixtures were not secured to the wall, posing a risk of injury to residents if they were to fall. Additionally, many of these light fixtures were non-functional, and the maintenance manager was unaware of these issues until they were pointed out during the survey. The maintenance manager relied on staff to report such issues, but there was a clear lack of communication and follow-up, leading to unresolved maintenance problems. The survey also revealed significant cleanliness issues within the facility. In one shared bathroom, there was a persistent and overwhelming odor resembling urine, and the toilet and surrounding areas were visibly dirty with dried stains. Despite daily cleaning routines, these issues persisted over several days, indicating a failure in housekeeping practices. The housekeeping supervisor acknowledged the problem but admitted to not being able to verify the work of her staff consistently. This lack of oversight contributed to the unsanitary conditions observed. Furthermore, the facility's furniture and fixtures were found to be in poor repair. Several rooms had furniture with exposed sharp edges due to missing wood or broken plastic, which posed a safety hazard to residents. The maintenance director was not aware of these issues, as he depended on nursing staff to report them. Additionally, the facility had damaged walls and ceilings with missing textured spackling, which were not addressed in a timely manner. The administrator and director of nursing expressed expectations for a clean and well-maintained environment, but the survey findings highlighted a disconnect between these expectations and the actual conditions within the facility.
Delayed MDS Assessments and Incomplete CAA in LTC Facility
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments within the required 14-day timeframe for several residents. Specifically, the assessments for Residents #6, #16, #21, #28, #29, #47, #68, and #78 were not completed within the regulatory time frame. The delays in completing these assessments were confirmed by MDS Nurses during interviews. The primary reason for the delay was attributed to turnover in the MDS staff and the need for the remaining staff to cover additional responsibilities typically handled by other members of the Interdisciplinary Team. Additionally, the facility failed to comprehensively complete the Care Area Assessment (CAA) for Resident #89. The significant change in status MDS assessment for this resident was submitted without the necessary analysis of findings for the triggered care area of psychotropic drug use. The MDS Coordinator acknowledged this oversight and explained that the assessment was submitted by a former coordinator, and she was unable to provide further details on how the error occurred. The Administrator and Director of Nursing were aware of the issues with MDS assessments. The Administrator noted that the assessments were already behind when he assumed his position, and the Director of Nursing emphasized the importance of completing CAAs comprehensively. Despite efforts to address the backlog, the facility continued to struggle with timely completion of MDS assessments due to staff turnover and increased workload.
Delayed MDS Assessments Due to Staff Turnover
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14 days of the Assessment Reference Date (ARD) for 14 out of 45 sampled residents. This deficiency was identified through a review of electronic medical records and staff interviews. The residents affected by this deficiency had their MDS assessments completed significantly later than the regulatory timeframe, with delays ranging from several weeks to over a month. The deficiency was primarily attributed to high turnover in the MDS staff positions, which led to a backlog in completing the assessments. MDS Nurse #1, who was responsible for assisting with the assessments, reported that she was only able to work at the facility once a week and had to cover multiple facilities. Additionally, the turnover affected other members of the Interdisciplinary Team, requiring the MDS Nurses to complete sections of the assessments typically handled by others, further contributing to the delays. The facility's Administrator confirmed that the MDS assessments were already behind when he assumed his position. The situation was exacerbated by the departure of a full-time and a part-time MDS Nurse, which further delayed the completion of assessments. Despite efforts to catch up, the facility struggled to maintain timely assessments, especially during periods of increased admissions.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to invite residents to participate in the development and implementation of their person-centered care plans. Specifically, two residents were not invited to attend care plan meetings or provide input regarding their care plans. Resident #50, who has intact cognition and was admitted with diagnoses including diabetes and anxiety disorder, was not invited to care plan meetings following her annual and quarterly MDS assessments. The comprehensive care plan for Resident #50 was last revised several months prior, and the resident confirmed she had not been invited to a care plan meeting since June 2024. Similarly, Resident #11, who has moderate cognitive impairment and was admitted with diagnoses including congestive heart failure and major depressive disorder, was not invited to participate in care plan meetings following her quarterly MDS assessment. The last documented care plan meeting for Resident #11 involved her family member and occurred several months prior, with no subsequent meetings scheduled. The facility's administrator acknowledged that the social worker responsible for scheduling these meetings had left the facility, and the care plan meeting schedule had not been updated since then. Despite some meetings being conducted, they were not documented in the residents' medical records.
Failure to Provide Prescribed Renal Diet
Penalty
Summary
The facility failed to provide a resident with a renal diet as ordered by the physician. The resident, who was admitted with diagnoses including diabetes and dependence on renal dialysis, had a specific diet order that excluded certain foods such as potatoes, tomato sauce, and orange juice. However, observations revealed that the resident was served meals containing these restricted items. The resident confirmed receiving inappropriate foods and expressed dissatisfaction with the meals provided. Interviews with facility staff, including the Dietary Manager and the Regional Director of Operations, revealed that the computerized meal tracking system failed to print the restricted items on the resident's meal tray ticket. This oversight led to dietary staff being unaware of the resident's specific dietary restrictions. The Registered Dietician and other staff members, including the Director of Nursing and the Administrator, acknowledged the expectation that the resident should have received the diet as ordered, but the system error resulted in the resident not receiving the correct diet since the order change.
Failure to Ensure Resident Accessibility to Light Switch
Penalty
Summary
The facility failed to accommodate the needs of a dependent resident, who was unable to access a light switch located on the left side of her bed. The resident, who had severe cognitive impairment and was bedridden, could not reach the switch cord, which was only 3 inches in length and positioned 5 feet from the floor. This issue persisted for over a month, as the resident had to rely on staff to control the light fixture. Despite the resident's condition and the importance of accessibility, the broken switch cord was not reported or addressed in a timely manner. Staff interviews revealed that a nurse aide was aware of the broken switch cord but did not notify the maintenance staff, instead using a wall switch near the entrance door to control the light. The maintenance manager, who conducted weekly checks, was unaware of the issue and relied on verbal or work order reports for repairs. The Director of Nursing expected staff to be attentive to residents' living environments and report repair needs promptly, emphasizing the importance of accessibility for dependent residents.
Inconsistent Advanced Directives for Resident
Penalty
Summary
The facility failed to maintain accurate advanced directives for a resident, leading to a discrepancy in the resident's care plan. The resident, who was severely cognitively impaired, had a Medical Orders for Scope of Treatment (MOST) form indicating a Do Not Resuscitate (DNR) status, signed by the responsible party. However, the resident's care plan listed them as Full Code, which was inconsistent with the MOST form and the electronic health record that also indicated a DNR status. Interviews with facility staff revealed a lack of clarity and responsibility regarding the updating of advanced directives. The Director of Nursing (DON) had assumed the responsibility for updating advanced directive care plans due to the absence of a social worker, but the discrepancy remained unaddressed. The Administrator and other staff members acknowledged the expectation for consistency across all areas of the resident's chart, but the inconsistency persisted, highlighting a breakdown in communication and responsibility within the facility's processes.
Failure to Notify Physician of Incomplete Urinalysis
Penalty
Summary
The facility failed to notify the Physician when a urinalysis (UA) was not completed for a resident who was admitted with a diagnosis that included bacteremia. The resident had a physician's order for a UA with culture and sensitivity due to urinary pain, which was ordered and marked as completed. However, upon review, there were no lab results for the UA. Nurse #6, who collected the specimen, stated that she placed it in the refrigerator for lab collection but was unaware that there were no results, and thus did not notify the Physician. The Nurse Practitioner (NP) was also not informed that the UA results were missing and expressed that she would have wanted to be notified if the UA was not completed or needed to be reordered. The Director of Nursing (DON) identified that the breakdown occurred because the requisition was not filled out, and the Administrator expected that the NP would be notified if a lab order did not reach the lab. The resident did not experience harm or a negative outcome due to the UA not being completed.
Failure to Immediately Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to adhere to its abuse policy and procedure by not immediately reporting an allegation of resident-to-resident abuse to the Administrator. The policy required that all alleged violations involving abuse or resulting in serious bodily injury be reported to the Administrator immediately, but not later than two hours after the allegation is made. In this case, a resident reported that another male resident entered her room and touched her inappropriately. The incident was documented by a nurse in a progress note, but there was no indication that the Director of Nursing (DON) or Administrator was notified at the time of the report. The progress note was written by a nurse on a later date, indicating a delay in reporting the incident. The facility became aware of the allegation only after the resident reported it again, leading to a delay in notifying the State Agency and law enforcement. Interviews with the involved nurse and facility staff revealed discrepancies in the reporting timeline, with the nurse unable to recall the incident and the DON not being informed promptly. This delay in reporting violated the facility's policy and procedure for handling abuse allegations.
Failure to Renew PASRR and Update Care Plans
Penalty
Summary
The facility failed to request a Preadmission Screening and Resident Review (PASRR) before the expiration date and did not develop comprehensive care plans that incorporated Level II PASRR determinations for two residents. Resident #21, who was admitted with schizoaffective disorder and anxiety disorder, had a PASRR Level II Determination Notification that expired without a new evaluation being requested. Additionally, Resident #21's comprehensive care plan did not address the Level II PASRR determination. The facility's Social Worker, who was responsible for overseeing the PASRR process, had left employment, and the Regional Director of Clinical Services (RDCS) was temporarily handling the PASRR requests. However, the RDCS was unaware of the expired PASRR for Resident #21. Similarly, Resident #104, admitted with schizophrenia, major depressive disorder, and post-traumatic stress disorder, had a PASRR Level II determination that expired without a new evaluation being requested. The comprehensive care plan for Resident #104 also failed to address the Level II PASRR determination. The RDCS, who was managing the PASRR process in the absence of a Social Worker, was not aware of the expired PASRR for Resident #104 until an audit was conducted. The Administrator acknowledged that care plans should have been developed to address the Level II PASRR determinations, but the turnover in the Social Worker position led to these oversights.
Lack of Discharge Planning for Residents
Penalty
Summary
The facility failed to implement a discharge planning process that involved the residents in developing a discharge care plan addressing their goals and post-discharge needs. Resident #50, who was admitted with diagnoses including diabetes, chronic pain, PTSD, and anxiety disorder, had intact cognition and expressed a desire to return to the community. Despite being approved for a Medicaid program to assist with the transition, there was no active discharge plan in place. The resident lost a housing assistance voucher due to delays and was not provided with the necessary support to complete applications or set up appointments, as the facility lacked a Social Worker to assist with these tasks. Similarly, Resident #70, with a chronic autoimmune disease, history of falls, and seizure disorder, also had intact cognition and aimed to return to independent living. Although approved for a Medicaid program, the discharge planning process stalled due to the absence of a Social Worker. The resident needed help applying for housing, but no staff member was available to assist, and no discharge care plan was developed. The facility's Administrator and Director of Nursing attempted to fill the gap left by the Social Worker's departure but did not document conversations or update the residents on their discharge plans. The facility's failure to develop and update discharge care plans for these residents resulted from the absence of a Social Worker, which left the residents without the necessary support to achieve their discharge goals. The Administrator acknowledged the oversight and confirmed that discharge care plans should have been developed and updated as the residents' plans progressed. The lack of documentation and communication with the residents further contributed to the deficiency in discharge planning.
Failure to Monitor Blood Sugar in Diabetic Resident
Penalty
Summary
The facility failed to obtain a blood sugar level as part of a change of condition assessment for a resident diagnosed with diabetes mellitus, who was being treated with oral blood glucose-lowering medication. The resident, who had moderately impaired cognition, was admitted with diagnoses including diabetes mellitus, chronic kidney disease, and chronic systolic congestive heart failure. On a specific day, the resident exhibited increased confusion and general weakness, prompting an evaluation using the SBAR (Situation Background Assessment Recommendation) tool. Although the SBAR included guidance to check the blood sugar, this was not done. Nurse #5 documented the resident's condition and vital signs but did not check the blood sugar level, despite the resident's history of diabetes and use of hypoglycemic medication. The nurse also failed to report the resident's use of oral hypoglycemic medication to the on-call MD. Later, the resident's daughter took the resident to the hospital, where the resident was found to have hypoglycemia, with blood sugar levels significantly below the normal range. The resident was treated with intravenous and oral glucose, and the hypoglycemic medication was discontinued. Interviews with the Nurse Practitioner, Medical Director, and Director of Nursing revealed that they expected the blood sugar to be checked as part of the assessment, especially given the resident's medical history. The Medical Director and DON acknowledged that it was an oversight by the nurse not to check the blood sugar, which should have been included in the assessment reported to the on-call MD. The Administrator also expected that the blood sugar level would be obtained and included in the assessment.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as Resident #4, who was dependent on a mechanical lift with two-person assistance for transfers. Despite this requirement, Nurse Aide (NA) #8, an agency staff member, manually transferred Resident #4 from a geriatric chair to her bed without assistance or the use of a mechanical lift. This action was observed during a continuous observation period and was contrary to the resident's care plan and Kardex, which both specified the need for a mechanical lift and two-person assistance. NA #8, who had been working at the facility for about a month, stated she was informed by another NA that Resident #4 required only a one-person assist for transfers. She also revealed that she did not receive any orientation upon hire and was unaware of what a Kardex was or how to access it. The Director of Nursing (DON) confirmed that Resident #4 required a mechanical lift and two-person assistance for transfers and that this information was accessible to all staff via the Kardex. The DON also mentioned that an orientation book was available at each nurse's station, and staff were expected to sign a document acknowledging receipt of orientation upon hire.
Failure to Secure Urinary Catheter Tubing
Penalty
Summary
The facility failed to ensure that the urinary catheter tubing was properly secured to prevent movement and trauma for a resident with an indwelling urinary catheter. The resident, who was admitted with obstructive and reflux uropathy, had a physician's order to secure the catheter tubing using an anchoring device every shift. Despite this order, during an observation, it was found that the anchoring device was not in place, and the resident confirmed that it was not routinely applied. The care plan indicated that the resident was at risk of complications and required the catheter to be secured, yet this was not consistently done. Nurses had initialed the Medication Administration Record (MAR) to indicate that the catheter tubing was secure, but during an interview, a nurse revealed that the resident would remove the anchoring device. The Nurse Practitioner and Director of Nursing both expected the device to be in place if the MAR was checked, but acknowledged that the resident had a history of removing it. This discrepancy between the MAR documentation and the actual practice led to the deficiency being identified during the survey.
Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to ensure that a resident received prescribed antibiotic eye drops, resulting in five missed doses. The resident, who had chronic conjunctivitis and moderate cognitive impairment, was prescribed Moxifloxacin eye drops to be administered twice daily. However, due to a series of communication and procedural errors, the medication was not delivered on time, leading to missed doses over several days. The issue began when a nurse realized the medication was running low and requested a refill from the pharmacy. The pharmacy indicated that the refill was too soon for insurance coverage, but the facility could pay for it. Despite this, the necessary form to authorize payment was not submitted in time to meet the pharmacy's delivery cutoff, causing further delays. The nurse and the Director of Nursing were not adequately informed of the situation, which contributed to the delay in resolving the issue. During this period, the resident's eye condition was observed to worsen, with increased redness and drainage, although it was not painful or itchy. The resident expressed concern about the missed doses, especially with an upcoming eye surgery. The Medical Director was aware of the situation and did not anticipate negative outcomes from the missed doses, but the deficiency in medication administration was evident due to the facility's failure to ensure timely delivery and administration of the prescribed medication.
Failure to Administer Prescribed Eye Drops
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who missed five doses of prescribed antibiotic eye drops. The resident, who had chronic conjunctivitis, was supposed to receive Moxifloxacin eye drops twice daily. However, due to a delay in the pharmacy's delivery of the medication, the resident missed doses on multiple occasions. The issue began when a nurse realized the medication was running low and requested a refill from the pharmacy. Despite the nurse's efforts to ensure timely delivery, the medication was not included in the subsequent shipments, leading to missed doses. Interviews with staff revealed that the nurse had contacted the pharmacy multiple times to inquire about the missing medication, but the issue was not resolved promptly. The Director of Nursing stated that she should have been notified earlier to follow up with the pharmacy. The Medical Director was aware of the situation and noted that while the resident was not expected to experience negative outcomes from the missed doses, the medication was necessary for treating the resident's conjunctivitis. The administrator acknowledged that the nurse should have informed the DON immediately when the medication was not delivered as expected.
Failure to Complete Urinalysis Due to Missing Requisition
Penalty
Summary
The facility failed to complete an ordered urinalysis (UA) for a resident who was admitted with a diagnosis of bacteremia. The resident had a physician's order for a UA with culture and sensitivity, which was documented as completed in the treatment administration record. However, upon review, there were no lab results available for the UA. Nurse #6 collected the specimen and placed it in the refrigerator for lab collection but did not fill out the necessary requisition form, which led to the specimen not being collected by the lab. The Director of Nursing (DON) discovered the uncollected specimen in the refrigerator and noted the absence of a requisition form as the reason for the oversight. The Nurse Practitioner (NP) was not informed about the missing lab results and expressed a desire to be notified in such situations. The Administrator expected the nursing staff to complete all necessary paperwork to ensure lab orders are processed and communicated to the NP if issues arise. The failure to complete the UA was attributed to the nurse's omission of the requisition form, resulting in the specimen not being sent for analysis.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically regarding portion sizes, for a resident who was cognitively intact and able to communicate his needs. The resident, admitted on 06/06/24, had a physician's order for a regular diet and a care plan indicating a preference for double protein portions. Despite this, the resident reported that he rarely received the larger portions he requested. On 12/02/24, the resident expressed his dissatisfaction with the dietary department's failure to provide the requested portion sizes, and on 12/03/24, he was observed receiving a standard breakfast portion without the requested double protein. The Dietary Manager acknowledged awareness of the resident's request for larger portions but failed to update the meal ticket accordingly. The resident was offered additional food only after all other residents had been served, which did not meet his immediate needs. Interviews with the Regional Director of Operations and the Director of Nursing revealed a lack of awareness and communication regarding the resident's dietary preferences, with the Director of Nursing noting that the care plan had not been updated due to the resident's recent hospitalizations. The Administrator also expressed an expectation that staff should honor residents' food preferences, indicating a breakdown in communication and execution of care plans within the facility.
Failure to Accurately Document Splint Application
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with a diagnosis of contracture of muscle in the right hand. A physician's order required the application of a right-hand splint, with specific instructions for its use and monitoring. However, observations on two separate days revealed that the resident did not have the splint applied, despite documentation in the Medication Administration Record (MAR) by a nurse indicating that the splint was applied on those days. During interviews, the nurse admitted to possibly signing off on the MAR by accident and acknowledged that the splint was not applied as documented. The nurse also confirmed that the order did not allow for the splint to be applied as tolerated, and there was an option to document if the resident did not tolerate the treatment. The Director of Nursing and the Administrator both expressed that they expected the splint to be applied if documented as such, and if not, a note should be written explaining why it was not applied.
Lack of Qualified Activity Director in Facility
Penalty
Summary
The facility failed to have a qualified professional to direct its activity program, which had the potential to affect all 106 residents. The Assistant Activity Director, who started working at the facility in October 2024, had no formal training or college degree and was unaware that the previous Activity Director was only acting in that role. The Assistant Activity Director could not provide details of any training received from the acting AD. Additionally, the Activity Assistant, who began working at the facility in late November 2024, also lacked formal training, a college degree, or state training courses, although she had some prior experience with adults with disabilities. The Administrator confirmed that the facility had been without a qualified Activity Director since August 2024, following the departure of the previous AD and Activity Assistant. During this period, the Admission Coordinator and evening receptionist temporarily assumed the roles of acting AD and Activity Assistant, respectively, without formal training. The Administrator acknowledged the facility's non-compliance with the regulation requiring a qualified AD and was in the process of conducting interviews to fill the position. However, at the time of the report, the facility remained without a qualified professional to direct the activity program.
Delayed MDS Assessments Due to Staff Turnover
Penalty
Summary
The facility failed to complete a discharge-return anticipated Minimum Data Set (MDS) assessment and entry tracking records within the regulated timeframes for two residents. Resident #47's discharge-return anticipated MDS assessment and entry tracking record were not completed within the regulatory timeframe, as they were marked completed on 07/23/24, despite the entry tracking record being dated 07/02/24. Similarly, Resident #83's entry tracking record dated 11/06/23 was not completed until 11/14/23, which was also outside the required timeframe. The deficiency was attributed to significant turnover in the MDS staff positions, which led to delays in completing the assessments. MDS Nurse #1, who was floating between several facilities, confirmed that the assessments fell behind due to the need to cover sections typically completed by other members of the Interdisciplinary Team, who were also affected by turnover. The Administrator acknowledged that the MDS assessments were already behind when he started in June 2024, and further staff departures exacerbated the issue. Despite efforts to catch up, the facility struggled to maintain timely completion of MDS assessments due to ongoing staffing challenges.
Privacy Curtain Deficiencies in Semi-Private Rooms
Penalty
Summary
The facility failed to provide adequate privacy for residents in two semi-private rooms, as observed during a survey. In room [ROOM NUMBER]-A, there was no ceiling mounting track for a privacy curtain, preventing the installation of a curtain around bed 207-A. This issue was confirmed by a nurse aide and the Maintenance Manager, who both acknowledged the absence of the necessary track. The resident in this room expressed a desire for a privacy curtain to block hallway light, indicating the importance of this feature for their comfort. In room [ROOM NUMBER], the privacy curtain for bed 304-A did not fully extend due to a malfunction in the mounting track. The curtain got stuck where the track curved, a problem that had been reported by the resident to nursing staff and maintenance. The Maintenance Manager identified that the wheels in the track were installed incorrectly, causing the curtain to get stuck. The Administrator later acknowledged issues with staff communication and reporting of environmental problems, which contributed to the oversight of these deficiencies.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a female resident with severe cognitive impairment from sexual abuse by a male resident with moderate cognitive impairment. The male resident was found in bed with the female resident, with his shorts pulled down and her gown and brief displaced, suggesting an intention to engage in sexual activity. The female resident, who was unable to move on her own, was found in a position that indicated she had been moved by the male resident. This incident was discovered by a nurse who immediately intervened and removed the male resident from the room. The male resident had a history of wandering behaviors, which were not adequately addressed by the facility staff. On the night of the incident, he was observed walking around the facility and was not under proper supervision, despite his known tendency to roam. The nurse assigned to the male resident's care was informed of his wandering behavior but failed to recognize it as a potential risk for abusive behavior. This lack of recognition and response contributed to the incident occurring. The facility staff, including the Director of Nursing and Assistant Director of Nursing, were notified of the incident, and law enforcement was contacted. The female resident was assessed for injuries, and although no immediate physical harm was noted, a forensic examination later revealed a rectal tear. The male resident was placed under one-to-one supervision following the incident, but the facility's failure to prevent the situation highlights a significant deficiency in protecting residents from abuse.
Removal Plan
- Resident #1 was removed from Resident #2's room and returned to his room where he was placed on 1:1 staff supervision.
- Notifications made to Administrator who ensured appropriate reporting requirements were made to the NC DHHS agency, local police department and Adult Protective Services.
- Resident #2 was assessed by LN #1 for signs of injury and no concerns were noted.
- Emergency Medical Services (EMS) was called and Resident #2 was transported to the hospital for further examination.
- The QAPI Committee held an Ad Hoc meeting to discuss root cause analysis of the facility's failure to protect a resident right to be free from sexual abuse.
- Social Worker completed abuse questionnaires and abuse education with cognitively intact residents.
- DON and ADON completed abuse audits on cognitively impaired residents.
- RDCS and DON completed abuse questionnaires with all facility and agency staff on the Abuse, Neglect and Exploitation Policy.
- All current facility staff and agency staff were in-serviced on the Abuse, Neglect and Exploitation Policy.
- The facility will no longer admit new residents under fifty-five or those with a homeless status without Ascent Governing Body approval.
- The DON, ADON, UM or SW will complete abuse questionnaires with facility and agency staff to validate understanding of the Abuse, Neglect and Exploitation Policy.
- The Administrator or SW will complete abuse questionnaires with five cognitively intact residents.
- The DON, ADON, SDC or UMs will complete abuse audits with five cognitively impaired residents.
- The Administrator, DON or SW will make rounding observations to identify high risk resident behaviors.
- RDO, VPCQA or RDCS will review Abuse allegations, adherence to the updated admission screening process and the facility corrective action plan.
- Results of monitoring will be presented by the Administrator with the QAPI Committee during QAPI meetings.
Failure to Preserve Evidence in Abuse Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedures effectively, particularly in the areas of employee training and investigation, by not preserving evidence that could be used in a sexual assault allegation. The incident involved a female resident with severe cognitive impairment and a male resident with moderate cognitive impairment. The male resident was found with his shorts pulled down, lying in bed behind the female resident, whose brief was torn in the back. This situation was perceived as an intention to engage in sexual activity. Upon discovering the situation, Nurse #1 and Nurse Aide #1 provided incontinence care to the female resident and discarded the brief, which could have been potential evidence in a criminal investigation. The facility's policy on abuse, neglect, and exploitation clearly states the importance of not tampering with or destroying evidence that could be used in such investigations. However, the staff involved did not adhere to this policy, as they were focused on maintaining the dignity of the female resident by cleaning her up before she was sent to the hospital for evaluation. Interviews with the staff revealed that they were not adequately prepared for such incidents and did not consider the implications of their actions on the investigation. The Assistant Director of Nursing and the Administrator acknowledged that the staff acted out of concern for the resident's dignity but failed to follow the facility's abuse policy regarding evidence preservation. This oversight affected the integrity of the investigation into the alleged abuse.
Facility Fails to Employ Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time Social Worker (SW) as required for a skilled nursing facility with more than 120 beds. The facility, which has 134 certified beds, employed a SW who did not possess the necessary bachelor's degree in social work or a related human services field. Instead, the SW held an associate's degree in medical billing and coding and had experience working in SW positions at smaller facilities with less than 120 beds. This discrepancy was identified during a review of the facility's Social Services Director job description and confirmed through staff interviews. The Administrator, who had recently started at the facility, acknowledged awareness of the regulation requiring a qualified SW and admitted that the issue had just been brought to his attention. The Vice President of Operations (VPO) explained that the decision to hire the unqualified SW was due to difficulties in finding suitable candidates. The VPO noted that the facility's Administrator had a bachelor's degree in a human service field and that a full-time SW with a master's degree in social work at a nearby sister facility could provide supervision and support to the facility's SW.
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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