Peak Resources- Shelby
Inspection history, citations, penalties and survey trends for this long-term care facility in Grover, North Carolina.
- Location
- 726 South Battleground Ave, Grover, North Carolina 28073
- CMS Provider Number
- 345229
- Inspections on file
- 25
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Peak Resources- Shelby during CMS and state inspections, most recent first.
A resident with type 2 DM had a new weekly semaglutide order entered into the EMR, but the drug was not available on multiple scheduled administration dates and was not actually given. An RN documented on the MAR that the dose was administered on one date and refused on another, later acknowledging these entries were incorrect and that the medication had been unavailable. There was no documentation that the MD/PA was notified that the ordered semaglutide was not being administered, and the PA reported she was unaware the medication had not been delivered or given until weeks later. The Administrator confirmed that providers are to be notified whenever a resident does not receive a prescribed medication, regardless of unavailability or refusal.
A resident with type 2 DM, weight gain, and varying blood sugars was started on weekly semaglutide by a PA after consultation with the medical director, but the order sent to the pharmacy lacked a specific dose. The pharmacist repeatedly notified the former DON that the order required clarification before the drug could be dispensed, yet no corrected order with dosage was provided until a new order specifying 0.25 mg was entered weeks later. During this period, nursing staff documented the drug as given or refused on the MAR despite it being unavailable on multiple dates, and the unit manager was unaware that the pharmacy needed clarification. The resident reported that the medication, intended to help regulate blood sugars and assist with weight loss, was not actually administered until weeks after it was first ordered.
A resident with CAD, HTN, DM, and prior CVA, who had moderately impaired cognition but was independent with dressing, footwear, and hygiene, was not provided appropriate foot care or podiatry services despite having thick, overgrown toenails causing pain with walking and shoe wear. A nurse conducting a weekly skin assessment noticed the long toenails but did not document the finding or initiate a podiatry referral because the resident had not complained. The resident was not placed on the podiatry schedule, and no podiatry consults were documented. NAs, who provided only set-up assistance for bathing and allowed the resident to dress and apply socks independently, reported they had not seen the toenails and had not been told of discomfort. Later observations by nursing staff and the wound nurse confirmed the toenails were excessively long and required podiatry trimming.
A resident with type 2 DM and recent significant weight gain was started on semaglutide once weekly, but the order entered into the EMR contained incomplete dosage information, and the verifying nurse sent it to the pharmacy without correction. The pharmacist reported multiple unsuccessful attempts by phone, fax, and email to obtain clarification so the drug could be dispensed, while nursing staff noted the medication was not available in the med room and assumed it had not yet been delivered, without contacting the pharmacy or consistently notifying the provider. As a result, the ordered semaglutide was not supplied or administered as intended, and the order was later discontinued.
Surveyors found an unopened vial of Lorazepam 2 mg/mL past its expiration date stored in a locked bin in a medication room refrigerator. A medication aide confirmed the expiration date and reported uncertainty about who is responsible for checking the room for expired meds, believing night shift staff only monitor refrigerator temperatures and that the Pharmacist visits monthly. The DON stated the Pharmacist checks for expired meds monthly and that nurses are expected to remove discontinued meds and place them in pharmacy return containers. The Administrator reported that nurses should review medication orders each shift, send back discontinued meds, and check carts for expired and discontinued meds before administration. The Pharmacist indicated he conducts monthly med pass observations, a team member checks the medication room every other month for expired meds and stock, and that the facility should not rely solely on pharmacy visits to identify expired medications.
A resident with type 2 DM had an order for weekly subcutaneous semaglutide to help regulate blood sugars and assist with weight loss, but the drug was not available for multiple scheduled doses. An RN documented on the MAR that the medication was administered on one date and refused on another, even though she later stated the medication was not available and was not given on those dates. The resident, who was cognitively intact, reported that the medication was not actually started until a later month. The pharmacist indicated the initial order lacked dosage information and that semaglutide was delivered only after a corrected order was received, while the Administrator stated she was unaware the medication had not been administered and that non-administration should be documented accurately.
A Treatment Nurse failed to follow the facility’s infection control policy requiring glove changes and hand hygiene between dirty and clean steps of wound care for three residents with pressure ulcers and surgical wounds. For each resident, the nurse cleaned the wound with gauze and wound cleanser, then, without changing gloves or performing hand hygiene, proceeded to apply topical agents, dressings, and wraps. The nurse later acknowledged awareness of the required glove-change and hand hygiene steps but stated she became nervous while being observed. The IP and DON both confirmed that the nurse should have changed gloves and performed hand hygiene between wound cleansing and application of clean dressings.
A resident receiving insulin injections twice daily was not having her blood sugar levels monitored due to a lapse in communication and order entry in the eMAR. The Nurse Practitioner discontinued the sliding scale insulin but did not intend to stop FSBS checks. Staff were unaware of the discontinuation, and the facility lacked a policy for FSBS use in diabetics.
A survey of a medication cart revealed deficiencies in insulin pen labeling and storage. Opened Glargine and Novolog insulin pens were undated, and Insulin detemir and Lispro pens were expired. An unopened insulin pen was improperly stored outside the refrigerator. Interviews with a nurse and the DON confirmed these issues, indicating lapses in medication management protocols.
Failure to Notify Provider When Ordered Medication Not Administered
Penalty
Summary
The deficiency involves the facility’s failure to notify the Physician/Physician Assistant when a resident did not receive a prescribed medication. A resident admitted with type 2 diabetes had an order written on 11/25/25 for weekly subcutaneous semaglutide (0.25 mg or 0.50 mg) on Mondays. The MAR showed the medication as administered on 12/01/25 at 8:00 AM, refused by the resident on 12/08/25, and not administered on 12/15/25 due to awaiting delivery from the pharmacy, with the order discontinued on 12/22/25. Review of the medical record revealed no documentation that the Physician/Physician Assistant had been notified that the semaglutide was not administered as ordered. During interview, the nurse assigned to the resident stated the semaglutide was not available in the medication room on 12/01/25, 12/08/25, or 12/15/25 and that she did not administer the medication on those dates. She acknowledged documenting in error on the MAR that the medication was given on 12/01/25 and that the resident refused it on 12/08/25, and stated she should have documented that the medication was unavailable. She reported that she generally notified providers when a resident did not receive a prescribed medication but could not recall notifying the Physician Assistant in this case. The Physician Assistant reported entering the semaglutide order in the EMR on 11/25/25 and notifying a nurse that it was ready to be sent to the pharmacy, and stated she was not informed that the order sent lacked a dose or that the medication was not delivered until 12/29/25. The Administrator stated that the Physician/Physician Assistant should be notified whenever a resident is not receiving a prescribed medication, whether due to unavailability or refusal.
Failure to Clarify Semaglutide Order and Obtain Medication as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a new medication order for semaglutide was clarified and processed so the medication could be obtained and administered as ordered. A physician assistant evaluated Resident #75, who had type 2 diabetes, weight gain of approximately 15 pounds in three months, and varying blood sugars, and entered an order on 11/25/25 for semaglutide to be given weekly. The order in the physician orders and MAR was written as semaglutide (0.25 mg or 0.50 mg) weekly, and the MAR showed an entry that it was administered on 12/01/25, refused on 12/08/25, and unavailable on 12/15/25, with discontinuation on 12/22/25 and a new order on 12/29/25 for semaglutide 0.25 mg weekly. The resident’s MDS documented that she was cognitively intact, had an active diagnosis of diabetes mellitus, and was receiving insulin injections daily, and her care plan identified risk for hypo- and hyperglycemic episodes with monitoring interventions. Resident #75 reported that semaglutide was ordered in late November to help regulate blood sugars and assist with weight loss but was not actually administered until January, and she did not question the delay because she believed it usually took a while for the facility to obtain new medications. She confirmed refusing the first two January doses because she had questions for the physician assistant about possible reactions, and stated that the medication was administered as ordered later in January. Nurse #2, who was assigned to the resident on day shift, stated that semaglutide was not available on three December dates and therefore was not administered, and she could not recall whether she notified the unit manager or provider about the unavailability. She further acknowledged that she documented in error on the MAR that the medication was administered on one date and refused on another, and that she should have documented that the medication was unavailable. Nurse #1, the unit manager, explained that new medication orders are entered into the EMR, verified, and sent electronically to the pharmacy, and that she verified the semaglutide order and sent it to the pharmacy but was not aware that the dose was missing or that clarification was needed. The pharmacist reported that the facility sent an order for semaglutide without dosage information and that the former DON was notified on four separate dates that the order needed to be resent with the dose before the medication could be dispensed and delivered. The pharmacist stated that a new order specifying semaglutide 0.25 mg weekly was finally sent on 12/29/25 and the medication was delivered on 12/31/25. The physician assistant and medical director both stated they were not informed that the pharmacy required clarification or that the resident had not received semaglutide until mid-January, and both stated that medications should be administered as ordered. The administrator stated that when the pharmacy notified the former DON that the order lacked dosage information, the former DON should have clarified the order with the physician assistant and sent an updated order to the pharmacy so the medication could be obtained and administered as ordered.
Failure to Assess and Arrange Podiatry Care for Long, Painful Toenails
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a resident with multiple medical conditions, including CAD, hypertension, diabetes mellitus, and a history of CVA. The resident’s care plan, revised on 12/07/25, identified the need for extensive and total staff assistance with ADLs, including grooming and personal hygiene, while also noting that the resident ambulated independently with a cane. A quarterly MDS documented that the resident had moderately impaired cognition but was independent with dressing, footwear, personal hygiene, and ambulation with a walker, and did not reject care. Despite these assessments, the resident’s weekly skin assessment dated 02/05/26, completed by Nurse #1, contained no notation that the toenails were long, thick, or required trimming or podiatry referral, even though Nurse #1 later acknowledged she had noticed the long toenails at that time but did not document them because the resident had not complained. Further record review showed the resident was not on the February 2026 podiatry clinic schedule, and there were no podiatry consultation reports or notes from admission through 02/11/26. During an observation and interview on 02/08/26, the resident removed his socks and displayed thick, long toenails on the left foot extending past the nail bed, reporting pain when putting on shoes and walking, and stating he had not reported this because he did not want to bother staff, although he believed staff had seen them. Subsequent observations with Nurse #1 and the Wound Care Nurse confirmed the toenails were long, thick, and in need of podiatry trimming, with the left hallux nail curved to the side and measured lengths up to 3 cm. Nursing assistants reported they had not seen the resident’s toenails because he dressed himself, wore his socks, and preferred to bathe in his room with only set-up assistance, and he had not voiced discomfort to them. The DON stated that NAs should have alerted nurses and that nurses should have assessed toenails during weekly skin assessments and placed the resident on the podiatry list when needed, while the Administrator reported she had not been informed of the issue and that the resident had not approached her with concerns.
Failure to Clarify and Obtain Ordered Diabetic Medication From Pharmacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a complete and clear prescription for a new diabetic medication and to respond to repeated pharmacy requests for clarification, resulting in the medication not being dispensed. A resident with type 2 diabetes, weight gain of approximately 15 pounds over three months, and noncompliance with a diabetic diet was evaluated by a Physician Assistant, who ordered semaglutide 0.25 mg once weekly to help regulate blood sugars and assist with weight loss. The physician order entered on 11/25/25 in the EMR read semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays, which the pharmacist later identified as lacking complete dosage information. The order was verified and sent to the pharmacy by the unit manager nurse on 11/28/25 without recognizing the incomplete dosage. The MAR showed one administration documented in error, one refusal, and one missed dose due to awaiting pharmacy delivery, and the order was discontinued on 12/22/25. Nursing staff did not ensure the medication was available or follow up appropriately when it was not in the medication room. The nurse assigned to the resident on the relevant dates reported that semaglutide was not available and that she assumed the new medication had not yet been delivered; she did not call the pharmacy to check the status and did not recall notifying the Physician Assistant, though she stated the unit manager nurse was aware. The unit manager nurse stated she believed the medication was not delivered because it was unavailable and did not follow up with the pharmacy. The pharmacist reported that the pharmacy attempted to contact the facility multiple times by phone, fax, and email on four separate dates to obtain clarification of the semaglutide order so it could be dispensed, but the facility did not provide a corrected order until 12/29/25. The Administrator stated she did not receive the pharmacy’s emails and could not confirm whether the former DON had received or acted on them, while also indicating that when a medication is not available, the assigned nurse, unit manager, and/or DON should contact the pharmacy or send a refill request in the EMR to ensure medications are available and administered as ordered.
Expired Lorazepam Vial Found in Medication Room Refrigerator
Penalty
Summary
Surveyors identified a deficiency in medication storage and monitoring when an unopened vial of Lorazepam 2 mg/mL with an expiration date of August 2025 was found in a locked bin in medication room [ROOM NUMBER]'s refrigerator. The observation occurred in the presence of a medication aide, who verified the expiration date on the vial. The report does not identify any specific resident associated with this medication or any clinical use at the time of the survey. During interviews, the medication aide stated she was unsure who was responsible for checking the medication room for expired medications and believed night shift staff only checked the refrigerator temperature. She also indicated that the Pharmacist visited monthly but needed to confirm details with the DON. The DON reported that the Pharmacist visits once per month to check for expired medications and that nurses are expected to remove discontinued medications from carts or the refrigerator and place them in pharmacy return containers. The Administrator stated that expired medications should be sent back to the pharmacy and that each nurse should check medication orders each shift and remove discontinued medications, as well as check carts for expired and discontinued medications before administering medications. The Pharmacist reported that he visits monthly for medication administration observations and that a team member visits every other month to check the medication room for expired medications and stock needs, and further stated that the facility should not rely on pharmacy visits to review medication stock for expired medications because pharmacy staff may not check the stock every month.
Inaccurate MAR Documentation for Ordered Semaglutide Therapy
Penalty
Summary
The facility failed to maintain accurate medication administration records for a resident with type 2 diabetes who had an order for semaglutide. Physician orders and the MAR showed an order dated 11/25/25 for semaglutide (0.25 mg or 0.50 mg) to be given subcutaneously once weekly on Mondays. The MAR reflected that semaglutide was administered on 12/01/25 at 8:00 AM, was refused by the resident on 12/08/25, and was not given on 12/15/25 due to awaiting delivery from the pharmacy, all documented by the same nurse. However, the resident, who was assessed as cognitively intact on a quarterly MDS, reported that although the PA ordered semaglutide on 11/25/25 to help regulate blood sugars and assist with weight loss, the medication was not actually administered until January 2026. In an interview, the nurse assigned to the resident on day shift stated that semaglutide was not available on 12/01/25, 12/08/25, or 12/15/25 and was not administered on those dates. She acknowledged that her MAR entries indicating administration on 12/01/25 and refusal on 12/08/25 were erroneous and that she should have documented the medication as unavailable. The pharmacist reported that the original order sent on 11/25/25 lacked dosage information, and a new order specifying semaglutide 0.25 mg was later sent, after which the medication was delivered. The Administrator stated she was not aware that the resident had not received semaglutide as ordered because it was not delivered and unavailable, and confirmed that when a medication is not administered it should be documented accurately in the resident record and on the MAR.
Failure to Follow Hand Hygiene and Glove-Change Protocol During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy during wound care for three residents. The facility’s policy, revised on 10/28/24, required staff to perform hand hygiene before and after donning gloves, to change gloves when moving from dirty to clean tasks, and to always change gloves between residents. During wound care for Resident #4, the Treatment Nurse was observed with a gown already on, sanitized her hands, and donned clean gloves. The dressing had already come off earlier during incontinence care. She cleaned the coccyx pressure ulcer with gauze soaked in wound cleaner and, without changing gloves or performing hand hygiene, applied Santyl ointment, wet-to-moist Dakin’s solution, packed the wound bed, and applied a super absorbent pad before discarding supplies and removing PPE. During wound care for Resident #62, the Treatment Nurse donned a clean gown and gloves, removed the old dressing from the resident’s right ankle, and cleaned the wound with gauze soaked in wound cleaner. While still wearing the same gloves used for cleaning, she applied an axeroform petrolatum dressing to the wound. She then collected and discarded the supplies, removed her gown and gloves, and washed her hands with soap and water only after the entire procedure was completed, without an interim glove change or hand hygiene between the dirty and clean portions of the wound care. For Resident #103, the Treatment Nurse entered the room wearing a gown, washed her hands, and put on gloves before removing the dressing from a right heel pressure ulcer. She then removed her gloves, used hand sanitizer, donned new gloves, and cleaned the ulcer with gauze soaked in wound cleaner. Without removing gloves or performing hand hygiene, she patted the ulcer dry with gauze, applied collagenase ointment with a cotton swab, covered the wound with calcium alginate and an abdominal pad, and wrapped the foot. After removing gloves and using hand sanitizer, she donned new gloves and removed the dressing from a surgical wound with staples on the resident’s left foot, then again removed gloves, sanitized her hands, and applied new gloves before cleaning the wound. She proceeded to cover the left foot wound with an abdominal pad and wrap it with gauze without changing gloves or performing hand hygiene between cleaning and dressing application. In interviews, the Treatment Nurse, Infection Preventionist, and DON all acknowledged that gloves should have been changed and hand hygiene performed between cleaning the wounds and applying clean dressings for all three residents.
Failure to Monitor Blood Sugar Levels in Insulin-Dependent Resident
Penalty
Summary
The facility failed to monitor a resident's blood sugar levels despite the resident receiving insulin injections twice daily. The resident, who was cognitively intact and required substantial assistance for most activities of daily living, expressed concern that her blood sugar was no longer being checked. She received 14 units of insulin in the morning and 16 units in the evening, but the staff had stopped checking her blood sugar, leading to episodes of increased sleepiness. The issue arose when the Nurse Practitioner discontinued the resident's sliding scale insulin order but did not intend for the finger-stick blood sugar (FSBS) checks to be discontinued. However, the FSBS checks were inadvertently stopped due to the way orders were entered into the electronic Medication Administration Record (eMAR). The facility's staff, including nurses and the consulting pharmacist, were unaware that the FSBS checks had been discontinued, and the resident's blood sugar levels had not been monitored since the sliding scale insulin order was discontinued. Interviews with the facility's staff revealed a lack of awareness and communication regarding the discontinuation of FSBS checks. The Director of Nursing and the Administrator were also unaware of the lapse in monitoring. The facility did not have a policy regarding FSBS use for diabetics, and the Medical Director mentioned that residents were assessed on a case-by-case basis for FSBS orders, with some consideration being given to using HbA1c levels for monitoring instead.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols for insulin pens, as observed during a survey of the Hall A medication cart. Specifically, the survey revealed that opened Glargine and Novolog insulin pens were not dated, and an opened Insulin detemir flexpen and Lispro insulin pen were past their expiration dates based on the open dates of 08/23/2024 and 09/24/2024, respectively. Additionally, an unopened insulin pen was improperly stored in the medication cart instead of the refrigerator, contrary to the manufacturer's instructions. Interviews with Nurse #1 and the Director of Nursing (DON) confirmed the deficiencies. Nurse #1 acknowledged the oversight in dating the insulin pens and the presence of expired pens. The DON reiterated that all insulin pens should be labeled with an open date and a 28-day expiration date, and that unopened pens should be refrigerated. The DON also stated that it was the responsibility of all nurses to check for expired medications in the carts, highlighting a lapse in the facility's medication management practices.
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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