Pelican Health Randolph Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 4801 Randolph Road, Charlotte, North Carolina 28211
- CMS Provider Number
- 345134
- Inspections on file
- 22
- Latest survey
- September 17, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Pelican Health Randolph Llc during CMS and state inspections, most recent first.
Surveyors found that PTAC units in several rooms were not properly aligned or sealed, resulting in visible gaps to the outside and crumbled insulation. In one room, water leakage from a misaligned unit led to wet, soiled linens beneath it. Maintenance staff had recently reinstalled the units after electrical work but failed to secure them correctly, and facility leadership was unaware of the issue until the survey.
A deficiency was identified due to the absence of a pest control program to prevent or manage mice, insects, or other pests within the facility.
A resident with quadriplegia, who was cognitively intact and fully dependent on staff for care, was repeatedly left without access to a call light device. Staff failed to provide the call button after care tasks, leaving the resident unable to call for assistance until prompted by a surveyor or after calling out for help. Staff interviews confirmed the omission was due to distraction or workload, and leadership stated that staff were expected to ensure call light accessibility.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A nurse aide observed a male resident fondling a female resident and reported the incident to the Administrator, who then notified the State Agency and local law enforcement but failed to notify APS as required by facility policy. The Administrator later stated she was unaware of the need to report the allegation to APS.
A resident who completed long-term antibiotic treatment and was discharged home did not have a transfer or discharge notice issued, and the Ombudsman was not notified in writing of the discharge. Staff interviews revealed that the Social Worker responsible for notifications was unaware of the requirement, and the Ombudsman had not received discharge lists for several months.
A resident with bilateral leg ulcers did not receive wound care as ordered by the physician, as the nurse only cleansed open areas and not the entire lower legs before applying unna boots. Another resident, who was dependent and had a feeding tube, missed a scheduled GI appointment because transportation was not arranged, with unclear responsibility among staff for EMS scheduling. These deficiencies were identified through direct observation, record review, and staff interviews.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Two residents with significant medical conditions, including diabetes and vascular disease, did not receive necessary foot assessments or toenail care. Their toenails became long, thick, and untrimmed, with staff acknowledging the need for podiatry intervention. Due to lapses in scheduling and lack of staff awareness, neither resident was seen by a podiatrist, and their foot care needs were not addressed.
Two residents with quadriplegia experienced unsafe mechanical lift transfers when staff failed to follow facility policy and manufacturer guidelines. In one case, a resident was injured after a single aide attempted a transfer alone and the lift struck the resident's forehead. In another case, two aides did not widen or lock the base of the lift during a transfer, causing equipment entanglement. Both incidents involved staff not following required procedures for safe resident handling.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs.
A resident who was dependent on enteral nutrition via a gastrostomy tube did not have their tube feeding setup properly labeled according to facility policy. Observations showed that the feeding bag was missing key information such as the resident's name, type of feeding solution, additives, nurse preparer, and infusion rate, despite staff acknowledging these requirements.
A resident with chronic respiratory failure and severe cognitive impairment did not receive oxygen at the physician-ordered rate of 2 LPM via nasal cannula. Over several days, the oxygen concentrator was observed set at 1 LPM, and nursing staff did not verify the correct flow rate during their assessments, despite clear orders and care plan interventions.
Staff failed to follow Enhanced Barrier Precautions and infection control policies when a nurse did not wear a gown during gastrostomy tube medication administration, a nurse aide did not don a gown for urinary catheter care, and a wound nurse did not perform proper hand hygiene or use gloves while preparing wound care supplies for two residents with indwelling devices. PPE was not readily accessible, and EBP signage was not clearly visible, contributing to the deficiencies.
A resident requiring assistance with ADLs was unable to reliably alert staff due to a malfunctioning call light system that failed to produce an audible alarm and lacked a manual hand bell. Staff and maintenance confirmed ongoing issues with the system, resulting in reliance on regular rounding rather than immediate response to call lights.
A resident with major depressive and anxiety disorders was prescribed PRN Haloperidol without a required 14-day stop date, and no AIMS assessment was conducted to monitor for side effects. Staff interviews revealed misunderstandings about the necessity of stop dates for hospice patients, and pharmacy recommendations for medication management were not followed.
A resident with peripheral vascular disease and a recent angioplasty did not receive the prescribed antiplatelet medication, Plavix, due to a failure in the facility's order entry and verification process. Nurse #2 misunderstood the medication order, and the second nurse check was not effectively performed, leading to the omission of Plavix from the resident's medication administration record. The error was identified by the facility's administration, and the Medical Director confirmed it as a significant medication error.
The facility failed to maintain accurate advanced directives for two residents, resulting in discrepancies between their care plans and medical orders. One resident's care plan incorrectly listed them as Full Code despite a DNR order, while another resident's care plan was not updated to reflect a change to DNR status. The Social Services Director acknowledged the errors, highlighting a failure in the facility's process for updating and maintaining consistent documentation.
A resident in an LTC facility experienced a 7.41% medication error rate due to two errors. The first involved nearly crushing Nifedipine ER tablets, which should not be crushed, risking improper medication release. The second error was administering incorrect eye drops, as the nurse used a different type without verifying with the physician. Interviews revealed a lack of awareness and communication among staff regarding these errors.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic ulcer, as required by their infection control policy. Observations showed the absence of PPE supplies and EBP signage, and the Wound Care Nurse did not wear a gown during wound care. Interviews revealed a lack of awareness and process for ensuring EBP for residents with wounds.
A facility failed to keep a urinary catheter drainage bag off the floor for a resident with a history of obstructive uropathy and chronic kidney disease. Despite recent in-service training, staff did not properly secure the bag, leading to it dragging on the floor and increasing the risk of infection.
The facility failed to post nurse staffing data at the beginning of each shift for two consecutive days. The Scheduler, responsible for posting the data, typically arrived after the first shift started and posted the data only once daily. During her absence, there was a lack of clarity and communication among staff regarding who should post the data, leading to the deficiency.
A resident with neuralgia and neuritis was assessed and approved by the IDT to self-administer pain relief creams, but this approval was not reflected in the care plan. The ADON completed the assessment and educated the resident but did not update the care plan. Interviews revealed confusion among staff about the responsibility for updating the care plan, with the MDS Nurse still in training and the DON acknowledging the omission. The NP confirmed the resident's competence and the need for a care plan, while the Administrator stated that only an IDT assessment was required.
A transporter failed to call EMS or have a resident assessed by a medical professional after the resident's wheelchair tipped over in a transportation van, causing him to hit his head. Despite being on Plavix, the transporter moved the resident back into a sitting position and transported him back to the facility without calling EMS. The facility's policy required calling EMS in such incidents, but the transporter did not follow this procedure.
A resident's wheelchair tipped over in a transport van due to improper securement, causing the resident to hit his head. The transporter failed to follow the manufacturer's instructions for securing the wheelchair, leading to the incident. The resident, who was on blood-thinning medication, experienced head pain and nausea and was sent to the hospital for evaluation.
A resident was observed with a medication cup at their bedside, which they took without a physician's order or care plan for self-administration. The resident, who was cognitively intact and had multiple diagnoses, insisted on taking the medications after breakfast. Nurse #1 left the medications at the bedside, believing it was acceptable due to the resident's alert state. However, the facility's DON and other staff confirmed that medications should not be left at the bedside without an assessment for self-administration.
Failure to Properly Seal and Install PTAC Units in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to properly install and seal packaged terminal air conditioners (PTACs) in four out of eight resident rooms reviewed across three of four halls. In multiple rooms, the PTAC units were not aligned with the wall, resulting in gaps ranging from one to two inches at the top of the units. These gaps allowed daylight from the exterior to be visible from inside the rooms, and the insulation present was found to be crumbled or in poor condition. In one room, wet, soiled towels and sheets with brown stains were found underneath the PTAC unit, which was leaning inward and not sealed to the wall. During a facility tour with the Maintenance Director, Regional Maintenance Director, and the Administrator, it was confirmed that the PTAC units remained improperly installed and the gaps persisted. The maintenance staff indicated that the PTAC units had been removed and reinstalled recently to replace electrical cords, but only the middle screws were secured during reinstallation, leaving the units misaligned. The facility leadership was not previously aware of these issues until the surveyors' observations.
Lack of Pest Control Program
Penalty
Summary
The facility did not have a pest control program in place to prevent or address the presence of mice, insects, or other pests. This deficiency was identified based on the lack of measures or systems to manage and control pests within the facility environment.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
Staff failed to ensure that a dependent resident with quadriplegia consistently had access to a call light device. The resident, who was cognitively intact but unable to use upper or lower extremities, required maximum assistance for all activities of daily living. During an observation, a nurse aide completed catheter care and began to leave the room without providing the resident with the call button. When prompted by the surveyor, the aide retrieved the call button and placed it by the resident's head, allowing him to activate it using the right side of his head. The aide admitted to forgetting to provide the call button due to being distracted by the care task. Later, the resident was heard calling for help from his room, and the call button was found hanging off the side of the bed, out of reach. Another nurse aide entered, assisted the resident, and confirmed the call button was accessible. Interviews with the resident revealed that staff often did not provide the call button, and staff interviews confirmed that the omission was due to being busy or distracted. Both the DON and the Administrator stated that staff were expected to ensure residents had access to call bells before leaving the room.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Resident-to-Resident Sexual Abuse to APS
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse to Adult Protective Services (APS) as required by its abuse policy. A nurse aide observed a male resident fondling a female resident in the hallway and reported the incident to the Administrator. The State Agency and local law enforcement were notified within hours of the incident, but the Department of Social Services/APS was not notified. The Administrator later stated in an interview that she was unaware of the requirement to report such allegations to APS. Documentation confirmed that the incident was not reported to APS, despite the facility's policy mandating immediate reporting of all alleged violations involving abuse.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding the discharge of a resident who had been admitted for long-term antibiotic treatment and was discharged home after completing the treatment. Review of the resident's electronic medical record showed that no transfer or discharge notice was issued to the resident. Staff interviews revealed that the Ombudsman had not received any transfer or discharge lists from the facility for several months and was not aware of this resident's discharge. Further interviews indicated that the former Social Worker, who was in training during the relevant period, did not send notifications of transfers or discharges to the Ombudsman and was unaware of this requirement. The Administrator stated that the facility did not have a Social Worker at the time of the survey and expected that communication with the Ombudsman regarding transfers and discharges would occur. The former DON confirmed that the Social Worker was responsible for this communication, but it was not completed for this resident.
Failure to Follow Physician Orders for Wound Care and Arrange Medical Appointment Transportation
Penalty
Summary
The facility failed to provide wound care to a resident with bilateral arterial and venous ulcers according to physician orders. The resident, who was cognitively intact and required assistance with most activities of daily living, had physician orders for bilateral unna boots to be applied from toes to knees, with wound cleanser to be used on both lower legs before application. During an observed wound care session, the Wound Nurse only cleansed the open ulcer areas and did not cleanse the entire lower legs, including areas with dry skin, before applying the unna boots. The Wound Nurse stated she was unfamiliar with the resident's wound care and believed the order was unclear, but did not seek clarification from the physician. Both the DON and Administrator confirmed that the expectation was for the nurse to follow the physician's order and to clarify any uncertainties before proceeding. Additionally, the facility failed to ensure transportation was arranged for a resident to attend a scheduled gastroenterology appointment. The resident, who was severely cognitively impaired, dependent for all care, and had a feeding tube, had a physician's order for a GI consultation. The appointment was documented in the facility's appointment book, but the resident did not attend, and no transportation was arranged. The Transportation Scheduler reported that he did not schedule EMS transportation and was unsure who was responsible for doing so. The Social Worker, who was responsible for making appointments, was unavailable for interview, and the former ADON did not recall why transportation was not arranged. The Administrator stated that the expectation was for transportation to be scheduled so residents would not miss appointments. These deficiencies were identified through observations, record reviews, and interviews with staff and family members. The failures included not following physician orders for wound care and not ensuring necessary transportation for a medical appointment, both of which were directly observed or confirmed by staff and documentation.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Provide Timely Foot Care and Podiatry Services
Penalty
Summary
The facility failed to assess and provide appropriate foot care for two residents, both of whom had significant medical conditions that increased their risk for foot complications. One resident had a history of cerebral infarction with hemiplegia and diabetes mellitus, was severely cognitively impaired, and was dependent on staff for all activities of daily living. The other resident had polyosteoarthritis, peripheral vascular and arterial disease, muscle weakness, and required assistance with personal hygiene. Despite these needs, neither resident received regular foot assessments to determine if nail care was needed, nor were their toenails trimmed as required. Observations revealed that both residents had long, thick toenails with crusty material underneath, and their toenails extended significantly beyond the tips of their toes. Nursing staff acknowledged that the toenails were too long and thick to be managed by nursing staff and that podiatry intervention was necessary, especially for the diabetic resident. However, neither resident was scheduled for or seen by the podiatrist during the facility's podiatry clinics, and there were no records of podiatry consultations in their medical records. Interviews with facility staff, including the DON and NP, indicated a lack of awareness regarding the residents' need for podiatry services. The DON explained that the absence of a social worker, who was responsible for scheduling podiatry appointments, may have contributed to residents not being placed on the podiatry schedule. The facility held podiatry clinics every three months, but the process for ensuring residents in need were seen was not maintained, resulting in unmet foot care needs for these residents.
Failure to Ensure Safe Mechanical Lift Transfers and Adherence to Manufacturer Guidelines
Penalty
Summary
The facility failed to provide safe mechanical lift transfers for residents dependent on such equipment, resulting in accident hazards and inadequate supervision. In one incident, a resident with quadriplegia, a history of traumatic brain injury, and chronic respiratory failure required a mechanical lift for all transfers. During a transfer, a nursing aide attempted to use the mechanical lift alone, despite facility policy and the resident's care plan requiring two staff members. The aide proceeded without assistance, and the lift's battery failed during the transfer. While attempting to maneuver the resident, the lift swung and struck the resident's forehead, causing a hematoma. The resident was subsequently lowered to the floor and transported to the hospital for evaluation. Interviews and witness statements confirmed that only one staff member was present during the transfer, and the aide had asked another staff member to falsely state she was present. In a separate incident, staff failed to follow the manufacturer's guidelines for the use of a mechanical lift during a transfer of another resident with quadriplegia. Observations revealed that two aides transferred the resident from a wheelchair to a bed without widening or locking the base of the mechanical lift, as required by the manufacturer's instructions. The lift was pushed tightly around the wheelchair, causing it to become stuck, and the unit manager had to maneuver the wheelchair to release it. Interviews with the involved staff confirmed that they did not ensure the base was widened or the wheels locked during the transfer, despite being aware of the correct procedure. Both incidents demonstrate a failure to adhere to facility policy and manufacturer guidelines for mechanical lift use, resulting in unsafe transfer practices. The deficiencies were identified through observation, record review, and interviews with residents and staff, affecting two of three residents reviewed for accident hazards, supervision, and device use.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Failure to Properly Label Enteral Feeding Setup
Penalty
Summary
The facility failed to follow proper procedures for labeling a continuous gastrostomy tube feeding for one resident who was dependent on enteral nutrition. The resident, who had chronic respiratory failure with hypoxia, diabetes mellitus, and was unable to eat by mouth, received all nutrition through a gastrostomy tube. Physician orders specified that the enteral feeding pump tubing, solution, and piston syringe should be changed nightly, and that the feeding should be administered continuously at a specified rate. The resident's care plan included interventions such as elevating the head of the bed and monitoring for complications related to tube feeding. During multiple observations, the enteral feeding bag was found to be inadequately labeled, missing required information such as the resident's name, type of feeding solution, additives, the name of the nurse who prepared the feeding, and the rate and method of infusion. Staff interviews confirmed that the facility's policy required this information to be included on the label, but it was not consistently done. The DON and NP both acknowledged the importance of proper labeling and confirmed that the observed practice did not meet facility expectations.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with chronic respiratory failure and hypoxia, who was dependent for all activities of daily living and had severely impaired cognitive skills, did not receive oxygen at the physician-ordered rate. The resident was admitted with orders for continuous oxygen at 2 liters per minute (LPM) via nasal cannula. Multiple observations over four consecutive days revealed that the oxygen concentrator was set at 1 LPM instead of the prescribed 2 LPM, despite the resident's care plan and physician's orders specifying the correct rate. Interviews with nursing staff and the DON confirmed that the oxygen flow rate was not checked as required during initial assessments, and the staff member responsible for the resident during the observed period did not recall verifying the flow rate on any of those days. The DON and Administrator both stated that staff are expected to follow physician orders for oxygen administration, and the NP confirmed that an active order specifying the flow rate must be followed. The failure to ensure the resident received oxygen at the prescribed rate was directly observed and acknowledged by facility staff.
Failure to Follow Enhanced Barrier Precautions and Infection Control Policies
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) and infection control policies during the care of residents with indwelling medical devices. Nurse #2 did not wear a gown while administering medications via a gastrostomy tube to a resident, despite an EBP sign being posted above the resident's bed. There was also no personal protective equipment (PPE) available in or outside the resident's room. Nurse #2 stated she did not see the EBP sign and was unaware that gown use was required for feeding tube care. The Director of Nursing (DON) confirmed that EBP signage had been moved from doors to above beds and that PPE had been relocated to storage rooms, making it less accessible to staff. Similarly, a nurse aide failed to don a gown while providing urinary catheter care to another resident, with no PPE available in or outside the room and the EBP sign placed behind the resident's bed. The nurse aide admitted to forgetting to wear a gown and typically obtained PPE from central supply before care. The DON and Administrator both acknowledged that the EBP policy required gown use for such care activities and expected staff to comply with infection control regulations. Additionally, the Wound Nurse did not follow hand hygiene or clean dressing policies while preparing and administering wound care. The nurse prepared wound supplies after sanitizing her hands but then touched unclean surfaces and handled wound care materials with ungloved hands, failing to sanitize again before proceeding. The supplies were placed on an unclean overbed table, and the nurse used her bare fingers to prepare gauze for wound cleansing. The DON and Administrator both confirmed that the Wound Nurse should have sanitized her hands and worn gloves during these steps, in accordance with facility policy.
Deficient Call Light System Fails to Alert Staff for Resident Needing Assistance
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the call light system was functioning properly for a resident who required assistance with activities of daily living. The resident, who had a history of cerebral infarction, hypertensive heart disease, and dysphagia, was cognitively intact and needed partial assistance with transfers and toileting. During an observation, it was found that while the call light at the bedside would illuminate the light above the room entry door and the communication panel at the nurse's station, no audible alarm sounded. Additionally, there was no manual hand bell available for the resident to use to call for assistance. Interviews with staff revealed that the call bell system had not been working correctly for some time, with issues such as the alarm not sounding and lights not functioning in certain rooms. Staff reported that, due to these ongoing issues, they relied on rounding every two hours to check on residents. The resident confirmed he could engage the call light but did not hear a noise and sometimes experienced delays in staff response. Maintenance and administrative staff acknowledged the persistent problems with the call bell system and indicated that the issue was known and under review.
Failure to Implement PRN Antipsychotic Stop Dates and AIMS Assessment
Penalty
Summary
The facility failed to adhere to regulations regarding the use of PRN antipsychotic medications, specifically Haloperidol, for a resident diagnosed with major depressive disorder and anxiety disorder. The resident, who was cognitively impaired and exhibited behaviors such as hallucinations, had an active physician order for Haloperidol without a stop date, contrary to the requirement that PRN antipsychotic medications must have a 14-day stop date. Interviews with staff, including a nurse and the hospice nurse, revealed a misunderstanding of the requirement for a stop date, with the hospice nurse indicating that the facility had not requested stop dates for PRN antipsychotic medications. Additionally, the facility did not conduct an Abnormal Involuntary Movement Scale (AIMS) assessment for the resident, which is necessary to monitor for side effects associated with antipsychotic drug therapy. The Director of Nursing acknowledged that an AIMS assessment should have been completed when the resident was started on Haloperidol and then every three months thereafter. However, the assessment was missed, and the Director of Nursing was unsure who was responsible for completing it. The Consultant Pharmacist had made recommendations, including the need for a 14-day limit on PRN antipsychotic orders and the completion of an AIMS assessment, but these recommendations had not been acted upon by the facility. The Medical Director and Administrator also expressed misconceptions about the necessity of stop dates for hospice patients, believing that terminal status exempted them from this requirement. This lack of compliance with medication management protocols and monitoring requirements led to the identified deficiency.
Significant Medication Error: Plavix Not Administered
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who did not receive an antiplatelet medication, Plavix, as ordered upon readmission. The resident, who had a history of chronic ulcer of the left heel, peripheral vascular disease, and cerebral infarction, was readmitted after a hospital stay where she underwent a drug-coated balloon angioplasty. The hospital discharge summary included an order for Plavix to be taken daily, but this order was not entered into the facility's electronic system by Nurse #2, who mistakenly thought it was a one-time order due to a misunderstanding of the start and stop dates. The error was compounded by the failure of the facility's process for verifying new admission orders. Nurse #2 did not clarify the Plavix order with the provider, and the second nurse check, which was supposed to ensure accuracy, was not effectively carried out. As a result, the resident's medication administration record for June did not include Plavix, and the resident did not receive the medication as prescribed. Interviews with the vascular PA and NP confirmed that Plavix was part of the standard protocol post-angioplasty to prevent re-occlusion of the blood vessel. The deficiency was identified when the Director of Nursing was informed by the Administrator about the missed Plavix order. The Medical Director acknowledged the omission as a significant medication error. Despite the error, the vascular PA and NP indicated that the lack of Plavix did not impact the resident's need for a left leg amputation, as the blood flow to the heel was not restored during the angioplasty, and the amputation was due to the occlusion of blood vessels leading to the heel.
Inaccurate Documentation of Advanced Directives
Penalty
Summary
The facility failed to maintain accurate advanced directives in the medical records for two residents. Resident #47 had a discrepancy between the Medical Orders for Scope of Treatment (MOST) form, which indicated a Do Not Resuscitate (DNR) status, and the care plan, which incorrectly listed the resident as Full Code. This inconsistency was identified during a review of the resident's records, and it was noted that the care plan should have been updated to reflect the change in the resident's health directive. The Social Services Director acknowledged the error, stating that health directives should be consistent across the medical record, care plan, and health directive binder. Similarly, Resident #45's records showed a mismatch between the physician's orders, which indicated a DNR status, and the care plan, which still listed the resident as Full Code. The Social Services Director admitted that the care plan was not updated when the resident's code status changed. The administrator confirmed that the care plan should have been revised to reflect the updated advanced directive. These discrepancies highlight a failure in the facility's process for ensuring that residents' advanced directives are accurately documented and consistently updated across all relevant records.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.41% error rate. This was due to two medication errors out of 27 opportunities, affecting one resident. The first error involved the administration of Nifedipine ER tablets, which were nearly crushed by a nurse despite being extended-release medications that should not be crushed. The nurse was stopped multiple times during the process and eventually realized the mistake after reviewing the medication administration record. The nurse acknowledged that crushing the ER tablets would release the medication all at once, which could cause blood pressure issues for the resident. The second error involved the administration of incorrect eye drops. The nurse was unable to locate the prescribed Artificial Tears and instead administered a different type of lubricating eye drop, believing them to be the same. However, the pharmacist confirmed that the two medications were different, although they served the same purpose. The nurse did not verify with the physician or obtain an order to use the alternative eye drops, leading to the administration of the wrong medication. Interviews with the Director of Nursing, the Nurse Practitioner, and the Administrator revealed a lack of awareness and communication regarding these medication errors. The Director of Nursing and the Nurse Practitioner both stated that the nurse should have clarified the medications before administration. The Administrator was informed of the Nifedipine ER error but was unaware of the eye drop error, indicating a need for better oversight and education on medication administration protocols.
Failure to Implement Enhanced Barrier Precautions for Resident with Chronic Ulcer
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not implementing Enhanced Barrier Precautions (EBP) for a resident with a chronic ulcer. The facility's policy requires EBP for residents with wounds to prevent the transmission of multidrug-resistant organisms. However, during multiple observations, it was noted that there were no personal protective equipment (PPE) supplies or EBP signage in the resident's room, and the Wound Care Nurse did not wear a gown while performing wound care. The resident in question had a chronic ulcer on her left heel, which required EBP according to the facility's policy. Observations revealed that the Wound Care Nurse only wore gloves and not a gown during wound care, which is a high-contact activity necessitating full PPE. The absence of PPE supplies and EBP signage was consistent over several days, indicating a systemic oversight in implementing the necessary precautions for the resident. Interviews with the Wound Care Nurse, Infection Preventionist, Director of Nursing, and Administrator revealed a lack of awareness and a process for ensuring EBP was in place for residents with wounds. The Infection Preventionist admitted to not having a good process for re-admissions needing EBP, which led to the oversight. The Director of Nursing and Administrator acknowledged the deficiency and the need for EBP for residents with wounds, but were unaware of the lapse until it was brought to their attention.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to keep a urinary catheter drainage bag off the floor for a resident, increasing the risk of infection. Resident #2, who has a history of obstructive uropathy and chronic kidney disease, was observed propelling herself in a wheelchair with the catheter drainage bag dragging on the floor. The resident was unaware of the issue, and staff had previously repositioned the bag to prevent it from touching the floor. However, the bag was not properly secured, leading to it dragging on the floor during the resident's movement from the dining room to her room, a distance of 226 feet. Nurse #1, who was working her first day at the facility, and Nurse Aide #1, who was responsible for the resident's care that day, both acknowledged that the catheter drainage bag should not be on the floor. Despite recent in-service training on catheter care and infection control, the bag was still improperly positioned. The Infection Control Preventionist and the Director of Nursing also confirmed that the catheter drainage bag should be kept off the floor to prevent infections. The Director of Nursing attempted to reposition the bag, but the resident moved it again due to discomfort with its placement near the wheelchair wheel. The facility had previously conducted an in-service training on catheter care, but the issue persisted, indicating a failure in ensuring consistent adherence to infection control protocols by the staff.
Failure to Post Nurse Staffing Data at the Beginning of Each Shift
Penalty
Summary
The facility failed to post nurse staffing data at the beginning of each shift for two consecutive days during the survey. On 4/30/24 at 11:00 AM, the nurse staffing data for 4/28/24 was observed, and on 5/1/24 at 10:37 AM, the nurse staffing data for 4/30/24 was observed. The data was not updated at the beginning of each shift as required. The Scheduler, who was responsible for posting the data, typically arrived after the first shift had started and left during the second shift. She admitted to posting the data only once daily and not adjusting it for any staffing changes per shift. Additionally, she was on vacation from 4/20/24 to 4/29/24 and did not ensure the data was posted correctly during her absence. Interviews with the Receptionist, ADON, DON, and Administrator revealed a lack of clarity and communication regarding the responsibility for posting nurse staffing data in the Scheduler's absence. The Receptionist stated she was not asked to post the data, and the ADON mentioned that the manager who arrived first should post it, but she did not typically check the postings. The DON was unsure who was responsible in the Scheduler's absence, and the Administrator expected the data to be posted daily but not necessarily at the beginning of each shift. This lack of coordination and adherence to regulatory requirements led to the deficiency in posting nurse staffing data accurately and timely.
Failure to Update Care Plan for Self-Administration of Medications
Penalty
Summary
The facility failed to update the comprehensive person-centered individualized care plan to reflect an assessment for a resident to self-administer medications. Resident #3, who was admitted with diagnoses including neuralgia and neuritis, was evaluated with intact cognition and no upper extremity impairment. Despite being assessed and approved by the interdisciplinary team (IDT) to self-administer pain relief creams, this approval was not reflected in the resident's care plan. The Assistant Director of Nursing (ADON) completed the Self Administration of Medications assessment and educated the resident on the process but did not update the care plan accordingly. Interviews with the ADON, MDS Nurse, Director of Nursing (DON), and Nurse Practitioner (NP) revealed a lack of clarity and communication regarding the responsibility for updating the care plan. The ADON believed it was the MDS Nurse's responsibility, while the MDS Nurse was still in training and not yet familiar with the process. The DON acknowledged that the care plan could have included the task but did not confirm if it should have been added. The NP confirmed that the resident was competent to self-administer the pain relief creams and should have had a care plan addressing this ability. The Administrator stated that the facility was not required to develop a care plan for self-administration but only to complete an IDT assessment, which was done.
Transporter Failed to Call EMS After Resident's Fall in Van
Penalty
Summary
Transporter #1 failed to call emergency medical services (EMS) or have a resident assessed by a medical professional before moving a resident after his wheelchair tipped over and he fell to the floor of a transportation van. The incident occurred when Transporter #1 pulled out of the dialysis center parking lot, causing the resident's wheelchair to tip backwards, resulting in the resident hitting the left occipital region of his head. Despite the resident being on Plavix, an anti-platelet medication that can increase the risk of bleeding, Transporter #1 did not call EMS and instead moved the resident back into a sitting position and transported him back to the facility. Upon arrival at the facility, the resident was assessed to have a bump on his head behind his left ear and reported head pain and nausea. The resident was then sent to the hospital for evaluation, where a CT scan of the head was negative, and he returned to the facility the same day. Interviews with the resident and Transporter #1 revealed that the transporter was aware of the facility's policy to call EMS in such incidents but failed to do so due to being upset by the incident. The facility's policy and procedure for transportation vehicles, dated 10/2018, required drivers to halt any transport that seemed unsafe and to report any incidents to the Administrator and appropriate authorities. The transporter had been trained on these procedures but did not follow them during the incident. The failure to call EMS and have the resident assessed by a medical professional before moving him off the floor of the van was identified as a deficiency in the facility's handling of the situation.
Failure to Secure Wheelchair Leads to Resident Injury During Transport
Penalty
Summary
The facility failed to provide safe transportation for a resident when his wheelchair tipped over in the transportation van, causing him to hit his head. The incident occurred when the transporter pulled out of the dialysis center parking lot, and the resident's wheelchair was not properly secured, leading to the fall. The resident, who was on blood-thinning medication, experienced head pain and nausea after the fall and was later sent to the hospital for evaluation. The investigation revealed that the transporter did not secure the wheelchair according to the manufacturer's instructions. The right front securement strap was positioned too far to the side, allowing the wheelchair to move and tip over. The Maintenance Director confirmed that the pin connectors and J-hooks were not correctly positioned, which contributed to the incident. The transporter, who had been with the facility for 16 months, had not experienced any previous incidents but failed to follow the proper procedure in this case. The resident involved in the incident was admitted to the facility with multiple diagnoses, including end-stage renal disease and diabetes, and used a manual wheelchair for mobility. The resident was cognitively intact and had limited range of motion due to a below-the-knee amputation. Despite the fall, the resident was alert and oriented when assessed by the Assistant Director of Nursing upon returning to the facility.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess whether the self-administration of medications was clinically appropriate for a resident who was observed to have a medication cup at their bedside. The resident, who was cognitively intact and had multiple diagnoses including acute posthemorrhagic anemia, end-stage renal disease, and diabetes, was admitted to the facility with a regimen of several medications to be taken in the morning. On a specific morning, the resident was observed with a medication cup containing 10 medications on their over-the-bed table, which they took after breakfast without a physician's order or a care plan in place for self-administration. Nurse #1, who was responsible for administering the medications, left them at the resident's bedside upon the resident's insistence, believing it was acceptable due to the resident's alert and oriented state. However, the facility's Director of Nursing and other staff members, including the Unit Manager and the Administrator, confirmed that medications should not be left at the bedside without an assessment for self-administration. The Nurse Practitioner noted that the resident sometimes refused medications, but missing a dose would not have harmed the resident. The incident highlighted a lapse in protocol adherence, as the resident had not been assessed for the ability to self-administer medications safely.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
