Pembroke Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pembroke, North Carolina.
- Location
- 310 E Wardell Drive, Pembroke, North Carolina 28372
- CMS Provider Number
- 345409
- Inspections on file
- 30
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Pembroke Center during CMS and state inspections, most recent first.
A resident without DM and with no insulin order received 10 units of insulin lispro when a nurse, distracted during med pass, confused two residents who shared the same last name and failed to verify the correct patient before administration. The resident, who was cognitively intact and admitted with influenza and pneumonia, had active orders for oxygen, albuterol, digoxin, and metoprolol but none for insulin, and the eMAR contained no insulin orders. After the injection, the resident questioned the medication, stating she was not diabetic, and subsequent interviews with the nurse, unit manager, DON, pharmacist, medical director, and administrator confirmed that the insulin was administered in error because the nurse did not follow the required resident-identification and medication-verification checks.
A resident with a feeding tube and GERD was given an expired compounded medication, Pantoprazole Suspension, for nine days via enteral administration. The medication's expiration was not checked by nursing staff before administration, resulting in eighteen doses of expired medication being given before the error was discovered. The resident was evaluated in the emergency department and had no adverse effects.
A facility failed to prevent the diversion of discontinued Hydrocodone-Acetaminophen tablets, resulting in 20 missing doses for a resident with pressure wounds. The medication order was not entered into the electronic record, and the medication card was not removed from the cart after discontinuation. Nursing staff did not consistently document administration or remove discontinued medications, and count sheets were altered without explanation. The resident did not experience missed pain medication, but the facility substantiated the misappropriation of controlled substances.
Surveyors found that medication carts were left unlocked and unattended, loose and unsecured pills were present in drawers, expired OTC medications were available for use, and inhalation medication vials were not labeled or dated as required. Staff and the DON confirmed these practices did not meet expected standards.
Staff failed to follow infection control and Enhanced Barrier Precautions protocols for multiple residents, including those with COVID-19, indwelling urinary catheters, gastrostomy tubes, and pressure ulcers. Observed lapses included not wearing required PPE such as gowns and gloves, improper handling and cleaning of equipment, and incorrect disposal of soiled linens, despite staff awareness of policies and recent infection control training.
The facility did not provide written grievance summaries to two residents with severe cognitive impairment after concerns were raised about nail care, dressing for appointments, and assistance with bathroom transfers. Staff, including the Administrator, DON, and Social Worker, were unaware of the requirement for written notification, resulting in missing or incomplete documentation of grievance resolutions.
Two NAs refused to provide transfer and incontinence care to a dependent, cognitively intact resident after a disagreement, leaving her in a soiled brief and wheelchair for several hours in a semi-private room. The resident was found distressed and humiliated, with care only provided after a shift change.
A resident dependent on staff for ADLs due to hemiplegia was left without incontinence care and assistance to bed after two NAs refused to provide care following a disagreement. The resident remained in a soiled brief for several hours until the next shift, when staff found her still in her wheelchair with dried fecal matter and visibly upset.
A resident with CHF and multiple comorbidities experienced significant, unverified weight fluctuations due to the facility's failure to ensure reweighs were performed when large discrepancies were recorded. Staff entered weights into the medical record without confirming accuracy, and nurse aides did not reweigh unless specifically instructed. The DON and physician confirmed that significant weight changes should have prompted reweighs, but this was not consistently done, resulting in inaccurate documentation.
A resident admitted with multiple advanced pressure ulcers and osteomyelitis did not receive timely initial wound assessments or wound care orders upon admission. Nursing staff failed to document wound descriptions, obtain necessary orders, or initiate wound treatments within the required timeframe. Delays were compounded by the unavailability of wound vac supplies and lack of a dedicated wound nurse, resulting in missed and delayed wound care interventions.
A nurse aide failed to follow the care plan and Kardex instructions requiring two-person assistance for a resident with hemiplegia and dementia during incontinence care. While providing care alone, the resident rolled off the bed, resulting in a head laceration and a C1 cervical spine fracture. The aide did not check the Kardex or request help from available staff, leading to the incident.
A resident with a history of a stage IV pressure wound and osteomyelitis had a discontinued order for Hydrocodone-Acetaminophen 5-325 mg, but the medication was not removed from the med cart as recommended by the consultant pharmacist. The DON missed the pharmacist's note to remove the discontinued medication, resulting in 20 missing tablets being discovered during a later count.
A resident with multiple stage IV pressure ulcers and osteomyelitis did not receive four scheduled doses each of Piperacillin and Vancomycin after admission due to failure to enter and communicate IV antibiotic orders in the electronic medical record and to the pharmacy, resulting in delayed administration.
A resident with cognitive intactness and significant physical impairments requested that her air conditioner remain on, but a NA turned it off against her wishes. After the resident protested, the NAs refused to provide incontinence care and assistance to bed, leaving the room without fulfilling her care needs. Facility leadership confirmed that staff failed to respect the resident's choices and should have provided care regardless of her response.
A resident with CHF and on diuretic therapy experienced a significant weight gain of 26.8 lbs over 19 days, but staff failed to notify the provider as required. The nurse entering the weight noted an alert for significant gain but did not compare previous weights or inform the provider or dietitian, resulting in no action being taken regarding the resident's change in condition.
Quarterly MDS assessments for two residents were not completed within the required 14-day timeframe after the ARD. Staff interviews confirmed that the MDS CRC was unable to complete assessments on time due to covering multiple facilities, and both the DON and Administrator were aware of the delays, which were attributed to a vacant MDS CRC position.
A resident with multiple chronic conditions experienced a significant weight gain of 26.8 pounds in 19 days. Staff did not verify the accuracy of this weight change or notify the RD for a nutritional assessment, despite the electronic medical record flagging the gain as significant. Required reweighting and communication protocols were not followed, and the RD was only made aware of the issue by the surveyor.
A required annual performance review was not completed for a nurse aide, as confirmed by personnel records and staff interviews. The DON, responsible for these evaluations, had not conducted any annual reviews for nurse aides since her hire, and the affected nurse aide confirmed she had not received her evaluation.
Two residents, both cognitively intact and requiring assistance with ADLs, became involved in a physical altercation over a privacy curtain, resulting in one resident sustaining multiple bruises, abrasions, and a suspected fracture while on a blood thinner. Neither resident had a behavioral care plan, and staff were unaware of any prior behavioral issues or incompatibility before the incident.
A resident with end stage dementia receiving hospice care did not have current hospice documentation, including care plans and physician orders, in the facility's medical record. Hospice staff maintained records on their tablets and did not provide timely documentation to the facility, while facility nurses did not receive reports or integrate hospice information into the care plan. The DON and administrator confirmed there was no process in place to ensure hospice documentation was monitored or included in the resident's care plan.
A resident received Hydroxyzine 25 mg daily instead of as needed due to a transcription error in the medication order. Despite multiple checks by staff, the error was not identified, and the medication was administered nightly for nearly two months. The resident experienced no adverse effects and was unaware of the daily medication.
A facility failed to apply an ace wrap to a resident's swollen foot as ordered by a physician after a fall, and also failed to monitor blood pressure before administering Hydralazine to another resident. The ace wrap was not applied despite visible swelling and pain, and blood pressure readings were not recorded for noon and bedtime doses of the medication, contrary to physician orders.
A facility failed to provide sufficient nursing staff, affecting a dependent resident who required two-person assistance for care. The resident experienced falls during care due to inadequate staffing, particularly on night shifts. Staff interviews revealed frequent staffing shortages, reliance on unreliable agency staff, and challenges in finding replacements for call-outs. The Director of Nursing acknowledged the issues and was assessing staffing agency reliability.
The facility failed to ensure 8 consecutive hours of RN coverage on multiple days due to a misunderstanding of agency staff credentials, resulting in LPNs being used instead of RNs. The issue was compounded by data entry errors in the PBJ report, which did not accurately reflect the presence of an RN on one of the days.
A facility failed to act on a Pharmacist's recommendations to clarify a resident's Hydralazine dosage and add blood pressure checks before administration. Despite repeated monthly reviews from July to October, the facility did not update the MAR or clarify the dosage, leading to continued confusion. The new DON was unaware of these issues due to staff turnover, and the Unit Manager only addressed it after consulting the physician.
A facility failed to maintain proper communication and coordination of hospice services for a resident, resulting in missing hospice documentation in the resident's medical record. Staff reported ongoing challenges in obtaining necessary documentation from the hospice provider, and hospice documents were found to be disorganized in a box, complicating access to information. A meeting was scheduled to address these issues with the hospice provider.
A resident with cognitive impairment wandered into another resident's room and took personal items, leading to a physical altercation when confronted. The resident who confronted the other responded to a swing by punching the other resident in the forehead. No injuries were reported, but the incident was substantiated as abuse. The facility failed to protect residents from physical abuse.
A resident with significant mobility impairments fell twice from their bed due to inadequate supervision and staffing in an LTC facility. Despite requiring two-person assistance, care was provided by a single aide on both occasions, leading to falls and minor injuries. The facility's failure to adhere to the care plan and ensure proper staffing contributed to these incidents.
The facility failed to maintain complete medical records for three residents, with missing documentation for medication administration and wound care treatments. An agency nurse did not sign off on medications for hypertension and diabetes, while several nurses could not recall completing or documenting wound care treatments. The DON was unaware of these issues until the survey.
A cognitively impaired male resident sexually abused a female resident deemed incompetent by the court. Despite the male resident's documented history of sexually inappropriate behaviors, the facility failed to adequately monitor or prevent him from accessing the female resident's room, leading to the incident. Previous warning signs were not acted upon, resulting in the abuse.
Insulin Administered to Wrong Resident Due to Failure to Verify Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when insulin was administered without a corresponding order. A cognitively intact resident admitted with influenza and pneumonia, and without a diagnosis of diabetes, had active physician orders for oxygen, albuterol, digoxin, and metoprolol, but no orders for insulin. The resident’s electronic MAR for the month showed no insulin orders. Despite this, the resident received 10 units of insulin lispro during a medication pass. On the day of the incident, a nurse working on the medication cart administered 10 units of lispro insulin to this resident instead of to the intended resident who shared the same last name. The nurse reported being distracted and acknowledged that she failed to adequately verify the correct resident before administering the medication. The resident questioned the injection, stating she was not diabetic and did not take insulin, after being told it was her evening insulin. The unit manager later confirmed that the nurse had given insulin to the wrong resident. Interviews with the DON, pharmacist, medical director, and administrator confirmed that the resident had no insulin order and that the insulin was given in error due to failure to verify the right resident. The DON and administrator both stated it was their expectation that the nurse verify the right resident, right medication, right dose, and right route prior to administration, which did not occur in this case. The pharmacist and medical director confirmed that the insulin administration was unintended for this resident and that it occurred because the nurse confused two residents with the same last name during the medication pass.
Expired Compounded Medication Administered via Enteral Tube
Penalty
Summary
A resident with a history of stroke with aphasia, gastrostomy tube feeding, and gastroesophageal reflux disease (GERD) was administered an expired compounded medication, Pantoprazole Sodium Oral Suspension, via enteral tube for nine days, totaling eighteen doses. The medication, which had a shortened expiration date due to its compounded nature, was stored in the medication cart and not checked for expiration prior to administration. The error was discovered after the resident had already received the morning dose, prompting notification of the responsible party and subsequent transfer to the emergency department for evaluation. The resident was found to have no acute complaints or adverse effects from the expired medication and was discharged back to the facility. The deficiency was identified through review of medication administration records, interviews with staff, the consulting pharmacist, and the physician. The consulting pharmacist confirmed that compounded medications have a short shelf life and require close monitoring of expiration dates. The physician stated that while no adverse effects were expected, nursing staff are required to ensure that expired medications are not present or administered. The incident was brought to the attention of facility leadership several months after it occurred, following a grievance filed by the resident's responsible party.
Failure to Prevent Diversion of Discontinued Narcotic Medication
Penalty
Summary
The facility failed to implement effective safeguards and systems to prevent the diversion of discontinued narcotic pain medication, specifically Hydrocodone-Acetaminophen 5-325 mg tablets, resulting in 20 missing tablets for one resident. The resident, who was cognitively intact and had a history of stage IV and stage II pressure wounds, was re-admitted with orders for Hydrocodone-Acetaminophen. Two separate physician orders were issued: one from the hospital and another from the facility physician, but the second order was not entered into the electronic medical record. Medication deliveries were signed in by nursing staff, and declining count sheets were maintained, but discrepancies arose between the count sheets and the Medication Administration Record (MAR), with some administrations not documented on the MAR and some signatures on the count sheet being illegible. The process for handling controlled substances was not consistently followed. The order for 54 tablets was not entered into the electronic record, and the medication card remained on the medication cart beyond the 14-day period specified in the order. Nursing staff failed to remove the discontinued medication card from the cart and return it to the pharmacy as required. During shift counts, it was discovered that the count on the narcotic sheet had been altered, with 20 tablets unaccounted for. Interviews with staff revealed confusion about responsibilities for removing discontinued medications and inconsistent practices regarding shift counts and documentation. Consultant pharmacists conducted periodic audits but did not review the specific resident's medication card during the relevant period. Communication lapses were noted between the nurse practitioner, nursing staff, and the DON regarding order entry and medication management. The facility substantiated the misappropriation of the resident's property, and the investigation was unable to determine who took the missing medication. The resident reported no issues with pain management and did not experience any missed doses, but the facility's failure to maintain accurate records and secure discontinued controlled substances led to the deficiency.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of drugs and biologicals. An unattended and unlocked medication cart was left facing the hallway for 13 minutes, during which time three staff members and a resident in a wheelchair passed by. The Unit Manager later acknowledged forgetting to lock the cart, and the DON confirmed that medication carts are expected to be locked when not in direct line of sight. Additionally, another medication cart was found to contain 11 loose, unsecured pills of various types, with both the nurse and DON stating that medication carts should be clean and free of loose pills. Further observations revealed expired over-the-counter medication (Vitamin B6) available for use in a medication storage room, which both the Unit Manager and DON agreed should not occur. On another medication cart, 20 vials of ipratropium bromide inhalation solution were found in an open foil package without a label or date opened, despite manufacturer instructions to discard the medication two weeks after opening. The nurse responsible was unaware of this requirement, and the DON stated that all medications should be labeled and dated when opened.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures in multiple instances involving residents requiring special contact and droplet precautions, as well as Enhanced Barrier Precautions (EBP). In one case, a resident who tested positive for COVID-19 was on special contact and droplet precautions, as indicated by signage on the door and the availability of PPE supplies nearby. Despite this, a nurse aide entered the resident's room without donning gloves or a gown, moved a mechanical lift out of the room into the hallway without cleaning it, and later re-entered the room again without appropriate PPE to assist the resident. The mechanical lift was left unattended in the hallway until instructed by a unit manager to clean and store it properly. The nurse aide admitted to forgetting the required PPE and expressed confusion between different types of precautions, despite having received infection control training. In another instance, two nurse aides provided a bed bath and repositioned a resident with an indwelling urinary catheter, who was on EBP, while wearing gloves but not gowns. Both aides acknowledged during interviews that they were aware of the resident's precaution status and the need for gowns but failed to comply, attributing the lapse to forgetfulness. The Director of Nursing confirmed that all staff had received infection control training, especially following a recent COVID-19 outbreak, and that PPE supplies were adequate and available. Additional deficiencies were observed when a nurse aide provided care to a resident with a gastrostomy tube and another with a pressure ulcer, both on EBP, while only wearing gloves and not a gown. The aide also placed soiled linens on the floor instead of in a plastic bag, contrary to facility policy and her training. The aide admitted to not following protocol due to being rushed or not bringing the necessary supplies into the room. Interviews with supervisory staff confirmed that the expectation was for staff to follow posted EBP signage and infection control procedures, and that further education was needed.
Failure to Provide Written Grievance Summaries to Residents
Penalty
Summary
The facility failed to provide written grievance summaries to residents or their representatives as required by its own grievance policy. For two residents who were both severely cognitively impaired, grievances were filed regarding concerns such as inadequate nail care, improper dressing for appointments, and lack of assistance with bathroom transfers. In both cases, the grievance logs and forms either lacked documentation of written notification of the resolution or contained written summaries that did not correspond to the specific concerns raised. Staff interviews revealed that key personnel, including the Administrator, Director of Nursing, and Social Worker, were unaware of the requirement to provide written grievance summaries to residents or their representatives. Instead, resolutions were communicated verbally or not at all, and written documentation was either missing or incomplete. This resulted in the facility not adhering to its policy and regulatory requirements for grievance resolution documentation.
Neglect Due to Refusal of Care by Nurse Aides
Penalty
Summary
A deficiency occurred when two nurse aides (NAs) on the 3:00 PM to 11:00 PM shift refused to provide necessary care to a dependent resident with hemiplegia, cerebral infarction, and anxiety disorder. The resident, who was cognitively intact and fully dependent on staff for transfers and incontinence care, requested assistance to be transferred to bed and to receive incontinence care after her evening routine. The NAs entered the resident's room with a mechanical lift, turned off her air conditioner against her wishes, and left the room without providing care after the resident used a curse word in response. The resident was left sitting in her electric wheelchair in a semi-private room, exposed to her roommate, and was not assisted to bed or provided incontinence care for several hours. The resident's roommate confirmed the sequence of events, stating that the NAs refused to provide care after the resident expressed her displeasure at the air conditioner being turned off. The roommate observed that the resident remained in her wheelchair until after midnight, when the next shift arrived. When the night shift NAs finally provided care, they found the resident's brief heavily soiled with dried, caked bowel movement, indicating that incontinence care had been delayed for a significant period. The resident expressed feelings of embarrassment and humiliation due to being left in this condition in front of her roommate. Interviews with the involved NAs revealed that they refused to provide care because they felt disrespected by the resident's language. Both NAs acknowledged that they left the facility at the end of their shift without assisting the resident. The nurse on duty was informed of the incident but was not aware that care had not been provided before the NAs left. The night shift NAs and nurse confirmed the resident's distress and the delay in care. The deficiency was identified through observations, record review, and interviews, demonstrating a failure to protect the resident from neglect and to uphold her right to receive necessary care.
Failure to Provide Incontinence Care and Assistance with ADLs
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to hemiplegia following a stroke, was not provided with necessary incontinence care and assistance to bed. The resident, who was always incontinent of bladder and bowel and required two staff members and a mechanical lift for transfers, requested help after soiling her brief. Despite activating her call light and requesting assistance, two nurse aides assigned to her care refused to provide the needed care after a disagreement regarding the room temperature and the resident's use of a curse word. The nurse aides admitted in interviews that they left the resident without care because they felt disrespected by her language. As a result, the resident remained in her wheelchair for several hours, waiting for the next shift to arrive. When the night shift nurse aides eventually assisted her, they found that she was still in her wheelchair, visibly upset, and had been incontinent for some time, with dried and caked fecal matter present. Interviews with additional staff, including the nurse on duty and the Director of Nursing, confirmed that the resident was not assisted to bed or provided incontinence care as required. The staff acknowledged that care should have been provided regardless of the resident's behavior, and that the refusal to provide care was not acceptable. The incident was corroborated by multiple staff interviews and direct observation of the resident's condition.
Failure to Verify Accuracy of Physician-Ordered Weights for Resident with CHF
Penalty
Summary
The facility failed to verify the accuracy of physician-ordered weights for a resident with congestive heart failure, resulting in inaccurate documentation of significant weight changes. The resident, who had multiple chronic conditions including CHF, COPD, and dementia, was at nutritional risk and had a care plan that included regular weight monitoring due to a history of weight fluctuations, fluid retention, and recent significant weight loss. Despite physician orders for weekly and monthly weights, and care plan interventions to weigh per policy, the facility did not ensure that weights were rechecked when large fluctuations were recorded. Review of the resident's medical record showed several instances of dramatic weight changes, such as a 20-pound loss in four days, without a reweigh being performed to confirm accuracy. Staff interviews revealed that nurse aides obtained weights and reported them to the unit manager, who entered them into the electronic medical record without always checking for significant changes. The unit manager acknowledged not directing staff to perform reweighs when large discrepancies occurred, contrary to facility policy. The nurse practitioner and physician both stated that significant weight changes should trigger a reweigh to ensure accurate data for clinical decision-making. Further interviews confirmed that nurse aides relied on instructions from nursing staff to perform reweighs and would not do so independently. The physician noted that some documented weights were implausible and had not been reported as changes in condition. The DON stated that staff were expected to review and compare weights, and to obtain a reweigh if there was a significant increase or decrease, but this process was not followed. As a result, inaccurate weights were documented, and significant changes were not verified or reported as required.
Failure to Complete Timely Wound Assessments and Initiate Wound Care on Admission
Penalty
Summary
A resident was admitted with multiple advanced pressure ulcers, including stage IV ulcers on the left ischium, sacrum, and right hip, a stage II ulcer on the right buttock, a deep tissue injury on the left heel, and osteomyelitis requiring intravenous and oral antibiotics. Upon admission, the facility failed to complete initial wound assessments within the first 24 hours, as required. There was no documentation of wound descriptions with measurements or physician orders for wound care until two days after admission. The initial wound care orders and assessments were not entered until the Unit Manager returned to work, and the responsible nurses on the weekend of admission were agency staff who did not complete the necessary documentation or obtain wound care orders. The resident's hospital discharge instructions included follow-up with a wound center and specific antibiotic regimens but did not provide detailed wound care orders. The facility did not initiate wound care treatments or document wound assessments until several days after admission. Orders for wound vac therapy and alternative wound dressings were delayed, and some were not administered or documented as completed on the days they were ordered. The wound vac was not available in the facility, and the order for its use was eventually discontinued by the Wound Care Physician due to lack of availability. The initial wound assessments with measurements were only completed three days after admission, and wound care treatments began at that time. Interviews with facility staff, including the Unit Manager, Medication Aide, Wound Care Nurse, Wound Care Physician, and DON, confirmed that the initial wound assessments and wound care orders were not completed as required upon admission. The lack of timely assessment and initiation of wound care was attributed to the failure of the weekend nursing staff to perform these duties, the absence of a dedicated wound nurse at the time, and the unavailability of necessary wound care supplies. The Wound Care Physician noted that the resident's wounds worsened during the stay, with factors including missed wound treatments and inadequate offloading.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide provided incontinence care to a resident with a history of cerebral vascular accident (CVA), hemiplegia, and dementia, who was severely cognitively impaired and required extensive two-person assistance with bed mobility and activities of daily living. The resident's care plan and Kardex both indicated the need for two-person assistance for bed mobility. Despite this, the nurse aide proceeded to provide care alone, positioning the resident on her side and attempting to change the sheets while using only one hand to stabilize the resident. During the care, the resident began to move and subsequently rolled off the bed onto the floor, sustaining a laceration to the forehead and a nondisplaced fracture of the first cervical vertebrae (C1). The nurse aide immediately called for help, and nursing staff responded to provide emergency care and notify emergency medical services. The resident was transported to the hospital for evaluation and treatment, where the injuries were confirmed. Interviews and documentation revealed that the nurse aide did not check the Kardex prior to providing care, although she was aware from previous experience that the resident required two-person assistance. The assigned nurse and other staff were available and would have assisted if asked, but the nurse aide did not request help and attempted to perform the care alone, directly leading to the resident's fall and injury.
Failure to Remove Discontinued Narcotic Medication Leads to Missing Tablets
Penalty
Summary
The facility failed to act on the consultant pharmacist's recommendation to remove a discontinued narcotic pain medication, Hydrocodone-Acetaminophen 5-325 mg, from the medication cart after the order for a resident was discontinued. The resident, who had been re-admitted with a stage IV pressure wound and osteomyelitis, had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain, which was completed as ordered. However, a subsequent delivery of 54 tablets was received and partially administered, with the order discontinued after 14 days. Despite the consultant pharmacist's note in the August pharmacy report instructing the removal and return of the discontinued medication, the medication remained on the cart. A random audit by the consultant pharmacist identified the issue, and the recommendation to remove the medication was communicated to the DON but was missed in error. As a result, 20 tablets of the discontinued narcotic were found to be missing when the count was checked several months later. Staff interviews confirmed that the pharmacist's recommendations were not routinely followed up on, and the DON acknowledged responsibility for acting on the monthly pharmacy reports but failed to do so in this instance.
Missed IV Antibiotic Doses Due to Failure in Order Entry and Communication
Penalty
Summary
A deficiency occurred when a resident admitted with multiple stage IV pressure ulcers, osteomyelitis, and paraplegia did not receive prescribed intravenous antibiotics (Piperacillin Sodium Tazobactam and Vancomycin) as ordered for the treatment of osteomyelitis. The hospital discharge instructions included specific orders for both antibiotics, but review of the Medication Administration Record (MAR) showed that the first doses were not administered until two days after admission, resulting in four missed doses of each antibiotic. There was no documentation in the resident's progress notes explaining the missed doses during this period. Interviews revealed that the Unit Manager, who was responsible for reviewing admission orders, did not ensure the antibiotic orders were entered into the electronic medical record upon admission. The admitting nurse did not send the antibiotic orders to the pharmacy or enter them on the day of admission. The pharmacy did not receive the orders until the following day, delaying delivery and administration. The Director of Nursing confirmed that the orders should have been entered and the antibiotics administered sooner.
Failure to Honor Resident's Right to Make Choices Regarding Room Temperature and Care
Penalty
Summary
A deficiency occurred when a nurse aide (NA) turned off a resident's air conditioning against the resident's explicit wishes, thereby failing to honor the resident's right to make choices. The resident, who had a history of hemiplegia, cerebral infarction, and anxiety disorder, was cognitively intact and dependent on staff for transfers and toileting hygiene. On the night of the incident, the resident requested assistance with incontinence care and to be helped to bed. When the two NAs entered the room, they asked if they could turn off the air conditioner due to the cold temperature, but the resident refused. Despite this, one NA turned off the air conditioner, prompting the resident to use a curse word in protest. Following the resident's response, both NAs refused to provide the requested care and left the room, stating they did not want to argue with the resident. The incident was witnessed by the resident's roommate, who confirmed that the NAs disregarded the resident's wishes and left after being spoken to disrespectfully. The NAs later reported the incident to the nurse on duty. Both NAs stated they had received training on resident rights, including the right to make personal choices. Interviews with facility leadership, including the DON and the Administrator, confirmed that the NAs should not have turned off the air conditioner without the resident's permission and should have provided care regardless of the resident's language. The staff's actions resulted in the resident's choices not being respected and necessary care being withheld.
Failure to Notify Provider of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the provider of a significant weight gain in a resident with a history of congestive heart failure (CHF) who was prescribed diuretic medications. The resident was admitted with multiple diagnoses, including CHF, atrial fibrillation, hypertension, and peripheral vascular disease, and had physician orders for daily weights and diuretic therapy. Over a 19-day period, the resident experienced a weight gain of 26.8 pounds, increasing from 220.2 lbs to 247 lbs. Despite this significant change, there was no documentation that the physician or nurse practitioner was notified of the weight gain, as required for residents with CHF. Interviews with facility staff revealed that the nurse responsible for entering the resident's weight into the electronic medical record noticed an alert indicating a significant weight gain but did not compare the current and previous weights to confirm the extent of the change. As a result, neither the medical provider nor the registered dietitian was informed. Both the DON and the NP confirmed that their expectation was for the provider to be notified of such changes, especially given the resident's CHF diagnosis and the potential need for treatment adjustments.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for two residents. For one resident, the quarterly MDS assessment had an ARD of 7/10/25 but was not completed until 7/30/25. For another resident, the quarterly MDS assessment had an ARD of 7/23/25 and was completed on 8/20/25. Staff interviews revealed that the MDS Clinical Reimbursement Coordinator (CRC) was aware of the late assessments and attributed the delays to her responsibilities across multiple facilities, which prevented timely completion. The Director of Nursing (DON) and the Administrator both acknowledged awareness of the late MDS assessments, with the Administrator citing a vacant MDS CRC position as the reason for the delays.
Failure to Verify Significant Weight Gain and Notify Dietitian
Penalty
Summary
The facility failed to ensure the accuracy of a resident's weight measurement and did not communicate a significant weight gain to the Registered Dietitian for further nutritional assessment. A resident with multiple diagnoses, including right above the knee amputation, atrial fibrillation, hypertension, congestive heart failure, and peripheral vascular disease, experienced a weight increase of 26.8 pounds over 19 days. The care plan for this resident included monitoring for fluid volume excess and required staff to alert the dietitian and physician to any significant weight changes. Despite the electronic medical record flagging the weight gain as significant, staff did not perform a reweight within 24 hours as required by facility policy, nor did they review previous weights before entering the new value. Interviews with the Unit Manager, Nurse Practitioner, and Registered Dietitian confirmed that a reweight should have been conducted promptly for any weight change exceeding 5% in a month or 10% in six months. The Registered Dietitian was not notified of the significant weight gain until informed by the surveyor, and no additional weights were documented after the initial flagged entry. The Director of Nursing also confirmed that the expectation was for nursing staff to perform a reweight within 24 hours in the event of such discrepancies, which did not occur in this case.
Failure to Complete Annual Performance Review for Nurse Aide
Penalty
Summary
The facility failed to complete a required annual performance review for a nursing assistant, as evidenced by the absence of documentation in the personnel file for the nurse aide hired on 7/30/24. Record review confirmed that no performance evaluation had been conducted within the past year. Interviews with the Administrator and the Director of Nursing (DON) revealed that the DON, who was responsible for conducting these reviews, had not performed any annual performance reviews for nurse aides since being hired in March 2025. The nurse aide also confirmed that she had not received her expected annual evaluation.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident's right to be free from abuse was not protected, resulting in a resident-to-resident altercation. One resident, with a history of bipolar disorder and bilateral below-the-knee amputation, engaged in a physical altercation with her roommate, who had a history of cerebral vascular accident and was on a blood thinner for atrial fibrillation. The incident began as an argument over the room's privacy curtain, escalating when both residents attempted to control the curtain using a reacher. The resident with bipolar disorder scratched and hit her roommate, causing multiple bruises, abrasions, and a hematoma on the roommate's left hand and arm, which later required hospital evaluation and treatment for a suspected fracture. At the time of the incident, neither resident had a care plan addressing behavioral disturbances, and both were assessed as cognitively intact with no prior behavioral symptoms directed toward others. The altercation was witnessed by a nurse aide who heard yelling and attempted to intervene, but both residents were initially unwilling to let go of the curtain. The nurse aide called for additional staff, and the residents were separated. The injured resident was found with significant bruising, scratches, and bleeding, and was subsequently transferred to the hospital for further evaluation and treatment. Interviews with staff and the residents confirmed that the altercation was related to a disagreement over the privacy curtain, and that there had been no prior incidents or complaints between the two. The resident who initiated the physical contact had previously been involved in a minor altercation with another resident but had no documented behavioral care plan. The lack of a behavioral care plan and the absence of interventions to address potential roommate incompatibility contributed to the failure to prevent the abuse.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to coordinate a plan of care with the hospice provider and ensure that required hospice documentation was present in the medical record for a resident receiving hospice care. The resident, who had Alzheimer's disease and end stage dementia, was admitted to hospice services, but the facility's electronic medical record lacked current hospice orders, a signed election form, a hospice plan of care, hospice physician orders, hospice physician notes, a hospice medication list, and hospice nursing notes. The most recent hospice documentation in the facility's record was several months old, despite ongoing hospice services. Interviews with facility and hospice staff revealed that hospice assessments and notes were maintained on hospice staff tablets and were supposed to be sent to the facility, but this did not occur as required. Facility nurses reported that hospice staff would have them sign their tablets after visits but did not provide verbal or written reports, and hospice documentation was not integrated into the facility's care plan. The Director of Nursing confirmed that there was no collaboration between the facility and hospice staff to update the care plan, and that the process for obtaining and coordinating hospice documentation was lacking. The administrator and Director of Nursing acknowledged that there was no established process to monitor and update hospice documentation or to ensure that hospice information was included in the facility's care plan. As a result, the resident's care plan did not reflect current hospice interventions or coordination between the facility and hospice provider, and essential hospice documentation was missing from the resident's medical record for an extended period.
Medication Order Transcription Error
Penalty
Summary
The facility failed to accurately transcribe a medication order for a resident, resulting in the resident receiving Hydroxyzine 25 milligrams daily instead of as needed for itching. The resident, who was admitted with diagnoses including paraplegia and dementia, was cognitively intact and required extensive assistance with activities of daily living. The medication was administered nightly from September through early November, despite the order specifying it should be given as needed. The error was not identified during the admission medication review process, which involved multiple checks by the unit managers, admitting nurse, and the Pharmacist. Interviews with the Nurse Practitioner, Unit Manager, and Pharmacy Consultant revealed that the medication was considered low dose and not harmful, but the frequency error was not caught during the admission review. The resident did not experience any adverse effects from the medication and was unaware of the medications he received daily. The Director of Nursing acknowledged the error in the medication order entry, indicating that it should have been entered accurately as needed rather than scheduled nightly.
Failure to Follow Physician Orders and Monitor Blood Pressure
Penalty
Summary
The facility failed to follow a physician's order for a resident who sustained a fall and was experiencing swelling in her left foot. The resident, who was admitted with diagnoses including dementia and repeated falls, was found on the bathroom floor and complained of foot pain. A physician ordered an ace wrap to be applied to the resident's left foot as needed for swelling. However, observations on two consecutive days revealed that the ace wrap was not applied, despite the resident's complaints of pain and visible swelling and bruising. The nurse assigned to the resident did not apply the ace wrap, and the Director of Nursing was unaware of the order until later. Another deficiency involved the failure to obtain blood pressure readings before administering the antihypertensive medication Hydralazine to a resident with hypertension. The physician's order specified that the medication should be held if the systolic blood pressure was less than 120 mmHg. However, the Medication Administration Record (MAR) showed that blood pressures were recorded only for the morning dose, not for the noon or bedtime doses. This oversight persisted over several months, as evidenced by the lack of recorded blood pressures for the specified times in the resident's electronic medical record. The Consultant Pharmacist had addressed the need for blood pressure checks in her monthly reviews, but the issue remained unresolved. The Director of Nursing, who began working at the facility in October, was not aware of the Hydralazine order or the missing blood pressure checks. The failure to record and monitor blood pressure readings before administering the medication was a significant oversight, as the medication could cause a drop in blood pressure, necessitating careful monitoring.
Insufficient Nursing Staff Leads to Resident Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the necessary supervision and assistance level was implemented in accordance with the resident's plan of care. This deficiency affected a dependent resident who required two-person assistance for activities of daily living. The resident experienced falls from the bed during care on two occasions, resulting in minor injuries. Interviews with the resident and staff revealed that the facility often did not have enough staff, particularly during the night shift, leading to situations where only one nurse aide was available to provide care that required two people. Staff interviews further highlighted the staffing issues, with nurse aides and nurses indicating that they frequently had to provide care alone due to the lack of available staff. The facility relied heavily on agency staff, who often did not show up for their shifts, exacerbating the staffing shortages. The Nursing Scheduler/Payroll Manager and the Director of Nursing acknowledged the staffing challenges, noting difficulties in finding replacements for last-minute call-outs and no-shows. The Director of Nursing, who was new to the area, was in the process of evaluating the reliability of staffing agencies.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage on five specific days within a 60-day review period. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 2, 2024, indicated that there was no RN coverage on several dates. Upon review, it was discovered that the facility mistakenly believed that agency nurses sent to cover shifts were RNs, when in fact, they were Licensed Practical Nurses (LPNs). This misunderstanding led to the absence of required RN coverage on the specified days. The Nursing Scheduler/Payroll Manager confirmed the lack of RN coverage on the identified dates and noted that an RN had worked on one of the days but did not punch the time clock due to being salaried. This discrepancy was not reflected in the PBJ report, likely due to data entry errors at the corporate level. The Administrator was unaware of the staffing issue and assumed the agency had provided RNs as requested. The facility's oversight in verifying the credentials of agency staff contributed to the deficiency.
Failure to Address Pharmacist's Recommendations for Medication Administration
Penalty
Summary
The facility failed to act on the Consultant Pharmacist's recommendations regarding the medication administration for a resident diagnosed with hypertension. The Pharmacist's monthly drug regimen review identified the need to clarify the dosage of Hydralazine and to add blood pressure checks prior to its administration. Despite these recommendations being made in July 2024, the facility did not update the Medication Administration Record (MAR) to include blood pressure checks, nor did they clarify the confusing dosage instructions. The resident was prescribed Hydralazine 25 mg to be taken three times a day, but the order was unclear whether the dose was 25 mg or 50 mg three times a day. The issue persisted through subsequent months, with the Pharmacist reiterating the need for clarification and blood pressure monitoring in September and October 2024. Interviews with the Consultant Pharmacist and facility staff revealed that the recommendations were not addressed due to staff turnover and lack of awareness by the new Director of Nursing (DON). The DON, who started in October 2024, was unaware of the outstanding pharmacy recommendations and had not prioritized them for correction. The Unit Manager eventually notified the physician, who confirmed the correct dosage and instructed to check blood pressure prior to administration.
Deficiency in Hospice Documentation and Communication
Penalty
Summary
The facility failed to maintain proper communication and coordination of hospice services for a resident receiving hospice care. The Nursing Facility Hospice Services Agreement required that hospice contact information and patient care details be documented in the resident's clinical record upon admission to hospice. However, the facility's records for the resident lacked essential hospice documentation, including the hospice agreement, provider order, certification for services, care plan, and visit notes from nursing, social work, and clergy. Interviews with facility staff revealed ongoing challenges in obtaining necessary documentation from the hospice provider. The social worker reported difficulties in acquiring a binder with the required hospice documentation and had been in contact with the hospice provider to address this issue. Despite efforts to communicate with the hospice director and arrange for documentation delivery, the facility continued to experience gaps in the resident's medical record. Further investigation showed that hospice documents were stored in an unorganized manner in a box in the medical records area, making it difficult for staff to access relevant information. The unit manager and medical records clerk acknowledged the disorganized state of the hospice documents and the lack of a systematic process for integrating hospice information into the electronic medical record. The administrator confirmed that a meeting was scheduled to address these communication issues with the hospice provider.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an altercation between two residents. Resident #80, who had a history of wandering and cognitive impairment due to vascular dementia, entered Resident #67's room and took several personal items. When Resident #67 confronted Resident #80 to retrieve her belongings, Resident #80 denied having them and swung at Resident #67. In response, Resident #67 punched Resident #80 in the forehead. Although no injuries were reported, the incident was substantiated as resident-to-resident abuse. Resident #80 was admitted with diagnoses including vascular dementia with behavioral disturbances and generalized anxiety disorder. Her care plan noted a history of wandering into other residents' rooms and taking their belongings, which had previously led to combative behavior. Resident #67, on the other hand, had intact cognition and no documented history of behavioral issues. The incident occurred when Resident #67 returned to her room and was informed by her roommate that Resident #80 had taken her belongings. This led to the confrontation and subsequent physical altercation. The facility's response included immediate notification of law enforcement and the Department of Social Services, as well as placing Resident #67 on one-to-one observation. Staff members, including Nurse #11, witnessed the incident and confirmed the sequence of events. The facility's investigation involved interviews with the involved residents and staff, and it was determined that Resident #80 did not recall the incident. Despite the lack of physical injuries, the facility's failure to prevent the altercation and protect residents from abuse was identified as a deficiency.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate care and supervision to a dependent resident, resulting in two falls from the bed during care. The resident, who had a history of brain neoplasm, hemiparesis, stroke, weakness, and seizures, required extensive assistance from two people for bed mobility and total assistance for transfers, toileting, and bathing. Despite these needs, the resident fell on two separate occasions due to inadequate staffing and failure to adhere to the care plan that required two-person assistance. On the first incident, a nurse aide attempted to provide incontinence care alone, despite knowing the resident required two-person assistance. The aide turned the resident onto her side, causing her to roll off the bed and sustain minor injuries. The facility was short-staffed, and the aide decided to proceed with care without assistance, leading to the fall. The resident was later transferred to the hospital for evaluation, where no significant injuries were found. In the second incident, another nurse aide also provided care alone, resulting in the resident sliding off the bed. The bolsters meant to aid in positioning were not properly attached, contributing to the fall. The resident was again assessed and found to have no significant injuries, but the incident highlighted ongoing staffing issues and failure to implement effective interventions to prevent further falls.
Incomplete Medication and Treatment Documentation
Penalty
Summary
The facility failed to maintain complete medical records for medication administration for three residents. Resident #36's Medication Administration Record (MAR) showed multiple instances where medications for conditions such as hypertension, hypocalcemia, constipation, anxiety, and depression were not signed off as administered by Nurse #13. Despite attempts to contact Nurse #13, there was no response, and the Director of Nursing (DON) was unaware of these omissions until the survey. Resident #38 also experienced similar issues with incomplete MAR documentation. Medications for hypertension and diabetes, including insulin administration, were not signed off by Nurse #13 on several occasions. The DON acknowledged awareness of documentation issues and noted that Nurse #13 was an agency nurse who failed to document medication administration and blood sugar checks as per physician orders. Resident #54's Treatment Administration Records (TAR) lacked documentation for physician-ordered wound care treatments on multiple dates. Interviews with several nurses revealed that they could not recall if the treatments were completed or why they were not documented. The DON, who was new to the position, expected accurate documentation of wound care treatments and recognized the existing issues with documentation inaccuracies.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect a female resident, who was deemed incompetent by the North Carolina Clerk of Court, from sexual abuse by a cognitively impaired male resident. On the morning of 05/15/24, a Nursing Assistant (NA) observed the male resident in the female resident's bed, performing oral sex on her. The female resident was incapable of giving consent due to her severe cognitive impairment. The male resident had a history of sexually inappropriate behaviors related to his cognitive loss and dementia, which was documented in his care plan. Despite this, the facility did not adequately monitor or prevent the male resident from accessing the female resident's room, leading to the incident of sexual abuse. The female resident had multiple diagnoses, including dementia with behavioral and psychotic disturbances, muscle weakness, hemiplegia, and chronic pain syndrome. Her care plan indicated she had tendencies to expose herself while lying in bed without privacy precautions. The male resident, who was moderately cognitively impaired, had a documented history of sexually inappropriate behaviors. On 05/11/24, the male resident was previously found attempting to get into the female resident's bed, but no further action was taken beyond removing him from the room. This lack of follow-up and monitoring allowed the male resident to re-enter the female resident's room on 05/15/24 and commit the act of sexual abuse. Interviews with staff revealed that the male resident had been restless and required frequent redirection on the night of the incident. Despite being placed at the nurses' station for observation, he was later returned to his room, where he managed to enter the female resident's room again. The facility's response to the initial incident on 05/11/24 was inadequate, as it did not involve a thorough investigation or increased monitoring of the male resident. This failure to act on the warning signs and the male resident's documented history of inappropriate behavior directly led to the sexual abuse of the female resident on 05/15/24.
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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