Perry Creek Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Raleigh, North Carolina.
- Location
- 5201 Clarks Fork Drive Nw, Raleigh, North Carolina 27616
- CMS Provider Number
- 345529
- Inspections on file
- 32
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Perry Creek Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of stroke, dementia, atrial fibrillation, dysphagia, and multiple other conditions was admitted on multiple oral meds, including an anticoagulant. One day after admission, staff documented that morning meds were not given and later noted the resident refused all meds due to difficulty swallowing, describing pooling of water and applesauce with crushed meds in the mouth and removal of the meds without ingestion. The nurse held the medications for the rest of the day and did not contact the provider about the missed doses or swallowing difficulty, while another nurse later reported administering the evening meds crushed in applesauce after extended effort. The physician and corporate nurse consultant later stated the MD should have been notified when the resident could not swallow medications.
A resident with chronic kidney disease, diabetes, anemia, polyneuropathy, and newly diagnosed congestive heart failure was readmitted from the hospital and evaluated by an NP for shortness of breath and abdominal fullness. The NP ordered a CBC with differential, BMP, and BNP/NT proBNP to monitor the resident’s condition, expecting the labs to be drawn at the next routine lab visit. The contracted lab’s phlebotomist signed daily lab tracking forms on multiple days, and facility staff interpreted these signatures as confirmation that the labs had been completed, despite minimal or unclear notations such as a single "unable" entry and no documented refusals. The resident reported that she had not had blood drawn and saw no evidence of venipuncture, and the Unit Manager later confirmed that the ordered labs were not actually obtained until several days after the original order, resulting in a delay in completing the provider-ordered testing.
Two residents experienced dignity-related failures when staff attention and basic personal needs were not appropriately prioritized. One resident, who was severely cognitively impaired and required supervision with eating, was assisted with a meal by a nurse aide who watched a video on a personal cell phone during the feeding, dividing attention between the device and the resident. Another cognitively intact resident had four house coats sent to the facility laundry and, due to delays and confusion in processing and returning the items, was left with no personal clothing for several days, wearing only a hospital gown and choosing not to leave her room. Interviews with staff and a responsible party confirmed that these actions and omissions did not support residents’ dignity and respect.
Two residents had inaccurately coded MDS assessments related to hospice status and diabetes medication. One resident who had formally elected hospice services was not coded on the admission MDS as receiving hospice because the MDS coordinator relied on an outdated census report that did not show the hospice admission. Another resident with type 2 DM had a weekly Ozempic (semaglutide) injection documented on the MAR, but no insulin orders or administration; however, an MDS nurse coded the quarterly MDS to show one insulin injection in the 7‑day look‑back period, mistakenly treating Ozempic as insulin. Leadership confirmed that hospice status and medications must be accurately reflected on MDS assessments.
Surveyors observed a medication cart on the 500 hall left unattended and unsecured, with multiple drawers containing prescription medications left open and the cart key hanging in the lock. No staff or residents were present near the cart during the observation. An RN later returned to the cart and admitted she had been assisting a resident to his room, did not have eyes on the cart, and knew it should not have been left unattended and unsecured. The Administrator stated he expects nursing staff to keep medication carts secured whenever they step away to prevent unauthorized access.
The facility did not develop or implement required policies and procedures for flu and pneumonia vaccinations, resulting in a deficiency related to immunization practices.
A resident who was readmitted with a history of stroke did not have their admission MDS assessment completed within the required 14-day timeframe. The delay was attributed to a backlog of pending MDS assessments and insufficient staffing, as the facility was seeking to hire another full-time MDS nurse and relied on part-time help.
A resident with dementia and delusions received regular doses of Quetiapine Fumarate, but the MDS assessment was inaccurately coded to indicate no scheduled antipsychotic use. This error was confirmed by both the Regional MDS Consultant and the Administrator.
An opened box of bisacodyl suppositories that had expired was found in a medication storage room. Staff interviews confirmed that nursing staff were responsible for checking and removing expired medications, but the expired suppositories remained in storage past their expiration date.
A nurse failed to wear required PPE, including gloves and a gown, when entering the room of a resident on contact precautions for conjunctivitis and administering medications via gastrostomy tube. Despite clear signage and available PPE supplies, the nurse did not follow infection control protocols, as confirmed by staff interviews and facility policy review.
The facility did not ensure that all residents and staff were educated about the COVID-19 vaccine, were offered the vaccine after education, and had their vaccination status properly documented.
A facility failed to ensure proper disinfection of glucometers, as a nurse used a shared glucometer without disinfecting it before or after use on a resident. Additionally, an agency medication aide cleaned an individually assigned glucometer with alcohol wipes instead of the approved disinfectant wipes. The facility's Director of Nursing confirmed that some glucometers were shared among residents and should be disinfected with EPA-approved wipes after each use.
A facility failed to follow infection control protocols, including improper disinfection of shared glucometers and inadequate COVID-19 precautions. A nurse used an unlabeled glucometer without disinfecting it, and another staff member used alcohol wipes instead of disinfectant wipes. Additionally, a nurse entered a COVID isolation room without eye protection and removed PPE outside the room. The facility's infection control policies were not reviewed annually, and linen carts were left uncovered.
The facility did not have a full-time certified Dietary Manager (DM) as the designated DM was still in school and not yet certified. The Regional DM, who was certified, managed the department by visiting the facility several times a week. The Administrator confirmed the situation, acknowledging the lack of certification for the facility DM.
The facility did not implement an antibiotic stewardship program, affecting all 127 residents. The DON, new to the position, admitted there was no active program and no monitoring of infections. The Corporate Nurse Consultant confirmed ongoing work on the infection control program but lacked documentation on infection tracking.
A facility failed to properly manage the return of discontinued medications for 11 residents, resulting in controlled substances being stored improperly in an unlocked filing cabinet. The DON did not follow the procedure for returning these medications to the pharmacy, despite being informed of the process. This led to a deficiency noted by surveyors.
The facility failed to address and communicate resolutions to repeated concerns raised by the Resident Council, including issues with call light response times, medication administration, and dietary complaints. Despite a process involving the Social Worker and department heads, residents reported ongoing dissatisfaction and a lack of feedback, indicating a breakdown in communication and follow-through by the facility's management.
The facility failed to maintain a safe environment by not addressing broken tiles in a shower room, which posed a hazard to residents. A resident reported standing on broken tiles while using the grab bar, and staff interviews revealed a lack of awareness and communication about the issue. The Regional Maintenance Consultant acknowledged the hazard, but the facility had been without maintenance staff for weeks, and leadership was unaware of the problem.
A long-term care facility failed to protect residents from the misappropriation of controlled medications, affecting multiple residents. Discrepancies were found in medication administration records, with missing documentation and tampered medication cards. A nurse was suspected of diverting medications, forging signatures, and tampering with medication cards. The facility reported the incident to authorities but did not provide a corrective action plan or document a plan of correction in QAPI meetings.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in documenting their medical conditions and treatments. A resident was not coded for opioid use despite daily administration, while others were not coded for serious mental illnesses or schizophrenia. Another resident was incorrectly coded for anticoagulant use. These errors were acknowledged by the MDS Coordinator and Administrator.
Two residents in an LTC facility experienced delays in starting prescribed antibiotic therapies due to failures in medication administration. One resident with diabetes and heart failure did not receive Clindamycin as scheduled, while another with Parkinson's disease missed a dose of Levofloxacin. Access issues to the medication dispensing system and communication failures contributed to these delays, although no harm was reported.
Controlled medications were improperly stored in an unlocked filing cabinet in the DON's office, rather than in a secure, double-locked system as required. The DON, who resigned, had not returned the medications to the pharmacy due to a lack of orientation and being occupied with a state survey. The facility had a history of medication diversion, and the improper storage was discovered during an observation by the Administrator and Corporate Nurse Consultant.
The facility failed to provide palatable and appetizing food at a safe temperature, as confirmed by resident complaints and a test tray. Residents reported issues with food being cold, tough, and unappetizing. A test tray revealed the chicken was tough and the mashed potatoes had an unappetizing texture. The Dietary Manager acknowledged the concerns and was attempting to address them.
The facility failed to implement an effective training program, lacking documentation for key training areas for four NAs. Interviews confirmed the absence of training in communication, resident rights, compliance and ethics, behavioral health, infection control, and QAPI in 2024. The DON had not conducted training since joining in December, and the Corporate Nurse Consultant could not provide documentation. The Administrator noted the absence of a Staff Development Coordinator, leaving training responsibilities to the DON.
The facility failed to accommodate a resident with a below-knee amputation in the new smoking area, which had a slope making it difficult to exit independently. Additionally, another resident's call light was not within reach, preventing them from requesting assistance. Staff interviews confirmed the call lights should be accessible, and the Administrator admitted no assessment was conducted before moving the smoking area.
A resident experienced an unwitnessed fall and expressed significant pain in her left knee, which was documented by a nurse but not communicated to the physician. The resident's x-ray later revealed a hairline fracture, and the physician confirmed he was not informed of the pain complaints, leading to a delay in medical intervention.
A nurse in an LTC facility left a medication cart unattended with residents' medical information visible on the computer screen. The nurse admitted to not locking the screen, and the DON confirmed the breach of confidentiality protocols.
A resident with Alzheimer's and aphasia was found soaked with urine due to improper incontinent care. The resident's care plan required assistance with toileting, but staff failed to check the resident adequately at shift change. The resident's adult brief was not positioned correctly, leading to wet clothing and bed linens. The Interim DON was unaware of the incident, and staff were expected to check residents every two hours.
The facility failed to provide adequate fire safety equipment in two smoking areas and did not complete a required smoking assessment for a resident with cognitive impairment and dexterity issues. Observations showed improper disposal of cigarette butts and lack of necessary fire preventative equipment. The resident was observed smoking unsupervised, highlighting the need for timely assessments.
A resident with a history of TIA and diabetes experienced an unwitnessed fall, resulting in knee pain. Despite documented pain levels between 3 and 6, no pain medication was administered, and the physician was not informed. The resident was later found to have a hairline fracture but received no pain relief upon returning from the hospital. Interviews revealed a lack of communication and adherence to pain management protocols.
The facility did not provide RN coverage for 8 consecutive hours on three days, despite having a census of over 100 residents. The Scheduler confirmed the absence of RN coverage and reported it to the Administrator, who could not provide evidence of RN presence on those days.
The facility failed to act on pharmacist recommendations and maintain documentation of physician responses for three residents. A resident with severe cognitive impairment continued on multiple medications without documented rationale. Another resident, cognitively intact, had no response to recommendations to discontinue or justify certain medications. A third resident with hypothyroidism had a low TSH level, but the pharmacist's recommendation to adjust medication and recheck TSH was not documented or followed up. The DON was unaware of the drug regimen review process.
Two residents experienced medication administration errors, resulting in a 7.41% error rate. One resident received Olanzapine at the wrong time due to technical issues with the electronic MAR, while another received an incorrect dose of calcium carbonate due to reliance on a pharmacy-labeled bottle. Staff interviews and record reviews confirmed these errors.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in medication administration and documentation. A resident with depression had conflicting orders for Zoloft and Sertraline, resulting in inaccurate MAR entries. Another resident with diabetes and renal disease had critical lab results, but the nursing assessment and physician notification were not properly documented. The errors were acknowledged by staff, highlighting the need for accurate record-keeping.
The facility failed to inform two residents about the arbitration agreement during admission, leading to a deficiency. Both residents, who were cognitively intact, signed the agreement without understanding it was not a condition of admission. The current Admissions Coordinator uses a script to explain the agreement, but the former coordinator, responsible for these admissions, was unavailable for comment. The Administrator expected the agreement to be explained in understandable language.
A facility failed to include a convenient venue selection in the Arbitration Agreement for a resident. The agreement, signed by a cognitively intact resident, lacked information on venue selection. The Administrator acknowledged the omission and noted that the facility changed ownership, with the current agreement including necessary components. The Administrator was not employed until later.
A resident's privacy was compromised due to a malfunctioning privacy curtain that did not close completely, leaving part of the bed visible from the door. The issue was not reported to maintenance, and staff were unaware of the problem, indicating a lapse in communication and reporting procedures within the facility.
Two residents in an LTC facility sustained injuries due to inadequate supervision and care. One resident, who was cognitively intact and at risk for falls, rolled off the bed during incontinence care, resulting in a hip fracture. The CNA was unaware of the need for a mechanical lift, and the Kardex indicated one-person assist, though the resident likely required two-person assist. Another resident, severely cognitively impaired and dependent on staff for transfers, suffered bruising and a probable toe fracture during a transfer. The care plan indicated one-person assistance, but staff interviews revealed the need for two-person assistance. The facility failed to investigate an unwitnessed fall, contributing to further injury.
The facility failed to manage blood glucose levels and respond to medical emergencies for two residents. One resident experienced severe hypoglycemia without receiving Glucagon as ordered, leading to unresponsiveness. Another resident had dangerously high blood glucose levels over two days, with inadequate monitoring and physician notification, resulting in a diagnosis of sepsis and hyperglycemia. Additionally, the facility did not perform necessary tests for another resident, indicating a pattern of inadequate care.
A resident with type 2 diabetes experienced repeated episodes of blood glucose levels over 400 mg/dL, but the facility failed to notify the physician or family. Despite critical symptoms, including elevated heart and respiratory rates, staff did not take appropriate action or document interventions. The resident was found nonresponsive and was only sent to the hospital after family insistence, where they were diagnosed with sepsis and hyperglycemia.
A resident with type 2 diabetes and other health issues experienced neglect when their critically high blood glucose levels were not properly monitored or addressed by facility staff. Despite consistent readings over 400 mg/dL, staff failed to notify the physician or initiate emergency services promptly. The resident was found nonresponsive, and EMS was delayed, leading to severe symptoms upon hospital admission. Staff interviews revealed confusion and inadequate oversight, contributing to the neglect.
A resident with a degenerative neuromuscular disease and bipolar disorder was found with maggots in her bed and contracted hand due to a fly infestation in the facility. Despite staff observing flies and the resident's complaints of hand pain, the issue was not addressed until maggots were discovered during a bath. The facility lacked a pest control contract, contributing to the infestation and the resident's undignified care.
The facility failed to maintain pest control services, resulting in a fly infestation affecting residents. One resident, with a degenerative neuromuscular disease, was found with maggots due to flies, while another resident struggled to eat as flies landed on her food. The facility had been without a pest control contract since May 2024, and the issue was not communicated to the administration.
The facility failed to create timely baseline care plans for new admissions, affecting three residents. One resident, admitted with multiple diagnoses, expressed a desire to return home, but discharge planning was delayed due to poor communication among staff. Another resident was discharged without a documented care plan, and a third resident also lacked a baseline care plan. Staff interviews revealed ongoing issues with the admission process, with acknowledgment of the need for improved procedures.
The facility failed to develop comprehensive care plans for residents, leading to inadequate care. A resident with mental illness did not have a care plan addressing her refusal of care, resulting in hygiene issues. Another resident with skin tumors lacked a care plan for specialized skin care, leading to inconsistent care. Additionally, a resident's indwelling catheter care and another's discharge planning were not included in their care plans, resulting in missed care and unaddressed transition needs.
The facility failed to maintain accurate records for controlled substances for three residents, with discrepancies in documentation and administration of Oxycodone and Morphine. Additionally, a resident reported missing doses of Clonazepam due to unavailability after returning from the hospital. The issues were identified during a period when a nurse was working under a restricted license for narcotic handling.
A resident receiving Coumadin for atrial fibrillation did not have Protimes/INRs completed as ordered, leading to critical INR values. Despite critical lab results, the facility failed to consistently monitor and document the resident's medication administration and lab draws. The resident was sent to the hospital due to elevated INR levels but returned without harm. Documentation issues were noted due to a transition to a new electronic medical record system.
The facility failed to accurately document vital signs, blood glucose readings, and medication administration for two residents. For one resident, blood glucose levels were not consistently recorded, and insulin administration was inaccurately documented, with agency staff and electronic record issues contributing to the problem. Another resident's medication administration was not documented on several occasions, with staff citing issues with a new documentation system and internet connectivity.
A resident was moved to a shared room without being allowed to see the room or meet the new roommate beforehand, leading to dissatisfaction and discomfort. The facility staff, including a new social worker and the admissions coordinator, were unaware of the resident's rights in the room change process.
A resident was moved to a new room that had not been cleaned, with medical equipment left in the bathroom. The Unit Manager confirmed the oversight, and the Housekeeping Director stated that the room should have been sanitized before the move.
Failure to Notify Physician When Resident Unable to Swallow Medications
Penalty
Summary
The deficiency involves the facility’s failure to consult the physician when a resident was unable to swallow ordered medications. The resident had a recent history of hospitalization for altered mental status related in part to multifocal stroke, and also had multiple myeloma, atrial fibrillation, chronic pain, depression, and a documented history of dysphagia. On admission, the resident was alert but confused and was ordered several oral medications, including apixaban for atrial fibrillation. On the day after admission, staff documented that the resident received morning and evening medications, with one medication aide reporting she crushed the medications in applesauce and another nurse reporting the resident took medications without specifying if they were crushed. The following morning, the assigned nurse documented on the MAR that the resident’s scheduled medications, including apixaban, were not administered. That same day, the nurse documented in a progress note that the resident refused all medications due to difficulty swallowing. In interview, the nurse described that the resident held water and then applesauce with crushed medications in his mouth without swallowing, with pooling of fluids and medications in the mouth, and that she and the responsible party ultimately removed the medications from his mouth. She stated she then held the medications for the rest of the day and did not contact the provider about the missed doses or the swallowing difficulty. Later that evening, another nurse documented administering the resident’s evening medications, reporting she crushed them in applesauce and, after taking time and going slowly, the resident was able to swallow them with sips of water. The physician and the corporate nurse consultant both stated in interviews that the physician should have been contacted when the resident could not swallow his medications.
Failure to Ensure Timely Completion of Ordered Laboratory Tests After Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered laboratory tests were completed in a timely manner for a resident recently readmitted from the hospital with multiple serious diagnoses, including chronic kidney disease, diabetes, anemia, polyneuropathy, and congestive heart failure. After readmission, the resident was followed by a provider group in addition to her physician and was documented as cognitively intact. On 2/20/26, an NP documented that a nurse had reported the resident was short of breath without hypoxia and had a feeling of abdominal fullness, though she was functionally at baseline. In response, the NP made medication changes and ordered a CBC with differential, BMP, and BNP/NT proBNP to monitor kidney function, anemia, and infection risk. The contracted lab company provided routine lab services six days per week, with the expectation that an order placed on a Friday would be drawn on Saturday if the requisition was in the lab book. The lab’s Risk Manager explained that the phlebotomist checked a lab book organized by date, signed a lab sheet each day, and was required to notify nursing and a lead phlebotomist if unable to obtain blood two days in a row. Review of the facility’s lab tracking forms showed the resident’s name listed for labs on 2/21/26, 2/24/26, and 2/25/26. On 2/21/26, the phlebotomist initialed the form, but there was no notation of refusal or inability to draw. On 2/24/26, the form contained only the notation “unable” by the resident’s name, with no further explanation. On 2/25/26, the resident’s name and labs again appeared with the phlebotomist’s initials at the top of the page and no notation that the labs were not drawn. During this period, the resident reported that she had recently returned from the hospital with a new diagnosis of congestive heart failure, was more short of breath, and very tired. She stated that while hospitalized she had required blood and that labs were supposed to be drawn at the facility but had not been done. She recounted being told she had refused blood work while asleep on one morning, though she did not recall this, and later being told that her blood work had been completed despite having no signs of a blood draw and no recollection of it. On 2/26/26, she reported that she still had not had lab work drawn. The Unit Manager stated that when the phlebotomist signed at the top of the lab sheet without a notation by a resident’s name, staff understood that the labs had been completed, but in this case the labs ordered on 2/20/26 were not actually obtained until 2/26/26. The Administrator and Nurse Consultant confirmed that their system relied on the phlebotomist’s initials at the top of the lab sheets to indicate completion and that, based on this, they believed the labs had been done on 2/21/26 and 2/25/26, even though they had not.
Failure to Maintain Resident Dignity During Meal Assistance and Laundry Services
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity and respect during care and daily routines. For Resident #72, who had cognitive communication deficit, muscle weakness, and was assessed as severely cognitively impaired, surveyors observed a nurse aide assisting her with breakfast while simultaneously watching a video on a personal cell phone. The aide sat at the head of the bed with the bedside table perpendicular to the bed and the phone placed on the table out of the resident’s view, playing a video with closed captioning and no sound. The aide’s attention alternated between the video and the resident as she offered bites of food. In interview, the aide stated no one had told her she could not watch a show on her phone while assisting residents with meals and reported she was watching a vampire series. Resident #72’s responsible party stated it was a disgrace that the resident’s caregiver divided attention between personal entertainment and the resident’s care. He emphasized that because the resident relied on staff for assistance, the aide should be fully present and 100% involved in providing care, and not focused on personal entertainment during meal assistance. The Regional Director of Clinical Services indicated uncertainty about whether the resident could respond to the aide and whether watching a video while assisting with a meal was a dignity concern, and acknowledged there was no facility policy regarding staff cell phone use. The Administrator similarly stated he would not recommend aides watch shows on their phones while assisting residents with meals and was unsure if it was a dignity concern, noting he would need to check the cell phone policy. For Resident #106, who was cognitively intact with no behaviors, the deficiency involved failure to ensure timely return of personal clothing, resulting in her wearing a hospital gown for three days and remaining in her room. The resident reported she had four house coats that were picked up by a nurse aide for laundry on a Friday, with the usual practice being same-day return, but as of several days later the laundry had not been returned and she had no other clothes. She stated she had been in a hospital gown since the laundry pickup, felt annoyed that she could not get dressed, and did not feel comfortable leaving her room while wearing a hospital gown, so she stayed in her room. Staff interviews revealed that the Housekeeping Director initially stated the clothes had been returned the same day but later corrected herself, acknowledging the items had not been laundered as scheduled and that staff had been looking for the resident’s clothes over the weekend, with the clothing ultimately not returned to the resident until several days after pickup. The Administrator stated he expected laundry for that hall to be completed on the scheduled day so residents would have their own clothing to wear.
Inaccurate MDS Coding for Hospice Status and Diabetes Medication
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for two residents. One resident with active diagnoses including anemia, heart failure, and diabetes mellitus elected hospice services on 1/19/26, as documented on an Election of Benefits for Hospice form. However, the resident’s admission MDS assessment dated later in January did not indicate that she was receiving hospice care. During interview, the MDS Coordinator stated he relied on the census report when completing the MDS and that the census report had not been updated to reflect the resident’s hospice admission, resulting in the hospice status not being captured on the MDS. The Administrator confirmed that MDS assessments should accurately reflect a resident’s hospice status. The second resident was admitted with a diagnosis of type 2 diabetes mellitus and had a physician’s order for Ozempic (semaglutide) to be administered subcutaneously once weekly for diabetes management. The medical record and MARs for October and November did not show any orders or documentation for insulin administration, but the November MAR documented administration of Ozempic on 11/1/25. The resident’s quarterly MDS assessment indicated that the resident received one insulin injection in the last seven days. In interview, the MDS nurse reported she coded the MDS to show one insulin injection based on the Ozempic administration, explaining she believed that because Ozempic was ordered for diabetes, it should be coded as insulin. The MDS Director clarified that Ozempic is not insulin and should not be coded as such, and the Administrator stated that MDS assessments should accurately reflect the medications residents receive.
Unattended and Unsecured Medication Cart on 500 Hall
Penalty
Summary
Surveyors observed that a medication cart on the 500 hall was left unattended and unsecured for several minutes. During continuous observation from 8:35 AM to 8:38 AM, the cart was noted to have three drawers containing prescription medications pulled open with medications exposed. The cart was unlocked, and the keys were hanging from the lock, with the cart facing the hallway. At the time of the observation, there were no staff or residents visible near or around the cart on the 500 hall. Nurse #3 was seen exiting a resident's room and then approaching the unsecured medication cart. In an interview conducted immediately afterward, Nurse #3 initially stated she had her eyes on the cart the whole time, but then clarified she had been assisting a resident to his room and did not have her eyes on the cart. She acknowledged that she knew the cart should not have been left unattended and unsecured with drawers open and the key left in the lock, and explained that she had been rushing and did not realize she left the drawers open or the key in place. In a separate interview, the Administrator stated he expected nursing staff to ensure medication carts were secured at all times whenever staff stepped away, emphasizing the importance of keeping carts secured while unattended to prevent access by unauthorized residents or staff.
Failure to Implement Flu and Pneumonia Vaccination Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified during the survey process, indicating that the required protocols for ensuring residents receive these vaccinations were not established or followed as mandated.
Failure to Complete Timely Admission MDS Assessment Due to Staffing Shortages
Penalty
Summary
The facility failed to complete an admission Minimum Data Set (MDS) assessment within 14 days of admission for one resident who was readmitted with a diagnosis of cerebral vascular accident (stroke). Record review showed that the admission MDS assessment, with an Assessment Reference Date (ARD) of 8/6/25, was still in process when reviewed on 8/20/25. Interviews with the MDS Coordinator and the Administrator confirmed that the assessment was not completed on time due to a high volume of pending MDS assessments and insufficient staffing, as the facility was in the process of hiring an additional full-time MDS nurse and had received only part-time assistance from corporate and a new part-time employee. This resulted in the resident not having a timely and complete assessment as required by regulations.
Inaccurate MDS Coding for Antipsychotic Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) Assessment for a resident who was admitted with dementia with delusions and was receiving antipsychotic medication, specifically Quetiapine Fumarate. Review of the resident's Medication Administration Record (MAR) showed that the antipsychotic was administered on multiple dates, but the admission MDS assessment incorrectly indicated that the resident had not received antipsychotic medications on a scheduled or routine basis. This inaccuracy was confirmed during interviews with both the Regional MDS Consultant and the Administrator, who acknowledged that the MDS should have reflected the resident's regular antipsychotic use.
Expired Medication Not Removed from Storage Room
Penalty
Summary
A box containing 40 bisacodyl suppositories, which had expired in April 2025, was found in an opened state in one of the medication storage rooms (Unit 2 Medication Storage Room) during an observation. Staff interviews confirmed that the expired medication should have been discarded at the time of expiration. The Unit Manager acknowledged that the expired suppositories should have been removed, and the interim DON stated that nursing staff were responsible for regularly checking and removing expired medications from storage rooms. The Administrator also indicated that all nursing staff were responsible for this task. The failure to remove the expired medication from the storage room led to the deficiency.
Failure to Use PPE for Resident on Contact Precautions
Penalty
Summary
A deficiency occurred when a nurse failed to follow the facility's infection prevention and control policies regarding contact precautions. Specifically, Nurse #1 entered the room of a resident who was under contact isolation precautions for conjunctivitis and administered medications via gastrostomy tube without wearing the required personal protective equipment (PPE), including gloves and a gown. The facility's policy and posted signage clearly indicated that all healthcare personnel must wear gloves and a gown when entering rooms of residents on contact precautions. PPE supplies were available outside the resident's room, and appropriate signage was posted. During interviews, Nurse #1 stated she was unaware that the resident was on contact precautions and acknowledged she should have worn PPE. The unit manager and staff development coordinator confirmed that the nurse should have used PPE as per facility policy and that ongoing in-services on infection control and transmission-based precautions were provided. The resident involved had a physician's order for contact isolation due to conjunctivitis, requiring these additional precautions.
Failure to Educate, Offer, and Document COVID-19 Vaccination
Penalty
Summary
Residents and staff were to be educated on COVID-19 vaccination, offered the vaccine if eligible following education, and have their vaccination status properly documented. The deficiency occurred due to a failure to ensure that all residents and staff received education about the COVID-19 vaccine, were offered the vaccine after education, and had their vaccination status accurately documented. The report specifically notes the lack of proper education, offering, and documentation for both residents and staff regarding COVID-19 vaccination.
Failure to Disinfect Glucometers Properly
Penalty
Summary
The facility failed to ensure that nursing staff were competent in following manufacturer's guidelines for cleaning and disinfecting glucometers. Nurse #1 was observed using a shared glucometer without disinfecting it before or after use on Resident #35. The glucometer was shared between Resident #35 and Resident #31, and Nurse #1 mistakenly believed it was individually assigned to Resident #35. This oversight occurred because Nurse #1 did not recall the proper disinfection procedure and there were no disinfectant wipes available on the medication cart at the time. Additionally, Medication Aide #1, an agency staff member, was observed using an individually assigned glucometer for Resident #32 and cleaning it with alcohol wipes instead of the approved disinfectant wipes. Medication Aide #1 was unaware of the presence of disinfectant wipes on the medication cart and had not checked for them. Although she had received training on the proper procedure, she did not follow it during the observation. The facility's Director of Nursing confirmed that some glucometers were shared among residents and should be disinfected with EPA-approved wipes after each use. However, there was no documentation of recent educational in-services on this procedure since September 2024. The lack of proper disinfection practices potentially exposed residents to blood-borne infections, as some residents in the facility had diagnoses that included blood-borne pathogens.
Removal Plan
- Nurse #1 was removed from the schedule and will be educated with a competency prior to returning to work.
- Current residents that receive finger stick blood sugar checks are at risk. Forty residents require FSBS and all forty have been provided their individual glucometer. The Assistant Director of Nursing completed an audit.
- Current residents who require finger stick blood sugars received their own individual glucometers and they were labeled and placed in an individual container. This was completed by the Director of Nursing and the Assistant Director of Nursing.
- Education was started by the Director of Nursing to current licensed nursing staff, including agency staff, on proper procedure for cleaning glucometers and for proper storage of glucometers.
- Employees not receiving this education will not be allowed to work until the education is received. The Director of Nursing will track the education to ensure that current staff have received.
- Education includes each resident who receives a finger stick blood sugar will have an individual glucometer that is labeled with their name and stored in an individual container inside the med cart. Education also includes the proper cleaning technique as recommended by the manufacturer guidelines. The cleaning product will be kept on each medication cart.
- The Director of Nursing or charge nurse will check the med carts daily to ensure that the cleaning product is present on each med cart.
- Current Licensed Nurses will complete a skills return demonstration on glucometer cleaning and storage. This will be completed by the Director of Nursing. Any licensed nurse will not be allowed to work until return demonstration has been completed.
- The Director of Nursing or charge nurse is responsible for ensuring new admissions who require finger stick blood sugars are provided with their own individual glucometer that is labeled with their name and stored in an individual container.
- New licensed nurses will receive this education and verify competencies during the orientation process by the Director of Nursing or charge nurse. Agency nurses will receive this education and competencies prior to the start of their shift.
Infection Control Deficiencies in Glucometer Use and COVID-19 Precautions
Penalty
Summary
The facility failed to implement proper infection control policies and procedures, particularly in the use and disinfection of glucometers. A nurse was observed using an unlabeled glucometer for a resident's blood glucose test without disinfecting it before or after use. This glucometer was shared between residents, increasing the risk of spreading bloodborne infections. The nurse admitted to not disinfecting the glucometer, assuming it was the responsibility of the previous user, and used alcohol pads instead of the required EPA-registered disinfectant wipes. Additionally, another staff member was observed using alcohol wipes instead of disinfectant wipes on a resident's individually assigned glucometer, despite having been trained on the correct procedure. The staff member was unaware of the presence of disinfectant wipes on the medication cart. This indicates a lack of adherence to the facility's infection control protocols, which require the use of specific disinfectant wipes to clean glucometers after each use. The facility also failed to maintain proper COVID-19 precautions. A nurse entered a COVID isolation room without wearing eye protection and removed PPE outside the room, contrary to the facility's policy. The nurse, an agency staff member, had not received COVID-19 and PPE training from the facility. Furthermore, the facility's infection control policies had not been reviewed annually, and linen carts were observed uncovered in hallways, posing a risk of contamination.
Removal Plan
- Current residents who require finger stick blood sugars received their own individual glucometers and they were labeled and placed in an individual container.
- Education to current licensed nursing staff, including agency staff, on proper procedure for cleaning/disinfecting glucometers and for proper storage of glucometers.
- Employees not receiving this education will not be allowed to work until the education is received.
- Track the education to ensure that current staff have received it.
- Education includes each resident who receives a finger stick blood sugar will have an individual glucometer that is labeled with their name and stored in an individual container inside the med cart.
- Education also includes the proper cleaning technique as recommended by the manufacturer guidelines.
- The cleaning product will be kept on each medication cart.
- Check the med carts to ensure that the cleaning product is present on each med cart.
- Educated the charge nurses.
- Ensure new admissions who require finger stick blood sugars are provided with their own individual glucometer that is labeled with their name and stored in an individual container.
- New licensed nurses will receive this education during the orientation process.
- Agency nurses will receive this education prior to the start of their shift.
- Assign the charge nurse to complete this task when needed.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to designate a full-time qualified director of food and nutrition services or a certified Dietary Manager (DM). Although the facility had a designated DM, he was not yet certified and was still in school to become a certified DM, with an expected completion date in June. The Regional Dietary Manager, who was certified, managed the department and supported the facility DM by visiting the facility several times a week. Observations during the survey confirmed that the facility DM was responsible for the day-to-day operations in the kitchen, despite not having the required certification. The Administrator acknowledged that the facility DM was not certified and confirmed the Regional DM's role in managing the kitchen temporarily.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program to monitor antibiotic usage, which had the potential to affect all 127 residents. The facility's policy on the Antibiotic Stewardship Program, effective since October 24, 2022, was designed to promote appropriate antibiotic use and reduce resistance. However, during an interview, the Director of Nursing (DON), who had been in the position for five weeks, admitted that there was no active Antibiotic Stewardship Program and that she had not had time to start one. She also acknowledged that the facility was not monitoring or tracking infections. The Corporate Nurse Consultant confirmed that the facility was working on their infection control program, which included the Antibiotic Stewardship Program, but there was no documentation on tracking or trending infections within the facility.
Improper Management of Discontinued Medications
Penalty
Summary
The facility failed to properly manage the return of discontinued medications, both controlled and non-controlled, for 11 residents. The Director of Nursing (DON) was responsible for collecting these medications from the medication carts and returning them to the pharmacy. However, the DON did not follow the established procedure for returning these medications, resulting in them being stored improperly in an unlocked filing cabinet in the DON's office. This included a variety of controlled substances such as Oxycodone, Lorazepam, and Morphine Sulfate, among others. The DON admitted to not knowing the procedure for returning controlled medications to the pharmacy and stated that she had not received an orientation on this process since starting at the facility. Despite being informed of the process by the pharmacist, the DON did not complete the necessary return forms or secure the medications properly. The medications were left unsecured in the DON's office, which was sometimes left unlocked, posing a risk to the safety and security of these medications. Interviews with other staff members, including unit managers and the interim DON, revealed that there was a lack of clarity and communication regarding the responsibility for returning medications. The unit managers would remove discontinued medications from the carts and give them to the DON, who was supposed to handle the return process. However, due to the DON's resignation and lack of action, the medications were not returned to the pharmacy as required, leading to the deficiency noted by the surveyors.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to effectively communicate and address concerns raised by the Resident Council over a period of several months. The report highlights that the facility did not maintain records of Resident Council minutes prior to November 2024 due to staff turnover, and there was no documented evidence of responses to grievances and recommendations made by the Resident Council from December 2023 through October 2024. This lack of documentation and follow-up was evident in the Resident Council minutes from November 2024 to January 2025, where concerns such as untimely call light responses, medication administration issues, and dietary complaints were repeatedly raised without documented resolutions. Interviews with residents and staff revealed a breakdown in communication and resolution processes. Residents expressed frustration that their grievances were not being acted upon promptly and that they received no feedback on the measures taken to resolve their concerns. The Activity Director, who was responsible for communicating these concerns to the administration, was unaware of any resolutions being implemented, indicating a lack of follow-through from the facility's management. The facility's new Administrator, who started in December 2024, outlined a process for addressing Resident Council concerns, involving the Social Worker and department heads. However, this process was not effectively communicated back to the residents, leading to ongoing dissatisfaction and repeated grievances. The report underscores the facility's failure to engage with residents and provide transparent communication regarding the resolution of their concerns, contributing to a persistent sense of neglect among the residents.
Failure to Maintain Safe Shower Environment Due to Broken Tiles
Penalty
Summary
The facility failed to maintain a safe and homelike environment by not addressing broken floor tiles in the 100-hallway shower room, which was used by residents for bathing. During a tour, broken tiles were observed in two shower stalls, and a resident reported having to stand on these broken tiles while using the grab bar for support. The resident had previously expressed concerns to staff but could not recall when or to whom. Interviews with staff revealed a lack of awareness and communication regarding the broken tiles, with some staff members unaware of the issue and others having reported it to maintenance without resolution. The Regional Maintenance Consultant acknowledged the need for tile replacement and identified the broken tiles as a potential hazard. However, the facility had been without a maintenance staff member for several weeks, and the Director of Nursing and Administrator were not informed of the issue. Attempts to contact the former Maintenance Director were unsuccessful, indicating a breakdown in communication and maintenance oversight within the facility.
Misappropriation of Controlled Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, specifically Oxycodone HCL, affecting six residents. The deficiency was identified through record reviews, observations, and interviews with staff, pharmacists, and pharmacy consultants. The investigation revealed discrepancies in medication administration records, missing documentation on controlled drug receipt records, and tampered medication cards. For instance, Resident #232's Oxycodone medication cards were missing after the resident's death, and there were inconsistencies in the controlled substance count sheets. Similarly, Resident #109 received doses of Oxycodone without corresponding documentation on the controlled drug receipt record, indicating potential misappropriation. The facility's investigation highlighted that Nurse #8 was involved in the removal and potential diversion of controlled medications. Nurse #8 was found to have forged a co-signature on the controlled substance count sheet and was suspected of tampering with medication cards. The investigation also noted that Nurse #8 refused to participate in a drug screening and was subsequently reported to the North Carolina Board of Nursing. The facility's Director of Nursing (DON) and Unit Coordinator conducted inspections of medication carts, discovering further tampering and missing medications. The facility reported the incident to the local police department and the state agency, but no charges were filed against the accused individual. The report also detailed the facility's failure to document resident assessments related to pain management and the lack of nursing staff education on changes in handling controlled medications. Despite conducting random audits and re-educating staff on medication card inspections, the facility did not provide a corrective action plan for the misappropriation of controlled medications. The deficiency was further compounded by the absence of a documented plan of correction in the Quality Assurance and Performance Improvement (QAPI) meetings, indicating a lack of comprehensive measures to address the issue.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in the documentation of their medical conditions and treatments. Resident #17, #67, and #4 were not correctly coded for having a Level II Pre-Admission Screening and Resident Review (PASARR) determination, despite their medical records indicating they had serious mental illnesses. Interviews with the MDS Coordinator revealed that these residents' MDS assessments should have reflected their Level II PASARR status. Resident #14's MDS assessment did not accurately reflect the use of opioid pain medication, despite the Medication Administration Record (MAR) showing daily administration of Oxycodone for pain management. The MDS Coordinator acknowledged the oversight, and the Administrator confirmed that the MDS should have accurately represented the resident's medication use. Similarly, Resident #41's MDS was not coded for schizophrenia, even though the psychiatric physician's note and medication records indicated treatment for this condition. The MDS Coordinator and Corporate Nurse Consultant discussed the need for more comprehensive documentation to support the coding. Resident #10's MDS was incorrectly coded to indicate the use of anticoagulants, although the resident was only prescribed antiplatelet medications. The MDS Coordinator admitted the error, and the Administrator emphasized the expectation for accurate MDS assessments. These coding inaccuracies highlight the facility's failure to ensure that residents' assessments accurately reflect their medical conditions and treatments, as required by regulatory standards.
Delayed Antibiotic Administration for Two Residents
Penalty
Summary
The facility failed to administer antibiotic medications as ordered by the physician, resulting in a delay in starting antibiotic therapy for two residents. Resident #90, who was moderately cognitively impaired and diagnosed with diabetes mellitus and heart failure, was prescribed Clindamycin for cellulitis. The medication was not administered as scheduled on the evening of 2/4/2025, despite being delivered to the facility. Nurse #9, who was responsible for administering the medication, did not have access to the medication automated dispensing system and was unaware that the medication was available there. The Interim Director of Nursing confirmed that the medication should have been administered as scheduled. Resident #59, who was cognitively intact and diagnosed with Parkinson's disease, was prescribed Levofloxacin for a urinary tract infection. The medication was not administered as scheduled on 2/15/2025 because it was not available, and the Medication Aide did not have access to the medication automated dispensing system. Nurse #2, an agency nurse, was informed of the issue but did not take action to obtain the medication. As a result, Resident #59 received only six days of the antibiotic instead of the prescribed seven days. Interviews with the facility's staff and pharmacy consultants revealed that the medication automated dispensing system contained the necessary antibiotics, but access issues and communication failures led to the delay in administration. Both residents did not experience harm due to the delay, according to the physician, but the facility's failure to administer the medications as ordered constitutes a significant medication error.
Improper Storage of Controlled Medications in Unlocked Cabinet
Penalty
Summary
The facility failed to maintain proper storage and handling of controlled medications, leading to a deficiency in compliance with regulations. Controlled medications were found stored in an unlocked filing cabinet in the Director of Nursing's (DON) office, which did not provide the required double lock system for controlled substances. This was discovered during an observation by the Administrator and Corporate Nurse Consultant, who found multiple controlled medications belonging to various residents in the unlocked cabinet. The deficiency was exacerbated by the resignation of the DON, who was responsible for returning controlled medications to the pharmacy. The DON admitted to not having received orientation on the process of returning medications and had stored the medications in the filing cabinet due to being busy with a state survey. The facility had a history of medication diversion, which prompted the removal of medications from carts to the DON's office, but this practice was not in line with proper storage protocols. Interviews with staff, including the interim DON and Unit Managers, revealed a lack of clarity and consistency in the process of handling controlled medications. The facility's practice was to store controlled medications on medication carts until collected by the DON, but due to the absence of a secure storage area, medications were improperly stored in the DON's office. The Administrator, who was new to the facility, was still learning the processes related to medication storage and return, contributing to the oversight.
Food Palatability and Temperature Deficiency
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for several residents. Resident Council minutes from December 2024 and January 2025 highlighted concerns about food palatability, with multiple residents expressing dissatisfaction with the taste and temperature of the food. Interviews with residents revealed consistent complaints about the food being served cold, tough, and unappetizing. For instance, one resident reported that the meat was dry and difficult to chew, while another resident, who had hemiplegia and used dentures, found the baked chicken too tough to eat and difficult to cut with one hand. A test tray conducted on February 18, 2025, confirmed these concerns. The tray, which included a chicken breast, mashed potatoes with gravy, and baked beans, was served at a temperature and texture that were not appetizing. The chicken was found to be tough, and the gravy on the mashed potatoes had a syrup-like texture. The Dietary Manager acknowledged the issues and noted that the dietary department was attempting to address these concerns by altering the menus. The facility's Administrator was aware of the ongoing complaints about food quality.
Deficiency in Staff Training Documentation and Implementation
Penalty
Summary
The facility failed to implement an effective training program for its staff, as evidenced by the lack of documented training for four Nursing Assistants (NAs). The review of the 2024 annual education records showed no evidence of training in key areas such as communication, resident rights, compliance and ethics, behavioral health, infection control, and Quality Assurance and Performance Improvement (QAPI). Interviews with NAs #9, #11, and #2 confirmed that they had not received training in these areas during 2024, although they did recall receiving dementia and abuse training in September 2024. NA #8 was unavailable for interview, and her personnel file also lacked documentation of the required training. The Director of Nursing (DON) stated that she had been with the facility since December and had not conducted any educational training. The Corporate Nurse Consultant believed the training had been completed but was unable to provide documentation. The facility's Administrator acknowledged the absence of a Staff Development Coordinator nurse, placing the responsibility for staff educational training on the DON. This deficiency in training documentation and implementation had the potential to affect all residents in the facility.
Failure to Accommodate Resident Needs in Smoking Area and Call Light Accessibility
Penalty
Summary
The facility failed to accommodate the needs of Resident #37, who was an independent and unsupervised smoker with a left below the knee amputation and dexterity problems. The designated smoking area was moved to a new location with a concrete slope, making it difficult for Resident #37 to exit independently. Despite being listed as an independent smoker, Resident #37 was unable to open the door and maneuver the wheelchair up the slope without assistance, as observed during an interview and observation. The resident expressed difficulty in exiting the new smoking area, and it was noted that no assessment was conducted to ensure residents could independently enter and exit the new area. Additionally, the facility failed to ensure that Resident #12's call light was within reach, preventing the resident from requesting assistance when needed. Resident #12, who was cognitively intact and required assistance with activities of daily living, was found with the call bell on the floor under the bed and later wrapped around the bed rail, both out of reach. Interviews with nursing assistants confirmed that call bells should be within reach, and Resident #12 was capable of using the call bell if it were accessible. The Administrator and Interim Director of Nursing acknowledged the issues but were unaware of the specific difficulties faced by the residents. The Administrator admitted that no assessment was conducted before moving the smoking area, and the Interim Director of Nursing confirmed that staff should ensure call bells are clipped within reach. These deficiencies highlight the facility's failure to accommodate the needs and preferences of residents, impacting their ability to independently perform daily activities and request assistance.
Failure to Notify Physician of Resident's Pain After Fall
Penalty
Summary
The facility failed to notify the physician of a resident's complaints of pain following an unwitnessed fall. The resident, who was cognitively intact, was found on the floor with her left knee bent and expressed significant pain. Despite the resident's consistent verbal expressions of pain, which were documented by Nurse #3, the physician was not informed of the resident's pain on the day of the fall or the following day. The facility had a standing order for pain medication, but the physician was to be notified if the pain persisted beyond 72 hours, which was not adhered to in this case. The resident's x-ray results revealed an acute hairline fracture of the left knee, which was not addressed until two days after the fall when the physician ordered an x-ray. The physician confirmed that he was not informed of the resident's pain complaints, which led to a delay in appropriate medical intervention. Interviews with the nursing staff and the Interim Director of Nursing confirmed that the physician should have been notified of the resident's pain complaints, highlighting a lapse in communication and protocol adherence within the facility.
Breach of Resident Medical Information Confidentiality
Penalty
Summary
The facility failed to protect the confidentiality of residents' medical information, as observed during a survey. Nurse #1 left the 100-hall medication cart unattended with Resident #43's medical information visible on the computer screen. This information included the resident's name, date of birth, code status, and a list of six different medications. The cart was positioned five feet from Resident #43's doorway, and Nurse #1 was observed entering the resident's room without securing the computer screen. Upon returning, Nurse #1 changed the display to Resident #26's medical information and again left the cart unattended while entering Resident #26's room. During an interview, Nurse #1 acknowledged the oversight, admitting she should have locked the computer screen to protect the residents' information. The Director of Nursing confirmed that Nurse #1 should have ensured the computer screen was locked to prevent unauthorized viewing of the residents' medical information. This incident highlights a breach in maintaining the privacy and confidentiality of residents' health care information, as required by facility protocols.
Failure to Provide Adequate Incontinent Care
Penalty
Summary
The facility failed to provide adequate incontinent care for a resident who was dependent on nursing staff for activities of daily living. Resident #33, who was admitted with Alzheimer's disease and aphasia, was found soaked with urine on the afternoon of 2/14/2025. The resident's care plan required one-person assistance with toileting and hygiene, and the Minimum Data Set assessment indicated the resident was severely cognitively impaired and incontinent of urine and stool. Despite these requirements, the resident was discovered with wet clothing and bed linens, indicating a lapse in care. Interviews with staff revealed that the on-coming and off-going nurse aides were responsible for checking residents at shift changes. However, on 2/14/2025, NA #9 did not check the residents with NA #12 at the end of the shift. NA #9 found Resident #33 soaked with urine upon starting her shift and noted that the resident's adult brief was not positioned correctly, leading to the wetting of the bed linens and pajamas. The Interim Director of Nursing was unaware of the incident, and it was noted that nursing staff were expected to check residents every two hours or as needed.
Inadequate Fire Safety and Smoking Assessment Deficiencies
Penalty
Summary
The facility failed to equip two designated resident smoking areas with adequate fire preventative equipment and did not complete a quarterly smoking assessment for a resident. Smoking Area #1 lacked smoking aprons, a fire blanket, and self-closing metal containers for ash disposal. Smoking Area #2, although equipped with some fire preventative items, also lacked a smoking blanket and proper metal containers for ash disposal. Observations revealed cigarette butts improperly disposed of in plastic trash cans, indicating inadequate fire safety measures. The facility was in the process of transitioning the smoking area from Smoking Area #1 to Smoking Area #2, but the necessary equipment had not been fully provided. Additionally, the facility failed to conduct a timely smoking assessment for a resident with a history of stroke and moderate cognitive impairment. The resident, who was listed as an independent unsupervised smoker, had not received a smoking assessment since December 2024, despite the requirement for quarterly assessments. The resident was observed smoking unsupervised, with dexterity issues noted, and dropping ashes onto the concrete. The Interim DON acknowledged the oversight in conducting the required smoking assessment.
Failure in Pain Management for Resident Post-Fall
Penalty
Summary
The facility failed to provide effective pain management for a resident who experienced an unwitnessed fall. The resident, who had a history of transient ischemic attack, cerebral infarction without deficits, and type 2 diabetes mellitus, was found on the floor with a complaint of significant knee pain. Despite the resident's repeated verbal expressions of pain, documented on a numerical pain scale ranging from 3 to 6, no pain medication was administered, and the physician was not notified of the resident's pain. The resident's care plan included interventions for fall risk, but after the fall, the facility did not follow through with appropriate pain management. The neurological assessments conducted by Nurse #3 consistently recorded the resident's pain, yet the standing order for Acetaminophen was not utilized, and the physician was not informed. The resident was eventually sent to the hospital for evaluation, where a hairline fracture of the left knee was identified, but still, no pain medication was administered upon return to the facility. Interviews with the nursing staff and the physician revealed a lack of communication and adherence to pain management protocols. Nurse #3 admitted to not administering the standing order for pain relief and failing to notify the physician. The physician was unaware of the resident's pain complaints, and the facility's administration expected the nursing staff to monitor and report pain, which was not done in this case.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours on three specific days, despite having a daily census of over 100 residents. On 12/30/24, 1/2/25, and 1/3/25, the staffing schedules revealed that no RN was working any shift, which was confirmed by the facility's daily staff postings. The Scheduler, who was responsible for verifying RN coverage two weeks in advance, acknowledged the lack of RN coverage on these dates and reported this to the Administrator. The Administrator was unable to provide evidence of RN coverage for the specified days, acknowledging that there should have been an RN present for 8 consecutive hours each day.
Failure to Act on Pharmacist Recommendations and Maintain Documentation
Penalty
Summary
The facility failed to act on recommendations made by the consultant pharmacist and maintain documentation of the physician's review and response to the pharmacist's findings for three residents. Resident #17, who had severe cognitive impairment, was taking multiple medications including Melatonin and Remeron. The pharmacist recommended discontinuing one of these medications, as well as discontinuing either Miralax, Bisacodyl, or Senna, but there was no response or rationale documented for continuing all medications. The Director of Nursing was unaware of the process for drug regimen reviews. Resident #67, who was cognitively intact, was taking several medications including Amlodipine, Lasix, Abilify, Klonopin, and Trazadone. The pharmacist recommended discontinuing some of these medications or providing a clinical rationale, but there was no response or documented rationale. The Director of Nursing again stated she was unaware of the process for drug regimen reviews, and the consultant pharmacist was unsure of the facility's follow-up process. Resident #11, with a history of hypothyroidism, had a low TSH level, and the pharmacist recommended decreasing her Levothyroxine and rechecking her TSH level. However, there was no documentation of the physician's response to this recommendation, and no order for a repeat TSH test was found. The Interim Director of Nursing acknowledged that the pharmacy recommendation should have been followed up on earlier, but was unsure why it was not addressed in September 2024.
Medication Administration Errors Lead to 7.41% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 7.41% during the observation period. This deficiency involved two residents. The first resident, admitted with a diagnosis of depression, was prescribed Olanzapine to be administered at bedtime. However, due to technical difficulties with the electronic medication administration records, a medication aide administered the medication incorrectly at 9:00 am instead of the scheduled 9:00 pm. The aide also failed to administer the Olanzapine at the correct time, as recorded by another nurse later that day. The second resident, with diagnoses including anemia and a bone fracture, was prescribed a combination medication containing calcium carbonate and Vitamin D. The nurse administered a chewable tablet containing 600 mg of calcium carbonate instead of the prescribed 300 mg. The nurse relied on the pharmacy-labeled bottle, which did not match the physician's order. Both incidents were confirmed through interviews with the staff and a review of the medication administration records.
Deficiencies in Medication Administration and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in medication administration and documentation. Resident #50, who was admitted with a diagnosis of depression, had conflicting physician orders for Zoloft and Sertraline, which are the same medication. The February Medication Administration Record (MAR) inaccurately recorded that both medications were administered on certain days, although only one was given. Nurse #4 acknowledged the error, stating she recognized the medications as the same and only administered one. The pharmacy confirmed only one order was filled, and the interim Director of Nursing (DON) confirmed the MAR was inaccurate. For Resident #34, who was admitted with diabetes and end-stage renal disease, the facility failed to document a nursing assessment and accurate physician notification time after receiving critical lab results. The lab results indicated a dangerously high glucose level, but subsequent blood glucose readings were normal. Nurse #8 reported notifying the physician immediately upon receiving the critical results and conducted an assessment, but this was not documented in the medical record. The physician confirmed the notification time and suspected the lab results were inaccurate due to hemolysis. The interim DON and Corporate Nurse Consultant confirmed the lack of documentation for the nursing assessment and the incorrect recording of the physician notification time. The absence of proper documentation in both cases highlights the facility's failure to adhere to professional standards for maintaining accurate medical records, which is crucial for ensuring resident safety and effective care management.
Failure to Inform Residents About Arbitration Agreement
Penalty
Summary
The facility failed to properly inform residents about the arbitration agreement during the admission process, leading to a deficiency in ensuring residents' rights to make informed decisions. Specifically, two residents, who were cognitively intact, were not adequately informed that signing the arbitration agreement was not a condition of admission. Resident #72, admitted on an unspecified date, signed the arbitration agreement on June 5, 2024, but later stated she did not recall signing it and would not have done so if it had been explained to her. Similarly, Resident #109, admitted on an unspecified date, signed the agreement on June 24, 2025, and reported that the forms were not explained, and she was unaware that signing was not mandatory for admission. The Admissions Coordinator, who started at the facility after these admissions, stated that the former Admissions Coordinator was responsible for explaining the arbitration agreement to these residents. The current Admissions Coordinator uses a script to explain the agreement and ensures residents or their representatives initial each section to confirm understanding. However, the former Admissions Coordinator was unavailable for an interview, and the Administrator, who joined the facility after these events, expected the agreement to be explained in a language the residents could understand. The deficiency highlights a lapse in the facility's admission process, where residents were not fully informed about the arbitration agreement, impacting their ability to make informed decisions.
Arbitration Agreement Lacks Venue Selection
Penalty
Summary
The facility failed to include a convenient venue selection for both parties in the Arbitration Agreement for a resident. This deficiency was identified during a review of the Arbitration Agreement signed by a resident, who was cognitively intact, on September 12, 2024. The agreement lacked information regarding the selection of a venue that would be convenient for both parties involved. During an interview, the facility Administrator acknowledged the expectation that the arbitration agreement should contain all required components. The Administrator also noted that the facility had changed ownership in June 2024 and that the current arbitration agreement in use included the necessary components. However, the Administrator was not employed at the facility until December 31, 2024.
Privacy Curtain Deficiency in Resident Room
Penalty
Summary
The facility failed to ensure full visual privacy for a resident in one of the rooms reviewed for privacy curtains. Observations on two separate occasions revealed that the privacy curtain in the room did not close completely, leaving approximately 24 inches of the head of the bed and the resident visible from the door. The issue was due to the curtain connectors getting stuck where the two tracks joined, preventing the curtain from closing fully. Interviews with the resident and staff indicated that the problem had persisted for a long time, but the resident did not recall reporting it, although they believed the staff was aware. The Activity Director stated that staff were responsible for notifying maintenance of such issues, but she was unaware of the problem. The facility's maintenance logs did not document any request for repair of the privacy curtain, and the former Maintenance Director could not be reached for comment. The Interim Director of Nursing and the Administrator were also unaware of the issue, indicating a breakdown in communication and reporting procedures within the facility.
Inadequate Supervision and Care Leads to Resident Injuries
Penalty
Summary
The facility failed to provide safe care to two residents, resulting in injuries. One resident, who was cognitively intact and had impairments in both lower extremities, was at risk for falls. During incontinence care, a CNA used a draw sheet to pull the resident towards her, causing the resident to roll off the bed and sustain a right hip fracture. The CNA was unaware if the resident required a mechanical lift and had been informed that the resident was a one-person assist. The Kardex indicated one-person assist for bed mobility, but the DON later stated the resident probably should have been a two-person assist. Another resident, who was severely cognitively impaired and dependent on staff for transfers, was found with bruising and a probable fracture of the fifth toe. The resident had a history of osteoporosis and was at high risk for injury. The bruising was reported to have occurred during a transfer from bed to a shower chair. The resident's care plan indicated one-person assistance for transfers, but staff interviews revealed that the resident required two-person assistance due to her inability to bear weight and contracted knees. The facility failed to investigate and analyze an unwitnessed fall that occurred, which resulted in further injury. The deficiencies were identified through observations, staff and physician interviews, and record reviews. The facility's failure to ensure proper assistance during care and transfers, as well as the lack of investigation into the causes of falls, contributed to the injuries sustained by the residents. The care plans and Kardexes did not accurately reflect the residents' needs, leading to inadequate supervision and care.
Failure to Manage Blood Glucose Levels and Respond to Medical Emergencies
Penalty
Summary
The facility failed to provide appropriate treatment and care for residents experiencing critical changes in their medical conditions, specifically related to blood glucose management. Resident #21 experienced a severe hypoglycemic event with a blood glucose level of 33 mg/dL, yet the facility staff did not administer Glucagon as per standing orders. This resulted in the resident becoming unresponsive, requiring emergency medical intervention. Upon EMS arrival, the resident's blood glucose was still critically low at 38 mg/dL, indicating a failure to effectively respond to the medical emergency. Resident #22 had a blood glucose level exceeding 400 mg/dL over two days, yet the facility failed to adequately assess and monitor the resident's condition. Despite the high glucose readings, there was no documentation of appropriate insulin administration or physician notification as required. The resident was found nonresponsive by a physical therapy staff member, with an elevated heart rate and respiratory rate, and was later diagnosed with sepsis and hyperglycemia at the hospital. The lack of timely intervention and communication with the physician contributed to the resident's deteriorating condition. Additionally, the facility did not implement physician-ordered laboratory tests and obtain necessary weights for Resident #16, which are critical for assessing the resident's medical condition. These deficiencies highlight a pattern of inadequate response to medical emergencies and failure to follow physician orders, impacting the health and safety of the residents involved.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to provide accurate notification to the physician regarding repeated episodes of a resident's blood glucose level registering greater than 400 mg/dL over two days. The resident, who had a history of type 2 diabetes mellitus, was not properly monitored or treated according to the physician's orders, which required notification if blood glucose levels exceeded 400 mg/dL. Despite the resident's critical condition, including an elevated heart rate and respiratory rate, the facility staff did not notify the physician or the resident's family in a timely manner. On multiple occasions, the medication aide recorded blood glucose levels of 400 mg/dL or higher but did not administer insulin as required, nor did they notify the physician. The unit manager and other nursing staff were informed of the elevated glucose levels but failed to take appropriate action or document any interventions. The resident was found nonresponsive by a physical therapy assistant, yet the facility delayed calling emergency medical services until the resident's family insisted on hospital evaluation. Interviews with staff revealed a lack of communication and documentation regarding the resident's condition. The physician was not informed of the sustained high blood glucose levels, and the facility did not notify the family of the resident's deteriorating condition. The resident was eventually diagnosed with sepsis and hyperglycemia upon hospital admission, highlighting the facility's failure to adhere to professional standards of practice in managing the resident's diabetes and notifying relevant parties of significant changes in the resident's health status.
Removal Plan
- Clinical assessments of all current residents in the facility to identify any other resident with a change in condition that requires medical attention and/or notification to the physician.
- 100% audit of all current resident's blood glucose readings documented to identify any other documentation of a resident with episodes of hypoglycemia and/or hyperglycemia to ensure notification to the attending physician was made.
- Facility employees will ensure significant changes, including hypoglycemia and/or hyperglycemia, are reported to the physician for appropriate intervention.
- Licensed nurse on duty will inform the resident, consult with the resident's physician, and notify the resident representative when there is a significant change in the resident's condition.
- Facilities nursing administrative team will review clinical documentation and physician orders to ensure any needed notification of changes to the physician and/or responsible party was done in a timely manner.
- Certified medication aides will obtain and document blood glucose readings in each resident's medical records and inform a Nurse on duty immediately on any blood glucose level less than 60, greater than 200, or based on the physician order.
- Facility licensed nurses on duty will assess the resident blood glucose level and provide appropriate intervention including notifying the physician in a timely manner.
- 100% education of all licensed nurses on the importance of notifying the physician and the responsible party in a timely manner for any change in condition, change of treatment/intervention, and/or incidents of sustained elevated blood glucose.
- Education will be completed, and any licensed nurses not educated will not be allowed to work until educated.
- Education will also be implemented in new hire orientation.
- Director of Nursing, Assistant Director of Nursing, and/or Unit Coordinators will monitor and track the completion of this education and will complete this education for any newly hired licensed nurses during the new hire orientation.
Neglect in Monitoring and Responding to High Blood Glucose Levels
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not comprehensively assessing and effectively monitoring a resident with critically high blood glucose levels. Over two days, the resident's blood glucose levels were consistently over 400 mg/dL, yet the facility staff did not accurately notify the physician or initiate emergency medical services in a timely manner. The resident was found nonresponsive by a physical therapy staff member, but EMS was not notified until hours later, resulting in the resident being transported to the emergency department with severe symptoms including an elevated heart rate, rapid respirations, and continued high blood glucose levels. The resident, who had multiple diagnoses including type 2 diabetes mellitus, dementia, and schizoaffective disorder, was on a care plan that required monitoring for signs of hypo/hyperglycemia and administering insulin as ordered. However, there were significant lapses in following these orders. On multiple occasions, blood glucose readings were either not taken or not documented, and insulin was not administered as prescribed. Additionally, there was confusion and lack of communication among staff, with medication aides relying on licensed nurses to document and notify physicians, which did not occur. Interviews with staff revealed a chaotic environment with inadequate oversight and documentation. Agency staff and medication aides were unsure of their responsibilities and the licensed nurses who were supposed to oversee them. The interim Director of Nursing and other staff were not aware of the resident's critical condition until it was too late. The resident's family was not informed of the resident's deteriorating condition until an anonymous call prompted them to visit the facility, leading to the eventual hospitalization of the resident.
Removal Plan
- The Governing body led by the President of Operation, the facility Administrator, Regional Director of Clinical Services, and Director of Nursing conducted the root cause analysis to identify the causative factor for this alleged noncompliance and implemented appropriate measures to correct and prevent the reoccurrences.
- The Root Cause Analysis identified the alleged noncompliance resulted from the failure of the facility employee to follow the professional standard of practice on managing repeated episodes of hyperglycemia for a resident who was non-responsive.
- The RCA further identified that the facility failed to have a system in place for medication aides to be informed of the licensed nurse responsible to oversee them while on duty.
- The governing body put forth the following plan for identification for those residents who are likely to suffer a serious adverse outcome as a result of the alleged noncompliance and implemented the measures below to alter the process to prevent a serious adverse outcome from occurring.
- The new Administrator has been educated by the President of Operation on reporting requirements to include reporting to Law enforcement and APS.
- Clinical assessments of all current residents in the facility were completed by the Director of Nursing, Assistant Director of Nursing, and/or Unit coordinator to identify any other resident with the change condition that require medical attention.
Resident Found with Maggots Due to Facility's Fly Infestation
Penalty
Summary
The facility failed to ensure the dignity and proper care of a resident, who was bedbound and diagnosed with a degenerative neuromuscular disease and bipolar disorder with psychotic features. The resident was found with multiple maggots in her bed, under her breast, and within her contracted hand. Prior to this discovery, staff had observed numerous flies in the resident's room and other parts of the facility, which were landing on the resident. The resident was cognitively intact but was totally dependent on staff for personal care, including bathing, dressing, hygiene, and bed mobility. The issue was first noted when the resident complained of hand pain, and staff observed dried blood and fragile skin on her contracted hand. Despite these observations, no maggots were initially found. The resident had a carrot device for her hand contracture, which she did not always keep in place, and she sometimes refused care. The presence of flies was a known issue in the facility, and staff had reported the problem to the Maintenance Director, who was aware but had not yet resolved it. The facility lacked a pest control contract due to a miscommunication during a change in ownership, resulting in no pest control services since mid-May. The maggots were discovered during a bath when a nurse aide found them in the resident's bed and on her body. The former DON removed the maggots, and the resident's hand was subsequently cleaned and treated. The resident's inability to feel the maggots due to her medical condition, combined with the facility's fly infestation, contributed to the severity of the situation. The facility's corporate Nurse Consultant was unaware of the maggot issue until the survey, indicating a lack of communication and oversight within the facility's management.
Pest Control Deficiency Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain routine and as-needed pest control services, resulting in a significant infestation of flies that affected the residents. Two residents were notably impacted, with one resident found to have maggots on her and in her bed. This resident, who had a degenerative neuromuscular disease and bipolar disorder with psychotic features, was bedbound and totally dependent on staff for care. The maggots were discovered in her contracted hand, which had fragile skin and previous skin breakdown. The presence of flies in her room was noted by multiple staff members, and it was suggested that the resident's habit of keeping snacks in her room might have contributed to the issue. Another resident was observed struggling to eat her meal as flies continuously landed on her food. This resident, who had mild cognitive impairment, expressed frustration about the constant presence of flies in her room. The flies were observed landing on her food, and she attempted to brush them away with her hand. The presence of flies was a widespread issue in the facility, as noted by staff, residents, and family members, with flies seen landing on residents and their food. The facility had been without a pest control service contract since May 2024 due to a miscommunication during a change in ownership. The maintenance director, who had been employed for about a month, was aware of the fly problem but had not arranged for pest control services. The corporate nurse consultant confirmed the lack of a pest control contract and indicated that the issue had not been communicated to the administration or corporate employees. The pest control technician, who had not visited the facility in recent months, emphasized the importance of identifying and eliminating the source of the fly infestation.
Failure to Create Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to create a person-centered baseline care plan and provide a summary to residents and/or their responsible parties within 48 hours of admission for three residents. Resident #7, who was admitted with multiple diagnoses including Type 2 Diabetes and chronic kidney disease, expressed a strong desire to return home. Despite being cognitively intact and able to perform some activities of daily living independently, Resident #7's request for discharge planning was not addressed promptly. The Rehabilitation Services Manager and Social Worker were unaware of the resident's request until it was brought to their attention by a surveyor, indicating a lack of communication and coordination among staff. Resident #6, admitted with cerebrovascular disease, was discharged to the community without documented evidence of a baseline care plan. The MDS/Care Plan Coordinator could not recall creating a care plan for this resident, highlighting a gap in the facility's admission process. Similarly, Resident #10, admitted with osteoarthritis and anxiety disorder, also lacked a documented baseline care plan. The MDS/Care Plan Coordinator again could not confirm if a care plan was created, suggesting systemic issues in the facility's procedures for new admissions. Interviews with facility staff, including the MDS/Care Plan Coordinator and the Nurse Consultant, revealed acknowledgment of problems with the admission process. The facility had been experiencing issues since July 2024, and processes were reportedly being developed to ensure baseline care plans were completed. However, the lack of immediate action and coordination among staff members contributed to the deficiencies observed during the survey.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their individual needs. One resident, diagnosed with a degenerative neuromuscular disease and bipolar disorder, was not provided with a care plan that addressed her refusal of care due to distrust of new staff members. This oversight contributed to inadequate hygiene care, resulting in the resident developing maggots in her hand. Despite being cognitively intact, the resident's mental illness and distrust of unfamiliar staff were not considered in her care plan, leading to her refusal of necessary care. Another resident, with a history of congestive heart failure and peripheral neurofibromatosis, did not have a care plan that addressed the specialized skin care required for his condition. The resident's skin tumors would drain and bleed, necessitating frequent linen changes and skin care, which were inconsistently provided by the staff. The care plan failed to include specific instructions for managing the resident's skin condition, resulting in inadequate care and discomfort for the resident. Additionally, the facility did not include care for an indwelling urinary catheter in the care plan of a resident with urinary retention, nor did it address discharge planning for a resident who intended to return to the community. The lack of a care plan for the urinary catheter led to missed catheter changes, while the absence of discharge planning goals left the resident's transition to the community unaddressed. These omissions highlight the facility's failure to ensure that care plans were comprehensive and tailored to the residents' specific needs.
Deficiencies in Controlled Substance Management and Medication Availability
Penalty
Summary
The facility failed to maintain an accurate accounting system for controlled substances for three residents, which was identified during a period when a nurse was working under a restricted license due to issues with narcotic handling. For Resident #27, the controlled drug receipt record for Oxycodone showed multiple instances where the medication was signed out without corresponding documentation on the medication administration record (MAR). This discrepancy was confirmed by the Corporate Nurse Consultant, who suggested that nurses were not documenting the administration of Oxycodone consistently. Resident #27 confirmed receiving the medication when requested, indicating that the issue was with documentation rather than administration. Similarly, Resident #26's records showed that Oxycodone was signed out without documentation on the MAR. The Corporate Nurse Consultant confirmed this issue, attributing it to nurses failing to document the administration of the medication. Resident #26 also confirmed receiving the medication when needed. In the case of Resident #28, who was under hospice care, there was a lack of documentation for the administration of Morphine, and the facility could not locate the controlled drug receipt records for the Morphine. The hospice nurse and the resident's responsible party expressed concerns about whether the Morphine was administered as ordered, as the resident appeared uncomfortable and had labored breathing. Additionally, the facility failed to ensure the availability and administration of medications for Resident #10, who reported missing doses of Clonazepam for anxiety since returning from the hospital. Nurse #1 confirmed the absence of Clonazepam on the medication cart and was unable to determine if it had been administered. The Pharmacy Manager indicated that the medication was returned and would be sent to the facility. The Corporate Nurse Consultant acknowledged the absence of the controlled substance log for Resident #10 and stated that staff should have ensured the medication was available when requested.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that Protimes/INRs were completed as ordered for a resident receiving Coumadin, an anticoagulant medication. The resident, who was admitted with a diagnosis of atrial fibrillation, had an order for weekly Protimes/INRs to be drawn on Mondays. However, the first Protime/INR in July was not completed until July 15, resulting in a critical INR value of 6.75, which was significantly above the therapeutic range of 2.0 to 3.0. Despite the critical value, the facility did not draw the Protime/INR as ordered on July 16, and the resident continued to receive Coumadin without appropriate monitoring. Subsequent lab results on July 18 showed even higher critical values, prompting the administration of Vitamin K to counteract the elevated INR. The resident was sent to the hospital on July 19 due to the supratherapeutic INR levels, although no active bleeding was observed. The hospital repeated the INR, which had decreased to 4.5, and the resident was discharged back to the facility with instructions to hold Coumadin and recheck the INR within 24 to 48 hours. Despite these instructions, the facility's documentation and administration of Coumadin remained inconsistent, with missed doses and incorrect documentation on the MAR. Throughout July and August, the facility continued to struggle with maintaining consistent and accurate monitoring of the resident's Protime/INR levels. Orders for Coumadin dosages were frequently changed, and lab draws were not consistently performed as scheduled. The facility's transition to a new electronic medical record system contributed to documentation issues, as noted by the Corporate Nurse Consultant. The facility pharmacy consultant and the resident's physician both acknowledged the problems with lab timing and documentation, but no harm was reported to have come to the resident from the elevated Protimes.
Documentation Failures in Medication and Vital Sign Records
Penalty
Summary
The facility failed to accurately and consistently document vital signs, blood glucose readings, and medication administration for two residents, leading to deficiencies in medical record documentation. For Resident #22, there were multiple instances where blood glucose levels were not documented correctly, and insulin administration was either not recorded or inaccurately attributed to medication aides. On several occasions, blood glucose readings exceeded 400 mg/dL, requiring physician intervention, yet there was no documentation of insulin administration or physician contact as ordered. The use of agency staff and issues with electronic medical records contributed to the lack of proper documentation. Resident #22's medical records showed inconsistencies in documenting blood glucose levels and insulin administration. Medication aides reported that they relied on licensed nurses to administer insulin and document it correctly, but this did not always occur. The facility's electronic medical record system did not allow for accurate documentation when blood glucose readings were above the glucometer's readable range, leading to further inaccuracies. Additionally, the facility lost paper medication administration records, exacerbating the documentation issues. For Resident #13, the facility failed to document the administration of levothyroxine sodium tablets on multiple occasions. Despite the medication being ordered for daily administration, the MAR did not reflect consistent documentation of its administration. Staff interviews revealed that some doses might have been missed, and there were issues with the new documentation system and internet connectivity, which were not reported to management. These documentation failures highlight significant lapses in the facility's ability to maintain accurate medical records for its residents.
Failure to Involve Resident in Room Change Process
Penalty
Summary
The facility failed to honor a resident's right to be informed and involved in the process of a room change. Resident #19, who was cognitively intact, was moved from a private room to a shared room for medical management reasons. The resident was informed of the room change on 8/26/24, and the move occurred on 8/27/24. However, the resident was not given the opportunity to see the new room or meet the new roommate before the move, which led to dissatisfaction with the new living arrangement. The resident expressed that the new roommate's behavior was disruptive, affecting her sleep and overall comfort. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's rights in the room change process. The social worker, who was new to the facility, was unaware that residents should be allowed to see their new room and meet their roommate before a move. The admissions coordinator, responsible for reassigning rooms based on changes in payment, did not facilitate this process either. This oversight resulted in the resident's dissatisfaction and discomfort with the new room assignment.
Failure to Provide Clean Environment for Resident Room Transfer
Penalty
Summary
The facility failed to ensure a clean and homelike environment for a resident who was moved to a new room. The resident, who was cognitively intact, was informed of a room change for insurance reasons. Upon moving on the specified date, the resident had to wait in the hallway for 20 minutes because the new room was not cleaned. Once moved in, the resident discovered that the room had not been cleaned, with medical equipment left in the bathroom that did not belong to her or her roommate. The Unit Manager, upon inspection, confirmed the presence of the medical items and acknowledged that the room should have been cleaned before the resident's move. The Housekeeping Director, who was not present on the day of the move, stated that it was expected for the housekeeping staff to remove all used medical equipment and sanitize the room, including the bathroom, before a resident was moved in. This expectation was not met, leading to the deficiency in providing a safe and clean environment for the resident.
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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