Piedmont Hills Center For Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 109 S Holden Road, Greensboro, North Carolina 27407
- CMS Provider Number
- 345116
- Inspections on file
- 27
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Piedmont Hills Center For Nursing And Rehab during CMS and state inspections, most recent first.
Two residents experienced significant changes in condition, including new behaviors, increased confusion, and falls, but staff failed to conduct thorough ongoing assessments, did not communicate abnormal findings or changes to medical providers, and did not follow post-fall protocols, resulting in delayed medical intervention and treatment.
A resident with severe cognitive impairment experienced an unwitnessed fall and subsequently had low pulse readings and a head hematoma. Nursing staff did not immediately notify the provider of these changes in condition, despite facility protocols requiring such notification. The provider and medical director were not informed until later, after the responsible party identified the injury and requested hospital evaluation.
A resident with severe cognitive impairment and dysphagia, prescribed a pureed diet with honey-thick liquids, was not adequately supervised during and after meals. Despite a known history of food-seeking behavior and a previous choking episode, the care plan lacked specific supervision interventions. The resident accessed unsafe food from an unattended meal cart, resulting in a fatal choking incident despite staff intervention.
A resident with a complex medical history, including anticoagulation therapy, fell from a raised bed during incontinence care due to inadequate supervision by a nurse aide. The aide momentarily removed her hand from the resident, leading to the resident rolling off the bed and sustaining a fatal head injury. The facility lacked a care plan addressing the resident's need for assistance with bed mobility.
A facility failed to develop a comprehensive care plan for a newly admitted resident requiring assistance with bed mobility. The resident, with multiple health conditions, was assessed to need partial/moderate assistance with daily activities. Despite this, no care plan was provided to address the resident's self-care and mobility needs, as confirmed by interviews with the MDS Nurse and Administrator.
The facility failed to accurately assess residents' tobacco use and functional abilities, leading to deficiencies in MDS assessments. Three residents were incorrectly coded as non-tobacco users, despite being smokers. Additionally, a resident's functional abilities section was left incomplete, despite being cognitively intact. The errors were attributed to reliance on an outside contract company for MDS assessments.
A resident, who was cognitively intact, was not offered the opportunity to participate in his care plan meetings for two years. The facility's Director of Social Work failed to document or recall recent care plan meetings for the resident, with the last documented meeting occurring over a year ago.
A resident was neglected when a Nursing Assistant and dietary staff failed to ensure the resident received lunch, despite being reviewed for food preferences. This deficiency was identified through record review, observation, and interviews, revealing a failure to provide an alternate meal preference during lunch.
The facility failed to develop comprehensive care plans for two residents, one requiring supervision for smoking and another needing assistance with ADLs. Despite assessments indicating these needs, the care plans lacked necessary interventions. Interviews with staff confirmed these oversights.
A resident's care plan was not reviewed since July, despite being cognitively intact and requiring quarterly reviews. The MDS Nurse, responsible for care plan updates, only reviews annually or with condition changes. The DON, new to her role, found some care plans were overdue for review. The Administrator confirmed the oversight but was unaware of the specific deficiency.
Two residents' medications were left on meal trays and discovered by dietary staff, highlighting a failure in medication management. Despite being informed, the facility did not conduct an investigation or notify the Medical Director. The involved staff had inconsistent recollections, and no corrective actions were taken.
A resident with diabetes and dementia did not receive necessary foot care, resulting in long and jagged toenails. Despite being dependent on staff for personal hygiene, there was no documentation of toenail trimming or podiatry services in her records. Staff interviews revealed communication breakdowns and oversight, with a nurse aide reporting the issue but no referral being documented. The DON acknowledged the oversight, indicating a failure in the facility's process for ensuring foot care.
Two residents in the facility received incorrect oxygen levels contrary to physician orders. One resident with COPD and other conditions was observed receiving 0.5 liters of oxygen instead of the prescribed 2 liters, while another resident's oxygen was set at 3.5 liters instead of 2 liters. Staff interviews confirmed the discrepancies, and adjustments were made after the observations. The facility's staff, including the DON and Physician, emphasized the importance of adhering to physician orders and regularly checking oxygen settings.
A resident did not receive an alternate meal preference during lunch due to miscommunication between staff. The resident, who was cognitively intact and independent with eating, requested a ham and cheese sandwich, which was not delivered due to a lack of follow-up. The resident remained hungry until the issue was discovered by a surveyor, and the sandwich was eventually provided.
A facility failed to complete a quarterly MDS assessment on time for a resident admitted with orthopedic aftercare and diabetes. The resident's self-care and mobility section of the MDS was not completed by the required date. The MDS Coordinator was on emergency leave, and the task was not completed by a contracted remote MDS nurse.
The facility failed to maintain a safe and clean environment, with missing baseboards, unclean walls, and unrepaired holes in several rooms. Maintenance and housekeeping issues were not effectively communicated or addressed, leading to prolonged deficiencies. The Administrator was unaware of these issues until inspections were conducted.
A facility failed to verify the competency of a Medication Aide in cleaning and disinfecting glucometers, leading to the use of a shared glucometer on multiple residents without disinfection. The aide, who had been working for two years, reported never having her competencies verified. The Staff Development Coordinator and Director of Nursing were unable to find training records, highlighting a lack of a strong training program. This deficiency posed a risk of exposing residents to bloodborne pathogens.
A Medication Aide in a long-term care facility failed to disinfect a shared glucometer between residents during blood glucose monitoring, contrary to the facility's policy and manufacturer's instructions. The aide was observed conducting finger stick blood sugar checks on multiple residents without cleaning the device, despite changing gloves and using hand sanitizer between uses. This practice posed a risk of spreading bloodborne pathogens, as the glucometer was not disinfected after each use, as required.
The facility failed to manage expired or discontinued narcotic medications, with multiple expired medications found on two units. Some expired medications were administered to residents, and staff interviews revealed inconsistencies in checking and returning expired medications. The administration acknowledged the need for improvement in medication management.
A facility failed to report an alleged misappropriation of narcotics involving a nurse who was involved in discrepancies with a resident's oxycodone medication. Despite being aware of the issue, the facility did not report it to the state agency as required, leading to a deficiency in compliance with federal reporting requirements.
Failure to Identify and Respond to Changes in Resident Condition and Incomplete Post-Fall Assessments
Penalty
Summary
The facility failed to identify and respond appropriately to significant changes in behavior and mental status for two residents, resulting in delayed medical intervention and treatment. In one case, a resident with a history of metabolic encephalopathy, stroke, and dysphagia exhibited new behaviors including undressing, increased confusion, and agitation. Despite these changes being reported by both staff and a family member, nursing staff did not conduct thorough ongoing assessments or notify medical staff of the changes. The family member expressed concern and requested that 911 be called, but the nurse declined, stating that staff would handle the situation. The resident was later found on the floor, naked and confused, by the family, who then called EMS. Upon hospital admission, the resident was diagnosed with acute encephalopathy, acute respiratory failure, hypotension, lactic acidosis, acute kidney injury, transaminitis, septic shock, and aspiration pneumonia, requiring intensive care and ventilator support. In another case, a resident with severe cognitive impairment and a history of metabolic encephalopathy and dementia experienced two falls in one day. After the first unwitnessed fall, neurological checks and vital signs were initiated, but a low pulse rate was documented twice and not reported to the nurse practitioner. The nurse practitioner, who assessed the resident after the first fall, was not made aware of the abnormal vital signs. Following a second fall, neurological checks were again initiated, but documentation errors occurred, and witness statements were not obtained. The responsible party reported a lack of monitoring and observed a head injury that was not initially documented by staff. Interviews with staff revealed gaps in communication, documentation, and adherence to protocols for monitoring and reporting changes in residents' conditions. Nursing staff did not consistently recognize or escalate significant changes in behavior or vital signs to medical providers, and there was a lack of thorough ongoing assessment following incidents such as falls or changes in mental status. These deficiencies resulted in delayed medical evaluation and treatment for the affected residents.
Failure to Notify Provider of Change in Condition After Fall
Penalty
Summary
The facility failed to immediately notify the physician after a resident experienced a change in condition following a fall. The resident, who was severely cognitively impaired and had diagnoses including metabolic encephalopathy and dementia with behavioral disturbance, had an unwitnessed fall in his room. Initial assessments by nursing staff noted no injuries, and neurological and vital sign checks were initiated as per protocol. However, during these checks, the resident exhibited a low pulse rate of 56 bpm on two occasions, which constituted a change in condition. Despite facility protocols requiring provider notification for such changes, the nurse did not inform the provider at that time. Later in the day, the resident's responsible party identified a hematoma on the resident's head and requested hospital evaluation. The responsible party reported concerns about monitoring and requested to speak with someone in charge. The Director of Nursing was eventually notified and, after discussion, the resident was sent to the hospital. Interviews with staff, the responsible party, and medical providers confirmed that the provider was not notified immediately when the change in condition was first observed, and that the nurse should have reported the low pulse and head injury promptly. Documentation and interviews further revealed that the nurse practitioner and medical director were not made aware of the low pulse readings or the head injury at the time they occurred. Both indicated they would have wanted to be notified immediately to assess the resident and determine if further intervention was needed. The facility's failure to notify the provider of the resident's change in condition after the fall constituted a deficiency in following required notification protocols.
Failure to Supervise Cognitively Impaired Resident with Dysphagia Results in Fatal Choking Incident
Penalty
Summary
A facility failed to provide necessary supervision to prevent an avoidable accident involving a severely cognitively impaired resident with a history of dysphagia and choking. The resident was prescribed a pureed diet with honey-thick liquids and required close supervision and assistance with feeding due to poor safety awareness and impulsivity. Despite these needs, the care plan did not include specific interventions for supervision during meals, and staff were not consistently monitoring the resident's access to food outside of prescribed meals. On one occasion, the resident experienced a choking episode in the main lobby after obtaining bread, which was not part of his prescribed diet. Staff intervened and the resident returned to baseline. Following this incident, staff were educated on the importance of adhering to prescribed diets, but no additional supervision measures were implemented. Subsequently, the resident accessed a hot dog from an unattended meal cart, began to choke, and despite staff performing abdominal thrusts and CPR, the resident was pronounced deceased after EMS was unable to revive him. Multiple staff interviews confirmed that the resident was known to seek food and had previously taken food from meal carts or other sources when not closely supervised. The facility's failure to implement and maintain adequate supervision and environmental controls, such as securing meal carts and monitoring residents with known food-seeking behaviors and swallowing disorders, directly contributed to the resident's access to unsafe food and the fatal choking incident. Staff awareness of the resident's risks and behaviors was inconsistent, and interventions to prevent access to inappropriate food were not effectively communicated or enforced.
Inadequate Supervision Leads to Resident's Fall and Fatal Injury
Penalty
Summary
The facility failed to provide adequate supervision and care in a safe manner for a resident, leading to a serious accident. The incident occurred when a nurse aide was providing incontinence care to the resident. The aide raised the bed to a high level and asked the resident to turn on her side. During this process, the aide momentarily removed her hand from the resident to pick up a brief that had fallen to the floor. This lapse in supervision resulted in the resident rolling off the bed and sustaining a head injury. The resident involved had a complex medical history, including end-stage renal disease, hypertension, diabetes, and a history of seizures. She was also on anticoagulation therapy with Eliquis due to a recent venous sinus thrombosis. At the time of the incident, the resident required partial to moderate assistance with bed mobility, as documented in her care assessments. Despite this, the facility did not have a care plan that adequately addressed her functional abilities and the level of assistance she required. Following the fall, the resident was assessed by a nurse and found to be incoherent and in pain. She was subsequently transferred to the emergency room, where imaging revealed multiple injuries, including fractured ribs and an increase in pre-existing subdural hematomas. The resident's condition deteriorated, leading to her admission to the ICU and eventual death. The immediate cause of death was determined to be complications from the blunt force injury to the head sustained during the fall.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring.
- Nurse #2 notified the unit manager that Resident #1 had a fall from the bed during care. The Unit Manager notified the Director of Nursing and the Administrator. The intervention included Resident was to be seen at the acute care hospital and for the fall to be discussed in the morning clinical risk meeting.
- Resident #1's care plan was updated to indicate she would require two staff assistance during care related to most recent fall.
- An audit was conducted by the DON, Regional Nurse Consultant, and the Minimum Data Set nurse, to identify any residents at risk for falls utilizing fall risk analysis report and Morse Scale report.
- The Activities of Daily Living care plans of the residents who are at risk for falls and/or have had falls in the past 30 days were reviewed to ensure they included if the resident required a level of assistance of minimum, moderate, or maximum assistance with bed mobility.
- This audit included residents who currently have devices care planned to ensure the device is in place.
- Kardex updates automatically in Point Click Care when the intervention is updated in the care plan, which CNAs can review under their documentation system of Point of Care.
- The DON identified 2 items related to Dycem and a weighted blanket. These two items were corrected immediately by DON and/or SDC.
- The Staff Development Coordinator began education on turning and repositioning during care, utilizing the appropriate level of care required, maintaining resident safety during care by maintaining physical contact, and utilizing any assistive devices according to resident's care plan/Kardex.
- Education was conducted in person with staff with an observed return demonstration completed to SDC.
- The education included an emphasis on the procedure for turning and repositioning resident when providing care, obtaining assistance when needed, maintaining resident's safety during care by maintaining physical contact, and repositioning a resident to the center of the bed when care is completed.
- SDC observed return demonstration included answering any questions, and/or re-educating 1:1.
- The education will be completed for clinical staff currently working and will continue with staff who provide care to residents including nurses, nurse aides, therapy.
- Those who were not educated will be educated and provide return demonstration prior to beginning their next scheduled shift.
- Newly hired staff including nurses, nurse aides, and therapy will receive the education from the SDC or designee and provide return demonstration to SDC, DON, or UMs during orientation and this will be conducted by the SDC or DON.
- The Activities Director conducted interviews with residents that had a Brief Interview for Mental Status > 12, to identify any resident concerns related to turning and repositioning during care.
- Interviews were completed. No concerns were identified.
- The DON conducted observations of residents and resident rooms identified to be at risk for falls to ensure the fall interventions placed on the plan of care were in place.
- The Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a newly admitted resident who required assistance with bed mobility. The resident, who was admitted with multiple diagnoses including dialysis-dependent end-stage renal disease, metabolic encephalopathy, and congestive heart failure, was assessed to be cognitively intact and required partial/moderate assistance with various activities of daily living, including bed mobility. Despite these findings, the facility did not provide a care plan addressing the resident's functional abilities related to self-care and mobility. Interviews with facility staff, including the MDS Nurse and the Administrator, confirmed the absence of a care plan for the resident's self-care and mobility needs. The MDS Nurse acknowledged that the resident required assistance and should have had a care plan in place. The Administrator indicated that care should be provided according to the plan of care, highlighting the oversight in developing a necessary care plan for the resident's functional status.
Inaccurate MDS Assessments for Tobacco Use and Functional Abilities
Penalty
Summary
The facility failed to accurately assess residents in the area of tobacco use and functional abilities, leading to deficiencies in the Minimum Data Set (MDS) assessments for four residents. Three residents, who were admitted with diagnoses that included tobacco use, were incorrectly coded as non-tobacco users in their MDS assessments. Interviews with the MDS Coordinator revealed that these residents were indeed tobacco users, and their assessments should have reflected this. The facility's Administrator and Director of Nursing acknowledged the expectation for accurate MDS coding, indicating a lapse in the assessment process. Additionally, the facility failed to complete the functional abilities and goals section for a resident with multiple diagnoses, including stage 4 kidney disease and diabetes. The self-care section of this resident's quarterly MDS assessment was left incomplete, despite the resident being cognitively intact and not having been hospitalized, which would have justified the omission. The MDS Nurse and Director of Nursing confirmed the oversight, attributing it to the reliance on an outside contract company for MDS assessments prior to the hiring of an in-house MDS Nurse.
Resident Not Included in Care Plan Meetings
Penalty
Summary
The facility failed to offer a resident the opportunity to participate in his care plan meetings, as required for person-centered care. The resident, who was cognitively intact and had been residing at the facility for two years, reported that no one had ever explained or discussed his care plan with him. This was confirmed by the absence of documentation in the medical record indicating that the resident attended or refused to attend his care plan meetings. The Director of Social Work, who was responsible for scheduling care plan meetings, stated that she would notify residents and their families about upcoming meetings. However, she was unable to recall the date of the last care plan meeting for the resident in question and acknowledged that there was no documentation of a meeting held in October 2024, despite there being one scheduled. The most recent documented care plan meeting for the resident was in March 2023, indicating a significant lapse in the facility's care planning process.
Neglect in Meal Provision for a Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when a Nursing Assistant and the dietary staff did not ensure that a resident received lunch. This incident involved a resident who was reviewed for food preferences. The deficiency was identified through record review, observation, and interviews with residents and staff, highlighting a lapse in providing an alternate meal preference during lunch.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, leading to deficiencies in addressing their specific needs. Resident #76, who was admitted to the facility, was identified as a smoker requiring supervision according to a smoking assessment. However, the resident's care plan did not include any interventions related to tobacco use or smoking, despite the resident being a smoker since admission. Interviews with the MDS Coordinator and the Director of Nursing confirmed that a care plan should have been developed to address the resident's smoking habits. Similarly, Resident #5, admitted with diagnoses including dementia and muscle weakness, required substantial to maximum assistance with various activities of daily living (ADL) such as toileting hygiene, personal hygiene, and transfers. Despite triggering the need for an ADL care plan, the resident's comprehensive care plan did not include any interventions to address these needs. The Director of Nursing acknowledged the oversight, confirming that the care plan should have reflected the resident's care requirements.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for one resident, identified as Resident #12, who was admitted to the facility on an unspecified date. The quarterly Minimum Data Set (MDS) indicated that the resident was cognitively intact. However, upon review, it was found that the resident's care plan had not been reviewed since July 3, 2024, despite documentation indicating a review was due on October 22, 2024. The MDS Nurse, responsible for ensuring care plan reviews, stated she only reviews care plans annually or if there is a change in condition, and she had not been in the role until September 2024. The Director of Nursing (DON), who had been in her position for three months, acknowledged that some residents' care plans had not been reviewed as required. She stated that it was the MDS Nurse's responsibility to track care plan review dates and that reviews should occur every three months or with a change in condition. The Administrator confirmed that care plans should be reviewed quarterly and with any change in condition, but was unaware of the oversight regarding Resident #12's care plan. The lack of review for Resident #12's care plan since July 2024 was not explained by the facility staff.
Medication Mismanagement on Meal Trays
Penalty
Summary
The facility staff failed to ensure that residents took their medications, resulting in medications being left on meal trays. This deficiency was identified for two residents, both of whom were cognitively intact. The medications were discovered by dietary staff on two separate occasions in August 2024. The facility's timeline indicated that the Administrator was informed of these incidents through pictures sent by the previous Dietary Manager and a Medication Aide. However, the timeline only noted that education was provided to the involved Medication Aides. Interviews with various staff members revealed a lack of clarity and communication regarding the handling of the medications found on the meal trays. The previous Dietary Manager reported the incidents to the Administrator and handed the medications to the previous Staff Development Coordinator, who was also acting as Unit Manager. However, the previous SDC did not complete an investigation and was unsure of what happened to the medications. The Regional Consultant, Regional Nurse Consultant, and the Director of Nursing confirmed that no investigation or follow-up actions were conducted, and the Medical Director was not informed of the incidents. The involved Medication Aides had differing recollections of the events, with one aide recalling leaving medication on a resident's tray at the resident's request, while the other aide denied involvement. The Unit Manager and Nurse involved did not recall being informed of the incidents. The Medical Director emphasized that staff should have identified the medications and notified medical personnel to assess any potential consequences for the residents. Overall, the facility's response to the medication errors was inadequate, with no investigation or corrective actions taken to address the issue.
Failure to Provide Adequate Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide adequate foot care and arrange podiatry services for a resident who was dependent on staff for personal hygiene due to diagnoses of diabetes and dementia. The resident was found to have long and jagged toenails extending beyond the tips of her toes, indicating a lack of proper foot care. Despite being cognitively intact and expressing a desire for her toenails to be trimmed, there was no documentation in her medical records from June to December indicating that she had received toenail trimming by staff or podiatry. Additionally, her comprehensive care plans did not address her need for assistance with activities of daily living, including foot care. Interviews with staff revealed a breakdown in communication and oversight regarding the resident's foot care needs. A nurse aide reported the condition of the resident's toenails to a nurse, but the referral to podiatry was not documented or acted upon. The social worker responsible for coordinating podiatry services did not recall receiving a referral for the resident. The nurse who conducted skin assessments did not notice the need for foot care, assuming the resident had already been referred to podiatry due to her diabetic condition. The Director of Nursing acknowledged the oversight and stated that residents needing podiatry services should be added to the schedule, highlighting a failure in the facility's process for ensuring necessary foot care for residents.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to follow physician orders for oxygen administration for two residents, leading to deficiencies in respiratory care. Resident #40, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), respiratory failure, and vascular dementia, was observed receiving oxygen at 0.5 liters per minute instead of the prescribed 2 liters. Despite her oxygen saturation levels remaining above 90%, the setting was not in accordance with the physician's order. Nurse #2 confirmed the discrepancy and adjusted the oxygen concentrator to the correct setting, acknowledging that Resident #40 could not adjust it independently. Resident #14, with diagnoses including COPD, congestive heart failure, and anxiety disorder, was observed with her oxygen concentrator set at 3.5 liters per minute, contrary to the physician's order of 2 liters. Multiple observations confirmed the incorrect setting, and Medication Aide #5 eventually adjusted it to the correct level. Resident #14, who was cognitively intact, stated she did not alter the settings herself. The facility's staff, including the Medication Aide and Unit Manager, acknowledged that nurses were responsible for ensuring the correct oxygen settings, but the oversight persisted. Interviews with the Director of Nursing and the Physician highlighted the expectation that staff should adhere to physician orders and regularly check oxygen settings. The Physician emphasized that any necessary adjustments to oxygen levels should be assessed and authorized by him. The failure to follow these protocols resulted in the facility not meeting the required standards for respiratory care for the residents involved.
Failure to Provide Alternate Meal Preference
Penalty
Summary
The facility failed to provide a resident with an alternate meal preference during lunch, resulting in the resident not receiving any lunch. The resident, who was cognitively intact and independent with eating, had expressed dissatisfaction with the food and often requested alternate meals, which were not provided. On the day of the incident, the resident requested a ham and cheese sandwich, which was communicated by a nursing assistant to a dietary aide. However, due to a lack of communication and follow-up, the sandwich was not delivered to the resident, leaving her without a meal until later in the afternoon. The nursing assistant believed the dietary staff would deliver the sandwich, while the dietary aide assumed the nursing assistant would return to deliver it. This miscommunication resulted in the resident remaining hungry until the issue was discovered by a surveyor. The dietary aide eventually offered the resident the sandwich after being informed of the oversight. The facility's administrator and assistant dietary manager acknowledged the expectation for staff to ensure residents receive their requested meals, but the process failed due to incomplete communication between staff members.
Failure to Complete Quarterly MDS Assessment on Time
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame for one resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation and diabetes mellitus. The admission MDS indicated the resident was cognitively intact. However, the self-care and mobility section of the resident's quarterly MDS, with an assessment reference date of November 19, 2024, was not completed by December 4, 2024. The MDS Coordinator was on emergency leave from November 25, 2024, to December 2, 2024, and stated that the section should have been completed and submitted by one of the facility's contracted remote MDS nurses by December 3, 2024.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in several rooms. Observations revealed that in six out of thirteen rooms, baseboards were either missing or not affixed properly, exposing drywall and creating an unkempt appearance. The Maintenance Assistant was unaware of these issues due to a lack of communication and the absence of a Maintenance Director, which led to reliance on verbal communication rather than the newly implemented electronic tracking system. The Administrator expected staff to report such issues, but the system was not effectively utilized. In another instance, a resident's room was found to have red/orange splatter on the wall and black marks on the doors, indicating inadequate cleaning. The resident reported that housekeeping did not clean her room daily. The Housekeeping Manager confirmed that housekeepers were responsible for cleaning visible dirt but acknowledged that time constraints might prevent thorough cleaning. The Administrator was not aware of these cleanliness issues until a walk-around inspection was conducted. Additionally, a room was observed to have multiple holes in the walls behind and below the residents' headboards, which had been present for at least a year according to the residents. The Maintenance Assistant admitted that walk-arounds were not conducted consistently, and they relied on housekeeping and nursing assistants to report issues through the computerized system. However, the holes were not reported, and the Administrator was unaware of these issues until the walk-around inspection.
Failure to Verify Competency in Glucometer Disinfection
Penalty
Summary
The facility failed to verify the competency of a Medication Aide (MA) in cleaning and disinfecting glucometers according to the manufacturer's instructions. This deficiency was observed when MA #1 conducted finger stick blood sugar (FSBS) checks on four residents using the same glucometer without disinfecting it between uses. MA #1, who had been working at the facility for approximately two years, reported that her competencies for cleaning and disinfecting glucometers had never been verified, and she had never cleaned and disinfected the glucometer between residents. The Staff Development Coordinator/Infection Preventionist (SDC/IP) and the Director of Nursing (DON) both revealed that they were unable to find records of training or verification of competencies for the medication aides, including MA #1. The SDC/IP, who had started her job three months prior, was unsure of what had been taught to the medication aides regarding glucometer cleaning and disinfecting. The DON, who started in April 2024, acknowledged the lack of a strong training and orientation program and noted that training folders were missing or incomplete. The facility's failure to ensure proper training and verification of competencies for cleaning and disinfecting glucometers resulted in the use of a shared glucometer without disinfection, posing a high likelihood of exposing residents to bloodborne pathogens. This practice was observed for four residents, and the facility was found to be out of compliance, with Immediate Jeopardy identified and later removed after corrective actions were implemented.
Removal Plan
- The Medical Director was notified of the incident.
- The IDT discussed education and systems to prevent future staff competency issues related to blood glucose monitoring.
- Education was provided to MA #1, all nurses, and medication aides.
- SDC #2 was notified by Nurse Consultant #1 of her responsibility to conduct education with nurses and medication aides regarding residents' personal glucometers for individual use, the proper steps to clean and disinfect a glucometer, storage of a glucometer, and where to locate a glucometer when needed.
- The education will be monitored by Staff Development Coordinator (SDC) #2 and included in all orientation processes for newly hired nurses and medication aides.
- The IDT team reviewed the manufacturer instructions to obtain the manufacturer recommendations for glucose cleansing and disinfecting.
- SDC #2 in-serviced Medication Aide (MA) #1 on the policy and procedure of cleaning and disinfecting glucometers, observed a return demonstration, and educated on potential consequences of not properly cleaning and disinfecting glucometers.
- The SDC then in-serviced all nurses and medication aides working.
- SDC began in-servicing all nurses and medication aides not currently working at the facility.
- All staff were instructed to see the Director of Nursing (DON) and/or SDC for a return demonstration.
- The SDC will educate all newly hired nurses, medication aides, and agency staff before receiving an assignment.
- The SDC will be responsible for keeping up with the newly hired staff and new agency staff.
- The new staff will be in-serviced on glucometer disinfection prior to working on a medication cart and will be required to perform a return demonstration for the DON or SDC before the next assignment.
- The glucometer policy was placed on every medication cart.
- The IDT made the decision to move all resident glucometers into the corresponding resident's room to be stored at the bedside.
- The glucometers were moved by the Unit Managers and education on the location of the glucometers was provided to all nurses and Medication Aides working.
- Any nurse, medication aide, or agency staff that were not working will receive education prior to starting the next scheduled shift.
Failure to Disinfect Glucometer Between Residents
Penalty
Summary
The facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents whose blood glucose levels required monitoring. Medication Aide (MA) #1 was observed conducting finger stick blood sugar (FSBS) checks on four residents consecutively without disinfecting the glucometer between uses. This practice was contrary to the facility's policy and the manufacturer's instructions, which require cleaning and disinfecting the glucometer after each use to prevent the transmission of bloodborne pathogens. During the observation, MA #1 was seen changing gloves and using hand sanitizer between residents but did not clean or disinfect the glucometer. MA #1 stated that she cleaned the glucometer at the start and end of her shift, as she was trained at another facility, and was unaware that individual glucometers were available for each resident. The facility's policy and the manufacturer's instructions clearly state that glucometers should be disinfected with an EPA-registered healthcare disinfectant effective against bloodborne pathogens after each use. The failure to disinfect the glucometer between residents was identified as an Immediate Jeopardy situation, indicating a high likelihood of exposing residents to the spread of bloodborne pathogens. The facility's Director of Nursing (DON) and other staff confirmed that individual glucometers were available for residents, but MA #1 was not familiar with the medication cart on the unit. The deficiency was observed for all four residents monitored for FSBS checks, highlighting a significant lapse in infection control practices.
Removal Plan
- The Medical Director was notified of the incident by the interdisciplinary team (IDT).
- The IDT discussed education and systems to put into place to prevent future staff competency issues related to blood glucose monitoring.
- Education to MA #1, all nurses, and medication aides will be monitored by Staff Development Coordinator (SDC) #2 and included in all orientation to newly hired nurses and medication aides.
- The IDT team reviewed the manufacturer's recommendations for glucose cleansing and disinfecting.
- SDC #2 in-serviced Medication Aide (MA) #1 on the policy and procedure of cleaning and disinfecting glucometers, observed a return demonstration, and educated on potential consequences of not properly cleaning and disinfecting glucometers.
- SDC then in-serviced all nurses and medication aides working and began in-servicing all nurses and medication aides not currently working at the facility on the telephone.
- All nursing staff and medication aides were instructed to see the Director of Nursing (DON) and/or SDC before their next shift for a return demonstration of blood glucose monitoring cleansing and disinfection process.
- The SDC will educate all newly hired nurses, medication aides, and agency staff regarding cleaning and disinfection of glucometers before receiving an assignment.
- The Unit Manager removed the glucometer of the discharged Resident (Resident #5) and discarded the glucometer.
- The Director of Nursing and Unit Manager assessed, cleansed, and disinfected all glucometers according to the manufacturer recommendations for glucose disinfection and the germicidal disposable wipes directions.
- An audit was conducted by Nurse Consultant #1 and Unit Manager to verify that residents had personal glucometers on the medication carts, bagged, and labeled.
- The Administrator notified [NAME] County Department of Health of the incident.
- The Health Department responded to the summary with recommendations to conduct laboratory blood work on all diabetics that receive blood glucose monitoring to screen for blood borne pathogens.
- The physician orders were entered into the laboratory system by the DON or designee.
- The glucometer policy was placed on every medication cart by the Assistant Nursing Home Administrator.
- The IDT team made the decision to move the glucometers off the medication carts and into each resident's room.
- Education was provided by the Unit Managers to all Nurses and Medication Aides regarding the location of the glucometers in the rooms.
- Any nurse or medication aide found to be sharing glucometers will be subject to disciplinary action.
Failure to Manage Expired Medications
Penalty
Summary
The facility failed to properly manage expired or discontinued narcotic medications, as evidenced by the findings during a review of medication carts on two different units. On 2 North, multiple expired or discontinued medications were found, including lorazepam, oxycodone-acetaminophen, alprazolam, and tramadol hydrochloride, which were not sent back to the pharmacy as required. These medications were associated with residents who either had no current orders for them or had passed away, indicating a lapse in the facility's medication management protocols. On 2 East, similar issues were identified, with expired tramadol and hydrocodone-acetaminophen tablets found in the medication cart. Some of these expired medications were administered to residents, highlighting a failure in the facility's process for checking and returning expired medications. The medication aides and nurses interviewed acknowledged that the expired medications should have been sent back to the pharmacy, but there was a lack of clarity on the frequency and responsibility for these checks. Interviews with various staff members, including the Medication Aides, Nurse, Unit Manager, Staff Development Coordinator, Pharmacist, Nurse Practitioner, Director of Nursing, and Administrator, revealed inconsistencies in the procedures for checking medication carts and returning expired medications. The staff indicated that there were no set schedules for these checks, and the responsibility was not clearly defined, leading to the oversight. The facility's administration recognized the need for improvement in medication storage and management practices.
Failure to Report Alleged Misappropriation of Narcotics
Penalty
Summary
The facility failed to submit a 24-hour and 5-day report to the State Agency after becoming aware of an allegation of misappropriation of property by a staff member. The incident involved a discrepancy in the narcotic count for a resident's pain medication, oxycodone, which was not reported in a timely manner as required by the facility's policy. The policy mandates that all alleged violations be reported to the Administrator, state agency, and other required agencies within specified timeframes, but this was not adhered to in this case. The issue arose when discrepancies were noted in the narcotic count for a resident's oxycodone medication. Nurse #2 was involved in multiple discrepancies, including administering and wasting oxycodone tablets without proper documentation or witness signatures. On one occasion, Nurse #2 claimed to have wasted three oxycodone tablets without producing them for a witness, leading to a discrepancy in the count. Despite these issues, the facility did not report the incident to the state agency, as the Administrator believed it was merely a suspicion without documented proof. Interviews with staff revealed that the Director of Nursing (DON) and the Administrator were aware of the discrepancies but did not take immediate action to report them to the state agency. The Administrator and DON conducted an internal investigation and consulted with the North Carolina Board of Nursing (NCBON) but failed to notify the state agency as required. The facility's inaction in reporting the alleged misappropriation of narcotics led to a deficiency in compliance with federal requirements for reporting suspected abuse, neglect, or theft.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
