Pine Ridge Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Thomasville, North Carolina.
- Location
- 706 Pineywood Road, Thomasville, North Carolina 27360
- CMS Provider Number
- 345144
- Inspections on file
- 24
- Latest survey
- July 9, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pine Ridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that several residents receiving oxygen therapy did not have required cautionary signage posted, and in one instance, a resident had two conflicting active oxygen orders documented and administered. Additionally, an unsecured oxygen tank was observed in a resident's room without proper signage. Staff and leadership interviews confirmed expectations for signage and order management were not met, and audits failed to identify these ongoing issues.
A resident with a history of CHF, CAD, and hypertension received blood pressure medications despite physician orders to hold them for low blood pressure readings. Medication administration records and staff interviews confirmed that Amlodipine, Isosorbide Mononitrate ER, and Carvedilol were administered outside of the prescribed parameters, with staff acknowledging the oversight. The Medical Director and facility leadership confirmed that orders were not followed as written.
A nurse administered the wrong dosage of Lyrica to a resident with severe cognitive impairment, giving a 100 mg dose intended for another resident instead of the prescribed 25 mg. The error was discovered during a narcotic count, and the nurse admitted to not checking the medication label before administration. The affected resident was assessed and showed no adverse effects.
A resident with a chronic foot ulcer did not receive daily wound care as ordered by the physician over a weekend. Although the Treatment Administration Record indicated the treatment was completed, interviews with the resident and staff confirmed the dressing was not changed and the assigned nurse overlooked the treatment. The DON and wound nurse were notified after the lapse was discovered.
A resident with a history of wandering and severe cognitive impairment entered another resident's room and bed during a period of indirect supervision. The incident occurred when staff were assisting another resident, and the wandering resident was not directly observed. This led to a physical altercation, resulting in a nasal fracture for the other resident, who also had severe cognitive impairment and required assistance with ADLs.
The facility did not provide written notifications to residents or their responsible parties regarding hospital transfers, relying instead on phone calls and sending documentation only with the resident. Additionally, a resident discharged home did not receive a discharge summary, and staff were unclear about who was responsible for this documentation.
Two residents experienced deficiencies in medical record accuracy: one had conflicting active orders for oxygen therapy, with staff documenting administration for both rates despite only one being used, and another did not receive ordered wound care, yet the MAR was inaccurately completed by a nurse who did not perform the treatment.
The facility failed to properly manage and store medications on the 200 Hall Medication Cart and in the 100/200/300 Hall Medication Storeroom. Observations revealed expired medications, undated vials, and improper storage of single-use and refrigerated medications. Nurse #1 and the DON confirmed these findings and acknowledged the need for proper dating, discarding expired medications, and notifying the pharmacy for replacements.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in areas such as resident rights, care planning, and maintaining a clean environment. Specific incidents included a nurse speaking to a resident in a demeaning tone, residents not being invited to care plan meetings, and unclean conditions with overflowing garbage. The facility also failed to develop comprehensive care plans for residents' nutritional needs and discharge plans.
A nurse spoke to a resident in a loud and demeaning tone, telling her to get back in her room and stop stalking her. The resident felt embarrassed and humiliated, and the incident was confirmed by another nurse and a surveyor. The nurse received a final written warning for her unprofessional behavior.
The facility failed to offer two residents and one family member the opportunity to participate in care plan meetings. One resident had not been invited to or participated in any care plan meetings for over a year, while another had not attended any meetings since her admission. A third resident, who was severely cognitively impaired, had not had a formal care plan meeting since February 2023.
The facility failed to develop comprehensive nutrition care plans for two residents, leading to significant weight loss. Despite recommendations from the RD, the Dietary Manager did not update the care plans, resulting in a lack of nutritional interventions.
The facility failed to limit the duration of PRN psychotropic medications to 14 days and did not provide a rationale for extending the orders for two residents. Both residents had active PRN lorazepam orders without a stop date, and no doses were documented as administered. The consultant pharmacist and DON acknowledged the oversight.
The facility failed to provide consents with the benefits and risks of receiving the influenza vaccine for two residents. One resident did not receive the vaccine at the Responsible Party's request, and another was not offered the vaccine due to issues with obtaining consent from family members. Both residents were severely cognitively impaired.
The facility failed to maintain walls and a door in good repair in three rooms on the 100-hall. Observations revealed gouged drywall, a broken bathroom door, and separated baseboard molding. The Maintenance Director acknowledged the need for repairs and prioritized safety-related issues.
Failure to Ensure Safe and Appropriate Oxygen Therapy Practices
Penalty
Summary
Surveyors identified multiple deficiencies related to the provision of safe and appropriate respiratory care for residents requiring supplemental oxygen. Several residents with physician orders for oxygen therapy were observed receiving oxygen via nasal cannula, but there were no cautionary oxygen signs posted either outside or inside their rooms. Staff interviews confirmed that signage was expected but not present, and both the DON and Administrator were unaware of the missing signs despite recent audits intended to ensure compliance. In one case, a resident had two active physician orders for different oxygen flow rates (2 L/min and 3 L/min) simultaneously, and both orders were being documented as administered on the MAR. The nurse responsible for entering the new order acknowledged that the previous order should have been discontinued but was not, resulting in conflicting active orders. The Medical Director, DON, and Administrator all confirmed that the previous order should have been discontinued when the new order was received. Additionally, a resident's oxygen tank was found unsecured in the room, not placed in a holster or rack, and there was no oxygen signage present. Staff interviews revealed a lack of awareness regarding the unsecured tank and missing signage, despite expectations that all oxygen users have appropriate signs posted and equipment properly secured. These findings were based on direct observations, record reviews, and staff interviews.
Failure to Hold Blood Pressure Medications per Physician Orders
Penalty
Summary
Nursing staff failed to follow physician orders regarding blood pressure medication administration for a resident with diagnoses including congestive heart failure, coronary artery disease, and hypertension. The resident had specific physician orders for Amlodipine, Isosorbide Mononitrate Extended Release, and Carvedilol, each with parameters to hold the medication if the resident's systolic or diastolic blood pressure fell below certain thresholds. Despite these orders, medication administration records showed that the resident received these medications on multiple occasions when their blood pressure readings were below the specified parameters. Interviews with medication aides and review of the medication administration record confirmed that the medications were given outside of the ordered parameters, with one aide acknowledging the administration as an oversight. The Medical Director stated that while a few doses outside parameters may not have caused serious harm, he expected staff to follow the written orders. The facility's Administrator and Director of Nursing also confirmed their expectation that staff adhere to medication hold parameters as ordered by the physician.
Medication Administration Error: Incorrect Lyrica Dosage Given
Penalty
Summary
A medication administration error occurred when a nurse failed to ensure the correct dosage of Lyrica was given to the correct resident. One resident with severely impaired cognition, who was prescribed Lyrica 25 mg twice daily, was instead given a 100 mg dose intended for another resident. The error was discovered during a narcotic count, which revealed that the 25 mg dose had not been removed from the correct resident's blister pack, while two 100 mg pills had been removed from the other resident's pack. The nurse involved could not recall if the correct medication was administered and admitted to not checking the medication label before giving the dose. The medication administration record indicated that the medication was provided, but did not note the error. The nurse self-reported the discrepancy after discovering it during the narcotic count and assessed the affected resident, who showed no adverse effects and maintained stable vital signs throughout the monitoring period. Interviews with facility staff, including the DON and Medical Director, confirmed the sequence of events and the nurse's failure to verify the medication label before administration. The incident involved two residents with different cognitive statuses and medication regimens, and the error was identified through routine medication count procedures rather than at the time of administration.
Failure to Provide Physician-Ordered Wound Care Treatment
Penalty
Summary
A deficiency occurred when a resident with a non-pressure chronic ulcer on the left foot did not receive wound care treatment as ordered by the physician. The resident's care plan identified multiple risk factors for skin breakdown, including peripheral vascular disease, diabetes, and mobility issues, and required daily cleansing and dressing of the affected toe. Despite these orders, the resident did not receive the prescribed wound care over a weekend, as confirmed by both the resident and the wound nurse. The Treatment Administration Record indicated that the treatment was documented as completed, but interviews revealed that the bandage had not been changed since the previous dressing by the wound nurse. The nurse assigned to the resident during the missed days acknowledged that the treatment was accidentally overlooked and not performed. The wound nurse and the DON were made aware of the missed treatments after discovering the unchanged bandage. The resident remained alert and oriented and was able to report the lapse in care. The facility's documentation and staff interviews confirmed that the physician's orders for wound care were not followed as required.
Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of wandering and severely impaired cognition entered another resident's room in the memory care unit. The wandering resident, who had previously been documented as entering other residents' beds, was not being directly supervised at the time. Staff had checked both residents approximately 15 minutes prior to the incident and found them asleep in their respective beds. During a period when staff were assisting another resident, the wandering resident entered the other resident's room, lay down in the bed, and was subsequently startled, resulting in physical contact that caused a nasal fracture to the other resident. The resident who sustained the injury had diagnoses including dementia, osteoporosis, and osteoarthritis, and was noted to be severely cognitively impaired, requiring limited assistance with most activities of daily living. This resident was not coded for behaviors or wandering on the Minimum Data Set (MDS) and had care plan interventions related to impaired memory and communication, but not for wandering or aggressive behaviors. The resident who wandered had a care plan that included interventions for wandering, such as documenting episodes, orienting the resident, and providing familiar objects, but was also not coded for wandering or behaviors on the MDS. The incident was discovered when the injured resident was found in the doorway, bleeding from the nose and mouth, and reported being hit by another resident. The staff member assigned to both residents responded immediately upon hearing the call for help. The investigation revealed that the wandering resident had a pattern of entering other residents' rooms and beds, and that staff did not witness the incident as it occurred during a lapse in direct supervision. The event resulted in a closed fracture of the nasal bone for the injured resident, who required hospital evaluation.
Failure to Provide Written Transfer Notices and Discharge Summaries
Penalty
Summary
The facility failed to provide written notification to residents or their responsible representatives regarding the reason for hospital transfers for multiple residents. In several documented cases, residents were transferred to the hospital for changes in condition such as stroke, feeding tube complications, vomiting, respiratory distress, and altered mental status. Although staff reported that a copy of the face sheet, medication administration record, DNR information, change in condition form, transfer form, and bed hold policy were sent with the resident to the hospital, there was no evidence in the medical records that written notices of transfer were provided to the residents or their responsible parties. Interviews with responsible parties confirmed that they were notified by phone but did not receive any written documentation regarding the transfers. Additionally, the facility did not provide a discharge summary or a recapitulation of the resident's stay to a resident who was discharged home. The responsible party for this resident reported not receiving a discharge summary, and staff interviews revealed a lack of clarity regarding who was responsible for completing this documentation. The social worker and DON were unaware of the requirement to complete and provide a discharge summary upon discharge. Staff interviews, including those with the unit manager, DON, administrator, and social worker, consistently indicated a lack of awareness of the regulatory requirement to provide written notices of transfer and discharge summaries to residents and their responsible parties. The documentation reviewed did not include any written notifications or summaries, and staff confirmed that their practice was to notify by phone only and send documentation with the resident to the hospital, but not to the responsible party.
Failure to Maintain Accurate Medical Records for Oxygen Therapy and Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, there were two active physician orders for oxygen therapy at different flow rates (2 liters and 3 liters per minute via nasal cannula), both of which remained active in the medical record. Medication administration records (MARs) reflected both orders, and staff documented administration for both, despite the resident only receiving oxygen at 2 liters per minute. The nurse responsible for entering the new order did not discontinue the previous order, and staff did not seek clarification about the conflicting orders. For another resident, wound care was not provided as ordered over a weekend, but the MAR was inaccurately documented to indicate that the treatment had been completed. The unit manager checked off the treatment as completed based on verbal confirmation from the assigned nurse, who later admitted to having overlooked the treatment. The resident confirmed that the wound dressing had not been changed as required, and the wound nurse verified that the same bandage was in place from a previous date. Documentation was completed by a nurse who did not perform the treatment, resulting in inaccurate medical records.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications on the 200 Hall Medication Cart and in the 100/200/300 Hall Medication Storeroom. Observations revealed multiple instances of expired medications, including Lantus insulin, Novolog insulin, Humalog insulin, and lidocaine solution, which were not discarded after their expiration dates. Additionally, some medications were not dated when opened, making it impossible to determine their shortened expiration dates. A single-dose vial of sterile water for injection was also found stored on the med cart after being opened, contrary to guidelines that it should be discarded after a single use. Furthermore, an unopened bottle of latanoprost eye drops was improperly stored at room temperature instead of being refrigerated as required by the manufacturer’s instructions. Nurse #1 confirmed these findings and acknowledged the need to contact the pharmacy for replacements and discard the improperly stored medications. The Director of Nursing (DON) expressed surprise at these findings, noting that the med carts had been inspected the previous week to ensure proper storage of medications. The DON also confirmed that nursing staff should have dated the vials of insulin, removed expired medications, and notified the pharmacy for replacements. Additionally, the DON stated that the single-use vial of sterile water should have been discarded immediately after its first use and that the unopened bottle of latanoprost eye drops should have been refrigerated until needed. In the 100/200/300 Hall Medication Storeroom, expired medications were also found, including acetaminophen suppositories, simethicone chew tablets, and Kaopectate medication. An opened multi-dose vial of Tuberculin PPD injectable solution was also found stored in the med room refrigerator beyond its 30-day use period. The DON confirmed that nursing staff should have dated everything as to when it was opened and discarded expired medications in accordance with the manufacturer's instructions. The hall nurses were responsible for checking the facility's stock medications in the Med Storeroom to ensure they were not expired.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeated deficiencies. These deficiencies were observed in areas such as Resident Rights/Exercise of Rights, Right to Participate in Planning Care, Develop/Implement Comprehensive Care Plan, and Safe/Clean/Comfortable/Homelike Environment. Specific incidents included a nurse speaking to a resident in a loud and demeaning tone, residents not being invited to care plan meetings, and the facility failing to maintain a clean environment with garbage observed in hallways and rooms. Additionally, the facility did not develop comprehensive care plans for residents' nutritional needs and discharge plans, as evidenced by record reviews and staff interviews. During the recertification and complaint surveys, it was found that the facility failed to treat residents with dignity, as seen in the case where a nurse's behavior made a resident feel embarrassed and humiliated. Other instances included residents not receiving timely incontinent care, leading to feelings of neglect and abandonment. The facility also failed to maintain a clean and homelike environment, with observations of overflowing garbage and unclean conditions. Furthermore, the facility did not involve residents in care planning meetings and failed to develop comprehensive care plans addressing specific needs such as nutrition and discharge planning. These repeated failures indicate the facility's inability to sustain an effective QAA program, as noted during interviews with the Administrator and other staff members.
Resident Dignity Violation
Penalty
Summary
The facility failed to treat a resident in a dignified manner, as evidenced by an incident involving a nurse and a resident. Nurse #2 spoke to Resident #17 in a loud and demeaning tone, telling her to get back in her room and stop stalking her. This interaction was overheard by a surveyor and another nurse, who confirmed the unprofessional and harsh manner in which Nurse #2 addressed the resident. Resident #17, who was cognitively intact and required substantial assistance with her activities of daily living, felt embarrassed and humiliated by the nurse's comments. She was waiting in the hallway for her pain medication and had not made any prior requests to the nurse before being spoken to in this manner. During interviews, Resident #17 expressed that she felt demeaned and treated like a child. Nurse #2 defended her actions by stating that she and the resident always spoke to each other in that manner and that the resident was waiting for her medications before a smoke break. The Director of Nursing confirmed that Nurse #2 received a final written warning due to her unprofessional language, and the Administrator documented the incident as a grievance. The facility emphasized that such behavior was not tolerated and that staff were expected to treat residents with dignity and respect.
Failure to Involve Residents and Family in Care Plan Meetings
Penalty
Summary
The facility failed to offer two residents and one family member the opportunity to participate in care plan meetings. Resident #47, who was cognitively intact and diagnosed with hemiplegia, had not been invited to or participated in any care plan meetings for over a year. The Social Worker (SW) responsible for scheduling these meetings could not provide documentation of Resident #47's participation since September 2022, despite the resident's most recent Minimum Data Set (MDS) being in January 2024. Similarly, Resident #49, who was also cognitively intact and diagnosed with secondary Parkinsonism, had not been invited to or attended any care plan meetings since her admission in June 2023. The SW confirmed that there was no documentation indicating Resident #49's participation in any care plan meetings since her admission. Resident #80, who was severely cognitively impaired and diagnosed with respiratory disease and dementia, had not had a formal care plan meeting since February 2023. Although the SW met informally with Resident #80's family member, no formal care plan meetings involving the interdisciplinary team were scheduled. The Administrator confirmed that Resident #80 should have had a scheduled care plan meeting every three months and that both the resident and the resident's representatives should have been invited. The SW acknowledged the oversight and the lack of formal documentation for these meetings.
Failure to Develop Comprehensive Nutrition Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan that included a focus on nutrition for two residents, leading to significant weight loss. Resident #90, who had diagnoses including cancer, dementia, and Type 2 diabetes, experienced a significant weight loss of 5.37% in one month. Despite recommendations from the Registered Dietitian (RD) to liberalize the diet and initiate a high-calorie supplement, the resident's care plan did not include any nutritional interventions. Interviews with staff revealed that the Dietary Manager was responsible for updating the care plans but had not done so for Resident #90. Similarly, Resident #75, who had a progressive neurological disease, seizure disorder, and dementia, also experienced significant weight loss. The resident required extensive assistance with eating and had increased nutritional needs. Despite these needs being documented by the RD, there was no care plan for nutrition in place. Staff interviews indicated that the Dietary Manager was again responsible for this oversight. Interviews with various staff members, including the MDS Nurse, the facility's Regional Dietary Consultant, and the Director of Nursing (DON), confirmed that the Dietary Manager was expected to complete the nutrition care plans. However, it was apparent that the Dietary Manager may not have been aware of this responsibility, leading to the deficiencies in the care plans for both residents.
Failure to Limit Duration of PRN Psychotropic Medications
Penalty
Summary
The facility failed to limit the duration of psychotropic medications ordered on an as-needed (PRN) basis to 14 days and did not indicate the duration and rationale for extending the PRN order beyond 14 days. This deficiency was identified for two residents. Resident #71 had a physician's order for 0.5 mg lorazepam to be given three times daily for anxiousness and another order for 1 mg lorazepam intramuscularly every 12 hours as needed for agitation. Both orders continued as active without a stop date, and no doses of the PRN lorazepam were documented as administered. The facility's consultant pharmacist and Director of Nursing (DON) acknowledged the oversight, with the DON stating the PRN order was inadvertently left on the resident's current orders. Resident #73 had a physician's order for 1 mg lorazepam to be given sublingually every 4 hours as needed for end-of-life care, anxiety, and agitation, with an indefinite end date. The resident's medication administration records showed no doses of the PRN lorazepam were administered, and the controlled substance inventory confirmed that none of the tablets were removed. The consultant pharmacist and DON confirmed the issue, with the DON noting that PRN psychotropic medications should have a stop date, typically limited to 14 days or extended up to 90 days with a designated stop date.
Failure to Obtain Consent for Influenza Vaccine
Penalty
Summary
The facility failed to provide consents with the benefits and risks of receiving the influenza vaccine for two residents. Resident #64, who was admitted with diagnoses of dementia with anxiety and stroke, did not have a consent form for the influenza vaccine in their medical record for the last year. The Director of Nursing confirmed that the consent form, which should have been reviewed with the Responsible Party, was missing. Resident #64 did not receive the influenza vaccine at the Responsible Party's request. The Director of Nursing stated that the nursing staff should obtain a signed consent form or a verbal consent witnessed by two nurses if the resident is cognitively impaired and unable to give consent themselves. Similarly, Resident #80, who was admitted with diagnoses of respiratory disease and dementia with agitation, also did not have a consent form for the influenza vaccine in their medical record for the last year. The Director of Nursing acknowledged the absence of the consent form and mentioned issues with obtaining consent from family members of cognitively impaired residents. As a result, Resident #80 was not offered the influenza vaccine. The Administrator confirmed that both residents should have been provided with the benefits and risks of receiving the influenza vaccine and that family members should have been contacted for consent if the residents were not cognitively intact.
Facility Failed to Maintain Walls and Door in Good Repair
Penalty
Summary
The facility failed to maintain walls and a door in good repair in three of the fifteen rooms reviewed on the 100-hall. Specifically, room 111 B had gouged drywall to the left of the bathroom door and a broken section of the bathroom door. Room 114 B's bathroom had a vinyl baseboard molding that had separated from the wall. Room 115 A had a section of gouged drywall behind the head of the bed. These deficiencies were observed on multiple occasions over several days. During an interview, the Maintenance Director acknowledged the need for repairs and stated that he prioritized repairs impacting resident safety first. He used a web-based software to manage building tasks and work orders. The Administrator confirmed that the Maintenance Director was expected to prioritize safety-related repairs before attending to cosmetic issues.
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.
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