Premier Living And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Waccamaw, North Carolina.
- Location
- 106 Cameron Street, Lake Waccamaw, North Carolina 28450
- CMS Provider Number
- 345185
- Inspections on file
- 20
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Premier Living And Rehab Center during CMS and state inspections, most recent first.
A resident was neglected when a Nurse Practitioner and other staff observed and documented signs and symptoms of pain, but no pain management interventions, including medications or non-pharmacological treatments, were provided. The DON confirmed that pain management should have been initiated to support the resident's daily care and therapy.
A resident admitted with Stage 2 pressure ulcers on both buttocks did not receive timely physician notification or appropriate wound care treatment orders. Facility protocols for cleansing, dressing, and physician notification were not followed, and the only order for barrier cream was not documented as administered. The wounds were not properly assessed or treated until several days later, resulting in the progression of one wound to an unstageable deep tissue injury requiring debridement.
A resident with a history of stroke, contracture, and cognitive impairment exhibited clear signs of pain during care and therapy, especially after a fall. Despite documentation of pain behaviors by therapy and nursing staff, no pain medications or non-pharmacological interventions were provided, and staff failed to communicate or assess the resident's pain in a timely manner. This resulted in a prolonged period without appropriate pain management.
The facility did not submit required payroll data to CMS via the PBJ system for two consecutive quarters. The Administrator, responsible for the submission, was unable to log in after the last successful entry and did not resolve the issue or follow up after initial attempts to seek assistance, resulting in missing data for both quarters.
The QAPI committee did not meet quarterly as required, with no meetings held for two consecutive quarters and the Medical Director absent from the last recorded meeting. The Nurse Practitioner was not involved in the QAPI process, and the Administrator canceled meetings instead of arranging for virtual participation. These actions resulted in the committee failing to fulfill its responsibilities for three consecutive quarters, affecting oversight in key areas such as weights, falls, and grievances.
A consultant pharmacist did not identify or report a medication irregularity during a monthly drug regimen review, resulting in a resident with major depressive disorder and cognitive impairment receiving Depakote beyond the prescribed discontinuation period. The order for gradual dose reduction and discontinuation was not properly entered by the DON, and the error was missed by both staff and the pharmacist, though no adverse outcomes were reported.
Surveyors found that drugs and biologicals were not consistently labeled with opened dates, expired medications were present on medication and wound treatment carts as well as in a storage room, and a wound treatment cart was left unlocked and unattended. Nursing staff and management were unaware of these issues, despite being responsible for regular checks and security.
Surveyors found expired and improperly labeled food items in kitchen storage areas, including thickened tea and dry goods, as well as significantly dented cans in stock rotation. Opened food items lacked proper dating, and cold food, such as potato salad, was held above the required temperature. Staff interviews confirmed lapses in food storage, labeling, and temperature control procedures.
The facility repeatedly failed to maintain an effective QAPI program, resulting in ongoing deficiencies such as not obtaining or implementing physician orders for pressure ulcer treatment, not labeling or discarding expired medications, and not accurately documenting medication administration. These issues persisted across multiple surveys, with the Administrator acknowledging missed QAPI meetings and lack of follow-through, and frequent staff turnover contributing to the ongoing noncompliance.
Three residents did not receive care as ordered: one did not receive timely or complete diagnostic imaging and follow-up for arm pain after a fall; another did not receive a physician-ordered TLSO brace for a spinal fracture; and a third did not receive the full prescribed course of antibiotics for a UTI due to medication availability issues and lack of pharmacy follow-up. Nursing and clinical staff did not ensure physician orders were carried out or communicate issues to providers.
A resident with a mood disorder continued to receive Depakote beyond the prescribed period and at the wrong dose after a DON failed to enter a 14-day stop date in the electronic medical record. Nursing staff administered both the incorrect dose and additional tablets, as the higher-dose medication was not removed from the med cart. The error was discovered during a survey, with no significant adverse outcomes reported.
The facility did not ensure accurate documentation of narcotic pain medication administration on the MAR for two residents, despite records showing the medications were dispensed and given. Additionally, there was a failure to properly document or carry out notifications to responsible parties and physicians regarding pressure wounds, with staff either omitting notifications or incorrectly recording that they had been made.
A resident who was bedbound and cognitively intact was transported to a medical appointment in a urine-soiled brief, wearing a hospital gown instead of personal clothing, and without her hair brushed. Staff failed to provide necessary personal care or ensure the resident was dressed appropriately before the ambulance arrived, resulting in the resident feeling embarrassed and exposed during the appointment.
The facility did not obtain or document informed consent for psychotropic medications before starting treatment for two residents with cognitive and psychiatric conditions. Both the DON and NPs confirmed there was no established process or form for obtaining consent, and the required discussions of risks and benefits with responsible parties were not documented.
A resident with severe cognitive impairment was admitted with stage 2 pressure ulcers, but the physician was not notified and appropriate treatment orders were delayed. As the wounds worsened, nursing staff and the wound care physician failed to inform the responsible party, with documentation errors indicating notification had occurred when it had not. The responsible party only learned of the wounds after discharge, following a grievance.
A resident with multiple complex diagnoses and a severe pressure ulcer was discharged without the responsible party being informed of the wound or receiving wound care instructions. The interdisciplinary team did not communicate the wound status or care needs, and discharge paperwork lacked this critical information, resulting in the responsible party only learning of the wound after discharge.
The facility did not accurately complete MDS assessments for three residents, including a resident with a femur fracture whose lower extremity impairment was not coded, a resident with stroke-related weakness who lacked an ADL assessment, and a resident admitted under Hospice whose MDS did not reflect Hospice services. Staff interviews confirmed these were oversights and that the assessments did not accurately represent the residents' care needs.
A resident with a gastrostomy tube and severe cognitive impairment did not receive prescribed nocturnal enteral feeding after returning from the hospital. Nursing staff failed to resume the continuous tube feeding as ordered, instead providing an undocumented bolus without physician authorization. The resident was left without appropriate nutrition, as confirmed by interviews with the RD, NP, and physician.
A resident with a recent right femur fracture and surgical repair experienced increased dependence in ADLs, including bed mobility and toileting, as well as a change in transfer status and new lower extremity impairment. Despite these significant changes, the required SCSA was not completed within the mandated timeframe, as confirmed by staff interviews and record review.
A resident admitted with hypertensive heart disease and heart failure was receiving hospice services, but the initial care plan did not address hospice needs. The omission was confirmed through record review and staff interviews, and hospice care was only added to the care plan at a later date.
The facility failed to notify the physician when two residents missed multiple doses of gabapentin, leading to severe pain and discomfort. Additionally, another resident received the wrong antibiotic without physician notification. Interviews revealed staff were unaware of the need to inform the physician about these issues, indicating a breakdown in communication and protocol adherence.
A long-term care facility failed to protect residents from neglect by not obtaining and administering significant medications as ordered, affecting multiple residents. One resident received an incorrect dosage of haloperidol and missed doses of carvedilol, leading to emergency department evaluation. Another resident missed 21 doses of gabapentin, resulting in severe pain and multiple emergency department visits. The facility also failed to notify physicians about missed doses of gabapentin and did not administer several doses of antibiotics for a resident with a stage 4 pressure ulcer, contributing to hospitalization and suspected sepsis.
Two residents in an LTC facility experienced severe pain and withdrawal symptoms due to the unavailability of prescribed gabapentin. Despite the residents' complaints and worsening conditions, nursing staff failed to report the issue or obtain the medication. Interviews revealed a lack of understanding and action regarding medication management, leading to significant distress for the residents.
The facility failed to provide scheduled medications for three residents, resulting in severe pain and emergency department visits. A resident missed 21 doses of gabapentin, leading to severe pain and muscle spasms, while another missed 14 doses, causing increased pain and anxiety. Staff were unaware of the medication ordering process, contributing to the deficiency.
A long-term care facility failed to prevent significant medication errors for multiple residents, leading to adverse health outcomes. One resident received an incorrect dosage of haloperidol and missed doses of carvedilol, resulting in emergency department evaluation. Another resident did not receive gabapentin, leading to severe pain and multiple hospital visits. Additional residents were affected by similar errors due to transcription mistakes and lack of medication availability.
The facility failed to follow its enhanced barrier precautions and hand hygiene policies during wound care for a resident, as the nurse did not wear a gown or perform hand hygiene between glove changes. Additionally, the facility lacked an infection surveillance plan, with the Infection Preventionist unable to provide documentation of infection tracking. The Administrator acknowledged the absence of infection control monitoring and was assisting the Infection Preventionist in organizing efforts.
The facility failed to provide necessary training on dementia care, infection control, and QAPI to its staff, as revealed by a lack of documentation and staff interviews. The absence of a Staff Development Coordinator and high turnover in the DON position contributed to this oversight, potentially affecting all residents.
The facility failed to complete MDS assessments on time for five residents due to staffing changes and training issues. The MDS Nurse was in training and relied on a remote nurse, leading to delays. The Administrator and DON were aware of the issue and acknowledged the impact of staffing changes on timely assessments.
The facility failed to complete quarterly MDS assessments within the required timeframe for several residents due to staffing changes and delays. Interviews with staff, including a Remote MDS Nurse and the Administrator, revealed that the facility was behind on assessments due to personnel changes and training issues.
The facility failed to accurately code MDS assessments for three residents, leading to deficiencies in care documentation. A resident with a diabetic foot ulcer was not coded for this condition, another receiving Methadone was not coded for opioid use, and a third on Rivaroxaban was not coded for anticoagulant use. The remote MDS nurse acknowledged these oversights, and the DON noted the lack of monitoring for assessment accuracy.
The facility failed to implement comprehensive care plans for several residents, including those with dementia, diabetes, and on anticoagulant medication. The MDS nurse, working remotely, missed initiating care plans for areas such as nutrition, activities of daily living, and anticoagulant use. Facility leadership cited staff turnover and remote work as contributing factors to these oversights.
The facility failed to involve residents and/or their representatives in care planning, as seen with two residents who had no documented care plan meetings. Another resident's care plan was not updated with new fall interventions in a timely manner, and a third resident's care plan was not developed within the required timeframe. These issues were attributed to a lack of a consistent MDS Nurse and unclear processes for care plan management.
The facility failed to ensure nursing staff were trained in obtaining medications from the pharmacy, resulting in missed doses of gabapentin for two residents. Interviews revealed that staff, including agency nurses and unit managers, were unaware of the procedures for ordering medications, leading to a deficiency in care.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, for 17 days. This deficiency was identified through record reviews and staff interviews, revealing that the facility did not have RN coverage on specific dates despite a census greater than 60 residents. Staff interviews highlighted challenges in maintaining RN coverage due to insufficient staff and resignations.
The facility failed to address pharmacy recommendations and medication errors for several residents, including incorrect antibiotic administration, non-compliance with PRN psychotropic regulations, and unaddressed high-risk medication errors. Communication gaps and inaction by the DON contributed to these deficiencies.
The facility failed to comply with regulations for PRN psychotropic medications, resulting in two residents receiving Ativan beyond the 14-day limit without proper documentation. Additionally, a resident was prescribed haloperidol without an appropriate diagnosis, and another resident did not receive timely AIMS assessments for antipsychotic monitoring. Communication issues and lack of training contributed to these deficiencies.
The facility failed to manage and store medications properly, resulting in expired and improperly labeled drugs across multiple medication carts and rooms. Expired COVID-19 vaccines and senna syrup were found in the South station medication room, while an unopened bottle of latanoprost eye drops was not refrigerated as required on the 400-hall cart. Additional expired and unlabeled medications were discovered on the 200-hall and 300-hall carts. The DON acknowledged a breakdown in the process for checking and labeling medications.
The facility failed to accurately document medication administration for two residents, leading to discrepancies in the MAR. One resident's medication was not available due to a pending authorization, yet nurses signed off on its administration. Another resident's medications were not documented due to EMR navigation issues after a room change. Staff interviews revealed errors and a lack of accountability in documentation.
The facility failed to report neglect allegations to APS and law enforcement within the required time frame for four residents. Despite being notified of the neglect and receiving an immediate jeopardy template, the Administrator was confused about the reporting requirements. The oversight was realized three days later, leading to a delay in notifying the appropriate authorities.
A facility failed to perform daily wound care and implement a hind off-loading boot for a resident with a diabetic foot ulcer, as ordered by the Wound Care Physician. Additionally, the facility did not follow orders to change an IV site every three days and ensure IV access for a resident on long-term antibiotic therapy, resulting in missed doses. These deficiencies were due to a lack of documentation, communication, and understanding among staff.
The facility failed to obtain physician-ordered weekly weights for several residents, impacting their nutritional monitoring and care. A resident with dysphagia, COPD, and diabetes experienced significant weight fluctuations due to inconsistent weight recording. Another resident with stroke and dementia faced similar issues, with significant weight loss not addressed. Two other residents also did not have weights recorded as ordered, highlighting a systemic issue in the facility's weight monitoring process.
A facility failed to transmit a resident's quarterly MDS within the required 7-day timeframe. The MDS was completed but transmitted late, as acknowledged by the MDS Coordinator. The Administrator confirmed the requirement for timely transmission.
The facility failed to create individualized baseline care plans within 48 hours for two residents admitted with complex medical conditions, including stroke and diabetes. Despite the administration of critical medications, such as anticoagulants, no care plans were documented, leading to severe health events for one resident. Staff interviews revealed a backlog of assessments and unclear responsibilities, contributing to the deficiency.
A facility failed to ensure a resident was seen by a physician within 30 days of admission. The resident, with multiple diagnoses including congestive heart failure and dementia, was only seen by a Nurse Practitioner. The facility's leadership acknowledged that the previous Medical Director's infrequent visits contributed to this deficiency.
The facility did not complete an annual performance review for a medication aide, hired in 2019, as required. The aide confirmed the evaluation was overdue, and the DON, responsible for the review, acknowledged the oversight without providing a reason. The Administrator was unaware of the lapse.
A facility failed to maintain proper communication and coordination of hospice services for a resident with multiple diagnoses, including congestive heart failure and dementia. Essential hospice documentation was missing from the resident's medical records, and hospice staff only provided verbal reports without leaving written notes. This led to incomplete records and a lack of coordination in the resident's care plan, as revealed through staff interviews.
A resident in an LTC facility experienced a lack of dignity and respect when a nurse refused to leave his room upon request and was verbally aggressive. Additionally, the resident was left unattended in the shower for over 15 minutes, leading to frustration and anger. The incidents involved a cognitively intact resident with a right below the knee amputation. Staff interviews confirmed the nurse's refusal to leave the room and the delay in responding to the resident's call bell in the shower.
A resident admitted with a pressure ulcer did not receive proper assessment or treatment due to inadequate communication and documentation by the nursing staff. Despite initial identification, the ulcer was not reported to the wound treatment nurse, resulting in a lack of treatment during the resident's stay.
A resident with mobility impairments was left unsupervised in the shower for over 15 minutes after a nurse aide left to go to a store without informing the assigned aides. The resident attempted to transfer himself, resulting in a minor injury. The call light was not answered promptly, and staff communication was lacking.
Failure to Provide Pain Management for Resident Reporting Pain
Penalty
Summary
A resident experienced neglect when the Nurse Practitioner failed to provide pain management treatment despite the resident reporting pain and exhibiting signs and symptoms of pain during assessments on two separate occasions. The resident was observed by the Nurse Practitioner, nursing aides, and an occupational therapist assistant to be in pain, yet no pain medications or non-pharmacological interventions were ordered. The Nurse Practitioner acknowledged in interviews that she should have ordered pain management at the time of her assessments but did not. The Director of Nursing confirmed that the resident's pain was neglected and that pain medications should have been ordered to assist with daily care and therapy participation.
Failure to Initiate Timely Pressure Ulcer Treatment on Admission
Penalty
Summary
A resident was admitted to the facility with a history of femur fracture, anemia, multiple myeloma, and prior stroke. Upon admission, the resident was found to have Stage 2 pressure ulcers on both buttocks, as documented by the admitting nurse. However, there was no evidence that the physician was notified of these wounds or that wound care treatment orders were obtained at the time of admission. The only order present was for the application of barrier cream after incontinence episodes, which was not documented as being administered in the treatment records. Despite facility standing orders requiring cleansing and dressing of Stage 2 wounds and physician notification, these protocols were not initiated until several days after admission. The wounds were not properly assessed or treated according to the facility's own guidelines, and the resident was not referred to the Wound Care Physician until six days after admission. During this period, there was no documentation of wound progression or further assessment, and the right buttock wound deteriorated to an unstageable deep tissue injury requiring debridement. Interviews with nursing staff and the Wound Care Physician confirmed that the initial wounds were not managed appropriately, and the necessary wound care interventions were delayed. The Wound Care Physician and Nurse Practitioner both indicated that the use of barrier cream alone was insufficient for Stage 2 wounds and that a more comprehensive wound care regimen should have been implemented immediately. The lack of timely notification, assessment, and treatment contributed to the progression of the resident's pressure ulcer.
Failure to Provide Timely Pain Management for Resident with Contracture and Post-Fall Pain
Penalty
Summary
A resident with a history of stroke, right-sided weakness, aphasia, vascular dementia, contracture of the right elbow, anxiety, and depression was admitted to the facility and identified as being at risk for musculoskeletal complications, including pain. Despite a care plan that included monitoring and reporting signs of pain, the resident was not provided with any scheduled or as-needed pain medication, nor were non-pharmacological interventions implemented. Multiple clinical notes from occupational therapy and nursing staff documented the resident exhibiting clear signs and symptoms of pain, such as groaning, grimacing, pulling away during care, and refusing therapy and activities of daily living (ADLs), particularly after a fall. The resident's pain was further evidenced by increased resistance to care and changes in arm positioning following the fall. Interviews with staff, including nurse aides, the occupational therapist assistant, and the nurse practitioner, revealed that the resident's pain behaviors were observed during care and therapy sessions. However, nurse aides did not consistently report these observations to nursing staff, often assuming the pain was related to the resident's contracture and that nurses were already aware. Nursing staff did not assess or document the resident's pain, nor did they notify the physician or nurse practitioner in a timely manner. The nurse practitioner acknowledged that pain management should have been initiated sooner, as the resident's pain was only addressed after repeated reports and a significant delay following the fall. Physician and director of nursing interviews confirmed that there was an expectation for pain to be assessed and managed when signs and symptoms were present, and for communication between nurse aides and nursing staff regarding observed pain. Despite these expectations, the resident went for an extended period without pain assessment or management, and no pain medications were ordered until much later. The lack of timely pain management and failure to implement non-pharmacological interventions constituted a deficiency in providing safe and appropriate pain management for the resident.
Failure to Submit Payroll Data to CMS for Two Quarters
Penalty
Summary
The facility failed to submit required payroll data to the Centers for Medicare and Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system for two consecutive federal fiscal year quarters: October through December 2024 and January through March 2025. Review of the PBJ Staffing Data Reports for both quarters revealed that no data was submitted, which triggered areas of concern. During an interview, the Administrator, who was responsible for submitting the PBJ data, stated that the last submission occurred in November 2024. The Administrator reported being unable to log in to the PBJ system after that date and did not know how to resolve the issue. Although the Administrator reached out for assistance with the log-in problem, she did not receive a response and did not follow up further. She acknowledged awareness of the requirement to submit PBJ data but confirmed that she had not done so for the affected quarters.
QAPI Committee Failed to Meet Quarterly and Lacked Required Members
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to meet at least quarterly as required by policy, with no meetings held during the first and second quarters of 2025. A review of the QAPI meeting minutes from the previous quarter showed that the Medical Director and Pharmacist were not in attendance, and the Nurse Practitioner was not involved or invited to participate in the QAPI program. Staff interviews confirmed that the Medical Director was not engaged in the QAPI process and that the Nurse Practitioner, who was present on site daily, was not asked to attend in the Medical Director's absence. The Administrator reported that the previous Medical Director worked remotely and was unable to attend meetings on site, and no attempts were made to have the Medical Director participate virtually. Instead, the Administrator canceled the QAPI meetings, resulting in the committee not convening since November. The facility's QAPI policy required specific committee membership and quarterly meetings, but these requirements were not met for three consecutive quarters, potentially impacting all residents. The Administrator acknowledged that the facility had not met expectations in areas such as weights, falls, and grievances, and that the lack of QAPI follow-through contributed to unsuccessful corrective efforts.
Consultant Pharmacist Failed to Identify Medication Irregularity During Review
Penalty
Summary
The Consultant Pharmacist failed to identify and report a medication irregularity during the monthly drug regimen review for a resident with major depressive disorder and moderately impaired cognition. The resident was prescribed Depakote 250 mg twice daily, which was later reduced to 125 mg twice daily for 14 days with instructions to discontinue due to the addition of Keppra. However, the order entered by the Director of Nursing did not include a 14-day stop date, resulting in the resident continuing to receive Depakote beyond the intended discontinuation period. The Medication Administration Record showed the resident received additional doses of Depakote after the 14-day period had elapsed. During the Consultant Pharmacist's monthly review, the medication change was noted, but no recommendations or identification of the irregularity were made. Interviews with the Psychiatrist and Physician confirmed that the Depakote should have been discontinued after 14 days, and the error was not detected by facility staff or the Consultant Pharmacist. The resident did not experience any reported adverse outcomes from the continued administration of Depakote, but the deficiency was identified for failing to follow proper medication regimen review and reporting procedures.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage, labeling, and security of drugs and biologicals. On one medication cart, a multi-dose oral inhaler (Trelegy Ellipta) was found without an opened date, despite manufacturer instructions requiring it to be discarded six weeks after opening. Nursing staff interviewed were unaware of the missing date and had not checked the medication cart for expired medications that day. Additionally, expired medications were found on two wound treatment carts and in a medication storage room, including Biofreeze pain relief spray, Minerin cream, Potassium Chloride IV solution, Gentamicin vials, a Normal Saline syringe, and Lisinopril tablets. Staff interviewed were not aware of the expired medications and indicated that all nurses, as well as the Unit Manager, were responsible for checking expiration dates, but these checks had not been performed or were insufficient. Further, one wound treatment cart was observed to be unlocked and unattended, with no staff present and no clear accountability for who left it unsecured. Interviews with nursing staff revealed uncertainty about who was responsible for the unlocked cart and expired medications. The Director of Nursing confirmed that assigned nurses and the Unit Manager were responsible for ensuring medication carts and storage rooms were checked for expired medications and that all medications were properly labeled and secured. However, these responsibilities were not consistently fulfilled, resulting in expired and improperly labeled medications being accessible and a treatment cart left unlocked.
Deficient Food Storage, Labeling, and Temperature Control in Dietary Services
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and temperature control in multiple areas of the kitchen and storage rooms. Surveyors observed expired food items in both the reach-in refrigerator and dry storage room, including opened cartons of thickened tea that were kept beyond the manufacturer's recommended use-by period, and several dry goods and condiments that were past their expiration dates. Some items, such as creamy wheat and vanilla pudding, lacked clear expiration dates, and staff were unaware of the appropriate shelf life for these products. Additionally, opened food items, such as a box of bacon, were found without proper dating. During inspections, significantly dented cans were found in stock rotation in the dry storage room, which had not been removed as required. The Dietary Manager acknowledged that these cans should not have been available for use and that a system for segregating and discarding dented cans was not in place at the time of the survey. The presence of these cans in active stock rotation indicated a lapse in routine inspection and removal procedures by dietary staff. Temperature control issues were also identified during meal service preparation. Cold food items, specifically potato salad, were found to be above the required holding temperature of 41 degrees Fahrenheit, with recorded temperatures of 47 and 48 degrees Fahrenheit. The Dietary Manager confirmed that the potato salad had been left out too long during delivery and restocking, resulting in improper cold holding. These deficiencies were observed during direct surveyor inspection and confirmed through staff interviews.
Repeated QAPI Failures Lead to Ongoing Deficiencies in Wound Care, Medication Management, and Documentation
Penalty
Summary
The facility failed to establish and maintain an effective Quality Assurance and Performance Improvement (QAPI) program, resulting in repeated deficiencies across multiple surveys. Specifically, the facility did not conduct quarterly QAPI meetings to review audits, systems, and procedures, and failed to monitor and evaluate action plans previously developed to correct identified issues. This lack of oversight led to the recurrence of deficiencies related to pressure ulcer treatment, medication labeling and storage, and accurate documentation of medication administration. The Administrator acknowledged responsibility for the QAPI program and admitted that meetings were cancelled when the Medical Director was unavailable, and that follow-through on corrective plans was lacking. During the surveys, it was found that the facility failed to obtain and implement physician orders for the treatment of a Stage 2 pressure ulcer, which progressed to an unstageable wound. Additionally, staff did not consistently record opened dates on medications or discard expired medications found on treatment and medication carts and in storage areas. There were also failures to maintain accurate medical records, particularly in documenting medication administration. These deficiencies were observed repeatedly over three federal surveys, and the Administrator cited frequent changes in key staff positions as a contributing factor to the facility's inability to sustain compliance.
Failure to Follow Physician Orders and Provide Prescribed Care
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. In the first case, a resident with a history of stroke, right side weakness, and cognitive impairment experienced a fall and subsequently developed right arm pain and swelling. Although a Nurse Practitioner ordered x-rays of the right wrist and lower arm, the order was not properly entered into the electronic record, resulting in a delay. When the x-rays were eventually performed, they did not include all the ordered views, and the recommendations for further diagnostic imaging to rule out a fracture were not followed. Both the Nurse Practitioner and the Director of Nursing admitted to not reading the x-ray results in their entirety, and the necessary follow-up was not completed until much later. In the second case, a resident with Parkinson's disease and dementia suffered a fall resulting in a T3 compression fracture. The hospital provided an order for a TLSO brace to stabilize the spine, but the facility did not obtain or provide the brace upon the resident's return. Nursing staff and the DON were aware of the order but did not secure the brace, and there was confusion regarding responsibility for obtaining it. The resident went without the required spinal support for several days, during which time she continued to experience pain and was observed without the brace in place. The third case involved a resident with a gastrostomy tube and a history of urinary tract infections who was prescribed a 7-day course of Sulfamethoxazole-Trimethoprim for a UTI. The resident received only 10 out of 14 prescribed doses because the liquid suspension was not available in the facility and staff did not contact the pharmacy or utilize the backup pharmacy. There was no documentation explaining the missed doses, and neither the Nurse Practitioner nor the DON were notified that the full course of antibiotics was not administered.
Failure to Discontinue and Dose Depakote Correctly
Penalty
Summary
A deficiency occurred when a resident with major depressive disorder and moderately impaired cognition continued to receive the anticonvulsant medication Depakote beyond the prescribed period and at the incorrect dose. The Psychiatrist had ordered a gradual dose reduction and discontinuation of Depakote, specifying a 14-day course of 125 mg twice daily, after which the medication was to be stopped due to the resident's concurrent use of Keppra. However, the order entered into the electronic medical record by the Director of Nursing did not include the 14-day stop date, resulting in the order remaining active past the intended discontinuation date. During medication administration, nursing staff continued to give Depakote to the resident after the 14-day period, and on at least one occasion, administered a 250 mg tablet instead of the prescribed 125 mg dose. The 250 mg tablets, which should have been removed from the medication cart when the new order was written, remained accessible and were used in error. Nursing staff were unaware that the Depakote should have been discontinued and that the correct dose was 125 mg, not 250 mg. The resident received 25 additional tablets of Depakote and the wrong dose over this period. Interviews with the Psychiatrist, Nurse Practitioner, and pharmacy representative confirmed that the medication was not discontinued as ordered and that the higher dose was administered. The resident did not exhibit any significant adverse outcomes or increased sedation as a result of the error, and no Depakote levels were checked since the medication was prescribed for mood and not for seizure control. The error was identified during a surveyor's observation and subsequent review of records and staff interviews.
Failure to Accurately Document Medication Administration and Pressure Wound Notifications
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, specifically regarding the documentation of narcotic pain medication administration and the notification of responsible parties and physicians about pressure wounds. For one resident with chronic pain, there were multiple instances where narcotic medications, including Hydrocodone/Acetaminophen and oxycodone, were signed out and administered as indicated on the controlled drug declining count sheets, but these administrations were not documented on the Medication Administration Record (MAR) for several dates across multiple months. Medication aides and nurses involved in administering these medications either did not sign the MAR or believed it was someone else's responsibility, resulting in incomplete medical records for controlled substances. Another resident was admitted with Stage 2 pressure wounds, but the admission progress note did not indicate that the responsible party or physician was notified of these wounds. The nurse who completed the admission note confirmed that no notification was made. Subsequent pressure injury assessments documented that the responsible party and physician were notified of more severe wounds, but the nurse who completed these assessments later stated that she had not actually made the notifications and had documented them in error, assuming others had already done so. Interviews with staff, including medication aides, nurses, and the Director of Nursing, confirmed that there were misunderstandings and lapses in responsibility regarding proper documentation on the MAR and in the notification process for pressure wounds. The Director of Nursing acknowledged that documentation should be accurate and complete, including both medication administration and notifications related to pressure injuries.
Resident Transported to Appointment Without Proper Personal Care or Attire
Penalty
Summary
A cognitively intact, bedbound resident with chronic pain, diabetes, and muscle weakness was transported to a physician appointment without being provided appropriate personal care and attire. The resident, who was dependent on staff for transfers and toileting and was incontinent of bowel and bladder, was taken to the appointment in a urine-soiled brief, wearing a hospital gown instead of her personal clothing, and without her hair being brushed. The resident reported feeling embarrassed and stated that she was not given the opportunity to communicate her needs before leaving for the appointment. Staff interviews revealed that the transportation schedule was made available to nurses daily, and it was the responsibility of the nursing staff to ensure residents were ready for their appointments. On the day of the incident, the nurse assigned to the resident instructed a nursing assistant to prepare the resident, but the nursing assistant did not provide the necessary personal care. The nurse observed that the resident was not properly dressed and did not have her hair brushed when the ambulance arrived but did not reschedule the appointment, resulting in the resident being sent out in an undignified state. The resident described the experience as distressing, noting that she was wheeled through a busy waiting room with her chest and shoulders exposed and feared she smelled of urine. The incident was confirmed through a grievance filed by the resident, and staff interviews corroborated that the resident was not provided with appropriate care or attire prior to leaving for the appointment.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the initiation of psychotropic medications for two residents with significant cognitive impairments and psychiatric diagnoses. For one resident with dementia, anxiety, and depressive disorder, Depakote was started for generalized anxiety without any documentation that the resident's representative was informed in advance of the risks or benefits. The Medication Administration Record confirmed the medication was administered as ordered, and interviews with the DON and Psychiatric Nurse Practitioner revealed that no formal consent process was in place, and there was uncertainty about who was responsible for obtaining consent. Similarly, another resident with schizophrenia, traumatic brain injury, and depressive disorder was started on lorazepam for anxiety without evidence that the responsible party was informed of the risks and benefits prior to administration. The resident's medical record lacked documentation of this required communication, and staff interviews confirmed that the facility did not have a consent form or consistent process for obtaining consent for psychotropic medications. Both the DON and Nurse Practitioners acknowledged the expectation for consent but indicated it was not being consistently obtained or documented.
Failure to Notify Physician and Responsible Party of Pressure Ulcer Development and Progression
Penalty
Summary
The facility failed to notify the physician of pressure ulcers identified on admission and did not inform the responsible party when a stage 2 pressure ulcer worsened to an unstageable pressure ulcer for a resident. Upon admission, the resident was documented as having two stage 2 pressure ulcers on the bilateral buttocks, but there was no evidence that the physician was notified or consulted regarding treatment. The standing treatment order for stage 2 ulcers was not initiated until several days after admission, and the physician was not made aware of the wounds at that time. Further review revealed that the responsible party was not notified when the resident's right buttock ulcer progressed from stage 2 to an unstageable deep tissue injury, and later to a stage 4 full thickness pressure ulcer following debridement. Nursing staff and the wound care physician both failed to notify the responsible party, with documentation errors indicating notification had occurred when it had not. The responsible party only became aware of the wounds after the resident was discharged, prompting a grievance. Interviews with staff confirmed that the physician was not notified of the pressure ulcers on admission, and the responsible party was not informed of the progression of the wounds. The facility's own standing orders required physician and wound care physician notification for stage 2 wounds, but this protocol was not followed. The resident involved had severe cognitive impairment and was dependent on staff for care and communication regarding their medical condition.
Failure to Inform Responsible Party and Provide Wound Care Instructions at Discharge
Penalty
Summary
The facility failed to implement an effective discharge plan for a resident with significant medical needs, specifically by not informing the responsible party of a pressure wound and not providing wound care instructions prior to discharge. The resident was admitted with multiple complex diagnoses, including a femur fracture, multiple myeloma, COVID-19, pneumonia, and encephalopathy, and was noted to have Stage 2 pressure ulcers on admission. Over the course of the stay, the resident developed an unstageable deep tissue injury to the right buttock, which was later debrided and identified as a Stage 4 pressure ulcer on the day of discharge. Despite the presence of this severe wound, there was no documentation that the responsible party was notified about the wound or the need for daily wound care. Interviews with nursing staff, the wound care physician, and the social worker confirmed that the responsible party was not informed of the wound or provided with wound care instructions. The discharge paperwork prepared by the social worker did not include information about the wound or required treatments, and the nurse who discharged the resident did not discuss the wound care needs with the responsible party, as this information was not present on the discharge form. The lack of communication and coordination among the interdisciplinary team resulted in the responsible party being unaware of the resident's wound and the necessary care required at home. The responsible party only became aware of the wound after discharge, when they contacted the facility with concerns. Documentation and interviews confirmed that the wound and its care requirements were not reviewed with the responsible party prior to the resident's discharge.
Inaccurate and Incomplete MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete and code Minimum Data Set (MDS) assessments for three residents. One resident was admitted with a right femur fracture and underwent surgical repair, but the MDS admission assessment did not reflect her lower extremity impairment, despite documentation and interviews confirming the impairment. Another resident, admitted with a stroke resulting in right side weakness and contracture, had no assessment completed for activities of daily living on the MDS, even though therapy services and participation in daily activities were documented. A third resident was admitted under Hospice services for hypertensive heart disease with heart failure, but the MDS did not indicate receipt of Hospice services, despite multiple staff and documentation confirming the resident was on Hospice at admission. These deficiencies were identified through record reviews and staff and resident interviews, which revealed that the MDS assessments were either incomplete or inaccurately coded, failing to reflect the residents' actual care needs and conditions. Staff interviews acknowledged these errors as oversights and confirmed the importance of accurate MDS completion to represent resident care accurately.
Failure to Administer Enteral Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral vascular accident, dysphagia, and a gastrostomy tube did not receive enteral tube feeding as ordered by the physician. The resident was admitted with orders for nocturnal tube feeding to be infused at 55 ml per hour for 10 hours each night. On the night in question, the resident experienced gastrostomy tube leakage and was sent to the hospital, where the tube was unclogged and flushed. The hospital found no further issues and the resident was returned to the facility with no new orders. Upon return to the facility, nursing staff did not resume the prescribed continuous tube feeding. The assigned nurse for the day shift found that the tube feeding was not infusing and that an old bag of nutritional supplement from two nights prior was still hanging at the bedside. The night shift nurse admitted to not administering the continuous feeding as ordered, instead providing a single bolus of the supplement, despite there being no physician order for this change in administration. There was also no documentation in the medical record of the bolus feeding being given. Interviews with the Registered Dietitian, Nurse Practitioner, and Physician confirmed that the resident should have received the continuous infusion as ordered and that no order existed to substitute a bolus feeding. The Director of Nursing also confirmed that the prescribed method of administration was not followed. The resident, who was severely cognitively impaired and unable to voice her needs, indicated through nonverbal communication that she had not received her feeding and was hungry.
Failure to Complete Significant Change Assessment After Resident's Decline
Penalty
Summary
The facility failed to complete a required Significant Change in Status Assessment (SCSA) for one resident who experienced notable changes in activities of daily living (ADL). The resident, who had a history of major joint replacement and a right femur fracture, was admitted to the facility and later sustained a fall resulting in a new right femur fracture. Following this incident, the resident was hospitalized and underwent surgical repair. Upon return to the facility, documentation indicated increased dependence in bed mobility and toileting, a change in transfer status, and a new impairment to the lower extremity. Despite these significant changes, a review of the Minimum Data Set (MDS) assessments revealed that an SCSA was not completed within the required 14-day timeframe. Staff interviews confirmed awareness of the regulatory requirements for completing significant change assessments, and it was acknowledged that the assessment should have been completed based on the resident's altered status. The MDS nurse was unable to provide a reason for the omission, and the administrator confirmed the expectation for timely and accurate completion of all MDS assessments.
Failure to Include Hospice Services in Initial Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan addressing hospice services for a resident admitted with hypertensive heart disease and congestive heart failure. Upon admission, the resident was receiving hospice services, as documented in the electronic health record. However, the initial care plan did not include hospice care, and the admission Minimum Data Set (MDS) did not reflect the resident's hospice status. The hospice care plan was not added until a later date, despite the resident's ongoing need for hospice services. Interviews with facility staff, including the Nurse Practitioner, MDS Supervisor, Director of Nursing, and Administrator, confirmed that hospice services should have been included in the initial care plan. The MDS Supervisor acknowledged the omission and emphasized the importance of accurate, person-centered care plans. The deficiency was identified through record reviews and staff interviews, which revealed the delay in incorporating hospice care into the resident's care plan.
Failure to Notify Physician of Missed Medications and Medication Errors
Penalty
Summary
The facility failed to notify the physician when scheduled medications were not administered to residents, leading to significant pain and discomfort. Resident #51, who was prescribed gabapentin for nerve pain, missed 21 doses over several days, resulting in severe pain, numbness, and muscle spasms. Despite these symptoms, the nursing staff did not inform the physician of the missed doses or the resident's increased pain levels. Interviews with various nurses revealed a lack of awareness regarding the necessity of notifying the physician about the unavailability of the medication and the resident's deteriorating condition. Similarly, Resident #46, who was also prescribed gabapentin for nerve pain, missed 14 doses over a week. This led to increased pain, trouble sleeping, anxiety, irritability, and nausea, severely impacting the resident's ability to perform daily activities. Again, the nursing staff failed to notify the physician about the missed doses and the resident's worsening condition. Interviews with the staff indicated a general misunderstanding of the protocol for handling unavailable medications and notifying the physician. Additionally, the facility administered the wrong antibiotic to Resident #39, who was discharged from the hospital with a prescription for Augmentin but received Amoxicillin instead. This error was not communicated to the physician, and the facility did not follow up on the pharmacy's recommendation to address the medication error. The Director of Nursing and the facility physician were unaware of the error until much later, highlighting a breakdown in communication and protocol adherence within the facility.
Removal Plan
- The facility completed an audit of all residents who had missed medications, changes in conditions, and/or a documented risk management report to ensure the physician had been notified.
- The facility identified concerns from the audit and reported them to the physician to ensure notification of change.
- The Director of Nursing educated Floor Nurses and Unit Managers on the process to notify the physician when there are missed medications, changes in conditions, and/or a resident who has a documented risk management report.
- Nurses will notify the physician immediately via phone call to the on-call service provider that is posted at each nursing station.
- The Director of Nursing and Unit Managers began in-person education with all nurses and medication aides, including full-time, part-time, as needed, and agency staff, on the importance of notifying the physician of any missed medications, changes in conditions, and documented risk management reports.
- No nurses or medication aides will work until they have received the above-noted education.
- The Director of Nursing is responsible for tracking the education and ensuring it is completed.
- The Director of Nursing and provider reviewed the facility provider communication log.
- The Director of Nursing will provide education to ensure all nurses and medication aides have comprehensive knowledge of how to utilize the provider communication log.
- Floor Nurses and Unit Managers will utilize the provider communication log daily to document any reason for why the provider should see a resident.
- Floor Nurses and Unit Managers will be responsible for ensuring the provider communication log is updated daily.
- All newly hired nurses and medication aides will be educated as noted above.
- The Director of Nursing will be responsible for completing the education with new hires.
Medication Administration Failures and Neglect in LTC Facility
Penalty
Summary
The facility failed to protect residents from neglect by not obtaining and administering significant medications as ordered, which affected multiple residents. Resident #269 was administered an incorrect dosage of haloperidol and missed 25 doses of carvedilol, leading to an elevated pulse and shortness of breath, requiring emergency department evaluation. Resident #51 missed 21 doses of gabapentin, resulting in severe pain and multiple emergency department visits for acute pain management. Similarly, Resident #46 missed 14 doses of gabapentin, leading to increased pain, trouble sleeping, and other symptoms. Additionally, the facility did not notify physicians about the missed doses of gabapentin for Residents #51 and #46, which is crucial as gabapentin should not be stopped abruptly. Resident #419 was not administered several doses of antibiotics for a stage 4 pressure ulcer, which contributed to hospitalization and suspected sepsis. The facility also administered incorrect antibiotics to Resident #39 and failed to administer multiple doses of medications for other residents, including antidepressants, pain medications, and anti-diabetic medications. The deficiencies were identified as neglect, with the facility failing to provide necessary care and services, such as obtaining and administering medications and notifying physicians of significant changes. These failures affected the residents' health and well-being, leading to emergency department visits and hospitalizations. The facility's actions were deemed to have placed residents in immediate jeopardy, which was later removed after implementing a corrective plan.
Removal Plan
- The Administrator, Director of Nursing, Social Worker, and Unit Managers began educating all staff on the facility abuse and neglect policy.
- Education will cover the importance of staff understanding that all residents have a right to be free of neglect and that failing to provide necessary care and services constitutes neglect.
- Education will include obtaining and administering medications as ordered, effectively managing pain, and notifying the physician of significant changes.
- No staff member will work until they have received the education.
- The Social Worker and Director of Nursing will track staff education completion.
- The Social Worker, Director of Nursing, and Unit Managers are responsible for completing education with all staff.
- All newly hired staff will receive the same education, completed by the Social Worker, Human Resources Coordinator, and/or Director of Nursing.
- The Social Worker, Human Resources Coordinator, and Director of Nursing will track education completion for new hires.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for two residents, leading to significant pain and withdrawal symptoms. One resident, who was prescribed gabapentin for nerve pain, missed 21 doses over several days due to the medication not being available. This resident experienced constant pain, numbness, and muscle spasms, which led to multiple visits to the emergency department for treatment. Despite the resident's complaints and the severity of her symptoms, the nursing staff did not report the issue to administration or take steps to obtain the medication. Another resident, also prescribed gabapentin for nerve pain, missed 14 doses over a week. This resident reported increased pain, trouble sleeping, anxiety, irritability, and nausea. The nursing staff documented the unavailability of the medication but did not notify the physician or administration about the resident's increased pain and the lack of medication. The resident expressed frustration over the facility's inability to provide the prescribed medication, which significantly impacted her daily routine and well-being. Interviews with staff revealed a lack of understanding and action regarding the unavailability of medications. Nurses frequently documented the absence of gabapentin but failed to escalate the issue or seek alternative solutions. The Director of Nursing admitted to being unaware of the requirements for ordering and reordering gabapentin, and the facility lacked a system to track medication refills effectively. This systemic failure resulted in residents experiencing severe pain and withdrawal symptoms due to the facility's inability to manage and administer prescribed medications.
Medication Unavailability Leads to Resident Pain and ED Visits
Penalty
Summary
The facility failed to ensure that scheduled medications were obtained and available for administration for three residents, leading to significant pain and emergency department visits. Resident #51, who was prescribed gabapentin for nerve pain, missed 21 doses over several days due to the facility's failure to obtain the medication from the pharmacy. This resulted in severe pain, muscle spasms, and two emergency department visits where she was treated for acute pain. The facility's staff, including nurses and unit managers, were unaware of the process for obtaining medications and did not take appropriate actions to ensure the medication was available. Resident #46, also prescribed gabapentin for nerve pain, missed 14 doses over a week, leading to increased pain, anxiety, and difficulty sleeping. The medication was returned to the pharmacy due to a lack of a controlled substance sign-out sheet, and no follow-up actions were taken to reorder the medication. Multiple staff members, including agency nurses, documented the medication as unavailable but did not attempt to obtain it or notify the pharmacy or physician. The facility's staff demonstrated a lack of understanding of the medication ordering and reordering process, contributing to the deficiency. Interviews with nurses and unit managers revealed confusion about whether a written or electronic prescription was required for gabapentin refills. The Consultant Pharmacist and Pharmacy Quality Assurance Specialist confirmed that a prescription was not needed for refills, indicating a systemic issue within the facility regarding medication management.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for multiple residents, leading to adverse health outcomes. One resident was administered an incorrect dosage of haloperidol, receiving 20 mg instead of the prescribed 4 mg, and missed 25 doses of carvedilol, a medication critical for managing heart conditions. This resident experienced elevated pulse and shortness of breath, necessitating an emergency department evaluation. The errors were attributed to incorrect transcription of medication orders by the previous Director of Nursing and a lack of verification by nursing staff. Another resident did not receive 21 doses of gabapentin, a medication for nerve pain, over several days, resulting in severe pain and multiple emergency department visits. The medication was unavailable, and nursing staff failed to take appropriate actions to obtain it. This resident experienced constant pain rated at 10 out of 10, numbness, and muscle spasms, which led to hospital evaluations for pain management. Additional residents were affected by similar medication errors, including missed doses of antibiotics, antidepressants, and other critical medications. These errors were due to a combination of transcription mistakes, lack of medication availability, and inadequate follow-up by nursing staff. The facility's systemic issues in medication administration and order verification contributed to these deficiencies, impacting the health and well-being of the residents involved.
Infection Control Deficiencies in Wound Care and Surveillance
Penalty
Summary
The facility failed to implement its policy for enhanced barrier precautions and hand hygiene during wound care for a resident. The facility's Enhanced Barrier Precautions policy requires the use of gowns and gloves during high-contact resident care activities, such as wound care. During an observation, the Treatment Nurse and the Wound Care Specialist physician initially donned gloves and gowns before entering the resident's room. However, after partially removing the dressing, the nurse re-entered the room without a gown and did not perform hand hygiene between changing gloves during the dressing change. The nurse acknowledged forgetting to wear a gown and believed changing gloves was sufficient without hand hygiene. The facility also failed to implement an infection surveillance plan to monitor and track infections. The Infection Preventionist, who started the position recently, was unable to provide documentation of infection tracking or surveillance from May 2023 through May 2024. Although monthly computer printouts of infections were available from January 2024 through June 2024, there was no evidence of active monitoring or tracking of infections. Interviews with the Director of Nursing and the Administrator revealed that the Infection Preventionist had not been monitoring or tracking infections within the facility. The Administrator, who is SPICE certified, acknowledged the lack of infection control monitoring and stated she was assisting the Infection Preventionist in organizing infection control efforts.
Deficiency in Staff Training on Dementia Care, Infection Control, and QAPI
Penalty
Summary
The facility failed to ensure that all staff received necessary training on dementia care, infection control policies and procedures, and the elements of the Quality Assurance Performance Improvement (QAPI) program. This deficiency was identified through a review of the facility's annual education records from April 2023 to May 2024, which showed no documented evidence of such training being conducted. Interviews with various staff members, including medication aides, nurse aides, and nurses, revealed a lack of awareness and recall of receiving the required training. Some staff members, such as Medication Aide #5 and Nurse #8, were unable to confirm having received any QAPI training, while others, like Nurse Aide #2, only recalled limited training sessions. The deficiency was further compounded by administrative challenges, including the resignation of the Staff Development Coordinator (SDC) and subsequent loss of training documentation. The Director of Nursing (DON) and the Administrator acknowledged the absence of a dedicated SDC and the high turnover in the DON position, which contributed to the oversight in scheduling and documenting the required training. The Administrator noted that the responsibilities for ensuring staff training fell to the DON, who had not recorded any training hours since March 2024. This lack of structured training and documentation had the potential to affect all residents in the facility.
Delayed MDS Assessments Due to Staffing Changes
Penalty
Summary
The facility failed to complete the comprehensive Minimum Data Set (MDS) assessments within the required timeframe for five residents. This deficiency was identified through record reviews and staff interviews. The residents affected were not assessed in a timely manner upon admission or during their annual assessments, as required by regulations. The delay in completing these assessments was attributed to staffing issues, particularly the turnover and training of MDS nurses. Interviews with MDS Nurse #2 revealed that she was still in training and had been relying on a remote MDS nurse to complete the assessments. She acknowledged that the assessments were behind schedule. The facility had experienced several personnel changes in the MDS nurse role, which contributed to the delay in completing the assessments within the regulatory timeframe. The Administrator and the Director of Nursing (DON) were aware of the issue. The Administrator noted the ongoing personnel changes since February and was actively seeking a solution. The DON confirmed that the expectation was for MDS assessments to be completed in a timely manner, but acknowledged that staffing changes had impacted their ability to meet this requirement.
Delayed MDS Assessments Due to Staffing Changes
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe for 14 out of 29 residents reviewed. This deficiency was identified through record reviews and staff interviews. Specific residents, including Resident #20, Resident #36, Resident #51, and others, had their MDS assessments either incomplete or completed past the required timeframe. For instance, Resident #20's assessment was listed as in progress and incomplete, while Resident #36's assessment was completed late. The issue was attributed to staffing changes and delays in the MDS assessment process. Interviews with facility staff, including the Remote MDS Nurse, MDS Nurse #2, the Administrator, and the Director of Nursing, revealed that the facility was behind on assessments due to personnel changes. The Remote MDS Nurse, contracted to complete assessments, acknowledged the backlog when she started. MDS Nurse #2, who began in May, was still in training and not fully responsible for completing assessments. The Administrator, in her position since February, noted multiple changes in the MDS Nurse role, contributing to the delay. The Director of Nursing confirmed the issue was due to staffing changes, impacting the timely completion of MDS assessments.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in their care documentation. Resident #50, who was admitted with a diabetic foot ulcer and peripheral vascular disease, was not coded as having a venous or arterial ulcer or a diabetic foot ulcer in the MDS assessment. Despite having a care plan addressing these conditions and receiving treatment for the diabetic foot ulcer, the remote MDS nurse did not include this information in the assessment, acknowledging the oversight during a review of the resident's medical records. Resident #61, who was receiving Methadone HCL for pain management, was not coded as receiving opioids in the MDS assessment. The remote MDS nurse, responsible for completing the assessment, missed this information despite the resident's care plan and medication administration records indicating ongoing opioid use. The Director of Nursing (DON) noted that the reliance on a remote MDS nurse due to staff turnover might have contributed to the oversight, as there was no monitoring of the accuracy of the MDS assessments. Resident #8, who was on Rivaroxaban for chronic atrial fibrillation, was not coded as receiving anticoagulants in the MDS assessment. The MDS nurse, working remotely, admitted that this could have been an error in coding. The facility's administrator acknowledged that the MDS assessments should be accurately coded and processed, indicating a lapse in ensuring the accuracy of the residents' medical documentation.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, as required by the Minimum Data Set (MDS) care area assessments. Resident #11, who was admitted with diagnoses including dementia and hearing loss, did not have care plans addressing psychosocial wellbeing, falls, nutrition, vision, communication, pressure ulcers, dental issues, pain, activities of daily living, or dehydration. The MDS nurse, who worked remotely, acknowledged the oversight, and the Director of Nursing (DON) and Administrator were unaware of the missing care plans due to staff turnover. Resident #219, admitted with cellulitis and diabetes, did not have a care plan for nutritional status despite receiving wound care and a therapeutic diet. The MDS nurse admitted to missing the initiation of the care plan, and both the DON and Administrator cited staff turnover as a contributing factor. Similarly, Resident #52, with diagnoses including dementia and chronic kidney disease, lacked care plans for nutritional status, activities of daily living, and urinary incontinence. The MDS nurse and facility leadership again pointed to staff turnover and remote work arrangements as reasons for the oversight. Resident #34, who had cancer and dementia, experienced significant weight loss and was on a mechanically altered diet, yet did not have a care plan for nutritional status. The MDS nurse and facility leadership acknowledged the deficiency. Additionally, Resident #16, who was on anticoagulant medication, did not have a care plan addressing the use of anticoagulants, despite experiencing a serious bleeding incident. The MDS nurse admitted the oversight, and the DON and Administrator attributed the failure to staff resignations and a backlog of MDS assessments.
Deficiencies in Care Planning and Documentation
Penalty
Summary
The facility failed to involve residents and/or their representatives in the care planning process, as evidenced by the cases of Resident #61 and Resident #16. Resident #61, who was cognitively intact, reported not having a care plan meeting since admission, and there was no documentation of such a meeting in the medical record. Similarly, Resident #16, who was severely cognitively impaired, had no documented care plan meeting with their representative. Interviews with the Social Worker and Director of Nursing revealed a lack of a clear process for scheduling and conducting care plan meetings, exacerbated by the absence of a consistent MDS Nurse. Resident #47's care plan was not updated with new fall interventions following incidents on 4/16/2024 and 5/29/2024. Although the resident was cognitively intact and had a history of falls, the care plan did not reflect the new interventions until 6/13/2024. The Remote MDS Nurse and the Director of Nursing acknowledged the delay in updating the care plan, attributing it to the inconsistency of having an MDS Nurse on-site and a backlog of MDS assessments. Resident #319's care plan was not developed within the required timeframe following the comprehensive assessment. The admission MDS assessment was completed on 5/1/2024, but the care plan was not initiated until 6/13/2024. The Remote MDS Nurse and the Director of Nursing indicated that the delay was due to the previous nurse's inability to keep up with assessments, and the responsibility for care plan development was not clearly managed.
Lack of Staff Competency in Medication Procurement
Penalty
Summary
The facility failed to ensure that nursing staff, including nurses, unit managers, and the Director of Nursing, were trained and competent in the process of obtaining medications from the pharmacy. This deficiency affected all ten staff members reviewed for pharmacy procedures. The lack of knowledge and training led to the failure to administer gabapentin as ordered for two residents, Resident #51 and Resident #46, over several days in May 2024. The medication was not obtained from the pharmacy, resulting in missed doses for both residents. Interviews with various staff members, including agency nurses and unit managers, revealed a widespread lack of understanding of the process for ordering and reordering medications. Many staff members, including agency nurses who had been working at the facility for several weeks, were unaware of the procedures to follow when a medication was unavailable. The Director of Nursing also admitted to being confused about the requirements for ordering gabapentin. This confusion and lack of training led to the failure to provide the necessary medication to the residents as prescribed.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, for 17 out of 130 days reviewed. This deficiency was identified through record reviews and staff interviews, which revealed that the facility did not have RN coverage for the required hours on specific dates from February to June 2024. The Payroll Based Journal (PBJ) report for the first quarter of 2024 and daily census posting sheets confirmed the absence of RN coverage, despite a constant census greater than 60 residents. Interviews with staff, including the Unit Manager, Director of Nursing (DON), and Administrator, highlighted the challenges faced in maintaining the required RN coverage. The Unit Manager acknowledged the scheduling issues and efforts to cover shifts, while the DON and Administrator noted the impact of insufficient RN staff and the resignation of MDS Nurses. The facility was aware of the problem and had been attempting to hire additional RNs and use agency staff to address the deficiency.
Failure to Address Pharmacy Recommendations and Medication Errors
Penalty
Summary
The facility failed to act on pharmacy recommendations for seven residents regarding medication administration and management. For Resident #39, a medication error occurred when Amoxicillin was administered instead of the prescribed Amoxicillin-Clavulanate, and the error was not addressed despite being flagged as a high priority by the Consultant Pharmacist. The Director of Nursing (DON) was aware of the recommendation but did not notify the physician or take corrective action. Resident #18 had a PRN order for Ativan without a stop date, which violated CMS regulations. Despite repeated pharmacy recommendations to address this issue, the DON did not act due to communication issues with the previous physician. Similarly, Resident #22 had a PRN Ativan order that was not properly reviewed or discontinued, even though the Consultant Pharmacist highlighted the need for compliance with the 14-day rule for PRN psychotropics. For Resident #50, Carvedilol was administered despite blood pressure readings that should have prompted the medication to be held, as per physician orders. The DON did not review or address this high-risk medication error. Resident #46 experienced a medication error with Gabapentin being out of stock, and the issue was not resolved. Resident #8 had multiple medication administration errors, including missed doses of Ozempic and Glipizide, which were not reported or reviewed by the DON, who disputed the accuracy of the pharmacy report. Lastly, Resident #47 did not receive a timely AIMS assessment despite being on antipsychotic medication, due to a communication gap between the DON and unit managers.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to adhere to regulations regarding the use of PRN psychotropic medications, as evidenced by the cases of two residents who were administered Ativan beyond the 14-day limit without appropriate documentation or rationale. Despite repeated recommendations from the Consultant Pharmacist to discontinue the PRN orders or provide justification, the facility did not take action. The Director of Nursing (DON) acknowledged awareness of the regulation but cited communication issues with the previous Medical Director as a barrier to compliance. The new physician, unaware of the ongoing issue, expected to be informed of such recommendations. In another case, a resident was prescribed haloperidol without an appropriate psychiatric diagnosis, as the medication was ordered for 'mood,' which is not a valid indication for antipsychotic use. The error originated from an incorrect order entry by the previous DON, and the pharmacy did not receive the necessary hospital discharge summary to verify the order. The Consultant Pharmacist and the new physician both confirmed that the prescription should have been clarified upon admission and after the resident's return from the emergency room. Additionally, the facility failed to conduct timely AIMS assessments for a resident receiving antipsychotic medications, which are necessary to monitor for involuntary movements. The Consultant Pharmacist recommended an AIMS assessment, but the DON did not review the recommendation due to internet outages and had not trained the unit managers on the new process for auto-populating these assessments. Consequently, the resident did not receive the required monitoring, highlighting a lapse in the facility's medication management and monitoring protocols.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications across multiple medication carts and rooms, leading to several deficiencies. In the South station medication room, expired medications, including 14 doses of COVID-19 vaccine and an 8-ounce bottle of senna syrup, were found. The Unit Manager acknowledged that nurses were responsible for checking expired medications, but the process was not effectively implemented. Additionally, on the 400-hall medication cart, an unopened bottle of latanoprost eye drops was not stored in the refrigerator as required by the manufacturer's instructions. Nurse #7 was unaware of who was responsible for ensuring proper storage. Further observations revealed expired and improperly labeled medications on the 200-hall and 300-hall medication carts. Expired ophthalmic solutions and an unlabeled Ventolin inhaler were found on the 200-hall cart, while the 300-hall cart contained an unlabeled ciloxan ointment and an expired atropine solution. Medication Aide #3, who was new to the role, was unsure of the procedures for checking medications. The Director of Nursing expressed that there was a breakdown in the process for checking and labeling medications, which led to these deficiencies.
Medication Administration Documentation Errors
Penalty
Summary
The facility failed to accurately document the administration of medications for two residents, leading to discrepancies in the Medication Administration Records (MAR). For Resident #10, there was a physician's order for Tetrabenazine 25 mg to be administered daily. However, the pharmacy had not dispensed the medication since early May due to a pending prior authorization, meaning the medication was not available in the facility. Despite this, multiple nurses signed off on the MAR indicating the medication was administered on several dates in May and June, which was confirmed to be in error during interviews with the staff. For Resident #8, there were multiple instances where medications, including Oxycodone/Acetaminophen, Rivaroxaban, Glipizide, and Ozempic, were not documented as administered in the MAR. The resident was listed as unassigned in the electronic medical record (EMR) after moving to a new room, which required nurses to navigate through different screens to document medication administration. This led to several missed documentation entries, although some staff indicated they had administered the medications but failed to document them properly. Interviews with the nursing staff and management revealed a lack of awareness and accountability regarding the documentation errors. The Director of Nursing acknowledged the issue with nurses documenting medications as unavailable and expressed an intention to hold them accountable for accurate documentation. The facility's Administrator also emphasized the expectation for medications to be administered as ordered by the physician.
Failure to Timely Report Neglect Allegations
Penalty
Summary
The facility failed to report an allegation of neglect to Adult Protective Services (APS) and law enforcement within the required time frame for four residents. The facility was officially notified of the neglect on June 13, 2024, at 2:15 PM when an immediate jeopardy template was issued. Despite submitting an initial report to the State Agency within the required time frame, the facility did not notify APS or law enforcement until June 16, 2024. This delay in notification was a significant oversight in the facility's response to the neglect allegations. The Administrator of the facility was informed of the neglect situation and received an immediate jeopardy template. However, there was confusion regarding the necessity to notify APS and law enforcement, as the neglect was identified by state surveying staff. The Administrator realized the oversight on June 16, 2024, and subsequently notified both APS and law enforcement. This lapse in timely reporting highlights a critical deficiency in the facility's handling of neglect allegations.
Failure to Follow Physician Orders for Wound and IV Care
Penalty
Summary
The facility failed to perform daily wound care treatments and implement a hind off-loading boot for a resident with a non-pressure diabetic foot ulcer, as per the Wound Care Physician's orders. The resident, who was cognitively intact, had a history of right below the knee amputation, peripheral vascular disease, left leg cellulitis, and a diabetic foot ulcer. Despite recommendations and orders from the Wound Care Physician to use a hind off-loading boot and specific wound care treatments, the facility did not document the application of the boot or the completion of daily wound care on several occasions. Interviews with staff revealed a lack of awareness and understanding of the order for the hind off-loading boot, contributing to the failure to provide the necessary care. Another deficiency involved the failure to follow physician orders for changing an intravenous (IV) site every three days and ensuring IV access for a resident receiving long-term antibiotic therapy. The resident, who had severe cognitive impairment and a stage 4 pressure ulcer, missed several doses of antibiotics due to the inability to establish IV access. Documentation showed multiple unsuccessful attempts by various nurses to restart the IV, and there was no evidence of timely intervention to address the issue, such as obtaining a PICC line or sending the resident out for IV access establishment. The deficiencies highlight significant lapses in following physician orders and ensuring proper wound and IV care for residents. The lack of documentation and communication among staff members contributed to the failure to provide the necessary treatments, potentially impacting the residents' health and recovery.
Failure to Obtain Physician-Ordered Weights
Penalty
Summary
The facility failed to obtain physician-ordered weekly weights for four residents, which was crucial for monitoring their nutritional status and wound care. Resident #36, who had a history of dysphagia, COPD, and diabetes, experienced significant weight fluctuations due to the facility's failure to consistently record weights as ordered. Despite recommendations from the Registered Dietitian (RD) for weekly weights and appetite-stimulating medication, these were not implemented, leading to difficulty in evaluating the resident's nutritional needs and interventions. Resident #38, diagnosed with stroke and dementia, also faced issues with weight monitoring. The resident's care plan included interventions for nutritional risk, but the facility did not follow through with the RD's recommendations for weekly weights and appetite-stimulating medication. This oversight resulted in a significant weight loss over several months, which was not adequately addressed by the facility's staff. Similarly, Residents #219 and #52 did not have their weights recorded as per physician orders. Resident #219, admitted with cellulitis and diabetes, required weekly weights for wound evaluation, but these were not obtained. Resident #52, who was severely cognitively impaired, also did not have weekly weights recorded as ordered. The facility's failure to implement a reliable system for obtaining and recording weights contributed to these deficiencies, as acknowledged by the Director of Nursing and other staff members.
Late Transmission of Quarterly MDS
Penalty
Summary
The facility failed to transmit the quarterly Minimum Data Set (MDS) for one resident within the required time frame. The resident in question was admitted to the facility, and their quarterly MDS was completed on April 15, 2024, but was not transmitted until June 11, 2024, exceeding the 7-day transmission requirement. During an interview, the MDS Coordinator acknowledged awareness of the late transmission. Additionally, the Administrator confirmed that all MDS should be transmitted in a timely manner as required.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop individualized person-centered baseline care plans within 48 hours of admission for two residents. Resident #16 was admitted with a diagnosis of stroke and was prescribed rivaroxaban, an anticoagulant, to be administered via a gastrostomy tube. Despite the administration of the medication, there was no baseline care plan documented in the resident's medical record. This oversight was highlighted when Resident #16 experienced severe bleeding and required emergency medical attention. Upon readmission, the issue persisted as no baseline care plan was created within the required timeframe. Similarly, Resident #319, admitted with type 2 diabetes, aphasia, and a recent stroke, also lacked a baseline care plan. The facility's MDS nurse, responsible for completing these plans, was unable to do so due to a backlog of assessments. Interviews with the facility's staff, including the Remote MDS Nurse, Director of Nursing, and Administrator, revealed a lack of clarity and consistency in the process of developing these care plans, contributing to the deficiency.
Failure to Ensure Timely Physician Visit
Penalty
Summary
The facility failed to ensure that a physician visit occurred for a resident within 30 days of admission. The resident, who was admitted with diagnoses including congestive heart failure, dementia, depression, anxiety, pain, seizures, hallucinations, and edema, was not seen by her attending physician as required. Instead, she was only seen by a Nurse Practitioner on a later date. The facility's Administrator and Director of Nursing acknowledged that the previous Medical Director was not visiting the facility as frequently as necessary, which contributed to the oversight in the resident's care.
Failure to Conduct Annual Performance Review for Medication Aide
Penalty
Summary
The facility failed to conduct a performance review every 12 months for one of the five nursing assistants reviewed, specifically Medication Aide #5. The personnel file for Medication Aide #5, who was hired on November 8, 2019, lacked evidence of a completed performance review since the date of hire. During a phone interview, Medication Aide #5 confirmed that her annual performance evaluation, due in November 2023, had not been conducted in the past year. The Director of Nursing (DON), who started at the facility in March 2024, acknowledged not having conducted the performance review for Medication Aide #5 but did not provide a reason for this omission. The Administrator stated that the DON was responsible for conducting the annual performance review and was unaware that it had not been completed.
Failure in Hospice Documentation and Communication
Penalty
Summary
The facility failed to maintain proper communication and coordination of hospice services for a resident receiving hospice care. The resident, who had diagnoses including congestive heart failure, dementia, seizures, and edema, was admitted to the facility and was receiving hospice services. However, the facility's medical records lacked essential hospice documentation, such as the physician order for hospice services, hospice plan of care, facility hospice care plan, hospice certification statement, hospice nursing visit record forms, and the election of hospice form. The only hospice-related documentation present were notes written by facility nurses about hospice visits, but no actual hospice notes were included in the resident's medical record. Interviews with facility staff, including the Director of Nursing (DON), Medical Records personnel, and a Nurse Practitioner, revealed that there was an expectation for hospice to provide complete documentation, which was not met. Hospice Nurse #12 admitted to keeping her documentation on an electronic device and only providing verbal reports to facility staff, without leaving copies of her notes. This lack of documentation and communication led to a disconnect between hospice and facility staff, resulting in incomplete records and a lack of coordination in the resident's care plan.
Resident Dignity and Assistance Deficiency
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a nurse refused to leave the resident's room upon request and when the resident was not assisted out of the shower when requested. The incident involved a resident who was cognitively intact and had a right below the knee amputation with a prosthesis. On one occasion, the resident reported that a nurse entered his room to administer medication, and despite the resident's repeated requests for the nurse to leave, she insisted on receiving a verbal confirmation of medication refusal. The nurse was verbally aggressive, and the situation escalated with both parties exchanging derogatory remarks. Witnesses confirmed the nurse's refusal to leave the room and the resident's increasing frustration. In a separate incident, the same resident was left unattended in the shower for over 15 minutes. The resident had requested an early shower due to an upcoming family visit. A nurse aide from another hall assisted the resident into the shower but left him there unattended. The resident used the call bell for assistance, but it was not answered promptly. The resident attempted to transfer himself from the shower chair to his wheelchair, which resulted in him banging his leg. Eventually, the nurse aide returned and assisted the resident, who was visibly upset and frustrated by the delay and lack of assistance. Interviews with staff revealed that the nurse aide and another nurse had left the facility to go to a store, leaving the resident in the shower without informing the assigned aides. The Director of Nursing stated that a staff member should always be present with a resident during a shower and that the call bell should have been responded to promptly. The failure to provide timely assistance and respect the resident's requests contributed to the resident's feelings of anger and frustration.
Failure to Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly assess, obtain physician orders for treatment, and communicate about a pressure ulcer for a resident, leading to a deficiency in care. The resident, who was admitted from the hospital with a pressure ulcer on the coccygeal region, was not provided with adequate documentation or treatment for the ulcer during their stay. Despite the initial identification of the ulcer by a nurse, there was no follow-up documentation or treatment plan established for the ulcer from the time of admission until discharge. Interviews with staff, including the Director of Nursing, Unit Manager, and Nurse Practitioner, revealed that the pressure ulcer was not reported to the wound treatment nurse for evaluation and treatment. The lack of communication and documentation resulted in the ulcer not being tracked or treated appropriately, as expected by the facility's protocols. The resident, who had multiple health conditions including diabetes and end-stage renal disease, required substantial assistance with daily activities and was frequently incontinent, further emphasizing the need for diligent wound care management.
Resident Left Unsupervised in Shower
Penalty
Summary
The facility failed to provide adequate supervision to a dependent resident, identified as Resident #50, who was left alone in the shower room for over 15 minutes. Resident #50, who has a right below the knee amputation with a prosthesis, coronary artery disease, high blood pressure, chronic kidney disease, and congestive heart failure, required supervision and assistance with transfers and showering. On the day of the incident, a nurse aide, NA #8, assisted Resident #50 into the shower but left him unattended to go to a store with Nurse #7, without informing the assigned aides or ensuring someone was available to assist the resident. The incident was captured on camera footage, showing that Resident #50 was left alone in the shower room after NA #8 exited. The call light was activated, but it was not answered for 16 minutes. During this time, Resident #50 attempted to keep warm by turning the water back on and tried to transfer himself from the shower chair to his wheelchair, which resulted in him banging his leg. NA #8 returned and assisted him out of the shower, but the resident expressed his frustration about being left alone. Interviews with staff revealed that NA #8 and Nurse #7 did not communicate with Nurse #9 or the aides assigned to Resident #50 about his presence in the shower. Nurse #9, who was at the nurse's station, did not hear the call light and was unaware of the situation. The Director of Nursing confirmed that residents should not be left alone in the shower due to safety concerns, especially for residents like Resident #50, who have mobility impairments and require supervision.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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