Premier Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jacksonville, North Carolina.
- Location
- 225 White Street, Jacksonville, North Carolina 28546
- CMS Provider Number
- 345217
- Inspections on file
- 22
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Premier Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A nurse aide assisted a severely cognitively impaired resident with dysphagia by standing rather than sitting at eye level during a meal, despite a chair being available and facility expectations to sit for dignity reasons. The DON confirmed that staff are expected to sit when assisting residents with meals.
Two residents had inaccuracies in their MDS assessments: one was not coded for having a PEG feeding tube and receiving tube feedings, and another was incorrectly coded as being discharged to a hospital instead of home. The errors were due to staff being unaware of the resident's current status or making unintentional coding mistakes, as confirmed by interviews with the DM, DON, and MDS nurse.
Several residents did not have their care plans properly developed or implemented, including a resident who was not assisted into a Geri chair as required, a resident with a PEG tube whose care plan omitted tube management, and two residents using BiPAP/CPAP machines for respiratory support without corresponding care plan interventions or physician orders. Staff interviews confirmed lack of awareness or oversight in following or updating care plans.
The facility did not obtain physician orders for BiPAP and CPAP use for two residents who were using these devices nightly, and failed to administer oxygen therapy as ordered for a resident with a tracheostomy, instead providing oxygen via nasal cannula at a lower rate based on the resident's preference without updating the care plan or notifying the physician.
A resident with significant mobility impairments was provided with bilateral quarter length side rails without documented attempts at alternatives, assessment of entrapment risk, review of risks and benefits, or obtaining informed consent. Multiple staff interviews revealed confusion about responsibility for completing the side rail assessment, and no documentation of the required process was found in the medical record.
A resident with a tracheostomy was observed receiving oxygen at 3L/min via nasal cannula, despite a physician's order for 4L/min via tracheostomy. Nursing staff documented in the MAR that the resident was receiving oxygen as ordered, rather than reflecting the actual administration method and rate. The DON and Administrator confirmed that the nurse should have contacted the provider to update the order instead of inaccurately documenting the care provided.
Staff failed to follow Enhanced Barrier Precautions by not wearing gowns during high-contact care activities, such as tracheostomy care and skin care, for residents with indwelling medical devices. Despite EBP signage and available PPE, nurses performed these procedures with gloves only, contrary to facility policy and prior education.
A resident with a diagnosis of dependence on supplemental oxygen was observed receiving O2 at 4 liters per minute instead of the prescribed 3 liters per minute. Despite documentation indicating compliance, staff interviews revealed a failure to ensure the correct administration of O2.
The facility failed to secure a medication cart on the 700-hall, leaving it unlocked and unattended on two separate occasions. Nurse #7 admitted to not locking the cart, and both the DON and Administrator confirmed that the cart should be locked unless the nurse is present.
The facility's QAA failed to maintain procedures and monitor interventions, leading to repeated deficiencies in areas such as MDS accuracy, care plan development, ADL care, fall prevention, medication security, and infection control. Specific issues included inaccurate MDS coding, inadequate care plans, insufficient assistance with eating and incontinence care, and lapses in hand hygiene and medication security.
A nurse aide failed to perform hand hygiene after handling items in a resident's room before delivering a meal to another resident. Despite the availability of hand sanitizer and prior training, the NA admitted to forgetting the protocol, which was confirmed by the Director of Nursing and the Administrator.
The facility failed to offer the flu vaccine during the flu season for two residents who were assessed as cognitively intact. Both residents had no documentation of being offered the flu vaccine, and the responsible nurses could not recall if they had offered the vaccine and did not document it.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
A nurse aide failed to treat a resident with dignity during a meal by standing while assisting the resident with eating, rather than sitting at eye level. The resident involved was severely cognitively impaired, totally dependent on staff for eating, and had a diagnosis of dysphagia. Observation showed the nurse aide standing next to the resident, who was seated in a specialized wheelchair, despite a chair being available in the room. The nurse aide stated she chose to stand, although facility expectations, as confirmed by the Director of Nursing, were for staff to sit while assisting residents with meals to maintain dignity, particularly for those with dementia.
Inaccurate MDS Coding for Nutrition and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of swallowing/nutritional status and hospitalization. For one resident, who had a percutaneous endoscopic gastrostomy (PEG) feeding tube in place and was receiving regular water flushes via the tube, the quarterly MDS assessment did not reflect the presence or use of the feeding tube or the administration of fluids through it. The Dietary Manager, responsible for coding the Swallowing/Nutrition section, was unaware that the resident still had a PEG tube at the time of assessment. Both the Director of Nursing and the Administrator confirmed that the MDS should have accurately documented the resident's feeding tube status. In another case, a resident's Discharge MDS assessment was incorrectly coded as a discharge to a short-term general hospital, when in fact the resident was discharged home. The error was acknowledged by the MDS nurse, who stated it was unintentional. The Director of Nursing and the Administrator both confirmed that the discharge location was home, not a hospital, and that the MDS assessment should have reflected this.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to implement and develop comprehensive, individualized care plans for several residents in key areas, as observed and documented by surveyors. One resident with severe cognitive impairment and functional limitations was dependent on staff for all transfers and mobility, with a care plan specifying daily use of a Geri chair. Despite this, repeated observations over several days showed the resident remained in bed, and staff interviews revealed that nurse aides either did not follow the care plan, were unaware of its requirements, or did not prioritize the intervention due to other tasks or lack of equipment in the room. The resident's responsible party confirmed that the resident was not regularly assisted into the Geri chair as intended. Another resident with a PEG feeding tube had a physician's order for regular tube flushes and received a significant portion of daily fluid intake via the tube. However, the care plan did not address the use of the feeding tube, despite the Minimum Data Set (MDS) assessment triggering a Care Area Assessment (CAA) for feeding tube use. Both the dietary manager and the DON acknowledged that the feeding tube should have been included in the care plan, but it was omitted without explanation. Additionally, two residents using noninvasive mechanical ventilators (BiPAP and CPAP machines) for respiratory conditions did not have their device usage reflected in their care plans. In both cases, the residents were observed using the devices, and staff confirmed their ongoing use. However, there were no corresponding physician orders or care plan interventions for these devices. MDS nurses responsible for care planning admitted to missing these interventions, either due to reliance on memory or because the care planning system did not automatically prompt for respiratory care based on MDS coding. The DON and administrator confirmed that these omissions were contrary to expected practice.
Failure to Obtain Physician Orders and Administer Respiratory Care as Ordered
Penalty
Summary
The facility failed to obtain necessary physician orders for the use of respiratory equipment for two residents and did not administer oxygen therapy as ordered for a third resident. One resident with a history of acute and chronic respiratory failure and obesity hypoventilation syndrome was admitted with instructions from the hospital to use a BiPAP machine at night and during naps. Despite the resident using the BiPAP machine nightly since admission, there was no physician order for its use, and the Medical Director was unaware the resident was using the device. The facility administration acknowledged that an order should have been requested at admission but was not. Another resident with a diagnosis of sleep apnea was observed using a CPAP machine, which she brought from home and used nightly. Nursing documentation confirmed the use of the CPAP, but there was no physician order for its use. The Medical Director was also unaware of this resident's use of the CPAP machine, and facility leadership confirmed that an order should have been obtained at admission but was not. A third resident with a tracheostomy had a physician order for oxygen at 4L per minute via tracheostomy to maintain oxygen saturation above 90%. However, the resident was consistently observed receiving oxygen at 3L per minute via nasal cannula, not as ordered. Nursing staff documented that the resident was receiving oxygen as ordered, but in interviews, admitted to providing oxygen via nasal cannula at a lower rate due to the resident's preference. The Medical Director and facility staff were not informed of the change in administration, and the care plan was not updated to reflect the actual practice or the resident's preference.
Failure to Complete Required Side Rail Assessment and Consent
Penalty
Summary
The facility failed to follow required procedures before installing and utilizing bilateral quarter length side rails for a resident. Specifically, there was no evidence that alternatives to side rails were attempted, that an assessment for entrapment risk was conducted, or that the risks and benefits of side rail use were reviewed with the resident. Additionally, informed consent was not obtained prior to the installation and use of the side rails. These omissions were identified through observations, record review, and interviews with the resident and staff. The resident involved was admitted with acute and chronic respiratory failure, was cognitively intact, and had impairments in both upper and lower extremities, requiring substantial to maximum assistance with bed mobility. The resident was observed multiple times with the side rails in the raised position and stated she needed them for bed mobility and positioning. Interviews with staff revealed confusion regarding responsibility for completing the side rail assessment, with the admitting nurse indicating it was the Unit Manager's responsibility, while the DON and Administrator stated the admitting nurse should have completed the assessment. No documentation of the required assessment or consent process was found in the resident's electronic medical record.
Failure to Accurately Document Oxygen Administration
Penalty
Summary
The facility failed to maintain accurate medical records regarding the administration of oxygen for a resident with a tracheostomy. The physician's order specified that the resident should receive 4 liters of oxygen per minute via tracheostomy to maintain oxygen saturation above 90%. However, repeated observations over several days showed the resident was receiving oxygen at 3 liters per minute via nasal cannula, not via tracheostomy as ordered. The resident was not in respiratory distress during these observations and confirmed that the correct rate should be 4 liters. Documentation in the Medication Administration Record (MAR) by the assigned nurse indicated that the resident was receiving 4 liters per minute via tracheostomy, consistent with the physician's order, even though the actual administration was 3 liters per minute via nasal cannula. The nurse acknowledged that she documented the ordered method and rate rather than the actual method and rate being used. Both the Director of Nursing and the Administrator confirmed that the nurse should have contacted the medical provider to update the order to reflect the resident's preference and actual practice, rather than inaccurately documenting compliance with the original order.
Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) policy during high-contact care activities for residents with tracheostomies. According to the facility's policy, EBP requires the use of both gowns and gloves for residents with indwelling medical devices, such as tracheostomies, during activities like transfers and hygiene care. However, observations revealed that staff did not consistently adhere to these requirements. In one instance, a nurse performed tracheostomy care for a resident without wearing a gown, despite EBP signage and the availability of gowns outside the resident's room. The nurse performed hand hygiene and donned gloves but omitted the gown. She later acknowledged forgetting to wear the gown, even though she had previously received education on EBP and typically followed the protocol. In another case, two nurses provided skin care and assisted with a transfer for a resident with a tracheostomy, again without wearing gowns. Both nurses wore gloves and performed hand hygiene, but neither donned a gown, even though PPE supplies were available and EBP signage was present. One nurse stated she did not usually wear a gown for this resident, citing the resident's discomfort, while the other admitted to not thinking about it at the time. The Director of Nursing confirmed that all staff had been educated on the EBP policy and that the observed actions did not align with facility protocols.
Failure to Administer Oxygen as Prescribed
Penalty
Summary
The facility failed to administer oxygen (O2) in accordance with the physician's order for Resident #44, who was admitted with a diagnosis of dependence on supplemental oxygen. The physician's order dated 3/15/24 specified that Resident #44 should receive O2 at 3 liters per minute via nasal cannula (NC). However, observations on 3/19/24 and 3/21/24 revealed that Resident #44 was receiving O2 at 4 liters per minute via NC. Despite documentation on the Medication Administration Record (MAR) indicating that Resident #44 was receiving O2 at the prescribed rate of 3 liters per minute, the actual flow rate was consistently observed to be higher. Interviews with staff, including Nurse #3 and Nurse Aide (NA) #6, indicated that they were aware of the physician's order but failed to ensure the correct administration of O2. Nurse #3 admitted that she might have checked another resident's O2 flow rate instead of Resident #44's. The Director of Nursing (DON) confirmed that the nurse should have verified the O2 flow rate to ensure compliance with the physician's order. The Administrator also acknowledged that physician's orders should be followed for the administration of O2, highlighting a lapse in adherence to prescribed medical care for Resident #44.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to secure resident medications stored in an unattended medication cart on the 700-hall. On two separate occasions, the medication cart was observed with the lock not engaged, indicating it was left unlocked. The first observation occurred on 03/21/24 from 8:32 AM to 9:01 AM, during which several staff members, residents, and visitors walked past the unattended cart. Nurse #7 returned to the cart at 8:44 AM and realized it was left unlocked. She admitted that she usually locks her cart. The second observation took place on 03/22/24 from 8:45 AM to 8:54 AM, with similar circumstances where the cart was left unlocked and unattended. Nurse #7 returned at 8:52 AM and acknowledged that the cart should have been locked when she was not in front of it. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the medication cart should be secured and locked unless the nurse is present at the cart. Both the DON and the Administrator stated that the nurse assigned to the medication cart is responsible for ensuring it is secured throughout their shift. The failure to lock the medication cart as required was identified as a deficiency in the facility's medication management practices.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that were previously put in place following multiple surveys. This resulted in repeated deficiencies in several areas, including the accuracy of assessments, development and implementation of comprehensive care plans, provision of ADL care for dependent residents, ensuring a hazard-free environment, proper labeling and storage of drugs and biologicals, and infection control. Specific instances included inaccurate coding of the Minimum Data Set (MDS) assessments for preadmission screening, falls, and hospice status, as well as failures in developing person-centered care plans for residents with respiratory services and a history of wandering. Additionally, the facility did not adequately assist dependent residents with eating, provide incontinence care, or offer alternate meal choices when necessary. There were also lapses in investigating and analyzing falls to implement appropriate interventions, securing resident medications, and following hand hygiene protocols during meal delivery service. The deficiencies were observed during various surveys, including recertification and complaint surveys. For example, during one survey, a nurse aide failed to perform hand hygiene after handling an overbed table and bed control, which could lead to cross-contamination. In another instance, the facility did not secure medications stored in an unattended medication cart. The facility also failed to comprehensively assess residents for fall risk and implement interventions to reduce the risk of falls. These repeated failures indicate a pattern of the facility's inability to sustain an effective Quality Assurance Program, as evidenced by the recurrence of similar issues across multiple surveys.
Failure to Implement Hand Hygiene Protocols During Meal Delivery
Penalty
Summary
The facility failed to implement their hand washing and alcohol-based hand sanitizer procedures as part of their infection control policies. During a meal delivery service, a nurse aide (NA) did not perform hand hygiene after moving an overbed table and handling a bed control in one resident's room before proceeding to deliver a meal to another resident. This lapse in protocol was observed despite the availability of hand sanitizer dispensers in the hallway and the NA's acknowledgment of the requirement to perform hand hygiene after such activities. The Director of Nursing confirmed that the NA should have performed hand hygiene after touching items in the resident's room. The NA admitted to being aware of the hand hygiene protocol but stated that she had been moving quickly and forgot to sanitize her hands. The Administrator also confirmed that hand hygiene should be performed after contact with a resident's environment to prevent the spread of germs. The NA had previously received infection control training, including hand hygiene, in May 2023.
Failure to Offer Flu Vaccine During Flu Season
Penalty
Summary
The facility failed to offer the flu vaccine during the flu season for two residents, Resident #56 and Resident #69, who were both assessed as cognitively intact. Resident #56 was admitted to the facility and had no documentation of being offered the flu vaccine. The Director of Nursing confirmed that the resident's health record lacked documentation of the flu vaccine being offered, and Resident #56 stated he was not offered the vaccine until a later date. Nurse #8, responsible for offering the flu vaccines, could not recall if she had offered the vaccine to Resident #56 and did not document it. Similarly, Resident #69 was admitted to the facility and also had no documentation of being offered the flu vaccine. The Director of Nursing noted the absence of documentation in Resident #69's health record, and the resident could not remember if she was offered the flu shot. Nurse #9, who was responsible for offering the flu vaccine to Resident #69, believed she had offered it but could not remember when and did not document it. Both residents were in the facility during the flu season, and the staff should have documented consent or refusal in their charts.
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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