Pruitthealth-carolina Point
Inspection history, citations, penalties and survey trends for this long-term care facility in Durham, North Carolina.
- Location
- 5935 Mount Sinai Road, Durham, North Carolina 27705
- CMS Provider Number
- 345551
- Inspections on file
- 24
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Pruitthealth-carolina Point during CMS and state inspections, most recent first.
Surveyors identified improper food storage and unsanitary conditions in the dietary department, including expired milk left available for service, an open bag of shredded cheese, an undated and open bag of rice, and improperly sealed and undated frozen chicken patties and ground beef in the freezer. They also observed a cutting board rack with dark brown debris contacting some boards, a stove/oven side with heavy grease buildup, a refrigerator door edge with thick dust and debris, and a visibly soiled condiment and silverware cart with dried debris and crumbs. Interviews with the DM and regional dietary leadership confirmed that staff were not consistently labeling, dating, sealing food items, or thoroughly cleaning equipment and workstations.
A resident with type 2 DM, neuropathy, circulatory issues, and hemiplegia, who required extensive assistance with ADLs, did not receive needed toenail care or podiatry services over several months. Facility records, including nurse notes, shower books, and weekly skin assessments, contained no indication that long, thick, jagged toenails were identified or addressed, and the resident was not placed on podiatry lists. CNAs reported they could not cut toenails and were supposed to notify nurses, but one CNA had not informed the nurse despite observing the condition. The charge nurse, SW, DON, and administrator each acknowledged the resident had not been identified for podiatry, despite facility expectations that nurses assess feet, arrange nail care, and ensure residents with DM are referred to the podiatrist.
A resident with diabetes, end stage renal disease, and a history of CVA, who required assistance with ADLs and personal hygiene, did not receive appropriate nail care despite a care plan directing staff to ensure clean, neatly trimmed nails and scheduled baths. Over multiple days, the resident’s fingernails were observed to be long with thick black debris underneath, while bath documentation sheets were missing for several months. NAs and the assigned nurse reported they had not noticed or reported the nail condition, and unit leadership and the DON acknowledged that nail care should have been completed with scheduled baths but had not assessed this resident’s nails or identified the lack of documentation.
A resident with a seizure disorder did not receive a prescribed dose of Lacosamide 50 mg for seven days because the medication was unavailable due to an expired prescription. Multiple nurses documented the missed doses but did not consistently notify the provider or pharmacy, leading to a delay in obtaining a new prescription. The resident continued to receive other antiseizure medications and showed no adverse effects during this period. The deficiency resulted from inadequate systems for ensuring medication availability and timely communication.
A cognitively impaired male resident in a LTC facility was found attempting to sexually abuse a female resident, who was also cognitively impaired and unable to defend herself. The male resident, with a history of socially inappropriate behavior, was seen naked in the hallway but was not stopped by staff. He entered the female resident's room, leading to the incident. Staff failed to intervene or notice the male resident's actions, resulting in a significant deficiency in resident protection.
The facility failed to accurately code MDS assessments for PASRR Level II for four residents, despite determinations from the North Carolina Department of Health and Human Services. Interviews with the Case Mix Director and Administrator revealed expectations for correct coding were not met, leading to deficiencies in the assessment process.
The facility failed to maintain cleanliness in the dry goods storage area and did not label or date food in the walk-in refrigerator. Additionally, a Dietary Aide was observed preparing food without a beard covering. The Dietary Manager and DON confirmed the need for immediate cleaning of spills, proper labeling of food, and adherence to hygiene standards.
A facility failed to develop an individualized ADL care plan for a resident requiring total assistance. Despite the resident's need for substantial to maximum assistance with various ADLs, the care plan did not address this requirement. Interviews with the MDS Coordinator and DON confirmed the omission, which contradicted facility protocols.
The facility failed to provide appropriate meal modifications for two residents with specific dietary needs. One resident with dysphagia did not receive a mechanically soft diet with adequate gravy, leading to difficulty swallowing. Another resident, who required food cut into bite-sized pieces, did not have this modification reflected on meal tickets, causing difficulty in eating. The dietary manager acknowledged errors in transferring special instructions to the meal tracker software.
A resident with intact cognition experienced a medication change due to increased facial pain, but neither the resident nor the Responsible Party (RP) were informed. The Nurse Practitioner (NP) instructed the nurse to discuss the changes with the resident, but the nurse failed to do so, citing being occupied with other tasks. The resident and RP later reported not being informed, and the Director of Nursing (DON) confirmed the notification should have occurred.
The facility failed to convey the personal funds of two deceased residents to their estates within the required 30-day period. A resident's $125.22 and another's $2,349.50 were not forwarded to the Clerk of Court or communicated to the families in time. These oversights were discovered during audits, revealing lapses in the facility's financial management processes.
A cognitively impaired, quadriplegic resident with a history of traumatic brain injury and aphasia was sexually abused by a cognitively intact resident with Parkinson's disease. The incident was discovered by a Nursing Assistant who found the perpetrator fondling the victim. The victim, unable to move or call for help, was examined and transferred to another facility. The perpetrator admitted to the abuse and left the facility against medical advice after being questioned by law enforcement. The facility was found to be in immediate jeopardy due to the failure to protect the resident from abuse.
The facility failed to protect a cognitively impaired resident from sexual abuse by another resident and did not effectively implement, monitor, and revise their quality assurance action plan. A previous incident also showed failure to protect a resident from mistreatment by staff.
Improper Food Storage and Unsanitary Dietary Equipment
Penalty
Summary
The deficiency involves failure to properly label, date, seal, and remove expired food items, as well as failure to maintain cleanliness of dietary equipment and storage areas. During an initial tour of the dietary department, surveyors observed two crates of chocolate milk cartons in the walk-in cooler that were past their expiration date but still available to be served, and a partially used 5-pound bag of shredded cheddar cheese left open to air, though dated as opened. In the dry food storage room, an undated bag of rice was found in an open plastic bag. In the walk-in freezer, an open cardboard box of frozen chicken breast patties with an open inner plastic bag was observed, with patties showing light edges suggestive of freezer burn, and three 5-pound rolls of frozen ground beef placed on a wire rack without any dates. Additional observations showed that equipment and surfaces in the dietary department were not adequately cleaned. The free-standing rack for cutting boards had a dark brown buildup of debris between sections where cutting boards were stored, with some boards touching the debris. One side of the stove/oven had a dark brown, sticky grease buildup. The bottom edge of a free-standing refrigerator door had thick dust and debris, and a utility cart holding condiments and silverware was visibly soiled with dried debris and crumbs between compartments and along the edges. Interviews with the Dietary Manager and the Regional Director of Dietary Services confirmed that staff had not been consistently checking dates, sealing and labeling food, or ensuring that cleaning tasks were completed according to expectations.
Failure to Provide Podiatry Services and Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide appropriate foot care and podiatry services to a resident with type 2 diabetes, neuropathy, circulatory complications, and hemiplegia/hemiparesis following a subarachnoid hemorrhage. The resident had moderately impaired cognition and required substantial to maximum assistance with activities of daily living. Review of the care plan, quarterly MDS, nurse progress notes, shower book, and weekly skin assessments from December through early February showed no documentation that the resident’s long toenails were identified, addressed, or that a podiatry appointment was arranged. The skin assessment sections attached to shower sheets were not checked to indicate a need for nail trimming, and the resident’s name did not appear on podiatry lists for the prior six months. On observation, the resident called out for help and reported toe pain; her great toenails and remaining toenails were noted to be long, thick, and jagged, and she was not wearing socks. Nurse aides reported that they could not cut the resident’s toenails and that their role was to inform the nurse when toenails needed cutting, especially for residents with diabetes who must be seen by a podiatrist. One nurse aide acknowledged she had not informed the nurse that this resident’s toenails needed cutting, and the charge nurse stated she had not cut the resident’s toenails and had not been asked to do so. The social worker reported the resident had not been identified as needing podiatry, and the DON stated that residents with diabetes should have their nails cut by podiatry and that nurses should assess feet and either cut nails or place residents on the podiatry list. The administrator stated he was unaware the resident needed podiatry and that nurses were responsible for ensuring the social worker received a current list of residents needing podiatry services.
Failure to Provide Required Nail and Personal Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care and personal hygiene assistance to a resident who required staff support with activities of daily living. The resident was admitted with recent partial amputation of two fingers, end stage renal disease, Type 2 diabetes mellitus, and a history of cerebrovascular accident. The admission MDS documented that the resident was cognitively intact, required substantial assistance for toileting hygiene, and needed set up/clean up assistance with personal hygiene. The care plan identified an ADL self-care deficit and included interventions to check nails to ensure they were clean and neat in appearance and to provide showers per schedule. Despite this, repeated observations over several days showed the nails on the resident’s left hand extended approximately a quarter inch beyond the fingertips with thick black matter under each nail. Record review showed the resident was scheduled for baths twice weekly on the night shift, but there were no shower or personal hygiene sheets for the resident from November through February. Night-shift NAs assigned on the resident’s bath days stated they relied on the posted bath schedule and a Bath Check List to document completion of care and to note nail care needs, but they reported they had not noticed the condition of the resident’s fingernails. Another NA who provided a bed bath reported no personal care issues and did not recall long or dirty nails. The nurse assigned to the resident was unaware of any nail care needs, stated no NA had reported concerns, and had not observed the nails. The Unit Manager and DON both stated that nail care was expected to be completed with scheduled baths and that NAs should notify nurses, especially for residents with diabetes, but they had not assessed this resident’s nails and did not know why no bath sheets existed for the resident. The Administrator stated it was unacceptable for residents to have dirty fingernails and that nursing staff were responsible for ensuring neat and clean nails.
Failure to Administer Prescribed Antiseizure Medication Due to Lapsed Prescription and Communication Gaps
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder and traumatic brain injury did not receive a prescribed twice-daily dose of an antiseizure medication, Lacosamide 50 mg, for seven consecutive days. The medication was not available due to an expired prescription, and multiple nursing staff documented the missed doses in the Medication Administration Record (MAR) but did not consistently notify the provider or pharmacy in a timely manner. Communication about the missing medication was fragmented, with some nurses leaving messages for the pharmacy or provider, while others assumed the issue had already been addressed by previous shifts. During this period, the resident continued to receive other antiseizure medications, including Lacosamide 200 mg, Levetiracetam, and Depakote, and did not exhibit any signs of seizure activity, agitation, or changes in vital signs. The resident and family were eventually notified about the missed doses, and the Medical Director was informed after several days, at which point a new prescription was sent to the pharmacy and the medication was delivered to the facility. Interviews with nursing staff, the Medical Director, and pharmacy personnel revealed that the lack of a systematic process for ensuring medication availability and prompt communication regarding missing medications contributed to the delay. Documentation in the MAR and communication logs showed that the issue persisted across multiple shifts, with inconsistent follow-up and escalation, resulting in a significant medication error for the resident.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired female resident from sexual abuse by a cognitively impaired male resident. The incident occurred when a male resident, who was severely cognitively impaired and had a history of socially inappropriate behavior, was found naked in the room of a female resident. The male resident was observed attempting to place his fingers inside the female resident's vagina. The female resident, also severely cognitively impaired, was unable to defend herself or call for help due to her condition. The male resident had been admitted with diagnoses including schizoaffective disorder and Parkinsonism, and his care plan included interventions for socially inappropriate behavior. However, on the night of the incident, a nurse aide failed to intervene when the male resident was seen in the hallway with only a towel around his waist. Subsequently, the male resident entered the female resident's room, leading to the incident of abuse. The female resident, who had dementia and was dependent on staff for most activities of daily living, was found in a vulnerable state, with her incontinence brief on the floor. The facility's video recordings and staff interviews revealed that the nurse on duty did not notice the male resident leaving his room or entering the female resident's room. The nurse aide assigned to the hallway did not address the male resident's inappropriate state of dress, and the nurse was reportedly inattentive at the nursing station. These lapses in supervision and intervention contributed to the occurrence of the abuse, highlighting a significant deficiency in the facility's ability to protect residents from harm.
Inaccurate MDS Coding for PASRR Level II
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for Level II Preadmission Screening and Resident Review (PASRR) for four residents. These residents, identified as Resident #43, Resident #45, Resident #58, and Resident #61, were all determined to require a Level II PASRR by the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services. However, their comprehensive MDS assessments did not reflect this requirement, as they were not coded for PASRR Level II or for Level II PASRR screening and conditions as mandated by the Resident Assessment Instrument (RAI) manual. Interviews with the Case Mix Director and the Administrator revealed that the MDS assessments were either coded inaccurately or the necessary information was not available at the time of coding. Both the Case Mix Director and the Administrator expressed that it was their expectation for all MDS assessments to be coded correctly according to the RAI manual. Despite these expectations, the facility did not meet the required standards for accurately coding the MDS assessments for the residents in question.
Deficiencies in Food Storage and Staff Hygiene
Penalty
Summary
The facility failed to maintain cleanliness and proper labeling in the dry goods storage area and the walk-in refrigerator. During an observation, a large white container without a lid was found in the dry goods storage area, with a significant amount of sugar spilled on the floor. The Dietary Manager acknowledged that the sugar was accidentally dropped during breakfast preparations and should have been cleaned immediately. Additionally, in the walk-in refrigerator, several opened cartons of thickened liquids and a container of diced fruit were found without labels or dates. The Dietary Manager confirmed that these items should be labeled with an opened date and discarded within 72 hours as per manufacturer recommendations. Furthermore, the facility did not ensure that dietary staff adhered to proper hygiene standards during food preparation. A Dietary Aide was observed working near the food preparation station without a beard covering, despite having facial hair. The aide admitted to forgetting to wear a beard covering at the start of his shift, although beard coverings were available in the dietary manager's office. The Director of Nursing reiterated the requirement for all male staff with facial hair to wear beard coverings while in the kitchen, and confirmed the necessity of dating thickened liquids and discarding them within the specified timeframe.
Failure to Develop Individualized ADL Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered activities of daily living (ADL) care plan for a resident who required total assistance with ADL. The resident, admitted with diagnoses including spondylosis, muscle weakness, lymphedema, and chronic pain syndrome, had intact cognition and required substantial to maximum assistance with various ADLs as per the quarterly Minimum Data Set (MDS) assessment. However, the resident's comprehensive care plans, last revised on 7/23/24, did not include a plan addressing her need for ADL assistance. Interviews with the MDS Coordinator and the Director of Nursing revealed that the ADL assistance plan was not included, despite the facility's protocol to provide such plans for all residents requiring assistance.
Failure to Provide Appropriate Meal Modifications for Residents
Penalty
Summary
The facility failed to provide appropriate meal modifications for two residents with specific dietary needs. Resident #68, who was admitted with dysphagia and assessed as severely cognitively impaired, was supposed to receive a mechanically soft diet with cream gravy mix. However, during dining observations, the resident was served meals that were too dry and not in the specified form, leading to difficulty in swallowing. The dietary staff did not ensure the meal tray matched the meal ticket instructions, resulting in the resident receiving inadequate meal modifications. Similarly, Resident #22, who had dysphagia and was assessed as cognitively intact, was supposed to have her food cut into bite-sized pieces as per physician orders. However, the meal tickets did not reflect these instructions, and the resident struggled to cut her food with a fork due to having only one tooth. The dietary manager acknowledged that the special instructions were not transferred correctly to the meal tracker software, leading to human error in meal preparation. The Director of Nursing confirmed that meal tickets should match physician orders to ensure residents receive the correct diet.
Failure to Notify Resident and Responsible Party of Medication Change
Penalty
Summary
The facility failed to notify a resident and the resident's Responsible Party (RP) of a medication change. The resident, who was admitted with diagnoses including stroke and atypical facial pain, was assessed with intact cognition. On a specific date, the resident complained of increased facial pain, prompting a nurse to contact a Nurse Practitioner (NP) who prescribed a change in medication. The NP instructed the nurse to discuss the changes with the resident, who was considered his own RP. However, the nurse did not inform the resident or the RP about the medication changes due to being occupied with other tasks. The resident later reported not being informed about the medication change and expressed confusion about the reason for the change. The RP also stated that they were not notified about the medication adjustments. Interviews with the NP and the Director of Nursing (DON) confirmed that the resident should have been informed of the changes and asked if they wanted their RP to be notified. The interim Administrator acknowledged that the nurse should have notified both the resident and the RP about the medication changes.
Failure to Convey Resident Funds Timely
Penalty
Summary
The facility failed to convey the personal funds of two deceased residents to their respective estates within the required 30-day period. Resident #281 had a trust account balance of $125.22 that was not forwarded to the Clerk of Court or communicated to the family within the stipulated time frame following the resident's death. This oversight was discovered during an audit conducted at the end of the month, revealing that the funds had not been appropriately managed as per federal regulations. Interviews with the Financial Counselor and the former Administrator confirmed that the responsibility for ensuring timely disbursement of funds lay with the Financial Counselors, who failed to perform the necessary audits and communications. Similarly, Resident #134 had a trust account balance of $2,349.50 that was not conveyed to the resident's estate within 30 days of death. The Financial Counselor admitted that the funds were not sent to the Clerk of Court, and the family was not informed about the availability of the funds. This discrepancy was also identified during an end-of-month audit. The Area President and the Financial Counselor acknowledged the failure to adhere to the policy requiring funds to be sent to the Clerk of Court within the designated period, highlighting a lapse in the facility's financial management processes for deceased residents.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively impaired resident (Resident #1) from sexual abuse by a cognitively intact resident (Resident #2). On 3/19/24, Resident #2 was found in Resident #1's room by Nursing Assistant #1, observed fondling Resident #1's penis with skin-to-skin contact. Resident #1, who was quadriplegic, had limited ability to move and was non-verbal, making him unable to stop the abuse or call for help. Resident #1's medical history included quadriplegia, traumatic brain injury, and aphasia, rendering him dependent on assistance for all activities of daily living. Resident #2, admitted with Parkinson's disease, had intact cognition and no prior behavioral issues documented upon admission. The incident was immediately reported to the Interim Director of Nursing, who separated Resident #2 from Resident #1 and initiated an investigation. Resident #1 was examined, sent to the emergency room, and later transferred to another facility. Resident #2 admitted to the abuse and left the facility against medical advice after being questioned by law enforcement. The police officer involved confirmed Resident #2's admission of the abuse and indicated that the case would be presented to the District Attorney for prosecution. The facility was found to be in immediate jeopardy due to the failure to protect Resident #1 from sexual abuse, which was only removed after implementing corrective actions.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility's quality assurance process failed to implement, monitor, and revise the action plan developed for the recertification/complaint investigation survey dated 7/13/22, resulting in a repeated deficiency in the area of abuse. During a complaint investigation survey on 4/9/24, it was found that the facility failed to protect a cognitively impaired dependent resident from sexual abuse by a cognitively intact resident. On 3/19/24, a nursing assistant found the cognitively intact resident fondling the dependent resident's penis. The dependent resident was unable to stop the abuse due to his limited mobility and inability to call for help. This incident affected one of three residents reviewed for abuse. In a previous survey on 7/13/22, the facility failed to protect a resident's right to be free from mistreatment, resulting in a resident sustaining a scratch on her face and nose from an altercation with staff. The resident was crying and stated that the altercation made her feel scared and anxious. The Administrator stated that the abuse incident on 3/19/24 was an unusual circumstance and different from the prior abuse incident on 7/13/22, and that the staff addressed the situation as best they could under the circumstances.
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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