Pruitthealth-rockingham
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockingham, North Carolina.
- Location
- 804 South Long Drive, Rockingham, North Carolina 28379
- CMS Provider Number
- 345378
- Inspections on file
- 20
- Latest survey
- April 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pruitthealth-rockingham during CMS and state inspections, most recent first.
The facility failed to maintain documentation of resolved grievances for nine months. The current administrator could not locate grievances from December 2023 to August 2024. The former administrator reportedly handed over the grievance log to the DON, who did not verify its contents. The Social Worker was not involved in the grievance process during the former administrator's tenure.
A nurse in an LTC facility misappropriated narcotic medications, affecting six residents. Discrepancies in medication records revealed that medications were signed out but not administered. The nurse left the facility mid-shift, leaving medication cups unattended. Staff discovered the issue, and the DON initiated an investigation, confirming the misappropriation. The incident was reported to authorities.
A nurse left her shift early, leaving pre-poured medications unsupervised on a cart, affecting multiple residents. This violated the facility's policy of preparing and administering medications one at a time. The incident was discovered by other staff, who then administered the medications. The facility lacked a process for ongoing monitoring to ensure compliance with professional standards.
A resident with dementia and impaired mobility was subjected to abuse by a nurse aide who tilted the resident's wheelchair and pushed it forcefully down the hall. Witnesses reported the incident, and the facility's investigation confirmed the abuse. The nurse aide was terminated, but the facility failed to provide a thorough plan of correction.
A facility failed to include a focus on anticoagulant therapy in a resident's care plan, despite the resident being prescribed Xarelto for atrial fibrillation. The omission was confirmed by the MDS nurse and the DON, who acknowledged that the care plan should have reflected the resident's medication regimen.
The facility failed to label and store insulin pens properly, as observed in two medication carts. An open Lantus Solostar insulin pen lacked a resident's name and prescribed dose, while unopened insulin pens were not refrigerated per manufacturer instructions. Additionally, an expired insulin pen was not discarded after 28 days. Staff interviews confirmed the need for proper labeling, storage, and disposal of insulin pens.
A resident with dementia and anxiety was denied their choice of coffee in the dining room, as a nurse aide removed them instead of fulfilling the request. The resident's preference for coffee, which helps manage anxiety, was not honored, leading to a deficiency in supporting resident self-determination.
A resident was readmitted to a facility with a sacral wound and heel redness, but the facility failed to obtain physician orders for treatment. Nursing staff applied treatments without orders, and the resident's wounds were later classified as a Stage 3 pressure ulcer and a deep tissue pressure injury. The DON confirmed the lack of orders and attributed it to new staff and the absence of a wound care nurse.
The facility failed to maintain accurate daily Posted Nurse Staffing sheets, with discrepancies found on three days between the posted sheets and the actual staff schedule. The NA/Staffing Scheduler confirmed the errors, citing a misunderstanding in counting staff splitting shifts. The Administrator was unaware of these inaccuracies.
Failure to Maintain Grievance Documentation
Penalty
Summary
The facility failed to maintain documentation of resolved grievances and evidence of the results of all grievances for nine out of thirteen months reviewed, from December 2023 to August 2024. During an interview, the current administrator, Administrator #1, stated that grievances from this period were not available for review as she did not have them. The Social Worker reported that the former administrator, Administrator #2, did not allow her to assist in the grievance process and was unaware of the location of the grievance log or copies of grievances. Administrator #2, when interviewed, claimed to have handed over the grievance log binder to the Director of Nursing (DON) in a box when she left the facility. The DON confirmed receiving a box from Administrator #2 in a parking lot but did not check its contents before placing it in Administrator #1's office. Administrator #1, who began working at the facility in August 2024, stated she had searched for the grievances and logs but was unable to find them. She was informed by the Social Worker that grievances were not recorded before her tenure. The facility provided Quality Assurance and Performance Improvement (QAPI) meeting minutes and a Performance Improvement Plan (PIP) dated August 2024, but these did not address the deficient practice, preventing the survey team from determining past noncompliance for grievances.
Misappropriation of Narcotic Medications by Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic medications, specifically oxycodone and hydrocodone, affecting six residents. The issue was identified when discrepancies were found in the controlled drug forms and Medication Administration Records (MAR) for these residents. Nurse #6 was responsible for signing out the medications, but the actual pill counts did not match the documented counts, indicating that medications were signed out but not administered to the residents as recorded. Nurse #6 was observed to have left the facility mid-shift, leaving medication cups filled with pills on top of the medication cart, which was unattended. This was discovered by other staff members, including Nurse #3 and Nurse #7, who noted that the narcotic count was off and several medications were missing. The Director of Nursing (DON) was notified, and an investigation was initiated, revealing that Nurse #6 had not returned to the facility to account for the missing narcotics. Interviews with staff members, including Nurse #3 and Nurse #7, indicated that Nurse #6 had complained of a headache and expressed a temptation to take a resident's narcotic. Despite being advised against it, Nurse #6 left the facility without ensuring the narcotics were properly accounted for. The DON reviewed camera footage and confirmed that no other staff had accessed the medication cart until the discrepancies were discovered. The facility reported the incident to the appropriate authorities, including the local police department.
Medication Administration Deficiency Due to Nurse's Departure
Penalty
Summary
The facility failed to adhere to professional standards for medication administration, as evidenced by the actions of Nurse #6 during the 9:00 PM medication pass on D hall. Nurse #6 pre-poured medications into cups and left them unsupervised on top of the medication cart, affecting 13 residents. This practice was against the facility's policy, which mandates that medications be prepared and administered one resident at a time, and not pre-poured or left unattended. On the evening of the incident, Nurse #6 left the facility mid-shift to visit the emergency room for a migraine, leaving the medication cart unattended with pre-poured medication cups on top. Nurse #6 did not ensure the medications were administered or documented before leaving, nor did she secure the cart or its keys. This left the medications vulnerable and unaccounted for, as noted by other staff members who later discovered the situation. The Director of Nursing and other staff members, including Nurse #3 and Nurse #7, were involved in addressing the situation after it was discovered. They verified that the medication pass had not been completed and subsequently administered the medications to the affected residents. The facility's investigation did not reveal a process for ongoing monitoring to ensure compliance with professional standards, which was a critical oversight in preventing such deficiencies.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a nurse aide tilted a resident's wheelchair back, let it down, and then pushed the wheelchair forcefully down the hall. This incident involved a resident with dementia, anxiety disorder, aphasia, and lack of coordination, who was admitted to the facility with these diagnoses. The resident was known to have moderately impaired cognition and exhibited verbal behavioral symptoms, requiring assistance with activities of daily living due to impaired mobility and cognitive status. On the day of the incident, the resident was in the dining room and requested coffee after finishing his meal. The nurse aide, who was assisting other residents, attempted to move the resident by tilting his wheelchair back to lift his feet off the floor. The aide then pushed the wheelchair forcefully down the hall without ensuring the resident's safety. Witnesses, including a floor technician and a housekeeper, observed the incident and reported it to the staffing scheduler, who then informed the Director of Nursing. The facility's investigation confirmed the abuse, and the nurse aide was suspended and subsequently terminated. The Director of Nursing and Administrator reviewed video footage that corroborated the witnesses' accounts. Despite the resident's inability to recall the event, the facility substantiated the abuse allegation based on the evidence gathered. The facility did not provide a thorough plan of correction to address the failure to protect the resident from abuse, which was necessary for the survey team to evaluate eligibility for past non-compliance.
Failure to Include Anticoagulant Therapy in Care Plan
Penalty
Summary
The facility failed to develop an individualized and comprehensive care plan for a resident who was prescribed anticoagulant medication. The resident, who was admitted with diagnoses including congestive heart failure and atrial fibrillation, had an active medication order for Xarelto, an anticoagulant, to be taken daily. Despite this, the resident's care plan, updated in January 2025, did not include a focus on anticoagulant therapy. This oversight was confirmed during an interview with the MDS nurse, who acknowledged the missing focus on the care plan. The Director of Nursing also confirmed that the care plan should have accurately reflected the resident's anticoagulant medication regimen.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to properly label and store insulin pens in accordance with professional principles and manufacturer instructions. During an observation of the D hall medication cart, a Lantus Solostar insulin pen was found open and in use without a label indicating the resident's name or prescribed dose. Nurse #2 confirmed that insulin pens should be labeled with the resident's name and the date they were opened, and should be discarded 28 days after opening. The insulin pen was subsequently given to Nurse #2 for disposal. Additionally, an observation of the A hall medication cart revealed unopened insulin pens that were not stored in the refrigerator as required by the manufacturer's instructions. A Lantus Solostar insulin pen was also found open and available for use with a date of 12/12/24, indicating it was not discarded after 28 days as required. Nurse #5 acknowledged the need for proper storage and timely disposal of insulin pens. Interviews with the Director of Nursing and the Pharmacist confirmed the facility's procedures for insulin pen storage and labeling, and the Pharmacist noted a previous instance where an expired insulin pen was removed but later found back in the cart instead of being disposed of.
Failure to Honor Resident's Choice for Coffee
Penalty
Summary
The facility failed to honor a resident's choice to receive coffee, which was a preference expressed by a resident with dementia, anxiety disorder, and aphasia. On a specific date, a floor technician witnessed the resident requesting coffee in the dining room. Instead of fulfilling this request, Nurse Aide #1 removed the resident from the dining room, as she was occupied assisting another resident. This action was taken despite the resident's known preference for coffee, which was also used to help manage his anxiety and agitation. The resident, who had moderately impaired cognition and required setup assistance for eating, was unable to recall the incident when later observed. Interviews with the facility's Administrator and Director of Nursing confirmed that the resident should have been provided with coffee as requested. The failure to provide coffee as requested was seen as a failure to support the resident's self-determination and choice, which is a right that the facility is required to promote and facilitate.
Failure to Obtain Treatment Orders for Pressure Ulcers
Penalty
Summary
The facility failed to obtain treatment orders for pressure ulcers when a resident was readmitted from the hospital, leading to nursing staff providing treatments without a physician's order. This deficiency affected a resident who was readmitted to the facility after hospitalization for an acute stroke. Upon readmission, the resident had a wound to the sacral area and redness on the left heel, but no treatment orders were obtained from the physician for these conditions. Nursing staff applied barrier cream and dry dressings without proper orders, and the resident's care plan included interventions for wound care that were not followed due to the lack of physician orders. Interviews with nursing staff revealed a lack of recall regarding the resident's condition and the care provided upon readmission. The Wound Care Provider later evaluated the resident and classified the sacral wound as a Stage 3 pressure ulcer and the left heel as a deep tissue pressure injury, providing specific wound care orders. The Director of Nursing confirmed the absence of treatment orders and attributed the oversight to having many new nurses and the lack of a wound care nurse at the time. The deficiency highlights the facility's failure to ensure proper wound care management and documentation for the resident upon readmission.
Inaccurate Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure accurate daily Posted Nurse Staffing sheets for three specific days. A review of the daily Posted Nurse Staffing sheets compared to the Staff Schedule/Assignment sheets from January 18, 2025, through February 18, 2025, revealed discrepancies in the number of actual unlicensed Nursing Assistants (NAs) that worked. On January 24, 2025, during the first shift, the daily Posted Nurse Staffing sheet indicated that seven unlicensed staff worked, while the Staff Schedule/Assignment sheet showed only five. Similar discrepancies were found on January 27, 2025, and February 7, 2025, where the daily sheets showed more staff than the schedule sheets. During a phone interview, the NA/Staffing Scheduler confirmed the discrepancies and admitted to being unaware that two staff splitting a shift should be counted as one. The Administrator also stated she was unaware of the inaccuracies in the daily Posted Nurse Staffing sheets.
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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