Ramseur Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ramseur, North Carolina.
- Location
- 7166 Jordon Road, Ramseur, North Carolina 27316
- CMS Provider Number
- 345523
- Inspections on file
- 20
- Latest survey
- August 19, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Ramseur Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
Surveyors identified inaccurate MDS coding for two residents: one received antipsychotic medication that was not documented on the MDS, and another was incorrectly coded as receiving insulin instead of semaglutide. The MDS coordinator confirmed the errors, and the responsible MDS nurse was unavailable for clarification.
A moderately cognitively impaired male resident was found inappropriately touching a severely cognitively impaired female resident. The male resident admitted to the behavior, and the female resident was unable to consent. The facility's investigation confirmed the incident, and the male resident was charged with sexual battery.
The facility failed to implement its abuse policy by not immediately reporting an allegation of sexual abuse, not providing a timely physical examination of the alleged victim, and not placing the alleged perpetrator under one-to-one observation. Additionally, the facility did not assess other residents for signs of abuse and failed to report the incident to Adult Protective Services promptly.
The facility failed to protect residents from the misappropriation of narcotic medication, specifically Oxycodone, prescribed to treat pain for three residents. Discrepancies in the Narcotic Count Sheets and falsification of records by an LPN, who tested positive for Oxycodone, indicated potential misappropriation of the medication.
The facility failed to develop individualized and comprehensive care plans for four residents, leading to deficiencies in their care. These included a lack of care plans for incontinence care, dysphagia and aspiration precautions, IV antibiotic use, and indefinite antibiotic use. The DON and MDS Nurse acknowledged these oversights.
The facility failed to ensure a fall mat was in place for a resident with dementia and a history of falls, as per the care plan. Despite the documented need for a fall mat following a fall incident, observations revealed its absence, and staff were unaware of the requirement. The DON confirmed the fall mat was present during a recent audit but was unaware of its current absence.
The facility failed to discontinue an order for PICC line dressing changes for a resident after the PICC line was removed, resulting in an active but unnecessary order in the MAR. This oversight was acknowledged by the Unit Supervisor and the Director of Nursing.
The facility's QAPI committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in areas such as MDS assessments, care plan revisions, and fall safety interventions. These issues were attributed to MDS Nurse and leadership turnover.
The facility failed to complete a Minimum Data Set (MDS) discharge assessment within the required time frame for a resident. The MDS Coordinator noticed the missing assessment after the resident had been discharged, and the corporate Nurse Consultant confirmed the expectation for timely transmission.
The facility failed to accurately code the MDS for a resident, incorrectly noting the administration of anticoagulant medication. The MDS Coordinator confirmed the error, and the Corporate Nurse Consultant expected accurate MDS assessments.
The facility failed to update the care plan for a resident after the removal of a JP drain and PICC line, leading to outdated information regarding antibiotic use and device management. Staff confirmed the oversight during interviews.
The facility failed to provide written notification to residents and/or their representatives for hospital transfers and a facility-initiated discharge. Two residents were transferred to the hospital without written notice, and another resident received a 30-day discharge notice without the Ombudsman being notified.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents. For one resident with schizoaffective disorder, bipolar type, physician orders indicated a monthly intramuscular injection of Haloperidol, an antipsychotic medication, which was administered as ordered in June and July. However, the quarterly MDS assessment did not reflect the use of antipsychotic medications during the look-back period. For another resident with obesity, physician orders specified weekly subcutaneous injections of semaglutide for weight loss, which were administered as ordered. The quarterly MDS assessment for this resident incorrectly documented the administration of insulin, despite no physician orders or evidence of insulin administration. Interviews with the MDS coordinator confirmed the inaccuracies in the MDS assessments for both residents. The assessments in question were completed by another MDS nurse, who was unavailable for interview. The facility administrator was unaware of the reasons for the incorrect coding and stated an expectation for all MDS assessments to be accurate.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free of sexual abuse. A moderately cognitively impaired male resident was found beside a severely cognitively impaired female resident's bed with his hand moving under the covers around her groin area. The female resident's brief was open, and there was stool on the outside of her brief and on her sheets, while the male resident had stool on his hands. The male resident admitted to inappropriate touching, stating he was 'playing around' with the female resident 'down there.' The female resident did not have the cognition to express or understand consent for physical sexual advances. The male resident had a history of dementia and stroke, and his care plan indicated episodes of verbally aggressive behaviors. The incident was observed by a nurse aide who reported the male resident's actions and the condition of the female resident. The male resident was interviewed by the social worker and admitted to the inappropriate behavior, acknowledging that he knew it was wrong. The police were notified, and the male resident was charged with sexual battery. The facility's investigation revealed that the male resident had no prior history of sexual aggression. The female resident's responsible party was notified, and the female resident was transferred to another room for her protection. The medical director evaluated both residents and determined that neither had the cognitive ability to give or withhold informed consent. The male resident was placed on every 15-minute observations following the incident, but he continued to wander the facility between these checks.
Removal Plan
- Social Worker talked with Resident #39 about the incident that occurred and explained to resident #39 what he had done wrong.
- The physician changed resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression.
- Resident #39 has been placed on 1 on 1 observation.
- MDS Nurse updated resident #39's care plan to reflect new behavior of sexual aggression and interventions for managing behavior.
- MDS Nurse updated care guide for resident #39 and staff notified of changes through care guide.
- MDS Nurse will continue to update interventions as needed.
- The Staff Development Coordinator educated 100% of facility staff on the facility abuse policy to include residents right to be free from abuse to include sexual, physical, mental, verbal and misappropriation of property as well as signs of abuse and reporting of abuse or potential abuse.
- Staff development Coordinator will provide education for abuse training to new hires during orientation.
- 1:1 supervision will be documented and reported to the facility Administrator and Director of Nursing to ensure monitoring of resident.
- The Director of Nursing will ensure the 1:1 staff member is provided each shift with the staffing coordinator.
- All CNA's will be educated by the Director of Nursing/Staff Development Coordinator on supervision of resident during 1:1 duty.
- Education will include a goal of 1:1 in protecting other residents from any sexual aggression by resident #39 and ensuring resident #39 does not encounter resident #7 and documenting of any aggression during shift.
- The facility completed Ad Hoc QAPI to review investigation and current action plan to ensure all components were done and followed.
- The facility administrator and Director of Nursing are responsible for continued compliance.
Failure to Implement Abuse Policy
Penalty
Summary
The facility failed to implement several components of its abuse policy, leading to a deficiency in handling an allegation of sexual abuse. Specifically, the facility did not immediately report the allegation of sexual abuse of a severely cognitively impaired female resident by a moderately cognitively impaired male resident to the Administrator. Additionally, the facility did not provide a physical examination of the alleged victim by a trained/licensed professional for signs of sexual abuse. The facility also failed to protect the alleged victim and other residents by not placing the alleged perpetrator on one-to-one observation immediately after the incident was reported. Furthermore, the facility did not assess all other residents for signs of sexual abuse when the allegation was reported, and it failed to report the allegation to Adult Protective Services in a timely manner. The incident involved a severely cognitively impaired female resident who was found by a nurse aide with a male resident's hand under her bed covers. The male resident had stool on his fingers, and the female resident's brief was open with stool on the sheets. The nurse aide reported the incident to a medication aide, who delayed reporting it to the unit supervisor by 30 minutes. The unit supervisor then reported the incident to the Director of Nursing, who initiated an investigation and called the police. However, the facility did not conduct an immediate physical assessment of the female resident, and the male resident was not placed under one-to-one observation until several hours later. Interviews with staff revealed that there was confusion and delay in reporting the incident, and the facility's policies were not followed. The Director of Nursing and the previous Administrator were unaware of the delays in reporting and the lack of immediate assessment and protection for the residents. The facility's failure to follow its abuse prevention, intervention, reporting, and investigation policies resulted in a deficiency that had the potential to affect other vulnerable residents in the facility.
Removal Plan
- The Regional Director of Operations and Regional Clinical Nurse educated the Director of Nursing, Administrator, Medical and Staff Development Coordinator on abuse policy to include residents' right to be free from abuse, signs of abuse, and reporting of abuse or potential abuse.
- Education included the process and action to protect residents if any type of abuse occurs according to facility policy and procedure on abuse, including assessment of all residents involved, immediate protection for all residents, immediate reporting to Management, state agencies, Ombudsman, APS, families, physician, and law enforcement.
- Staff Development Coordinator and/or Director of Nursing educated all nursing staff on proper procedures for reporting any suspected abuse and immediate reporting to the Administrator and Director of Nursing for direction.
- Education included direction for resident assessment immediately following an incident, physician notification by Nurse for direction of care for resident, and need to send out to hospital for further examination.
- Social Worker talked with Resident #39 about the incident and explained what he had done wrong.
- The physician changed Resident #39's medication to add Zoloft 25mg tablet daily by mouth for aggression.
- Resident #39 has been placed on one-to-one observation.
- The facility completed AdHoc QAPI to review investigation and current action plan to ensure all components were done and followed.
- The facility provided documentation of the in-service education that was provided to all staff which included the review of the facility's Abuse Policy and included immediate reporting of any allegations of abuse to the Administrator immediately, provide a physical examination by a trained/licensed professional for any signs of sexual abuse, provide protection for the resident that is the victim of abuse, provide protection for all other residents when an allegation of abuse is reported, and report any allegations of abuse to the proper authorities.
- The Staff Development Coordinator ensured all staff are educated regarding the reporting of abuse allegations to the administrator immediately, provide a physical examination by the physician or if the physician is not available send the resident to the emergency department for evaluation if there is an allegation of sexual abuse, provide protection for the abused individual and all other residents, and reporting of allegations of abuse to the proper authorities.
- Observations of Resident #39 were made and the facility was providing one-to-one observation of the resident.
- Facility staff (sampled from all disciplines) were able to verbalize the types of abuse, what steps they should take to assess and protect the resident of an alleged abuse, and what authorities should be notified of allegations of abuse.
- The facility provided skin assessments that were completed on residents with a Brief Interview for Mental Status (BIMS) of less than 9 and interview forms that were completed on all residents with a BIMS of 9 or above.
- The facility notified Adult Protective Services of the allegation of sexual abuse for Resident #7.
- The facility provided minutes of their Quality Assurance Performance Improvement (QAPI) meeting.
Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic medication, specifically Oxycodone, prescribed to treat pain for three residents. Resident #16 had an order for Oxycodone 10 mg every 6 hours as needed for pain. The Narcotic Count Sheet indicated discrepancies where Nurse #12 documented wasting the medication without proper verification. Despite the resident reporting no concerns about her pain management, the records showed that Nurse #12 had a history of addiction and tested positive for Oxycodone on 2/28/24, suggesting potential misappropriation of the medication. Resident #75 had an order for Oxycodone 5 mg every 4 hours as needed for pain. The Narcotic Count Sheet for February 2024 documented that Nurse #12 wasted a tablet, allegedly witnessed by Nurse #6. However, Nurse #6 later stated that she did not waste the medication with Nurse #12, indicating falsification of records. Drug testing for Nurse #6 was negative, further pointing to Nurse #12's involvement in the misappropriation. Resident #239 had an order for Oxycodone 10 mg every four hours as needed for pain. The Narcotic Count Sheet showed that Nurse #12 signed out the medication multiple times on 2/28/24, despite the resident's pain assessments indicating no need for the medication. The resident confirmed that she only requested Oxycodone once on 2/27/24, further highlighting the discrepancies in medication administration by Nurse #12.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for four residents, leading to deficiencies in their care. Resident #2, who was admitted with a displaced subtrochanteric fracture of the right femur and diabetes mellitus with diabetic polyneuropathy, was occasionally incontinent of bladder and always incontinent of bowel. Despite this, there was no care plan related to incontinence care. Both the Director of Nursing (DON) and the Minimum Data Set (MDS) Nurse acknowledged the oversight. Resident #85, who had severe cognitive impairment and dysphagia, did not have a care plan addressing dysphagia or aspiration precautions, which was also confirmed as an oversight by the DON and MDS Nurse. Resident #66, admitted with an infection and inflammatory reaction due to an internal right knee prosthesis requiring intravenous (IV) antibiotics, lacked a care plan for IV antibiotic use. This was similarly acknowledged as an oversight by the DON and MDS Nurse. Resident #78, who had severe cognitive impairment and was on Ciprofloxacin for a polymicrobial bacterial infection for at least a year, did not have a care plan for the indefinite use of antibiotics. The MDS Coordinator and the DON both confirmed this was an oversight. These deficiencies indicate a failure to provide person-centered care plans tailored to the specific needs of the residents.
Failure to Implement Fall Safety Interventions
Penalty
Summary
The facility failed to ensure a fall mat was in place for Resident #31 according to the care planned fall safety interventions. Resident #31, who was admitted with diagnoses including dementia and lack of coordination, had a documented fall on 1/27/23, after which a fall mat was placed beside her bed as a safety measure. However, during observations on 4/30/24 and 5/1/24, the fall mat was not present beside the bed, in the room, or in the bathroom. Interviews with nursing staff and nurse aides revealed that they were unaware of the requirement for a fall mat for Resident #31, and the Director of Nursing confirmed that the fall mat had been present during an audit in March 2024 but was unaware of its current absence. The care plan for Resident #31, last reviewed on 4/22/24, included the use of a fall mat as an intervention for her risk of falls due to impaired balance, history of falls, dementia, and psychotropic medication use. Despite this, the fall mat was not in place during the survey, indicating a failure to implement the planned safety intervention. This deficiency was identified through record review, observations, and staff interviews, highlighting a lapse in the facility's adherence to the care plan designed to prevent accidents for Resident #31.
Failure to Discontinue PICC Line Care Order
Penalty
Summary
The facility failed to clarify a consultation note and discontinue an order for PICC line care for Resident #78. The resident was readmitted from the hospital with a diagnosis of polymicrobial bacterial infection and had a PICC line present. An order was placed for PICC line dressing changes every seven days. However, an Infectious Disease progress note indicated that the PICC line was to be removed on 4/5/24. Despite this, the order for dressing changes remained active in the Medication Administration Record (MAR) from 4/5/24 to 4/30/24. On 5/1/24, during an observation of personal care, it was noted that Resident #78 no longer had a PICC line. The Unit Supervisor reviewed the progress note and acknowledged that the order should have been discontinued but was not, attributing it to an oversight. The Director of Nursing confirmed that a clarification order should have been obtained to discontinue the PICC line dressing change order when the PICC line was removed.
Repeated Deficiencies in Quality Assurance and Resident Safety
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions following an annual recertification and complaint survey. This resulted in repeated deficiencies in the areas of Accuracy of Assessments and Free of Accident Hazards/Supervision/Devices. Specifically, the facility failed to complete a Minimum Data Set (MDS) discharge assessment within the required time frame for one resident and failed to accurately code the MDS in the area of medication for another resident. These issues were attributed to MDS Nurse turnover, as stated by the Administrator during an interview. Additionally, the facility failed to review and revise care plans in critical areas such as antibiotic use and JP drain management for one resident. There were also failures in ensuring fall safety interventions, such as the placement of a fall mat, and providing adequate supervision to prevent resident-to-resident altercations and safe transfers for high-risk residents. These repeated deficiencies across multiple surveys indicate a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program, which the Administrator attributed to leadership turnover.
Failure to Complete MDS Discharge Assessment on Time
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) discharge assessment within the required time frame for one resident. Resident #58 was admitted and had an admission MDS assessment completed. Nursing documentation noted that the resident was discharged home, but no discharge MDS assessment was found in the resident's record. The MDS Coordinator explained that she usually opens the MDS assessment when aware of a pending discharge but noticed the discharge assessment for this resident had not been transmitted. The corporate Nurse Consultant confirmed that MDS assessments are expected to be transmitted within the required timeframe.
Inaccurate MDS Coding for Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident in the area of medication. Resident #24, who had been readmitted with diagnoses including Stroke and coronary artery disease, had a Significant Change in Status MDS assessment that incorrectly noted the resident had received anticoagulant medication. A review of the resident's February 2024 Medication Administration Record (MAR) revealed that the resident had not received anticoagulant medication but had received antiplatelet medication. During an interview, the MDS Coordinator confirmed that she checked the MAR when completing MDS assessments and acknowledged that anticoagulant medication should not have been coded. The Corporate Nurse Consultant also stated that she would expect MDS assessments to be accurate.
Failure to Update Care Plan for Removed Medical Devices
Penalty
Summary
The facility failed to review and revise the care plans for a resident in the areas of antibiotic use and JP drain management. The resident was admitted with diagnoses including a urinary tract infection, an abscess to the left kidney requiring a JP drain, and a right foot diabetic ulcer. Despite the removal of the JP drain and PICC line on 03/25/24, the resident's care plan, dated 04/04/24, still indicated the presence of these devices and the need for IV antibiotics. Interviews with the MDS Nurse and the Director of Nursing confirmed that these care plan areas should have been updated and removed, but this was overlooked.
Failure to Provide Written Notification for Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to residents and/or their representatives regarding hospital transfers and a facility-initiated discharge. For Resident #78, there was no documentation of a written notice of transfer provided to the resident or their representative for hospital transfers on two separate occasions. Interviews with the wound nurse, Social Worker, and Director of Nursing revealed that while the resident's representative was notified via phone, no written notice was sent. The Administrator was unaware of this lapse in protocol and expected the regulation to be followed. Similarly, Resident #86 was transferred to the hospital without written notice being provided to the resident or their representative. The Social Worker and Director of Nursing confirmed that they did not send written notifications for hospital transfers. Additionally, Resident #64 received a 30-day discharge notice, but the facility failed to send a copy of this notice to the Ombudsman. The Social Worker admitted to not notifying the Ombudsman due to waiting for documentation from the Business Office Manager, who clarified that such documentation was not necessary for notifying the Ombudsman. The Administrator confirmed that the Social Worker should have notified the Ombudsman when the discharge notice was issued.
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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