Rich Square Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rich Square, North Carolina.
- Location
- 300 North Main Street, Rich Square, North Carolina 27869
- CMS Provider Number
- 345356
- Inspections on file
- 20
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Rich Square Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure a comprehensive and accurate facility-wide assessment by not involving direct care staff, residents, or family members, and by listing outdated administrative personnel. The staffing plan did not address shift-specific or weekend needs, nor did it specify required skills and competencies for licensed nursing staff and CNAs. The staff position list was inaccurate, and the current Administrator had not updated the assessment since starting employment.
A resident with a history of stroke and hypertension did not have documented evidence that they or their representative received education about advance directives or the right to accept or refuse treatment. Although the NP and Administrator stated that education was provided by phone, this was not recorded in the medical record, and the resident could not recall receiving such information.
Two residents were not provided with the required CMS SNF Advanced Beneficiary Notice (ABN) before their Medicare Part A skilled services ended, despite receiving a Notice of Medicare Non-Coverage (NOMNC) and remaining in the facility. Staff interviews revealed confusion over who was responsible for issuing the SNF ABN, leading to the deficiency.
Surveyors identified that the facility failed to accurately code the MDS assessments for three residents, resulting in omissions regarding anticonvulsant medication use, prescribed diet, and hearing aid use. One resident was not coded for receiving anticonvulsant medications despite active orders and administration, another was incorrectly coded for a mechanically altered diet instead of a regular diet, and a third was not coded for hearing aid use despite regular use confirmed by staff and observation.
Two residents did not have individualized care plans addressing their specific needs: one required side rails for positioning due to weakness, and another used hearing aids for hearing loss. Despite assessments and repeated observations confirming these needs, the MDS Nurse did not include them in the care plans, and this omission was acknowledged by the DON and Administrator.
Care plans were not updated for two residents: one did not have pain, antihypertensive, or anticoagulant medications included in the care plan despite physician orders, and another continued to have a wander guard intervention listed after the device was discontinued. The MDS Nurse, responsible for care plan updates, missed these revisions, and both the DON and Administrator confirmed the omissions.
A resident with pain and diabetic neuropathy received lidocaine 4% pain patches that remained on the skin for longer than the manufacturer's recommended 12 hours due to unclear physician orders. Nursing staff removed and replaced patches after approximately 24 hours, and the orders lacked clear removal times. Interviews with the nurse, Pharmacy Consultant, NP, and DON confirmed the orders did not specify the required 12-hour removal, resulting in the patches being left on too long.
A resident with Alzheimer's disease and diabetes, who had experienced significant weight loss, did not receive physician-ordered nutritional supplements (ice cream and a nutritional shake) during lunch meals on multiple occasions. Despite clear orders and documentation, dietary staff failed to add the supplements to the meal tray, and this omission was confirmed through observation and staff interviews. The deficiency was identified through record review, direct observation, and interviews with dietary staff, the RD, and the NP.
A nurse failed to perform hand hygiene between glove changes while administering medications to a resident, including eye drops, nasal spray, and a pain patch. The nurse donned and removed gloves multiple times without using hand sanitizer as required by facility policy, only performing hand hygiene upon leaving the resident's room. The DON confirmed this was not in accordance with infection control procedures.
The facility did not provide written notification to the Ombudsman for the hospital transfers of two residents, including multiple transfers for one resident due to acute medical conditions and another for abnormal lab results. Documentation of required notifications was missing, and staff interviews confirmed that the notifications were either not sent or could not be located.
A facility failed to perform a Significant Change in Status MDS assessment for a resident who was discharged from hospice services. The resident, admitted with hypertension and dementia, continued receiving hospice care upon admission. However, when hospice services ended, the required assessment was not completed. The MDS Coordinator, new to the facility, was unaware of the oversight, which the Administrator acknowledged as a failure to meet required time frames.
A resident with chronic respiratory failure was using supplemental oxygen without a physician's order, and there was no signage indicating oxygen use outside their room. Nursing staff failed to recognize the absence of both the order and signage, as confirmed by interviews with the Nurse Unit Manager and DON.
The facility failed to document education and refusal of influenza and pneumococcal vaccines for two residents, both severely cognitively impaired. There was no record of vaccine administration or education provided to the residents or their representatives. The DON confirmed the lack of written consent indicating education was provided when vaccines were refused.
The facility failed to document COVID-19 vaccine education and refusal for two residents who were severely cognitively impaired. The DON stated that the vaccine was offered before her employment, but the facility did not obtain written consent confirming education and refusal.
A facility failed to provide a resident and the ombudsman with written notice of transfer/discharge when the resident was hospitalized. The resident, who was cognitively intact, did not receive a notification letter, and the facility's EMR lacked documentation of the notice. Staff interviews revealed that the issue was not identified until months later, and the Social Worker admitted to not notifying the ombudsman due to inexperience.
A resident was transferred to the hospital without receiving the bed hold policy in writing, as required. The facility's staff, including the Clinical Nurse Consultant and the DON, confirmed that the policy was not issued during transfers at that time. The issue was not identified until months later, indicating a systemic oversight.
Deficient Facility Assessment and Inaccurate Staffing Plan
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment as required. The assessment did not involve all necessary parties in its development, specifically lacking input from direct care staff, residents, resident representatives, and family members. Additionally, the assessment listed outdated administrative personnel, including a former Administrator, Medical Director, and Social Worker, rather than the current staff. The staffing plan included in the assessment only provided the desired number of full-time equivalent (FTE) nurses and CNAs, but did not address specific staffing needs for each shift, weekends, or account for changes in the resident population. The staff type and position list was also inaccurate, listing a Staff Development Coordinator (SDC) position that did not exist at the facility. Further, the facility assessment did not specify the required skills and competencies for licensed nursing staff and CNAs. During an interview, the current Administrator confirmed she had not reviewed or updated the facility assessment since her employment began and acknowledged the inaccuracies in the staff position list. No additional documentation regarding the facility assessment was provided at the time of the survey exit. These deficiencies had the potential to affect all 54 residents in the facility.
Failure to Document Advance Directive Education
Penalty
Summary
The facility failed to provide written information to a resident and/or their representative regarding the right to accept or refuse medical or surgical treatment and the opportunity to formulate an advance directive. The resident, who was admitted with diagnoses including high blood pressure and a history of stroke, was found to be cognitively intact according to a recent assessment. Review of the resident's electronic medical record showed a full code physician order, but there was no documentation indicating that education about advance directives or the opportunity to formulate one had been offered to the resident or their representative. During interviews, the resident was unable to recall receiving any education about advance directives. The facility's Administrator and Nurse Practitioner both stated that education had been provided to the resident's representative via a phone call, but acknowledged that this conversation was not documented in the medical record. Attempts to contact the resident's representative for confirmation were unsuccessful.
Failure to Provide SNF ABN Prior to Medicare Part A Discharge
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents prior to the termination of their Medicare Part A skilled services, as identified through record reviews and staff interviews. In both cases, the residents were given a Notice of Medicare Non-Coverage (NOMNC) indicating the end of their Medicare Part A coverage, but there was no evidence in their medical records that a SNF ABN was reviewed with or provided to them. Both residents remained in the facility after their Medicare Part A coverage ended. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for issuing the SNF ABN. The Business Office Manager and Social Worker each believed the other was responsible for providing the SNF ABN, and the Administrator was under the impression that the Social Worker handled all beneficiary notices. This miscommunication resulted in the SNF ABN not being issued to the affected residents, as required.
Inaccurate MDS Coding for Medications, Diet, and Hearing Aid Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the areas of anticonvulsant medication use, prescribed diet, and use of a hearing aid. For one resident with Alzheimer's Disease and cerebrovascular disease, the MDS assessment did not reflect the administration of two anticonvulsant medications, gabapentin and divalproex sodium, despite active physician orders and documentation in the Medication Administration Record. The MDS Nurse acknowledged missing this information during the assessment process. Another resident, who was cognitively intact and had no swallowing issues, was incorrectly coded as receiving a mechanically altered diet on the MDS, even though physician orders and meal observations confirmed a regular diet with thin liquids. The Dietary Manager, responsible for this section of the MDS, admitted to making an error in coding. Additionally, a third resident with a cognitive communication deficit was not coded for hearing aid use on the MDS, despite observations and staff interviews confirming regular use of hearing aids. The MDS Nurse stated she was unaware of the resident's use of hearing aids at the time of assessment.
Failure to Develop Person-Centered Care Plans for Side Rail Use and Hearing Aid Management
Penalty
Summary
The facility failed to develop person-centered care plans for two residents in key areas. For one resident with Alzheimer's Disease, the Side Rail Use assessment indicated a request for side rails to assist with turning, repositioning, and transfers due to weakness. Despite repeated observations of the resident in bed with side rails in place, the care plan reviewed and updated did not include any documentation or plan for the use of side rails for positioning. Interviews with the MDS Nurse, DON, and Administrator confirmed that the MDS Nurse was responsible for care plan development and acknowledged that a care plan for side rail use should have been in place but was not. Another resident with dementia and behavioral disturbances was observed using hearing aids, although the most recent MDS assessment coded the resident as having adequate hearing without hearing aids. The care plan did not address hearing loss or the use of hearing aids, despite multiple observations of the resident using them and the resident's own statements about their use. The MDS Nurse stated she was unaware of the resident's use of hearing aids and had not developed a care plan for this need. Both the DON and Administrator confirmed that the MDS Nurse was responsible for ensuring care plans addressed hearing loss and hearing aid use, which had not occurred in this case.
Failure to Revise Care Plans for Medication Management and Elopement Interventions
Penalty
Summary
The facility failed to revise and update care plans for two residents in accordance with physician orders and changes in their care needs. For one resident with end stage renal disease, hypertension, and diabetes, the care plan did not include interventions or monitoring for pain management, antihypertensive medication, or anticoagulant therapy, despite physician orders for these medications. The MDS Nurse, responsible for updating care plans, confirmed that these areas were missing and acknowledged that the anticoagulant medication, added after her start date, was not incorporated into the care plan. Both the DON and Administrator confirmed that these omissions should have been addressed, with the DON noting that the anticoagulant should have been added when ordered and the other medications upon readmission. Another resident with Alzheimer's disease and severe cognitive impairment had a care plan that continued to list a wander guard intervention after the device had been discontinued by physician order. The MDS Nurse, who completed the relevant MDS assessment and quarterly care plan review, did not update the care plan to reflect the removal of the wander guard. Observations confirmed the absence of the device, and both the DON and Administrator stated that the care plan should have been revised to accurately reflect the resident's current interventions.
Failure to Clarify Lidocaine Patch Orders Leads to Extended Application
Penalty
Summary
A deficiency occurred when the facility failed to clarify physician orders for lidocaine 4% external pain patches, resulting in the patches remaining on a resident's skin beyond the manufacturer's recommended duration of 12 hours. The resident, who had diagnoses including unspecified pain and diabetic neuropathy, had two active physician orders for lidocaine patches—one for the left side with a specified removal time and one for the right side without a removal time. During medication administration observation, a nurse was seen removing patches that had been in place for approximately 24 hours and immediately applying new ones to the same areas. The nurse stated she was following the order times and did not clarify the removal time for the right-side patch with the physician. Interviews with facility staff, including the nurse, Pharmacy Consultant, Nurse Practitioner, and Director of Nursing, revealed that the orders did not align with the manufacturer's instructions, which require the patch to be removed after 12 hours and not reapplied for another 12 hours. The Pharmacy Consultant and Nurse Practitioner both confirmed that the orders should have specified a 12-hour on, 12-hour off schedule, and the Director of Nursing acknowledged that the orders were not accurate and should have included the removal time. At the time of observation, the resident's skin was intact without redness or irritation.
Failure to Provide Prescribed Nutritional Supplements to Resident with Weight Loss
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease and diabetes, who had experienced significant weight loss, did not receive prescribed nutritional supplements as ordered by the physician and recommended by the Registered Dietitian (RD). The resident had active orders for daily ice cream and a nutritional shake to be added to the lunch tray to prevent further weight loss. Despite these orders being clearly documented and included on the meal ticket, observations on two consecutive days revealed that neither the ice cream nor the nutritional shake were present on the resident's lunch tray. Interviews with dietary staff confirmed that the supplements were omitted due to oversight during meal tray preparation. The resident's medical record showed a notable decline in weight over several months, with the RD documenting a 10.9% weight loss over 159 days and emphasizing the need for the supplements to meet nutritional requirements. The care plan identified the resident's nutritional risk and included interventions to maintain adequate nutritional status. Both the RD and the Nurse Practitioner confirmed that the supplements were necessary and should have been provided as ordered. The dietary department, including aides and supervisors, acknowledged responsibility for ensuring supplements were added to trays but failed to do so, resulting in the deficiency.
Failure to Perform Hand Hygiene Between Glove Changes During Medication Administration
Penalty
Summary
Nurse #2 failed to follow the facility's infection prevention and control program policies and procedures during a medication administration observation. Specifically, Nurse #2 did not perform hand hygiene before donning gloves, between glove changes, or immediately after removing gloves while administering multiple medications to a resident. The nurse was observed donning clean gloves without hand hygiene, using gloved hands to administer eye drops, removing gloves, donning new gloves without hand hygiene, administering nasal spray, and again removing gloves without performing hand hygiene. The nurse then adjusted the resident's oxygen tubing and handed the resident a medicine cup with pills using ungloved hands, followed by donning clean gloves without hand hygiene to apply a pain patch. Hand hygiene was only performed upon exiting the resident's room. The facility's policies clearly state that hand hygiene must be performed prior to donning gloves and immediately after removing them, and that glove use does not replace hand hygiene. During interviews, Nurse #2 acknowledged forgetting to use hand sanitizer between glove changes, and the Director of Nursing, who also serves as the Infection Preventionist, confirmed that the observed actions were not in accordance with facility policy.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding the transfer of two residents to the hospital. For one resident, there were three separate hospital transfers for conditions including chest pain, difficulty breathing, altered mental status, low blood pressure, and shortness of breath. In each instance, the medical record documented the resident's discharge and subsequent return to the facility, but there was no documentation that the Ombudsman had been notified of these transfers. Attempts to locate the previous Social Worker's documentation or to interview her were unsuccessful, and the Administrator reported being unable to find any records of Ombudsman notification, suggesting that documentation may have been removed when the previous Social Worker left the facility. For the second resident, a transfer to the hospital occurred for further evaluation of abnormal laboratory results. The Social Worker interviewed stated she typically emailed the list of transfers to the Ombudsman but could not find any record of notification for this particular transfer. The Administrator confirmed that no documentation could be found to show that the Ombudsman had been notified. The Social Worker acknowledged that the notification may have been overlooked during the relevant period.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to perform a Significant Change in Status Minimum Data Set (MDS) assessment for a resident who was reviewed for hospice care. The resident was admitted with diagnoses including hypertension and dementia and was receiving hospice services prior to and upon admission. A CMS Notice of Medicare Non-Coverage indicated that the resident's hospice services were ending, but a significant change assessment was not completed when the resident was discharged from hospice services. The MDS Coordinator, who had just begun working at the facility during the time of the transition, was not aware that the significant change assessment was not done. The Administrator acknowledged that MDS assessments should be completed within required time frames and attributed the oversight to the MDS Coordinator's transition into the facility.
Failure to Obtain Physician Order and Signage for Oxygen Use
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen and did not apply appropriate signage indicating the use of oxygen outside a resident's room. The resident, who was readmitted to the facility with diagnoses including congestive heart failure and chronic respiratory failure, was observed using oxygen without a corresponding physician's order in their medical record. Nursing documentation noted the resident was on oxygen at 2 liters per minute via nasal cannula upon return to the facility, but no order was found in the electronic medical record. Additionally, there was no signage outside the resident's room indicating the use of oxygen, which is a safety requirement. Interviews with nursing staff, including a nurse and the Nurse Unit Manager, revealed a lack of awareness regarding the missing signage and the absence of a physician's order for oxygen use. The Director of Nursing acknowledged that nursing staff should have contacted the physician for an order upon the resident's return from the hospital and ensured the appropriate signage was in place.
Failure to Document Vaccine Education and Refusal
Penalty
Summary
The facility failed to document the provision of education regarding the influenza and pneumococcal vaccines and the refusal of these vaccines by two residents. Resident #41, who was severely cognitively impaired, had no documentation in their electronic medical record (EMR) indicating receipt of the influenza vaccine for the 2023-2024 season or any history of receiving a pneumococcal vaccine. The facility was unable to provide written documentation that Resident #41 or their representative had received education about these vaccines to consent or refuse their administration. Similarly, Resident #152, also severely cognitively impaired, had no documentation in their EMR of receiving the influenza vaccine for the 2023-2024 season or any history of receiving a pneumococcal vaccine. Although there was a record of refusal for these vaccines in 2021, the facility did not have documentation that Resident #152 or their representative had been educated about the vaccines for the current season. The Director of Nursing, who also served as the Infection Preventionist, confirmed that the facility did not obtain written consent indicating education was provided when residents or their representatives refused the vaccines.
Failure to Document COVID-19 Vaccine Education and Refusal
Penalty
Summary
The facility failed to document the provision of education regarding the COVID-19 vaccine for the 2023-2024 season and the refusal of the vaccine by two residents, Resident #41 and Resident #152. Resident #41, who was severely cognitively impaired, had no documentation in the electronic medical record (EMR) indicating that they or their representative received education about the COVID vaccine. Similarly, Resident #152, also severely cognitively impaired, had a recorded refusal of the COVID vaccine on January 4, 2023, but there was no documentation that education was provided to them or their representative regarding the vaccine. The Director of Nursing, who also served as the Infection Preventionist, stated that the COVID vaccine was offered and administered to all residents or their representatives before her employment at the facility. However, the facility did not obtain written consent confirming that education was provided and that the residents or their representatives refused the vaccine. This lack of documentation led to the deficiency identified during the survey.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide written notice of transfer or discharge to a resident and the ombudsman when the resident was transferred to the hospital. The resident, who was cognitively intact, did not receive a written letter notifying her of the reason for her discharge to the hospital. The facility's electronic medical record did not contain any written notice of transfer or discharge for the resident's hospitalization. Interviews with facility staff revealed that the issue of not providing written notices was not identified until February 2024. The Clinical Nurse Consultant and the Director of Nursing confirmed the absence of written notices for transfers or discharges. The Social Worker, who was new to long-term care, admitted to not notifying the ombudsman of the resident's transfer. The Administrator acknowledged that the resident and the ombudsman did not receive the required notifications due to the oversight.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide the bed hold policy in writing to a resident at the time of transfer to the hospital. This deficiency was identified during a review of records, resident interviews, and staff interviews. Specifically, Resident #29, who was cognitively intact, was transferred to the hospital on 12/14/2023 due to feeling weak. However, there was no documentation in the resident's electronic medical record indicating that the bed hold policy was provided at the time of transfer. The resident later confirmed in an interview that she did not recall receiving the policy. Interviews with facility staff, including the Clinical Nurse Consultant and the Director of Nursing, revealed that the facility was not issuing the bed hold policy to residents or their representatives at the time of transfer during the period in question. The Director of Nursing, who started at the facility shortly before the incident, was unable to explain why the policy was not being issued. The Administrator also confirmed that the facility was unaware of the issue until February 2024, indicating a systemic oversight in the facility's procedures for handling transfers.
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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