Richmond Pines Healthcare And Rehabilitation Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamlet, North Carolina.
- Location
- Highway 177 S, Hamlet, North Carolina 28345
- CMS Provider Number
- 345293
- Inspections on file
- 20
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Richmond Pines Healthcare And Rehabilitation Cente during CMS and state inspections, most recent first.
Pharmaceutical services failed to provide the correct Depakote dose and form for a resident with epilepsy. The physician’s order was for Depakote 125 mg sprinkle capsules, 2 capsules PO three times daily, but the pharmacy repeatedly dispensed 500 mg delayed-release tablets in Smartpass pouches labeled to give 2 capsules three times daily, not matching the ordered dose. Pharmacy records and packing slips confirmed multiple deliveries of the 500 mg tablets. Interviews revealed that a pharmacist entered the wrong dose into the Smartpass system, described as human error, and the automated system then packaged and sent the incorrect medication strength. Nursing documentation showed that a nurse was later notified by a pharmacist that the wrong dose had been sent, and the DON stated that, in addition to relying on the pharmacy, nurses are responsible for checking medications against active orders.
A resident with epilepsy and severely impaired cognition received an incorrect Depakote dose for several days when pharmacy-dispensed Smartpass pouches contained 500 mg capsules instead of the ordered 125 mg capsules, resulting in administration of a much higher dose than prescribed. The MAR continued to show the lower ordered dose while staff administered the higher-dose pouches. The previous DON and multiple nurses worked the med cart during this period; the previous DON acknowledged administering the incorrect dose without using the scanner or comparing the pouch to the MAR. Other nurses and a med aide reported their usual practice of scanning and comparing Smartpass pouches to the MAR but did not recall identifying the discrepancy at the time. The DON and the physician later stated that nursing staff should have read and compared the medication on hand with the active MAR order to detect the mismatch.
A resident who was cognitively intact and largely independent with personal care was found to be without privacy curtains in a shared bedroom for several months. Surveyors twice observed the room with no curtains, and the resident reported using curtains in the past for privacy from a roommate during visits and rest. Direct care staff and a medication aide who routinely worked with the resident had not noticed the missing curtains. The Environmental Services Manager stated that curtains are supposed to be replaced the same day they are removed for laundering and acknowledged that the curtains had been taken down due to a skin infection and not replaced. The Administrator reported that management conducted daily room rounds but had not identified the missing curtains.
A resident with heart failure, hypertension, and severe cognitive impairment was admitted with consent from the representative authorizing both influenza and pneumonia vaccines, with no prior vaccine dates documented. The admission MDS recorded that these immunizations were not given because they were not offered, and the medical record contained no evidence that either vaccine was administered or that consent was withdrawn. The representative later confirmed the vaccines were not given despite her expectation they would be, and the former IC nurse acknowledged being aware of the request from daily meetings but did not administer the vaccines and could not provide a reason.
A resident with heart failure and hypertension was admitted with a signed consent authorizing COVID-19 vaccination, and the admission MDS documented severe cognitive impairment and that the COVID-19 vaccine was not given because it was not offered. The medical record contained no documentation of COVID-19 vaccine administration, no indication that consent was withdrawn, and no evidence of recent vaccination. The resident’s representative confirmed the vaccine was not given and had not been communicated as administered, while the former IC nurse acknowledged knowing the resident requested the vaccine, discussed during morning meetings, but did not administer it and had no reason for the omission. The Administrator stated that new admissions and requested immunizations are discussed in daily meetings and that residents are expected to receive vaccines as requested.
The facility failed to post accurate staffing information, with discrepancies in RN coverage for 13 days and missing resident census for 54 days. The Unit Manager, an RN, was not counted on staffing sheets, and the Staff Scheduler was unaware of the requirement to include the resident census. The Administrator expected accurate postings.
Incorrect Depakote Dose Dispensed and Administered Due to Pharmacy Entry Error
Penalty
Summary
Pharmaceutical services failed to provide the correct dose and form of Depakote for a resident with unspecified convulsions/epilepsy. The resident had an active order dated 03/16/25 for Depakote Sprinkle Capsule 125 mg, 2 capsules by mouth three times a day. Instead, the pharmacy dispensed Depakote 500 mg delayed-release tablets, packaged and labeled in Smartpass pouches with instructions to give 2 capsules three times a day to equal 250 mg, which did not match the ordered dose or form. Pharmacy records and packing slips showed multiple deliveries of Depakote 500 mg tablets on three separate dates, each with quantities consistent with ongoing administration of the incorrect medication strength. According to interviews, a pharmacist entered the incorrect Depakote dose into the Smartpass system, and this error was described as human error and a failure by pharmacists to pay attention when entering the order. The incorrect entry then flowed through the automated packaging process, resulting in the wrong medication strength being dispensed and sent to the facility. Nursing notes documented that a nurse was notified by the pharmacist on 04/02/25 that the wrong Depakote dose had been sent. The DON, who was not employed at the time of the incident, stated that while she expected the pharmacy to send the correct medication, dose, and form, it was also the nurse’s responsibility to check all medications against active orders.
Failure to Prevent Significant Medication Error with Incorrect Depakote Dose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when Depakote was administered at an incorrect dose over multiple days. The resident was admitted with unspecified convulsions/epilepsy and had an active order dated 03/16/25 for Depakote Sprinkle Capsules 125 mg, 2 capsules by mouth three times a day. The resident’s MDS indicated severely impaired cognition, no behaviors, and no rejection of care, and she received scheduled anticonvulsant medications during the review period. The March electronic MAR showed that she received Depakote 125 mg, 2 capsules three times daily from 03/17/25 through 03/31/25, with one documented refusal on 03/28/25 at 9:00 PM. A medication error was later identified when the pharmacy notified the facility that the wrong Depakote dose had been dispensed. The Medication Error Report completed by the previous DON documented that the pharmacy had dispensed Depakote 500 mg, 2 capsules three times a day, while the active order was for Depakote 125 mg, 2 capsules three times a day. The report stated that the resident received the incorrect dose for 6 days. The investigation summary indicated that weekly Smartpass medication rolls were delivered on 03/27/25, and on 04/02/25 the pharmacy notified the facility that the wrong dosage had been dispensed for this resident. The previous DON verified that the active Depakote order on the MAR and the order printed on the Smartpass pouch were not the same. Nursing staff actions and inactions contributed to the continuation of the incorrect dosing. The previous DON stated that the pharmacy believed the error was related to nursing staff not using the medication scanner when preparing medications, and she acknowledged that she herself worked the medication cart on two nights and administered the incorrect Depakote dose without using the scanner or comparing the Smartpass pouch to the MAR. Multiple nurses and a medication aide who worked during the period when the incorrect dose was administered either did not recall the medication error or only recalled receiving general education on using scanners. Several nurses described their usual practice as scanning each Smartpass pouch and comparing it to the MAR, reading and comparing orders, and stated that if the dose had been different from the MAR they would have noticed it, but they could not explain how the incorrect dose was missed at the time. The DON and the attending physician both stated that nursing staff should have read and compared the medication on hand, including the Smartpass pouch, with the active MAR order to detect the discrepancy, and the physician noted that staff did not report any signs or symptoms of Depakote toxicity and that the resident may have refused medications at times without this being consistently documented on the MAR.
Failure to Maintain Privacy Curtains in Shared Bedroom
Penalty
Summary
The deficiency involves the facility’s failure to provide required privacy curtains in a shared bedroom, preventing residents from having visual privacy when needed. Record review showed that one resident, cognitively intact and generally independent with personal care given set-up and supervision, had been without privacy curtains in her room for an extended period. Surveyor observations on two consecutive days confirmed that no privacy curtains were present in the resident’s room. The resident reported that the curtains had been missing for about seven to eight months and stated that, although she performed personal care in the bathroom, she previously used the privacy curtain for privacy from her roommate when visitors were present or when she was resting in bed. Staff interviews revealed that direct care staff and a medication aide who routinely provided care and medications to the resident had not noticed the absence of privacy curtains. Review of the medical record showed an order to wash all clothes, bed linens, coats, and blankets in hot water for a skin infection, and the Environmental Services Manager stated that when privacy curtains were removed for laundering, a fresh set should be put up the same day. He recalled that the resident’s privacy curtains had been removed for laundering due to a skin infection and admitted he forgot to have a new set installed. The Administrator, who had been in the facility for five weeks, stated she would have expected same-day replacement of curtains when removed for laundering and noted that daily room rounds were reportedly completed by multiple management team members, yet the missing curtains had not been identified.
Failure to Administer Authorized Influenza and Pneumonia Vaccines on Admission
Penalty
Summary
The facility failed to administer influenza and pneumonia vaccines on admission to a resident who had authorized these immunizations. The resident was admitted with diagnoses including heart failure and hypertension and was assessed on the admission MDS as severely cognitively impaired. On the admission consent form, the resident’s representative checked “yes” to authorize both the flu vaccine, to be given annually unless medically contraindicated, and the pneumonia vaccine, to be given on admission unless medically contraindicated. The spaces to document the dates of the last flu and pneumonia vaccines were left blank. The admission MDS documented that influenza and pneumonia immunizations were not given because they were not offered. Record review showed no documentation that the resident received either the flu or pneumonia vaccine after admission and no documentation that consent for immunizations had been withdrawn or that the vaccines had been given in the recent year. In a phone interview, the resident’s representative stated that the resident had not received flu or pneumonia vaccines on admission, that she had signed the consents, and that no one from the facility had communicated that the vaccines were administered. The former IC nurse confirmed she had not provided flu or pneumonia vaccines to this resident, despite being aware from daily morning meetings that the resident had requested them, and reported no reason for not administering them. The Administrator stated that new admissions and requested immunizations were discussed in daily morning meetings and that the representative was unsure if the resident had received vaccines prior to admission and was going to obtain that information, but the expectation was that residents would receive vaccines when requested.
Failure to Administer COVID-19 Vaccine After Documented Consent on Admission
Penalty
Summary
The deficiency involves the facility’s failure to administer a COVID-19 vaccine to a newly admitted resident despite documented consent and no contraindications or withdrawal of consent. The resident was admitted with diagnoses including heart failure and hypertension, and the admission consent form, signed by the resident’s representative and admissions staff, explicitly authorized administration of the COVID-19 vaccine annually unless medically contraindicated. The consent form indicated “yes” for COVID-19 vaccine authorization, and the space for the last date the COVID-19 vaccine was received was left blank. The admission MDS assessment documented the resident as severely cognitively impaired and recorded that the COVID-19 immunization was not given because the vaccine was not offered. Review of the medical record showed no documentation that a COVID-19 vaccine was administered and no documentation that consent for immunizations had been withdrawn or that the resident had received the COVID-19 vaccine in the recent year. Interviews further confirmed that the vaccine was not provided. The resident’s representative reported that the resident had not received COVID-19 vaccines on admission and that no one from the facility had communicated that the vaccine had been given. The former IC nurse stated that, prior to leaving her position, she had not provided a COVID-19 vaccine to this resident. She explained that new admissions were discussed during the morning meeting, that she was aware the resident had requested a COVID-19 vaccine, and that she had no reason for not administering it. The Administrator reported that new admissions and requested immunizations were discussed in daily morning meetings and that the resident’s representative was uncertain if the resident had received vaccines prior to admission and was going to obtain that information, but there was an expectation that residents receive vaccines as requested.
Inaccurate Staffing Information and Missing Resident Census
Penalty
Summary
The facility failed to post accurate staffing information as required, leading to discrepancies in the reported number of nursing staff. Specifically, for 13 out of 57 days reviewed, the daily nurse staffing sheets did not accurately reflect the presence of a Registered Nurse (RN) who was scheduled to work. The Unit Manager, who is an RN, was not counted as RN coverage on the daily staffing sheets, despite being scheduled to work the day shift on those days. This discrepancy was confirmed by the Staff Scheduler during an interview, who acknowledged the oversight and the Administrator expressed an expectation for accurate staff postings. Additionally, the facility did not include the resident census on the daily nurse staffing sheets for 54 out of 57 days reviewed. The absence of the resident census was noted for all shifts across the majority of the days in the review period. The Staff Scheduler admitted to being unaware of the requirement to include the resident census on the daily postings, and the Administrator confirmed that the resident census should have been present as required.
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.
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.
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.
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.
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.
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 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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