Ridgewood Living & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, North Carolina.
- Location
- 1624 Highland Drive, Washington, North Carolina 27889
- CMS Provider Number
- 345228
- Inspections on file
- 24
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Ridgewood Living & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments experienced two falls from bed during care, resulting in head injuries requiring ER treatment. In both cases, staff failed to follow the care plan's required level of assistance for bed mobility—one aide used improper technique during a bed bath, and another provided incontinence care alone without checking the care plan or seeking help, despite the resident's need for two-person assistance.
The facility did not provide or document required COVID-19 vaccine education, offers, or outcomes for two residents with medical conditions, nor did it maintain documentation that any of its 156 staff received education or were offered the vaccine, despite facility policy and CDC guidance.
The facility did not ensure nurse aides received the federally required 12 hours of annual in-service training, including abuse prevention and dementia care education. Review of staff files and interviews with facility leadership confirmed that several nurse aides lacked documentation of completed training, and key staff were unaware of the training requirements.
A resident's MDS assessment was inaccurately coded to reflect both a fall with injury and a fall without injury, when only one fall with injury had occurred. The MDS nurse misread incident report dates, leading to the error, which was confirmed through staff interviews and record review.
A resident with chronic kidney disease and muscle weakness, who used bilateral grab bars for bed mobility, did not have side rail usage included in their care plan. Despite assessments and staff awareness of the resident's use of grab bars, the care plan was not updated to reflect this, resulting in a lack of individualized, person-centered planning.
A nurse failed to maintain sterile technique while providing tracheostomy care to a resident in a vegetative state, including not performing hand hygiene or donning sterile gloves before handling sterile equipment and placing clean dressings. Facility leadership confirmed that proper infection control protocols were not followed during the observed care.
Two residents were provided with bilateral grab bars without prior attempts at alternatives, proper assessment for entrapment risk, or documented review of risks and benefits. Staff did not obtain informed consent, and care plans and records lacked references to the use of grab bars. Facility staff, including the DON and Administrator, were unaware of the requirements for bed rail use and did not know the residents were using the devices.
A nurse failed to follow Enhanced Barrier Precautions (EBP) by not wearing a gown while providing tracheostomy care to a resident, despite facility policy and posted signage requiring both gloves and gowns for high-contact care. The nurse believed EBP was only needed for incontinence care and only recognized the requirement after reviewing the posted instructions. Facility leadership confirmed that the EBP policy was not followed during this incident.
A resident with COPD and a history of tobacco use was not provided education on the benefits and side effects of the pneumococcal vaccine, was not offered the vaccine, and had no documentation of consent, refusal, or administration in the medical record. Interviews with the resident, responsible party, and staff confirmed the vaccine was neither offered nor discussed, and the required documentation was missing.
A resident's controlled pain medication (oxycodone) was removed from their medication card and replaced with Buspirone tablets, which were not currently prescribed. The tampering was discovered by a nurse who noticed the pills did not match the expected appearance. The incident was confirmed through staff interviews, medication record review, and drug testing of staff with access to the medication cart, both of whom tested positive for oxycodone. The resident did not miss any prescribed doses and reported receiving pain medication when requested.
The facility did not maintain an effective pest control program in the laundry room, as brown crawling bugs were observed and standing water covered by cardboard was present. Staff reported frequent pest sightings, but pest control treatments were inconsistently documented and the laundry area was only treated monthly, not weekly as expected. There was no clear record of which areas were treated, contributing to ongoing pest issues.
A facility failed to control a German cockroach infestation affecting residents, with cockroaches observed in beds, on walls, and personal items. Despite weekly pest control services, the issue persisted, and staff did not effectively report or address the problem. A pest control contract for a cleanout was initiated but not fully implemented, leaving residents in distress.
The facility failed to accurately code the MDS for oxygen use for four residents, despite physician orders and MAR documentation confirming oxygen administration. The MDS coordinator misunderstood the coding criteria, leading to a deficiency in the assessment process. Administrative staff acknowledged the oversight.
A facility failed to conduct a quarterly interdisciplinary care plan meeting for a resident with multiple diagnoses, including hemiplegia and diabetes. The resident, assessed as cognitively intact, had her last care plan meeting several months prior, with no subsequent meeting held as required. Both the resident and a social worker confirmed the lapse, and the administrator acknowledged the requirement for quarterly meetings.
A resident with diabetes mellitus did not receive a physician-ordered nutritional shake with breakfast, despite it being listed on the meal tray ticket. The Unit Manager delivered the tray without the shake, and the Nurse Aide failed to verify the tray contents or obtain a replacement. The nurse inaccurately documented the shake's consumption. Interviews revealed procedural lapses in ensuring meal accuracy and obtaining missing items.
A facility failed to properly clean and store a syringe used for enteral feeding for a resident in a persistent vegetative state. The syringe was observed with debris and liquid, stored improperly with the plunger inside. Nursing staff admitted to reusing the syringe for medication administration and checking residuals, contrary to facility protocol, which required separate drying of the syringe and plunger.
Two residents in an LTC facility were repeatedly served foods they disliked, despite these preferences being documented on their meal tickets. One resident, cognitively intact, was served green beans and carrots, while another, moderately cognitively impaired, received milk, eggs, and fish. The CDM confirmed that dislikes were recorded but could not explain the oversight. Interviews revealed communication lapses among dietary staff, leading to the deficiency.
The facility failed to accurately document the application of a splint and the intake of a nutritional supplement for two residents. A resident did not have a left-hand splint applied as ordered, yet it was documented as applied. Another resident did not receive a nutritional shake with breakfast, but the MAR inaccurately showed partial consumption. The inaccuracies were acknowledged by the staff involved.
A resident with a history of intracerebral hemorrhage and fall risk was found multiple times with her call light out of reach, despite her care plan requiring it to be accessible. Staff interviews confirmed the oversight, and the facility had longer call light cords available but did not use them.
A facility failed to assist a resident, who was cognitively intact and admitted with a stroke, in establishing advanced directives, as required by their policy. Staff interviews revealed no documentation or recollection of offering assistance, leading to a deficiency in care.
A resident with cognitive impairment and hemiplegia did not have a prescribed hand splint applied as ordered for contracture prevention. Despite the care plan and physician's orders, staff interviews and observations confirmed the splint was not consistently applied, with a nurse aide admitting to forgetting the task. The DON acknowledged the oversight.
A nursing assistant in an LTC facility failed to follow infection control protocols by placing soiled linens on the floor instead of in a plastic bag. This action was against the facility's policy, which aims to prevent cross-contamination. Staff interviews confirmed the breach in protocol, highlighting the risk of spreading germs throughout the building.
Failure to Provide Adequate Supervision and Safe Care During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and significant physical limitations experienced two separate incidents of falling from bed during care, resulting in injuries that required emergency room evaluation and treatment. In the first incident, a nurse aide was providing a bed bath and rolled the resident away from herself, contrary to safe technique, and then turned to grab a towel, during which time the resident rolled off the bed. The bed was elevated approximately two feet from the floor, and the resident sustained a scalp hematoma. The resident was dependent on staff for bed mobility and required total assistance, as documented in her care plan. In the second incident, the same resident, now with a care plan updated to require two-person assistance for bed mobility, was being provided incontinence care by a single nurse aide. The aide did not check the resident's care plan or Kardex prior to providing care and did not request assistance, despite other staff being available. While attempting to clean the resident after a large bowel movement, the aide pulled the resident closer using a draw sheet and then turned her, resulting in the resident rolling off the bed, which was elevated about three feet from the floor. The resident sustained a 15-centimeter scalp laceration requiring wound closure with sutures and staples. Both incidents involved a failure to follow the resident's assessed needs and care plan instructions regarding the required level of staff assistance for bed mobility and repositioning. Staff involved either did not use the correct technique or did not verify and adhere to the care plan, leading to preventable accidents and injuries during routine care activities.
Failure to Provide and Document COVID-19 Vaccine Education and Offerings
Penalty
Summary
The facility failed to provide required education regarding the benefits and possible side effects of the COVID-19 vaccine, did not offer the vaccine, and did not document either a refusal or administration of the vaccine in the medical records of two residents over the past 14 months. Both residents were cognitively intact and had medical conditions such as depression and chronic obstructive pulmonary disease (COPD). Their medical records lacked documentation of COVID-19 vaccine education, offer, or outcome, despite interviews indicating that the residents recalled being offered the vaccine or refusing it due to past experiences. Additionally, the facility did not maintain documentation that staff were provided education about the benefits and risks of the COVID-19 vaccine, nor did it document that staff were offered the vaccine or given information on how to obtain it within the past 14 months. Interviews with the Infection Preventionist, DON, and Administrator revealed uncertainty about current CDC recommendations and an absence of recent education or vaccine offers for staff. The facility had 156 regular and contract staff, none of whom had documentation of COVID-19 vaccine education or offer in the reviewed period. The facility's own policy required that all staff and residents receive education about the COVID-19 vaccine, including information consistent with CDC and FDA guidance, and that the vaccine be offered with documentation of acceptance or refusal. Despite having access to the vaccine through the pharmacy and previous rounds of vaccination, the facility did not ensure ongoing compliance with these requirements for both residents and staff.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service training, including mandatory education on abuse prevention and dementia care. Record reviews for three nurse aides revealed missing documentation of completed in-service training within the previous 12 months, despite their employment during that period. Interviews with the Staff Development Coordinator and the Director of Nursing confirmed a lack of awareness regarding the federal requirement for annual in-service training, including abuse and dementia topics. The Administrator acknowledged the deficiency, attributing it to turnover in the staff development position, which resulted in lapses in tracking and providing the necessary training.
Inaccurate MDS Coding of Resident Fall Events
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of falls for one resident. The resident was admitted to the facility and subsequently experienced a fall from bed, resulting in a significant scalp laceration that required staples and sutures. The annual MDS assessment for this resident indicated both a fall with no injury and a fall with injury since the prior assessment. However, a review of the medical record revealed only one fall with injury during this period. During interviews, the MDS nurse acknowledged that the coding of an additional fall with no injury was an error, explaining that she misread the date on an incident report from the previous year. Both the Director of Nursing and the Administrator confirmed that MDS assessments are expected to be coded accurately.
Failure to Include Side Rail Use in Resident Care Plan
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan to address the use of side rails for a resident with chronic kidney disease stage 5 and generalized muscle weakness. The resident was admitted with significant mobility limitations, requiring partial to moderate assistance with bed mobility and substantial to maximal assistance with moving from lying to sitting. Despite being cognitively intact and using bilateral grab bars to assist with rolling over in bed, the resident's care plan did not reference the use of side rails. An assessment completed by a nurse indicated that the resident did not need or use side rails, and the most recent care plan review also omitted any mention of side rail usage. Observations confirmed that the resident was using bilateral grab bars, and the resident reported using them for assistance during care. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed that the responsibility for updating the care plan with side rail usage information was understood but not executed. The omission was identified through observation, record review, and staff interviews, demonstrating a lack of comprehensive care planning for the resident's actual needs and equipment in use.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
Nurse #4 failed to maintain sterile technique during tracheostomy care for a resident in a persistive vegetative state with a tracheostomy. During the procedure, Nurse #4 performed hand hygiene and donned clean gloves, then removed the trach cap, soiled gauze, and inner cannula. Without performing hand hygiene or donning sterile gloves, she handled and inserted a new sterile inner cannula and placed clean split gauze. Additionally, when preparing to suction the resident, Nurse #4 donned sterile gloves over soiled gloves rather than removing the soiled gloves and performing hand hygiene first. Interviews with facility leadership, including the DON, Administrator, and Infection Preventionist, confirmed that Nurse #4 did not follow proper infection control protocols, specifically failing to perform hand hygiene and don sterile gloves before handling sterile items. The improper technique was observed during direct care and acknowledged by the nurse involved, as well as by facility leadership, who stated that these actions did not meet professional standards of practice for infection prevention.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to follow required procedures before installing and using bed rails (grab bars) for two residents. For both residents, staff did not attempt or document alternatives to bed rails prior to their use. Assessments completed by nursing staff indicated that bed rails or assist devices were not indicated for the residents at the time, yet bilateral grab bars were observed in use on both residents' beds. Staff interviews revealed a lack of awareness that grab bars are considered side rails and that alternatives should be tried and documented before use. Neither resident had a completed assessment for entrapment risk, nor was there evidence that the risks and benefits of bed rail use were reviewed with the residents or their representatives. Informed consent for the use of grab bars was not obtained or documented for either resident. The care plans and medical records did not reference the use of grab bars, and the required consent forms could not be located in the residents' charts. Staff, including the DON and Administrator, were unaware of the need for these steps and did not know that the residents were using bilateral grab bars. Both residents had significant medical conditions, including chronic kidney disease, diabetes, and generalized muscle weakness. One resident was cognitively intact and used the grab bars to assist with bed mobility, while the other was severely cognitively impaired and dependent on staff for mobility. Despite these conditions, the facility did not follow the necessary protocols for bed rail use, including assessment, documentation, and consent.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
Nurse #4 failed to follow the facility's Enhanced Barrier Precautions (EBP) policy during high-contact care for a resident with a tracheostomy. The EBP policy, dated 4/24/24, requires staff to don gloves and gowns prior to performing high-contact resident care activities, such as tracheostomy care, to reduce the spread of multi-drug-resistant organisms (MDROs). During an observation, Nurse #4 performed hand hygiene and donned gloves but did not wear a gown while providing tracheostomy care and suctioning to the resident, despite clear signage and available personal protective equipment (PPE) at the resident's door indicating the requirement for both gloves and gowns. Upon interview, Nurse #4 stated she did not wear a gown because she believed EBP was only necessary for incontinence care, and only realized the requirement after reading the posted EBP sign. The Infection Preventionist, Director of Nursing, and Administrator all confirmed that Nurse #4 should have worn a gown in addition to gloves during the procedure, as per facility policy. The Medical Director noted that the respiratory tract is not a sterile space and did not believe the resident was put at risk, but acknowledged the policy was not followed.
Failure to Educate, Offer, and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide education regarding the benefits and possible side effects of a pneumococcal immunization, offer the immunization, and document either refusal or administration for one resident with a diagnosis of COPD who was a current tobacco user and moderately cognitively impaired. The resident's medical record did not contain any documentation of education about the pneumococcal vaccine, consent or refusal, or evidence that the vaccine had been administered. Interviews with the resident and her responsible party confirmed that neither recalled being offered the vaccine or receiving education about it, and both indicated willingness to accept the vaccine if it had been offered. The Infection Preventionist acknowledged awareness of residents not being up to date with pneumococcal vaccines and described an ongoing process to address the issue, starting with new admissions and proceeding chart by chart. However, the resident in question had not yet been included in this process. The Director of Nursing and the Administrator both confirmed the absence of required documentation for education, consent, refusal, or administration of the pneumococcal vaccine for this resident. The Medical Director also stated that the resident should have been offered the vaccine.
Misappropriation and Substitution of Controlled Medication
Penalty
Summary
A facility failed to protect a resident's right to be free from misappropriation of controlled medications when it was discovered that seven oxycodone tablets, prescribed as needed for pain, were removed from the resident's medication card and replaced with similar-looking Buspirone tablets. The tampering was first noticed by a nurse who, upon responding to the resident's request for pain medication, observed that the pills in the card did not match the expected appearance of oxycodone. Further inspection revealed that the back of the medication card had been incised and taped closed, and the substituted pills were identified as Buspirone, a medication previously discontinued for the resident. The medication administration record showed that the last documented administration of oxycodone was by a nurse who could not be reached for follow-up. The incident was reported internally after the discovery, and it was confirmed that the resident did not miss any prescribed doses of pain medication, as the medication was ordered on an as-needed basis and the resident rarely requested it. The investigation included interviews with multiple staff members, review of medication records, and confirmation that the resident's insurance was initially billed for the replacement oxycodone, which was later corrected to bill the facility instead. Interviews with staff and pharmacy personnel confirmed the misappropriation and substitution of the controlled medication. Drug tests were administered to staff who had access to the medication cart, and both tested positive for oxycodone. The resident reported that she received pain medication when requested and did not experience unaddressed pain. The facility's investigation did not substantiate abuse or neglect, but the misappropriation of controlled substances was clearly documented through observations, interviews, and record reviews.
Failure to Maintain Effective Pest Control in Laundry Room
Penalty
Summary
The facility failed to maintain an effective pest control program in the laundry room, as evidenced by the presence of brown crawling bugs observed on the walls and floor near the washing machines. Standing water was found on the floor, covered by a flattened cardboard box, which staff stated was used to prevent slipping but was also identified by the pest control representative as a potential harborage for pests. The Housekeeping and Laundry Director reported frequent pest sightings and stated these were reported to maintenance and entered into the electronic tracking system. However, the pest control logbook from June to August did not show any service requests for the laundry area. Interviews with facility staff and the pest control contractor revealed inconsistencies in the frequency and documentation of pest control treatments. The pest control representative treated the laundry area only monthly, while common areas were treated weekly, and there was no documentation specifying which areas were treated. The Assistant Maintenance Director confirmed that the laundry room itself had not been treated, only the laundry chute, and there were no records of specific areas treated during pest control visits. The Administrator expected weekly treatment of the laundry room, but this was not occurring, and the lack of documentation and targeted pest control contributed to the ongoing pest issue in the laundry area.
Cockroach Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant infestation of German cockroaches affecting four residents. Observations revealed cockroaches crawling on beds, walls, and personal items in residents' rooms. Housekeeping staff and residents reported frequent sightings of cockroaches, indicating a pervasive issue. Despite weekly pest control services, the infestation persisted, with cockroaches observed in multiple rooms and hallways. Interviews with staff and residents highlighted a lack of communication and reporting regarding the cockroach problem. Housekeeping staff admitted to seeing cockroaches regularly but did not report them, assuming management was already aware. Residents expressed distress over the presence of cockroaches, with some reporting that the insects crawled on them and their belongings. The Director of Housekeeping and other staff members acknowledged the infestation but seemed resigned to merely killing the cockroaches when seen, rather than implementing a comprehensive solution. The facility had initiated a pest control contract for a roach cleanout in some rooms, but the process was incomplete and not yet extended to all affected areas. The pest control company recommended a thorough cleanout process, which involved removing residents and personal items from rooms for treatment. However, the facility had not fully implemented this plan, and the infestation continued to affect residents' living conditions. The Medical Director was unaware of the cockroach issue and did not believe it posed a medical risk, despite the potential for exacerbating respiratory issues.
Failure to Accurately Code MDS for Oxygen Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for oxygen use for four residents, leading to a deficiency in the assessment process. Resident #3, who was admitted with chronic obstructive pulmonary disease, congestive heart failure, oxygen dependence, and hypoxemia, was not coded for oxygen use on her MDS assessment despite having a physician's order for continuous oxygen. Similarly, Resident #75, diagnosed with chronic obstructive pulmonary disease and diabetes, was not coded for oxygen use, although her physician's orders specified oxygen administration at bedtime and while napping. Both residents' Medication Administration Records (MAR) confirmed the administration of oxygen as per the orders. Resident #121, with a diagnosis of chronic obstructive pulmonary disease, and Resident #328, with a fracture of the right femur and asthma, were also not coded for oxygen use on their MDS assessments. Both residents had physician orders for continuous oxygen, which were documented in their MARs. Interviews with the MDS coordinator revealed a misunderstanding in coding criteria, as she only coded for oxygen use if the term 'hypoxia' was explicitly mentioned in the physician's order. The Director of Nursing and other administrative staff acknowledged that the residents should have been coded for oxygen use, indicating a lapse in the facility's assessment procedures.
Failure to Conduct Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to conduct a quarterly interdisciplinary care plan meeting for one of the residents reviewed for care planning. Resident #8, who was admitted with diagnoses including hemiplegia, diabetes mellitus, unsteadiness on feet, cerebrovascular disease, muscle weakness, hyperlipidemia, and hypertension, was assessed as cognitively intact. Her last care plan meeting was documented on February 13, 2024. During interviews, both the resident and the social worker confirmed that no subsequent care plan meeting had occurred since that date, despite the requirement for quarterly meetings. The administrator also acknowledged that care plan meetings were supposed to be held quarterly for residents.
Failure to Provide Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to provide a nutritional supplement as ordered by the physician for a resident diagnosed with diabetes mellitus. The resident was admitted with a care plan indicating a risk for nutritional problems due to poor oral intake, with a goal to maintain stable weight. Despite a physician's order for a nutritional shake three times a day to prevent weight loss, the resident did not receive the shake with his breakfast on the observed date. The resident's meal tray ticket listed the shake, but it was missing from the tray delivered by the Unit Manager, and the oversight was not corrected by the Nurse Aide responsible for checking the meal ticket against the tray contents. The Nurse Aide mistakenly believed the nutritional shakes had been discontinued due to the resident's previous refusals, and the nurse inaccurately documented that the resident consumed 50% of the shake without verifying its presence. Interviews with the Unit Manager, Dietary Manager, and Director of Nursing revealed a lack of adherence to procedures for ensuring meal tray accuracy and obtaining missing items. The Administrator confirmed that the kitchen should ensure the presence of nutritional shakes on trays, and staff should contact the kitchen for replacements if items are missing.
Improper Cleaning and Storage of Enteral Feeding Syringe
Penalty
Summary
The facility failed to properly clean and store a syringe used for enteral feeding for a resident in a persistent vegetative state with a feeding tube. The resident, who was admitted with diagnoses including muscle weakness, persistent vegetative state, and anoxic brain damage, received more than half of their total calories and fluid intake through tube feeding. Observations revealed that the syringe was stored with the plunger inside, in a plastic bag beside the resident's bed, with visible debris and liquid at the base of the plunger. This was noted on two separate occasions. Interviews with nursing staff indicated that the syringe was reused for medication administration and checking residuals. The nurses admitted to rinsing the syringe and plunger but then storing them together in a bag to dry, contrary to the facility's protocol. The Director of Nursing confirmed that the correct procedure was to clean the syringe and plunger with soap and water, dry them with a paper towel, and store them separately to dry. The failure to adhere to these procedures resulted in the observed deficiency.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to a deficiency in meeting their nutritional needs. Resident #27, who was cognitively intact, expressed her dislike for green beans and carrots, which were repeatedly served to her despite being listed as disliked foods on her meal ticket. She had not been contacted by the dietary department since her readmission, as her dislikes were already recorded from a prior admission. Observations confirmed that her meal trays contained the disliked vegetables, contrary to her stated preferences. Resident #117, who was moderately cognitively impaired, also experienced a similar issue. She disliked milk, eggs, and fish, yet these items were served to her on multiple occasions. Her meal ticket clearly listed these dislikes, but observations showed that scrambled eggs and milk were still included in her meals. The Certified Dietary Manager (CDM) confirmed that residents' dislikes were recorded and should have been honored, but could not explain why these residents received foods they disliked. Interviews with dietary staff revealed a breakdown in communication and procedure. The dietary aide was responsible for reading meal tickets and informing the cook of any dislikes, but failed to do so in some instances. The evening aide relied on the dietary aide to communicate dislikes and did not independently verify the meal tickets. The Director of Nursing and the Administrator acknowledged that the residents should not have received foods they disliked, indicating a lapse in the facility's adherence to dietary protocols.
Inaccurate Documentation of Treatment and Nutrition
Penalty
Summary
The facility failed to accurately document the application of a left-hand splint for a resident, which was ordered for contracture prevention. The order specified that the splint should be applied after breakfast and removed after supper. However, on the morning of June 10, 2024, the resident reported that the splint had not been applied, and observations confirmed this. Despite this, the nurse documented in the Treatment Administration Record (TAR) that the splint was applied at 8 AM. The nurse admitted to not checking if the splint was actually applied and acknowledged that she documented it based on routine practice rather than verification. Additionally, the facility failed to accurately document the intake of a nutritional supplement for another resident. A physician's order required the resident to receive a nutritional shake three times a day with meals. On June 11, 2024, the resident did not receive the shake with breakfast, yet the Medication Administration Record (MAR) inaccurately reflected that the resident consumed 50% of it. The nurse responsible for the documentation initially claimed to have verified the intake with a nurse aide, but later realized there was a miscommunication and that the shake was not provided. The Director of Nursing and the Administrator both emphasized the importance of accurate documentation in residents' records.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs of Resident #54 by not ensuring her call light was within reach, as required by her care plan. Resident #54, who was admitted with a diagnosis of intracerebral hemorrhage and was at risk for falls, was observed multiple times with her call light out of reach. Despite being moderately cognitively impaired and having functional limitations in her upper extremities, the resident was unable to reach her call light, which was hanging from the headboard on the opposite side of her bed. This situation left her unable to call for assistance, causing frustration as she had to wait for staff to enter her room. Interviews with staff, including Nurse Aide #6 and the Director of Nursing, confirmed that the call light was not within reach and that it should have been. NA #6 admitted to not ensuring the call light was accessible after leaving the resident's room, and the Director of Nursing emphasized the importance of keeping call lights within reach. The facility had longer call light cords available, but they were not utilized in this instance, leading to the deficiency in accommodating the resident's needs.
Failure to Assist Resident with Advanced Directives
Penalty
Summary
The facility failed to provide the opportunity for a resident to establish advanced directives and document this in the medical record. The facility's policy required staff to offer assistance in establishing advanced directives if a resident or their representative had not already done so, and to document the offer and the resident's decision in the medical record. However, for one resident who was cognitively intact and admitted with a diagnosis of stroke, there was no documentation indicating that the resident was offered assistance with advanced directives or that she refused such assistance. Interviews with various staff members, including the social worker, admissions director, and nursing staff, revealed that there was no recollection or documentation of conversations with the resident about establishing advanced directives. The admissions director confirmed that while she inquired about existing advanced directives upon admission, she did not offer assistance in establishing them if they were not already in place. This lack of documentation and failure to offer assistance led to the deficiency identified in the report.
Failure to Apply Hand Splint as Ordered
Penalty
Summary
The facility failed to apply a hand splint to a resident as ordered, which was necessary for maintaining and preventing further decline in the resident's range of motion. The resident, who was moderately cognitively impaired and had a history of muscle weakness, cerebral infarction, and flaccid hemiplegia affecting the left side, was supposed to have a left-hand splint applied daily after breakfast and removed after supper. Despite this order, observations and interviews revealed that the splint was not applied on multiple occasions, as confirmed by the resident and staff members. On several occasions, the resident reported that the splint was not applied, and observations confirmed the absence of the splint. Interviews with staff, including a nurse and a nurse aide, revealed that the splint was not applied as required, with the nurse aide admitting to forgetting to place it. The Director of Nursing acknowledged that the splint should have been applied as ordered, indicating a lapse in following the care plan and physician's orders for the resident's contracture prevention.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to handle soiled linen in a manner that prevents the spread of infection for a resident reviewed for infection control and prevention. During an observation of incontinence care, a nursing assistant placed soiled bath cloths and towels directly on the floor instead of in a plastic bag as per facility protocol. After removing her soiled gloves and washing her hands, she left the room to retrieve plastic bags, returned, and then placed the soiled items into the bags. This action was contrary to the facility's policy, which requires contaminated laundry to be placed in a bag or container at the location where it is used. Interviews with staff, including the nursing assistant involved, a nurse, the Staff Development Coordinator/Infection Control Nurse, and the Director of Nursing, confirmed that the soiled linens should not have been placed on the floor. The staff acknowledged that placing soiled linens on the floor could lead to cross-contamination, as germs could be transferred to the floor and spread throughout the building. The facility's protocol was to place soiled linens directly into a plastic bag to prevent such risks, and staff had been educated on proper infection control practices.
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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