River Bend Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Asheville, North Carolina.
- Location
- 213 Richmond Hill Drive, Asheville, North Carolina 28806
- CMS Provider Number
- 345432
- Inspections on file
- 28
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at River Bend Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia was allegedly struck on the side of the head by a nurse aide, but the witnessing NA did not report the incident at the time, despite believing it could be abuse. Months later, the NA informed an agency nurse, who also failed to notify facility leadership as required by the abuse policy and instead only contacted APS after her shift. Facility policy required immediate reporting of all abuse allegations to the Administrator and other agencies within specified time frames, as well as immediate investigation and protective measures. Due to these inactions, the Administrator and DON were not promptly informed, and the facility’s investigation and protection of the resident were delayed.
A resident with dementia and severe cognitive impairment fell while handling meal tray lids and was assisted up and back to bed by a NA without immediate RN/LPN assessment. The NA did not clearly report the fall to the assigned nurse, who, after hearing a scream, found the resident already in bed and was told only that the resident had been taking tray lids off a cart. No focused post-fall assessment occurred at that time. Later that night, another NA and nurse noted the resident could not walk and had a swollen right elbow, leading to x-ray orders. X-rays completed the next day revealed acute fractures of the right olecranon and right hip/femoral neck, and the resident was transferred to the hospital for surgical repair. Leadership and the NP confirmed that NAs were expected not to move residents after a fall and to notify nursing for assessment, which did not occur in this case.
An agency nurse signed out multiple doses of controlled narcotics for six residents on narcotic control sheets during a single night shift without corresponding entries on the MARs, despite residents having orders for scheduled and PRN Oxycodone, Hydromorphone, Tramadol, and Hydrocodone‑Acetaminophen. In one case, a resident with both scheduled and PRN Oxycodone had doses signed out at non‑scheduled times and on multiple narcotic sheets, including an unexplained tablet count change without dates or signatures, while the MAR lacked matching administration records. Another nurse later noticed that PRN narcotics were signed out for a resident who usually did not request pain medication, and that resident denied receiving the medication. A second agency nurse admitted signing as a witness to narcotic waste at the first nurse’s request without observing the disposal, and a pharmacist later confirmed that resident narcotics had been misappropriated and required replacement.
The facility failed to ensure accurate reconciliation and proper witnessing of wasted narcotic medications when an agency nurse signed as a witness to oxycodone waste without visually observing the disposal. One resident had scheduled oxycodone for pain and another had PRN oxycodone, with an agency nurse signing out multiple doses for both on the same evening. A staff nurse later noticed missing PRN oxycodone for a resident who typically did not request pain medication and saw that the doses were not documented as administered on the MAR, and the resident denied receiving them. Review of narcotic sheets confirmed that the waste entries were co-signed by another agency nurse who later reported she had signed as a witness at the first nurse’s request without actually seeing the medications being wasted.
A resident with a history of stroke and right-sided paralysis suffered a fall during an assisted transfer, resulting in severe pain and later-confirmed leg fractures. Due to ineffective staff communication and lack of interpreter use, the resident's pain was not properly assessed or managed for two days, and pain medication was delayed and initially ineffective. The resident did not have a pain care plan, and staff failed to notify a provider or use an interpreter until the nurse practitioner intervened and ordered appropriate pain relief.
A resident who experienced a fall and acute leg pain had x-rays performed, which revealed nondisplaced fractures of the proximal tibia and fibula. Although the x-ray results were received and acknowledged by nursing staff and the DON, the results were not communicated to a medical provider until the following day, resulting in delayed medical intervention and hospital evaluation.
A resident with a history of stroke and right-sided hemiplegia reported a fall in the bathroom and experienced severe pain, bruising, and swelling in her right leg. Despite multiple staff members being made aware of the incident and the resident's acute pain, there was a breakdown in communication and no physician was notified until the following day. This delay resulted in postponed x-rays, medical intervention, and hospital evaluation, with subsequent diagnosis of acute tibia and fibula fractures.
A resident who spoke Spanish fell during a staff-assisted transfer, resulting in acute leg fractures and significant pain. Staff failed to promptly notify a medical provider, did not use an interpreter to assess the resident's pain, and delayed both pain management and communication of x-ray results. The resident was not properly assessed after the fall and required hospitalization for her injuries.
A resident who required substantial assistance for transfers fell during a staff-assisted transfer, resulting in acute pain and undetected fractures. Staff failed to report the fall, did not assess or document the injury, and did not notify a medical provider in a timely manner. Communication breakdowns and lack of adherence to protocol led to delayed diagnosis and treatment, with the resident ultimately requiring hospitalization for fractures.
A resident with right-sided hemiplegia, dependent for transfers, was assisted off the toilet by staff using a stand and pivot transfer instead of the required mechanical lift. During the transfer, one staff member left to get a wheelchair and the other was not attentive, resulting in the resident falling and sustaining acute right tibia and fibula fractures. The incident was not immediately reported or documented, and the resident's pain and injury were not promptly addressed, leading to delayed medical intervention.
Multiple MDS assessments were inaccurately completed, including failure to document a swallowing disorder for a resident with documented symptoms, incorrect coding of pressure ulcers as present on admission for a resident who developed them after admission, and failure to note edentulism despite clinical evidence. Additionally, two residents were incorrectly coded as using physical restraints, although neither was actually restrained, and the facility was restraint free. These errors were confirmed by staff and attributed to remote completion of assessments and lack of a dedicated MDS Coordinator.
A resident with intact cognition was not invited to participate in care plan meetings following multiple MDS assessments. The resident expressed a desire to be involved in these meetings, but staff interviews confirmed that care plan meetings had not been held or documented for this individual during the current year.
A resident with severe cognitive impairment and limited mobility was unable to access the light switch in their room due to a broken and unreachable switch cord. Nursing staff were unaware of the issue because the cord was hidden by a lamp, and the maintenance director relied on staff reports to identify such problems. The resident had to repeatedly request assistance from staff to control the light, highlighting a failure to accommodate the resident's needs.
Two residents with significant mobility and self-care deficits did not have their needs for transfers, bathing, and personal and oral hygiene addressed in their care plans. One resident with cerebral palsy and another with a below-knee amputation both required substantial staff assistance, but their care plans lacked interventions for these ADL needs due to staff oversight and absence of an MDS Coordinator.
Two residents with cognitive impairment and mobility limitations had bed rails installed without documented risk assessments or informed consent. Staff interviews confirmed that required assessments and consents were not completed prior to bed rail use, and leadership acknowledged the lack of a clear process for ensuring these steps were followed.
A resident with dementia and dysphagia, who was ordered to receive nectar thick liquids, was served thin tea during a meal. Staff failed to remove the inappropriate liquid from the resident's reach, and a staff member unaware of the dietary order provided a straw, allowing the resident to drink the thin liquid and cough. The deficiency was confirmed through staff interviews and review of the resident's care plan and diet order.
A resident who was cognitively intact and had signed consent to receive the influenza vaccine did not receive it, as the vaccine was not administered or documented. The resident was absent during the scheduled vaccination clinic, and despite the facility having vaccines available, the dose was missed due to process changes and leadership turnover.
A resident with intact cognition and Managed Medicaid coverage was issued a 30-day discharge notice for non-payment after the facility failed to submit a claim to the insurance due to an incorrect payer source designation. The resident and their representative were not prepared for the discharge, and ongoing billing statements were received despite insurance approval for the stay. Staff interviews confirmed that required processes for insurance billing and Medicaid transition were not followed, leading to the deficiency.
A resident was discharged to the community without a completed discharge summary, as only the Therapy section was filled out while other required sections, including Nursing, Dietary, Social Services, Activity, Reason for Discharge, Medical Summary, and Acknowledgement, were left blank. The Social Worker confirmed the oversight and lack of consistent documentation, and the Administrator was unaware of the incomplete record.
A resident with hypertensive heart disease missed three scheduled doses of prazosin hydrochloride after nursing staff failed to request a timely refill from the pharmacy. The medication was not available on the cart, and staff did not follow up with the pharmacy or notify the DON, resulting in a gap in administration and increased blood pressure readings for the resident.
A resident with a history of stroke and right-sided hemiplegia, whose primary language was Spanish, was unable to effectively communicate her needs due to the facility's lack of a consistent and reliable translation system. Staff relied on the resident's roommate, who had dementia, or used gestures and personal translation apps without formal guidance. The resident reported distress over not being understood, and staff and leadership confirmed there was no established process for providing translation services.
A resident with osteoporosis missed three consecutive days of scheduled tramadol due to nursing staff failing to timely request a prescription refill, inadequate documentation, and unsuccessful attempts to access the medication from the Pyxis system. Despite available pharmaceutical resources, the medication was not obtained or administered as ordered, resulting in a gap in pain management.
Nursing staff failed to administer a prescribed opioid pain medication to a resident for three consecutive days due to delays in refilling the medication and obtaining necessary signatures, despite the resident being at risk for pain and having a care plan in place. The resident received as-needed acetaminophen during this period, and pain assessments indicated minimal discomfort. The facility's emergency medication supply contained the needed medication, but it was not used. Staff interviews confirmed the error and identified missed opportunities to prevent the lapse.
A resident reported falling and experiencing acute knee pain while being assisted in the bathroom. Although the incident was communicated among nursing staff and assessed by a supervisor, no documentation, assessment, or incident report was completed in the medical record. Each nurse assumed the other would handle the required post-fall protocol, resulting in a lack of recorded follow-up.
Survey results were kept in a binder in the lobby, but there was no signage indicating its location, and all resident rooms were behind a locked, coded door. Residents were unaware of where to find the survey results and would need staff assistance to access the binder.
A resident with a history of traumatic brain injury and impulse control disorder physically assaulted two other residents with severe cognitive impairment, resulting in one resident sustaining a head injury and requiring emergency evaluation. Both incidents occurred in common areas with staff nearby, and the aggressive resident's behavioral triggers were known but not effectively managed, leading to physical abuse and harm.
A resident with intact cognition and a history of anxiety and depression reported being attacked and cursed at by a male nurse aide, but the allegation was not immediately reported to the nurse, DON, or Administrator as required by policy. The accused aide remained on shift with access to other residents, and the incident was not reported to Adult Protective Services in a timely manner. Staff interviews revealed confusion about reporting protocols and a lack of immediate protective action for the resident.
A facility failed to protect residents from misappropriation of controlled medications, involving two nurses who appeared impaired on duty. One resident's morphine was taken by a nurse who tested positive for the drug, while another nurse fraudulently signed out oxycodone for two residents, including one deceased. The incidents were confirmed through investigations and reported to authorities.
The facility failed to implement recommended nutritional interventions for two residents. One resident with severe protein-calorie malnutrition did not receive the prescribed liquid protein supplement, while another resident with dysphagia received less enteral feeding than ordered. Despite communication of the RD's recommendations, the orders were not consistently followed, leading to deficiencies in care.
The facility failed to ensure that physician visits were conducted every 30 days for the first 90 days of admission for several residents. This deficiency was identified through record reviews and staff interviews, revealing that six out of twelve sampled residents did not receive the required physician visits. The issue was compounded by a lack of awareness among the Medical Records staff regarding the specific regulatory requirements for MD visits.
The facility failed to provide RN coverage for at least 8 consecutive hours on six occasions due to the resignation of the weekend RN supervisor and instability in the nurse administration team after a corporate change.
The facility failed to secure and store medications properly, with an opened Silvadene cream left unattended in a resident's room and expired medications found in storage areas. Insulin and eye drops were improperly stored at room temperature. Staff interviews revealed a lack of regular checks and awareness, attributed to leadership turnover.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and did not follow hand hygiene protocols. Staff were observed not using required gowns and gloves during high-contact care activities, and there was a lack of EBP signage and PPE near residents' rooms. Interviews revealed staff were not trained on EBP, and improper glove use and hand hygiene practices were noted during incontinence care.
A resident with severe cognitive impairment and multiple diagnoses was not invited to participate in care planning meetings, nor was their Resident Representative (RR). The oversight occurred after a change in facility management, leading to missed meetings due to unclear responsibilities for scheduling. The Social Worker acknowledged the issue and was working on improving the process.
The facility failed to protect the private health information of two residents by leaving their medical records visible on an unattended medication cart. A nurse admitted to being distracted, despite having completed HIPAA training. The facility expects staff to follow HIPAA guidelines to safeguard resident information.
A facility failed to prevent resident-to-resident abuse when a cognitively impaired resident with a history of aggression hit another resident, causing injuries. Despite being aware of the aggressive resident's history, the facility did not implement specific interventions or increased supervision. The incident was witnessed by a visitor, and the facility substantiated the abuse allegation.
A facility failed to report and investigate an alleged abuse incident involving a resident with moderate cognitive impairment. A resident reported witnessing another resident being held down and provided care against her will by a male staff member. The Medical Records Director informed the Administrator, who dismissed the report, stating it did not count as abuse. The facility's policy requires immediate investigation and reporting, but the Administrator did not take the necessary steps, resulting in a delayed response.
The facility failed to develop comprehensive care plans for two residents, one with urinary retention and dementia, and another with diabetes and end-stage renal disease. Both residents had specific dietary and medical needs that were not addressed in their care plans. The Regional MDS Consultant, responsible for completing MDS assessments remotely, acknowledged the oversight and confirmed that these areas should have been included in the care plans.
A resident's PICC line was flushed with heparin by a nurse without a physician's order, despite the resident being on anticoagulant therapy. The nurse stated it was facility policy, but the NP confirmed an order was necessary.
A facility failed to remove and return controlled medications after a resident's death, leading to drug diversion. A nurse fraudulently signed out oxycodone tablets under other nurses' names, which was discovered when another nurse noticed discrepancies in the medication count. Interviews revealed that the facility's protocol for handling medications of deceased residents was not followed, contributing to the incident.
A facility failed to document the refusal or acceptance of flu and pneumonia vaccinations for a resident. The resident, who was cognitively intact, had no records of receiving, being offered, or refusing the vaccinations. Interviews revealed that consent forms were lost during a company ownership transition, leading to the documentation lapse.
The facility failed to complete daily nurse staffing sheets for 27 days, leaving columns for staff numbers and hours worked blank, only noting total hours. The Scheduling Coordinator, who took over in March 2024, could not find the original sheets and filled them retroactively. The Regional Clinical Nurse Consultant cited instability in the nursing administration team since a corporate takeover as a contributing factor.
The facility failed to complete baseline care plans for two residents within 48 hours of admission, affecting their dialysis and nutritional needs. One resident with diabetes and end-stage renal disease did not have a care plan addressing dialysis and nutrition, while another with diabetes and malnutrition lacked a timely care plan. The issue arose from nurses being unaware of the need to print and review the care plan with residents or their Responsible Parties.
A resident with dementia and other medical conditions experienced significant weight loss due to the facility's failure to obtain weekly weights and implement recommended nutritional supplements. The resident's weight fluctuated significantly, and staff interviews revealed confusion and lack of follow-up on the resident's weights. The Director of Nursing confirmed the weight loss and acknowledged the failure to implement the Registered Dietitian's recommendations.
The facility failed to submit an Initial Allegation Report within 2 hours for an abuse incident involving two residents. One resident, who was severely cognitively impaired, grabbed another resident's arm, causing bruising. The Administrator delayed the report submission, believing he had 24 hours unless there was significant bodily harm.
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two cognitively impaired residents. The investigation lacked proper documentation and did not include interviews with relevant staff and residents present during the incident.
Failure to Implement Abuse Reporting Policy Resulting in Delayed Investigation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy when an allegation of staff-to-resident abuse was made, resulting in delayed internal reporting, investigation, and protection of the resident. The facility’s policy dated 9/1/24 required that all alleged violations be reported immediately, but no later than two hours after the allegation, to the Administrator, State Agency, APS, and other required agencies when applicable, and that an immediate investigation and protective measures be initiated. Resident #1, who had dementia without behavioral disturbances, was allegedly subjected to physical abuse when Nurse Aide (NA) #1 observed NA #2 push Resident #1’s head to the side with an open hand placed above her ear and temple area sometime in September 2025. NA #1 believed that putting hands on a resident in this manner would be considered abuse but did not report the incident at the time and continued to observe NA #2 working on the floor, including providing care to Resident #1, after the incident. Months later, during the last week of January 2026, NA #1 informed an agency nurse (Nurse #1) that he had witnessed NA #2 hit Resident #1 on the side of the head in the past, and he demonstrated the motion, which Nurse #1 interpreted as NA #2 popping the resident’s head with an open hand. Nurse #1 believed the incident should have been reported but did not notify facility leadership, including the DON or Administrator, as required by policy; instead, after her shift she contacted APS directly. The Administrator later documented that APS came to the facility on 1/30/26 to investigate an allegation that NA #2 slapped Resident #1. Interviews with the DON and Administrator confirmed that staff were expected to report suspected or observed abuse immediately to a supervisor and that the supervisor must immediately notify the Administrator so the facility could promptly investigate and protect the resident. Both NA #1 and Nurse #1 failed to follow the facility’s abuse reporting policy, leading to delayed notification of the Administrator and delayed facility investigation and protective actions for Resident #1.
Failure to Report and Assess Resident Fall Resulting in Undiagnosed Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly assessed by a nurse after a fall because a nurse aide did not appropriately report the fall. The resident had dementia with severe cognitive impairment and a history of two or more prior falls without injury. On the evening in question, the resident was in or near her room handling tray lids when she lost her balance and fell. NA #2 witnessed the fall, helped the resident up, and assisted her back to bed instead of leaving her in place and immediately notifying a nurse for assessment. In her written statement, NA #2 said she told the nurse that the resident had fallen, but in a later interview she admitted she did not report the fall correctly and acknowledged she should have reported it. Around the same time, Nurse #2 heard the resident scream and went to the room, finding the resident already in bed, tense and frightened but without obvious signs of pain, bruising, or swelling. Nurse #2 questioned NA #2 in the hallway; NA #2 appeared agitated and only described the resident taking tray lids off the cart, without mentioning a fall. NA #1, who was nearby, corroborated that he heard the scream, saw NA #2 coming out of the resident’s room, and heard NA #2 tell Nurse #2 only that the resident had been taking tray lids off the cart, with no report of a fall. As a result, Nurse #2 did not have information that a fall had occurred and did not perform a focused post-fall assessment at that time. Later that evening, during the night shift, NA #3 attempted to get the resident up for a scheduled shower and found she could not stand, appeared weak, and struggled to get up. NA #3 reported this to Nurse #3, who then assessed the resident and noted that she could only take one or two steps before yelling out and grabbing her right leg, and that her right elbow was swollen. Nurse #3, who had not received any report of a new fall on that date and only knew of a prior fall two days earlier, contacted the on-call provider and obtained orders for x-rays of the right elbow, hip, and leg. The x-rays, completed the following day, showed acute fractures of the right olecranon and right hip/femoral neck, leading to the resident’s transfer to the hospital for surgical repair. The facility’s DON, Administrator, NP, and Medical Director all stated that NAs should not move a resident after a fall and should notify a nurse so the nurse can assess for injury, and that the facility’s fall protocol required a nurse assessment before moving a resident, which did not occur immediately after this resident’s fall because the fall was not properly reported by NA #2.
Misappropriation of Controlled Narcotics and Inadequate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled narcotic medications, contrary to its Abuse, Neglect and Exploitation policy that prohibits exploitation and misappropriation of resident property. An agency nurse (Nurse #1) worked a single 12‑hour night shift and signed out multiple doses of controlled substances for six residents on narcotic control sheets without corresponding documentation of administration on the Medication Administration Records (MARs). For one resident with scheduled Oxycodone 10 mg three times daily and PRN Oxycodone 5 mg, Nurse #1 signed out Oxycodone 10 mg at times that did not match the scheduled administration times and documented one scheduled dose as given on the MAR, while also signing out PRN Oxycodone 5 mg on separate narcotic sheets that were not documented as administered on the MAR. A third narcotic sheet for this resident showed an unexplained change in tablet count from 28 to 26 without dates or signatures. For five additional residents with PRN orders for Hydromorphone, Oxycodone, Tramadol, and Hydrocodone‑Acetaminophen, Nurse #1 signed out multiple doses on the narcotic records during the same night shift, but none of these doses were documented as administered on the MARs by Nurse #1 or any other nurse. In two cases, narcotic sheets for Oxycodone 10 mg included entries where Nurse #1 documented wasting of tablets at illegible times, with Nurse #2 signing as a witness. However, the MARs for these residents contained no corresponding entries indicating that the medications had been administered. One nurse later reported that a resident whose PRN narcotics had been signed out denied taking the pain medication, and the MAR showed no administration entries for those doses. The facility became aware of the issue when a staff nurse (Nurse #3) noticed an unusual number of PRN narcotics signed out for a resident who typically did not request pain medication and found missing PRN Oxycodone that the resident denied receiving. Subsequent review of narcotic sign‑out sheets revealed discrepancies attributed to Nurse #1, including multiple narcotic withdrawals without MAR documentation for six residents. An email from the DON and Nurse #2 confirmed that Nurse #2 had signed as a waste witness for narcotics for two residents at Nurse #1’s request without actually observing the disposal. The pharmacist recalled the misappropriation of resident narcotics and confirmed that the facility later replaced all unaccounted‑for narcotic medications at facility expense.
Failure to Properly Witness and Reconcile Wasted Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective systems for accurate reconciliation and proper wasting of narcotic medications, specifically oxycodone, for two residents. One resident had a standing order for oxycodone 10 mg three times daily for pain, and review of the narcotic record showed that an agency nurse (Nurse #1) signed out oxycodone doses on a specific evening. The same record showed that another agency nurse (Nurse #2) signed as a witness to the disposal of an oxycodone 10 mg tablet at an illegible time. A second resident had an order for oxycodone 10 mg every three hours as needed for pain, and the narcotic record indicated that Nurse #1 signed out oxycodone doses for this resident on the same evening, with Nurse #2 again signing as a witness to the disposal of an oxycodone 10 mg tablet at an illegible time. The facility became aware of a possible misappropriation of residents’ property when a staff nurse (Nurse #3) reported concern to the DON that as-needed narcotics were being signed out for a resident who usually did not request pain medication, and that some as-needed oxycodone was missing for one of the residents. Nurse #3 also noted that the medications were not signed as administered on the MAR and that the resident denied taking the pain medication. Subsequent review of the narcotic sign-out sheets showed that Nurse #2 had signed as a witness to Nurse #1’s disposal of narcotics for both residents. In an email to the DON, Nurse #2 admitted signing the narcotic sheets as a waste witness at Nurse #1’s request without visually observing the disposal of the medications, contrary to the facility’s standard practice that nurses visually witness narcotic waste before signing as a witness.
Failure to Provide Timely and Effective Pain Management After Resident Fall
Penalty
Summary
A resident with a history of stroke and right-sided hemiplegia experienced a fall during an assisted transfer, resulting in acute pain and later confirmed fractures of the tibia and fibula. The resident, whose preferred language was Spanish and required an interpreter, reported severe pain immediately after the fall, rating it as 9 out of 10. Despite these reports, there was ineffective communication among staff, and a medical provider was not notified of the fall or the resident's pain until two days later. During this period, staff failed to use an interpreter to accurately assess the resident's pain level or the effectiveness of any interventions. Documentation and interviews revealed that the resident repeatedly expressed pain through both verbal and non-verbal cues, such as grimacing, crying, and grabbing her knee. Staff members, including nurse aides and nurses, were made aware of the resident's pain and the fall, but there was a lack of timely action to address her needs. Pain assessments were documented as zero on the medication administration record, despite clear evidence of pain, and the resident did not receive any pain medication until ibuprofen was ordered and administered two days after the incident. This initial pain management was ineffective, and there was no evidence that a provider was contacted for additional or alternative pain control until the nurse practitioner was notified of the x-ray results. The resident did not have a care plan in place for pain, and staff did not consistently use interpreters to communicate with her, resulting in inadequate assessment and delayed treatment. The nurse practitioner, upon finally being notified and using an interpreter, assessed the resident and ordered opioid pain medication, which was effective. The deficiency was identified through record review, interviews, and direct observation, showing a failure to provide safe and appropriate pain management for a resident with acute pain following a fall.
Failure to Notify Physician of Critical X-ray Results Following Resident Fall
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician of critical x-ray results for a resident who experienced acute pain following a fall. The resident reported falling in the bathroom, landing on her right knee, and experiencing immediate and ongoing severe pain. The day after the fall, the nursing supervisor contacted the on-call provider, who ordered a right leg x-ray. The x-ray was performed and results indicating acute, nondisplaced fractures of the proximal tibia and fibula were received by the facility later that day. Despite the x-ray results being available and acknowledged by multiple staff members, including the nursing supervisor and the DON, the results were not communicated to a medical provider until the following day. The nursing supervisor relayed the results to other nurses but did not instruct them to notify the physician, nor did she do so herself. The DON also reviewed the results and confirmed with the nursing supervisor that she had received them, but did not provide explicit instructions to notify the physician. The night shift nurse was informed of the fracture but was not asked to take further action. As a result, the physician and nurse practitioner were not made aware of the resident's acute fractures until the next day. This delay in communication led to a delay in medical intervention and evaluation in the emergency department. The resident ultimately required a two-day hospitalization, with orthopedics recommending a hinged knee brace and non-weight bearing status. Interviews with the nurse practitioner, medical director, and on-call physician confirmed that no notification of the x-ray results was received over the weekend, and that appropriate action would have been taken had they been informed in a timely manner.
Failure to Notify Physician of Resident Fall and Acute Pain
Penalty
Summary
A deficiency occurred when facility staff failed to notify a physician after a resident reported a fall and was experiencing acute pain. The resident, who had a history of stroke and right-sided hemiplegia, communicated in Spanish that she had fallen in the bathroom while being assisted by two staff members. Despite the resident's clear reports of significant pain and visible signs of injury, including bruising and swelling of the right knee and shin, staff did not immediately notify a physician or initiate appropriate medical interventions. Multiple staff members became aware of the resident's pain and the reported fall, but there was confusion and lack of clear communication regarding responsibility for notifying the physician and completing post-fall assessments. The day shift Nursing Supervisor was informed of the incident but did not contact the physician, instead instructing the day shift nurse to handle the situation. The day shift nurse, having already given report to the night shift nurse, assumed the night shift nurse would complete the necessary notifications and documentation. The night shift nurse, in turn, believed the day shift nurse had already addressed the issue. As a result, no physician was notified on the day of the fall, and no immediate medical evaluation or intervention was provided. It was not until the following day, after the resident's family member called the facility to inquire about the fall and pain management, that the Nursing Supervisor contacted the on-call provider. An x-ray was then ordered, revealing acute nondisplaced fractures of the proximal tibia and fibula. The delay in physician notification and medical intervention resulted in the resident experiencing prolonged pain and a delay in receiving appropriate care, including hospitalization and orthopedic management.
Failure to Protect Resident from Neglect and Delayed Medical Response After Fall
Penalty
Summary
A resident who primarily spoke Spanish experienced a fall during a staff-assisted transfer, resulting in immediate pain to her right knee. The nursing supervisor was informed of the fall and the resident's pain, but did not report the incident or the pain to a medical provider. There was no evidence that staff used an interpreter to accurately assess the resident's condition or pain level at the time. The lack of effective communication among staff led to a delay in notifying a medical provider about the fall and the resident's pain until the following day. When the medical provider was finally notified, orders were given for an x-ray and ibuprofen for pain management. The x-ray, which revealed acute fractures of the proximal tibia and fibula, was completed, but the results were not communicated to a medical provider until the next day. During this period, the resident continued to experience significant pain, which was not effectively managed, as the first administration of pain medication was delayed and proved ineffective. The resident reported, through an interpreter days later, that no one had asked her if she was hurt after the fall and that she was simply put back into bed. The deficiencies identified included failure to protect the resident from neglect, failure to notify the physician of the fall and subsequent pain, inadequate assessment and documentation following the fall, failure to provide a safe transfer, and ineffective pain management. The resident ultimately required hospitalization for her injuries, and orthopedic recommendations included a hinged knee brace and non-weight bearing status for the affected leg. Facility leadership declined to comment on whether the incident constituted neglect.
Failure to Recognize and Respond to Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with a history of stroke and right-sided hemiplegia, who was cognitively intact and required substantial assistance for transfers and personal care, experienced a fall during a staff-assisted transfer from the toilet. The nurse aides involved did not report the fall to a nurse, and the resident was not assessed by a nurse or medical provider before being moved and transferred back to bed. The resident immediately experienced pain in her right knee, but staff did not inquire about injury or pain, nor did they document the incident or perform a comprehensive assessment at the time. Communication failures among staff further contributed to the deficiency. The night shift nurse aide learned of the resident's pain and the fall from the resident's roommate and reported it to the nursing supervisor, who then assessed the resident but did not observe significant injury at that time. The nursing supervisor instructed the assigned nurse to follow fall protocol, including contacting the physician, but there was no evidence that these steps were taken. The assigned nurse did not document the incident, perform vital signs, or complete an incident report, citing time constraints and lack of specific instructions. The night shift nurse also did not take further action, assuming the day shift nurse was responsible. The lack of timely assessment and communication led to a delay in medical evaluation and intervention. The resident continued to experience pain, and it was not until the following day that the on-call provider was notified and an x-ray was ordered. The x-ray, which revealed acute proximal tibia and fibula fractures, was not communicated to a medical provider until the next day, further delaying appropriate treatment. The resident ultimately required hospitalization and orthopedic intervention. Throughout the incident, there was a lack of documentation, failure to follow established protocols, and ineffective communication among staff, resulting in delayed recognition and treatment of a significant injury.
Failure to Provide Safe Transfer and Adequate Supervision Resulting in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with right-sided hemiplegia and a history of stroke, resulting in a fall and acute fractures of the right tibia and fibula. The resident, who was dependent for transfers and required a total mechanical lift with two-person assistance according to her Kardex, was instead assisted by staff using a stand and pivot transfer. During a transfer from the toilet, one staff member left to retrieve the wheelchair, leaving the resident holding onto an assist rail with her non-functional right hand, while the other staff member was not paying attention. The resident lost her balance, fell onto her right knee, and immediately experienced significant pain. The care plan did not specify the transfer method, and staff did not follow the Kardex instructions for a mechanical lift. After the fall, the resident was returned to bed by staff without being asked if she was hurt, and no immediate assessment or documentation of the incident was completed. Multiple staff interviews revealed inconsistencies in the account of the transfer and the fall, with some staff denying any unusual events and others expressing concern about the resident's instability during toileting. The resident, who spoke only Spanish, was not provided with an interpreter during the incident, which contributed to communication barriers. The injury was not reported to nursing supervisors or documented in a timely manner, and there was a delay in notifying the physician and obtaining appropriate medical evaluation. The resident remained in pain for an extended period before the injury was properly assessed and diagnosed. The lack of adherence to the resident's transfer requirements, insufficient supervision during the transfer, and failure to promptly recognize and report the fall led to a delay in treatment. The resident ultimately required hospitalization for management of her fractures, and the incident was confirmed through interviews with the resident, her roommate, family, and facility staff.
Inaccurate MDS Assessments for Swallowing Disorders, Pressure Ulcers, Dental Status, and Restraints
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents, resulting in deficiencies in the areas of swallowing disorders, pressure ulcers, dental status, and physical restraints. For one resident with protein-calorie malnutrition and dysphagia, both a speech therapy evaluation and a nutrition evaluation documented clear signs and symptoms of a swallowing disorder, including loss of food from the mouth, coughing, and complaints of pain when swallowing. However, the quarterly MDS assessment did not reflect these symptoms, and the Regional MDS Consultant acknowledged this was an oversight due to the absence of a dedicated MDS Coordinator. Another resident with dementia and malnutrition was found to have two unstageable pressure ulcers that developed after admission, as documented by the Wound Care Practitioner. Despite this, the discharge MDS assessment incorrectly coded the ulcers as present on admission. Additionally, the same resident was observed to be edentulous and receiving pureed food, but both the admission and significant change MDS assessments failed to indicate the absence of natural teeth, despite a speech therapy evaluation noting edentulism upon admission. The MDS assessments were completed remotely, and the Regional MDS Consultant confirmed the errors after reviewing the medical records. Further inaccuracies were identified in the coding of physical restraints. One resident with intact cognition was documented in the MDS as using bed rails as a physical restraint, although the resident used the rails for mobility and repositioning, and the facility was restraint free. Another resident with moderately impaired cognition was incorrectly coded as using a chair restraint, despite being able to self-transfer and having no device preventing rising from the chair. These errors were confirmed by the Regional MDS Consultant and the Administrator, who both stated that the MDS assessments did not accurately reflect the residents' conditions or the use of restraints.
Failure to Invite Resident to Participate in Care Planning
Penalty
Summary
A resident with intact cognition was readmitted to the facility and underwent several Minimum Data Set (MDS) assessments, including quarterly and annual reviews. Record review revealed there was no evidence that the resident was invited to participate in care plan meetings following these assessments. The resident reported having attended care plan meetings in the past but could not recall the last time one was held, and expressed a desire to participate in future meetings to provide input about his care. Interviews with the Social Worker (SW) and Administrator confirmed that the SW was responsible for tracking and inviting residents to care plan meetings, but had not consistently documented these meetings in the resident's medical record. The SW acknowledged that care plan meetings for this resident had not been held during the current year, and that the process had lapsed. The Administrator confirmed the expectation that care plan meetings should be scheduled and held with resident participation, as per regulatory guidance.
Failure to Ensure Resident Accessibility to Light Switch
Penalty
Summary
A dependent resident with severely impaired cognition and limited mobility was unable to access the light switch in his room due to a broken switch cord. The cord, which was only 2.5 inches long, was located 5 feet from the floor and 6 feet from the bed, making it unreachable for the resident, who required assistance to stand and walk. The resident reported that he had to rely on nursing staff to turn off the light, which was inconvenient and required repeated requests for assistance. He expressed a desire for the maintenance staff to repair the switch cord to better accommodate his needs. Nursing staff who regularly cared for the resident were unaware of the broken switch cord, as it was obscured by a tall table lamp. The maintenance director stated that he conducted weekly walkthroughs to identify repair needs and also relied on nursing staff to report issues, but acknowledged the need for immediate repair in this case. Both the DON and the facility administrator confirmed that residents should have full accessibility to their light fixtures at all times and that staff are expected to promptly report and address such repair needs.
Failure to Address ADL and Transfer Needs in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all activities of daily living (ADL) needs for two residents. One resident with cerebral palsy, who was dependent on staff for mobility and transfers and required assistance with all ADL tasks except eating, did not have a care plan that addressed his needs for transfers, bathing, and personal and oral hygiene. Although his care plan addressed limited physical mobility, it omitted specific interventions for his ADL care needs. Interviews with the resident and staff confirmed that he required substantial assistance and the use of a mechanical lift for transfers, but these needs were not reflected in his care plan. The omission was attributed to the absence of a dedicated MDS Coordinator at the time. Another resident with a right below-knee amputation, who required substantial assistance for transfers, also had a care plan that did not reflect his need for transfer assistance. The Regional MDS Consultant acknowledged that the transfer status was overlooked due to a personal emergency affecting MDS staff during the care plan's initiation. Both the consultant and the administrator confirmed that the care plans should have included these essential details to guide staff in providing appropriate care.
Failure to Complete Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to assess the risks of entrapment and complete bed rail assessments, as well as failed to obtain informed consent prior to the installation of bed rails for two residents. For one resident with dementia and Parkinson's disease, there was no documentation of a bed rail assessment since admission, despite the resident having severely impaired cognition and being dependent on staff for bed mobility. Observations showed the resident using bilateral quarter-length bed rails with staff assistance, and interviews with staff confirmed that bed rail assessments and informed consent from the responsible party had not been completed. Another resident with a non-displaced fracture and osteoporosis, who was her own responsible party, also had no bed rail assessment documented since admission. This resident had moderately impaired cognition and required substantial assistance for bed mobility, but was observed to be ambulatory and able to stand without assistance. Staff interviews indicated that bed rail assessments were supposed to be completed upon admission and quarterly, and that consent was required for residents with impaired cognition, but these steps had not been followed. Interviews with the Rehab Therapy Director, DON, and Regional Clinical Director of Operations revealed a lack of a clear process and communication regarding responsibility for bed rail assessments. It was acknowledged by leadership that assessments should be completed prior to bed rail installation, upon admission, and quarterly, but this was not occurring in practice. Maintenance was also expected to ensure proper installation and fit of bed rails, but the required assessments and consents were not documented for the residents involved.
Failure to Provide Prescribed Nectar Thick Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with dementia and dysphagia, who was ordered to receive nectar thick liquids, was provided with a cup of tea of thin liquid consistency during a lunch meal service. The resident's care plan and diet card both indicated the need for nectar thick liquids, but the meal tray included thin tea. A nurse aide recognized the inconsistency and removed the tea from the resident's hand but did not remove it from the tray or out of the resident's reach. The resident subsequently picked up the cup and took a sip, resulting in a cough. The Business Office Manager, unaware of the resident's dietary restrictions, provided a straw for the tea, further enabling access to the thin liquid. Interviews revealed that the nurse aide relied on the diet card to verify the meal but did not anticipate the resident would reach for the tea. The Business Office Manager was not aware of the resident's thickened liquid order and assumed the tea was appropriate since it was on the tray. The Speech Therapist confirmed that the resident's diet order for nectar thick liquids was in place to prevent aspiration and that thin liquids should not have been served with meals. The administrator acknowledged that the resident was not provided with fluids of the prescribed consistency as ordered by the physician.
Failure to Administer Influenza Vaccine to Consenting Resident
Penalty
Summary
A deficiency occurred when a resident who was cognitively intact and had expressed a desire to receive the influenza vaccine did not receive it. The resident had a signed, though undated, informed consent form in her medical record indicating her wish to be vaccinated. Despite this, the medical record showed no documentation of the influenza vaccine being administered since October 2023. The resident recalled being offered the vaccine and completing the consent form, but stated she never received the vaccine, possibly because she was out of the facility at an appointment during the scheduled vaccination clinic. The DON confirmed the presence of the signed consent and the absence of documentation for vaccine administration. The facility had used an outside company to conduct a vaccination clinic, and residents not present or admitted after the clinic were to be placed on a list for the next clinic. However, the facility also had influenza vaccines available for administration outside of scheduled clinics. Due to changes in facility leadership and the new vaccination process, the resident's vaccination was missed.
Failure to Bill Managed Medicaid Results in Improper Discharge Notice
Penalty
Summary
The facility failed to ensure that the basis for a resident's discharge met the required criteria, specifically regarding the handling of payment and insurance claims. A resident with intact cognition was admitted with coverage through a Managed Medicaid plan, but the facility listed the payer source as private pay and did not submit a claim to the insurance for payment. As a result, the resident was issued a 30-day discharge notice for non-payment, despite having insurance coverage that should have been billed. The resident and their representative were not expecting the discharge and had planned for a longer stay to arrange for accessible housing. The representative also reported receiving ongoing billing statements totaling over $50,000, with no indication that insurance had been billed or had paid any portion of the charges. Interviews with facility staff revealed that approval for the resident's stay had been obtained from the Managed Medicaid plan, but due to the incorrect payer source designation, no claim was submitted. The Business Office Manager confirmed that the process to transition the resident to long-term traditional Medicaid was not initiated as required, and the Administrator was unaware that the insurance had not been billed. The discharge notice was issued based on non-payment of a presumed co-payment amount, but staff acknowledged that co-payment amounts are typically determined only after a claim is submitted. The former Business Office Manager, who may have had further information, was unavailable for interview.
Incomplete Discharge Summary Documentation for Discharged Resident
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status for one resident who was discharged to the community. Record review showed that the discharge summary assessment for this resident was initiated but left incomplete, with only the Therapy section filled out and all other required sections, including Nursing, Dietary, Social Services, Activity, Reason for Discharge, Medical Summary, and Acknowledgement, left blank. The Social Worker, who was responsible for completing the Social Services section, confirmed during an interview that he did not consistently enter documentation into the resident's medical record and that the completion of the discharge summary was overlooked. The resident in question had intact cognition and no active discharge plan in place at the time of the quarterly MDS assessment. Although the Social Worker stated that a care plan meeting was held with the resident and their representative to discuss discharge plans and needs, there was no documented evidence of this in the medical record. The Administrator was unaware that the discharge summary had not been completed and stated that all sections should be completed by the respective departments according to regulatory guidelines.
Missed Antihypertensive Medication Doses Due to Untimely Refill Request
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received all scheduled doses of prazosin hydrochloride, a medication prescribed for hypertensive heart disease. The resident was admitted with a diagnosis of hypertensive heart disease without heart failure and had intact cognition. Physician orders indicated the resident was to receive prazosin hydrochloride 5 mg at bedtime and amlodipine 5 mg daily. While the resident consistently received amlodipine, the last dose of prazosin hydrochloride was administered on 06/07/25, after which three consecutive doses were missed. The missed doses resulted from a failure to request a timely refill from the pharmacy before the medication supply was depleted. Nurse #3 discovered the medication was unavailable on the cart and noted a refill request had been made, but did not follow up with the pharmacy or notify the DON. The MAR reflected that the medication was not administered and was held for three days. The pharmacy records showed the order was on hold pending clarification and receipt of a new prescription from the NP, which was not received until 06/11/25, at which point the medication was dispensed and administration resumed. During this period, the resident's blood pressure readings increased, and the resident reported not receiving the medication to both nursing staff and the NP. Interviews with staff confirmed that the expected protocol was to reorder medications 5-7 days before depletion and to notify the DON if a medication was unavailable. However, these steps were not followed, resulting in the resident missing three scheduled doses of prazosin hydrochloride.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide ongoing, consistent, and effective communication methods for a resident whose primary language was Spanish and who did not speak English. The resident, who was cognitively intact and had a history of cerebral infarction with right-sided hemiplegia, required an interpreter as documented in her care plan and Minimum Data Set (MDS) assessment. Despite this, staff interviews and observations revealed that there was no established or reliable system in place for staff to communicate with her in her preferred language. Staff members, including nurses and nurse aides, reported relying on the resident's roommate, who spoke both Spanish and English, to interpret the resident's needs. However, the roommate was noted to have a diagnosis of dementia and was not considered a reliable or appropriate interpreter. Some staff attempted to use gestures or translation apps on their personal phones, but there was no formal guidance or training provided by the facility on how to communicate with non-English speaking residents. Several staff members stated they had not been informed of any translation services available for use with the resident. The resident herself expressed frustration and distress over her inability to communicate her needs to staff, stating that only her roommate helped her and that staff did not attempt to use translation tools. The facility's social worker and other leadership acknowledged that there was no defined process or service in place for translation at the time of the survey, and that staff were unsure of what resources, if any, should be used to facilitate communication with non-English speaking residents.
Failure to Ensure Timely Refill and Administration of Scheduled Opioid Medication
Penalty
Summary
A deficiency occurred when the facility failed to maintain effective systems for acquiring and administering a scheduled opioid pain medication, tramadol, resulting in a resident missing three consecutive days of their prescribed pain management. The resident, who had osteoporosis and was receiving tramadol 50 mg once daily for generalized pain, did not receive the medication as ordered due to lapses in the medication refill process and lack of timely action by nursing staff. The Medication Administration Record showed that after the last dose was given, subsequent scheduled doses were not administered, and appropriate documentation was lacking for at least one of the missed doses. The breakdown began when the nurse who administered the last available tablet did not request a new prescription, and subsequent nurses also failed to initiate the refill process in a timely manner. One nurse attempted to start the refill but was delayed by the need for a nurse practitioner's signature and did not escalate the issue to the Director of Nursing. Additionally, attempts to access tramadol from the facility's Pyxis automated dispensing system were unsuccessful due to login issues, and the nurse did not notify supervisory staff about this barrier. Communication between shifts occurred, but the medication was still not obtained from the Pyxis or a local back-up pharmacy, despite these resources being available. Interviews with staff and the nurse practitioner revealed that the expectation was for nurses to begin the refill process 5-7 days before the medication ran out, especially for controlled substances. The failure to follow this protocol, combined with ineffective use of available pharmaceutical resources and lack of urgency among staff, led to the resident missing three days of scheduled pain medication.
Failure to Administer Prescribed Pain Medication for Three Consecutive Days
Penalty
Summary
Nursing staff failed to administer a prescribed opioid pain medication, tramadol, to a resident for three consecutive days, resulting in a significant medication error. The resident, who had severe cognitive impairment and was at risk for pain, had a physician's order for daily tramadol and as-needed acetaminophen for pain management. The medication administration record showed that the last dose of tramadol was given, after which the medication ran out and was not refilled in a timely manner. Nurses documented the absence of tramadol and initiated the refill process, but delays occurred due to the need for a nurse practitioner's signature and pharmacy delivery schedules. During the period when tramadol was unavailable, the resident received as-needed acetaminophen for mild pain, with pain assessments documented as low or absent. Despite the lack of tramadol, there were no documented progress notes on one of the days, and communication between nursing staff and the pharmacy was ongoing to resolve the medication shortage. The facility's emergency medication supply (Pyxis) contained tramadol, but it was not accessed for the resident during the lapse. Interviews with nursing staff and the nurse practitioner confirmed the medication error and acknowledged that the incident could have been avoided with earlier action. The Director of Nursing stated that refills for controlled medications should be initiated several days in advance to prevent such gaps. The administrator and DON both noted that the resident did not experience significant pain during the lapse, but the failure to administer tramadol as ordered constituted a significant medication error.
Failure to Document Resident Fall and Acute Pain
Penalty
Summary
A deficiency occurred when staff failed to document a reported fall and associated acute pain for a resident. The resident reported falling onto her right knee while being assisted in the bathroom by two staff members, resulting in immediate pain. Despite the resident's report and the nursing supervisor's assessment of pain, there was no documentation or assessment information in the medical record for the date of the incident. The last progress note was from the previous day, and no new documentation appeared until the following afternoon. Interviews revealed that the nursing supervisor assessed the resident and communicated the incident to both the outgoing and incoming nurses, instructing them on necessary actions. However, neither nurse completed the required documentation, assessment, or incident report. Each nurse assumed the other would handle the post-fall protocol, resulting in a lack of recorded assessment, notification, or follow-up in the resident's chart, as confirmed by facility leadership.
Survey Results Binder Not Accessible to Residents or Public
Penalty
Summary
The facility failed to post survey results in a location accessible to all residents and did not provide signage indicating the location of the survey results in areas accessible to the public. Observations over several days revealed that the survey results were kept in a binder on a side table in a waiting room located in the lobby. There was no signage in the lobby or resident hallways to indicate where the survey results binder could be found. All resident rooms were located behind a locked door that required a code to open, restricting resident access to the lobby area where the binder was kept. During a Resident Council Meeting, all residents present were unaware of the location of the survey results binder. After being informed, several residents stated they would need to ask staff to let them through the locked, coded door to access the lobby and the binder. The Administrator confirmed that the binder in the waiting room was the only copy available in the facility and acknowledged the lack of signage indicating its location. The Administrator also stated that residents could ask staff for access if they did not know the code themselves.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two separate incidents involving a resident with a history of traumatic brain injury, bipolar disorder, and impulse control disorder. In the first incident, a moderately cognitively impaired resident physically assaulted a severely cognitively impaired resident by punching her in the face, causing her to fall backward and sustain a head injury. The injured resident was sent to the emergency room, where a CT scan revealed a small intraventricular hemorrhage and a scalp hematoma. The resident was evaluated by neurosurgery and returned to the facility after being deemed stable. In a separate incident, the same resident shoved another severely cognitively impaired resident, causing her to fall to the floor. Although this second resident was not injured, the event was witnessed by staff and confirmed through interviews and documentation. Both incidents occurred in common areas of the facility, with staff present in the vicinity. The resident responsible for the physical altercations had documented behavioral triggers related to personal space and belongings, and his care plan included interventions such as frequent observation and monitoring for behavioral triggers. However, these interventions did not prevent the physical abuse from occurring. The residents involved in these incidents had significant cognitive impairments and exhibited behaviors such as wandering and invading others' personal space, which contributed to the altercations. Staff interviews and video footage confirmed that the aggressive resident's behaviors were known and that staff had been educated on his triggers. Despite this, the facility did not effectively prevent the physical abuse, resulting in harm to at least one resident and the potential for fear, pain, and anxiety among those affected.
Failure to Implement Abuse Reporting and Resident Protection Policies
Penalty
Summary
The facility failed to implement its abuse prevention and reporting policies after a resident reported being attacked and cursed at by a male nurse aide. The resident, who had intact cognition and a history of anxiety and depression, informed a female nurse aide during the night shift that a male staff member had attacked and cursed at her. The nurse aide reported this to a medication aide, whom she considered her supervisor, but did not escalate the allegation to the nurse, DON, or Administrator as required by facility policy. The medication aide stated that the resident only expressed a preference not to have a male aide and did not mention abuse, while the male aide involved denied any inappropriate behavior and was not immediately removed from the facility, remaining on shift with access to other residents. The facility's abuse policy required immediate reporting of all alleged violations to the Administrator and Adult Protective Services (APS), and immediate action to protect the alleged victim, including removal or suspension of the accused employee. However, the allegation was not reported to the nurse or administration until the resident's responsible party informed the Administrator the following morning. The accused aide was only removed from the schedule after the morning report, and there was no immediate assessment of the resident for injury or further risk during the night shift. Staff interviews revealed confusion about reporting protocols and a lack of direct communication to the appropriate supervisory personnel. Additionally, the facility failed to report the alleged sexual abuse to Adult Protective Services in a timely manner. Although the Administrator and social worker eventually contacted the Department of Social Services, this did not occur until several days after the initial allegation was made known to facility leadership. The delay in reporting to APS was confirmed by both the previous DON and Administrator, who acknowledged the requirement to notify APS promptly but did not do so as stipulated by policy.
Misappropriation of Controlled Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of controlled medications, affecting three residents. Resident #29, with a diagnosis of acute respiratory distress, had an order for morphine sulfate as needed for pain. The facility discovered that Nurse #6 misappropriated Resident #29's morphine after a change in his behavior was noted. A drug screening confirmed Nurse #6 tested positive for morphine, and a police investigation found the missing medication in his possession. The facility's investigation substantiated the misappropriation, and the North Carolina Board of Nursing was notified. Resident #58, admitted with a right tibia fracture, had an order for oxycodone for pain management. Nurse #7 was found to have fraudulently signed out oxycodone under Nurse #3's name, which was confirmed by discrepancies in the controlled substance count sheets and Resident #58's statement. Additionally, Resident #113, who had passed away, had oxycodone signed out fraudulently by Nurse #7. The facility's investigation confirmed the misappropriation, and the local sheriff's office was notified. The incidents involved staff members who appeared impaired while on duty, leading to the misappropriation of controlled substances. Nurse #6 and Nurse #7 were both found to have taken medications without authorization, affecting the residents' medication management. The facility's failure to prevent these incidents resulted in the misappropriation of residents' property, violating their rights to be free from such actions.
Failure to Implement Nutritional Recommendations for Residents
Penalty
Summary
The facility failed to implement the recommended nutritional interventions for two residents, leading to deficiencies in their care. Resident #25, diagnosed with diabetes mellitus and severe protein-calorie malnutrition, was recommended to receive 30 ml of liquid protein twice daily. However, this order was not transcribed to the Medication Administration Record (MAR) and was not administered from the start date of 10/30/23 through 06/27/24. Despite being cognitively intact and independent with eating, Resident #25 experienced a gradual long-term weight loss, and the Registered Dietitian (RD) noted that the recommendation for liquid protein was not followed. Resident #51, with a history of cerebrovascular accident and dysphagia, was ordered to receive enteral feedings with a 1.5 calorie nutritional supplement of 270 ml when oral intake was less than 50%. However, during an observation, Nurse #5 administered only 237 ml of the supplement. The RD confirmed that the nutritional needs were still being met with the lesser amount, but the order was not followed as written. Resident #51's oral intake ranged from 0 to 25% for most meals, and the RD had noted that the current plan of care was adequate to meet nutritional needs. Interviews with the RD and the Regional Nurse Consultant revealed that the RD's recommendations were communicated to the facility staff, but there was a breakdown in following through with the physician's orders. The RD's recommendations were sent via email to the Director of Nursing, the Regional MDS Coordinator, and the Dietary Manager, but the orders were not consistently implemented, leading to the deficiencies noted in the care of Residents #25 and #51.
Failure to Ensure Timely Physician Visits for New Admissions
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first 90 days of admission for several residents. This deficiency was identified through record reviews and staff interviews, revealing that six out of twelve sampled residents did not receive the required physician visits. For instance, Resident #2, admitted with conditions such as cerebrovascular disease and dementia, was not seen by the facility's Medical Doctor (MD) since admission, although visits by a Nurse Practitioner (NP) were documented. Similarly, Resident #16, with diagnoses including diabetes and cirrhosis of the liver, was only seen once by the MD after admission, despite multiple NP visits. The same pattern was observed for Resident #22, who had end-stage renal disease and other serious conditions, and was only seen once by the MD. The facility's failure to adhere to the regulatory requirement for monthly MD visits during the initial 90 days of admission was consistent across these cases. The issue was compounded by a lack of awareness among the Medical Records staff regarding the specific regulatory requirements for MD visits. The MD was reportedly managing his own schedule, and the Medical Records staff were only tracking the last visit by either the MD or NP, not specifically ensuring compliance with the monthly MD visit requirement. This oversight led to the deficiency being identified during an audit conducted by the Medical Records staff, following concerns raised by the MDS Coordinators.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for at least 8 consecutive hours per day on six specific dates within the review period. The deficiency was identified through a review of daily nurse staffing sheets and time clock reports, which showed a lack of required RN coverage on the dates of 04/27/24, 04/28/24, 05/20/24, 05/21/24, 05/26/24, and 06/08/24. Interviews with the Scheduling Coordinator and the Regional Clinical Nurse Consultant revealed that the absence of RN coverage was primarily due to the resignation of the weekend RN supervisor and challenges in maintaining a stable nurse administration team, particularly the Director of Nursing position, following a change in corporate ownership in September 2023.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly secure and store medications, leading to several deficiencies. An opened bottle of Silvadene cream was found unattended in a resident's room, with the resident unaware of how it got there. Staff interviews revealed that the cream should have been stored in the treatment cart. Additionally, expired over-the-counter medications were found in the medication storage room and on a medication cart, with no designated staff assigned to regularly check for expired medications. This oversight resulted in expired medications remaining on the shelves, contrary to the manufacturer's guidelines. Further deficiencies were noted in the storage of insulin and eye drops. Insulin pens and bottles were found stored at room temperature for an unknown duration, contrary to the manufacturer's guidelines that require refrigeration. Staff interviews indicated a lack of awareness and time to check medication carts for proper storage and expiration. The Acting DON and Administrator acknowledged the issues, attributing them to a lack of leadership due to frequent turnover in the nursing department. They expected nursing staff to maintain proper medication storage and ensure the facility was free of expired or unattended medications.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Observations revealed that staff did not use the required gowns and gloves during high-contact care activities for residents with central lines, feeding tubes, tracheostomy, and urinary catheters. For instance, a nurse was observed performing care on a resident with a PICC line without wearing a gown, and another nurse was unaware of the need for EBP when administering enteral feeds. The lack of EBP signage and personal protective equipment near residents' rooms further highlighted the facility's non-compliance. Interviews with staff, including nurses and nurse aides, indicated a lack of awareness and training regarding EBP. Several staff members, including a medication aide and a nurse, reported not receiving any education on EBP, and the acting Director of Nursing confirmed the absence of such training. The Regional Nurse Consultant and Infection Preventionist acknowledged that the information on EBP was provided to the former Director of Nursing, but it was not implemented or communicated to the staff. Additionally, the facility failed to follow its hand hygiene policy during incontinence care. An observation of a nurse aide providing care to a resident showed improper glove use and hand hygiene practices, such as not changing gloves between cleaning different body sites and not performing hand hygiene after removing soiled gloves. The acting Director of Nursing and the Regional Nurse Consultant both expressed expectations for proper hand hygiene practices, which were not met by the staff.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to invite a resident and/or their Resident Representative (RR) to participate in care planning, as evidenced by the case of a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia and dementia. The resident was admitted to the facility and had several Minimum Data Set (MDS) assessments completed, but there was no evidence that care plan meetings were held or that the resident or their RR were invited to provide input. The RR was unaware of the facility's process for conducting care plan meetings and recalled attending only one meeting at the time of admission. The deficiency was attributed to a breakdown in the process following a change in facility management. The responsibility for scheduling and facilitating care plan meetings was transferred to the Social Worker (SW) during the transition, leading to missed meetings. The SW acknowledged the oversight and was working on improving the process. The Regional Clinical Nurse Consultant confirmed the lack of care plan meetings and noted that a Performance Improvement Plan (PIP) was attempted but deemed insufficient. Both the Regional Clinical Nurse Consultant and the Administrator recognized the issue as a result of unclear responsibilities regarding care plan meeting schedules.
Failure to Protect Resident Health Information
Penalty
Summary
The facility failed to protect the private health information of two residents by leaving confidential medical information unattended and exposed in areas accessible to the public. During an observation, a medication cart was left unattended in the hallway with the Medication Administration Record (MAR) of a resident visible on the computer screen. This screen displayed the resident's name, picture, and current medications, making it accessible to anyone passing by. Nurse #1, responsible for the cart, admitted to being distracted and acknowledged the oversight, despite having completed HIPAA training. A similar incident occurred later when the same nurse left another resident's MAR visible on the unattended medication cart. The nurse was seen talking to a staff member away from the cart, leaving the screen accessible to unauthorized individuals. The Acting Director of Nursing and the Administrator both expressed that it was expected for all staff to follow HIPAA guidelines and safeguard residents' personal health information at all times. The facility provides HIPAA training during orientation and annually thereafter.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement effective interventions to prevent resident-to-resident physical abuse, resulting in an incident where a severely cognitively impaired resident with a known history of aggression hit another resident. Resident #23, who had a history of major neurocognitive disorder secondary to traumatic brain injury and chronic aggression, was admitted to the facility without specific interventions or increased supervision in place. On the day of the incident, Resident #23 hit Resident #11, who also had severe cognitive impairment and a history of physical behaviors, causing a small cut and bruising. The incident occurred when Resident #11 entered Resident #23's room, leading to Resident #23 striking Resident #11 multiple times. A visitor witnessed the event and informed the staff, who then separated the residents. The facility's investigation confirmed the abuse, noting that Resident #23 admitted to hitting Resident #11 because he was blocking the door. Despite being aware of Resident #23's aggressive history, the facility did not have adequate measures in place to prevent such incidents. The facility's investigation revealed that the staff was notified of the incident by a visitor, and both residents were assessed for injuries. The Administrator acknowledged awareness of Resident #23's aggressive behavior history but was not aware of any specific interventions implemented upon his admission. The facility substantiated the abuse allegation as it was a witnessed incident, but no specific precursor to the aggression was identified.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedures, specifically in the areas of reporting and investigation. An allegation of abuse was reported by a resident, who claimed to have witnessed another resident being held down and provided care against her will by a male staff member. This allegation was communicated to the Medical Records Director, who then informed the Regional MDS Consultant and the Administrator. However, the Administrator dismissed the report, stating it did not count as abuse and did not need to be reported to the State Agency. The facility's policy requires immediate investigation and reporting of abuse allegations to the State Agency within specified timeframes. Despite this, the Administrator did not initiate an investigation or report the incident to the State Agency. The Medical Records Director provided a detailed account of the alleged incident, but the Administrator did not recall being informed of the specifics and did not take the necessary steps to address the allegation. The deficiency affected a resident with moderate cognitive impairment, who was allegedly involved in the incident. The failure to report and investigate the allegation promptly resulted in a delay in addressing the potential abuse. The Regional Clinical Nurse Consultant later confirmed that the initial report should have been submitted when the allegation was first reported, but it was overlooked, leading to a delayed response from the facility.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, comprehensive care plans for two residents, focusing on nutritional risk and indwelling catheter management. Resident #2, admitted with urinary retention and dementia, had a physician's diet order for a regular diet with pureed texture and regular/thin liquids, and a suprapubic catheter order. The admission MDS assessment indicated intact cognition and dependence on staff for self-care tasks, including eating, with an indwelling catheter and a mechanically altered diet. Despite these assessments, Resident #2's comprehensive care plan did not address nutrition or catheter management. The Regional MDS Consultant, who completed the MDS assessments remotely, acknowledged the oversight and confirmed that these areas should have been included in the care plan. Similarly, Resident #22, admitted with diabetes, end-stage renal disease, and dependence on renal dialysis, had a physician's diet order for regular texture and regular/thin liquids, with additional dietary instructions from dialysis. The admission MDS assessment showed intact cognition and required assistance with self-care tasks and mobility, receiving dialysis services and a therapeutic diet. However, the comprehensive care plan for Resident #22 lacked a plan addressing nutritional risk. The Regional MDS Consultant confirmed the absence of a nutritional care plan and stated it was the responsibility of the MDS staff to ensure comprehensive care plans were completed.
Failure to Obtain Physician's Order for Heparin Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of heparin used by a nurse to flush the peripherally inserted central catheter (PICC) for a resident. The resident was admitted with diagnoses including diabetes mellitus and pulmonary embolism and was at risk for complications related to anticoagulant therapy. The care plan included administering medications as ordered by the physician and monitoring for side effects. However, there was no current physician's order for flushing the PICC line with heparin, which was observed being done by a nurse without a written order. During an interview, the nurse confirmed the absence of a written physician's order for the use of heparin to flush the PICC line, stating it was the facility's policy to use this method. The Nurse Practitioner also confirmed that a physician's order specifying the dose of heparin was necessary, especially since the resident was already on anticoagulant medication, apixaban. The facility's policy for central catheter flushing was mentioned, but it was not followed in this instance, leading to the deficiency.
Failure to Secure Controlled Medications After Resident's Death
Penalty
Summary
The facility failed to properly manage controlled medications following the death of a resident, leading to drug diversion. Resident #113, who was admitted with thrombocytopenia, had an order for oxycodone to manage pain, which was discontinued after his death. However, the controlled medications were not removed from the medication cart and returned to the pharmacy as required. This oversight allowed the medications to remain accessible and ultimately led to their misappropriation. Nurse #7 was implicated in the diversion of controlled substances, as she was found to have signed out oxycodone tablets fraudulently under the names of other nurses. The discrepancies were discovered when Nurse #3, who took over the medication cart, noticed that her name was falsely used to sign out medication for another resident. Further investigation revealed that the signatures on the controlled substance count sheet for Resident #113 were also falsified, indicating that Nurse #7 had diverted the medications. Interviews with staff, including the Acting DON and the Administrator, highlighted a lack of adherence to the facility's protocol for handling medications of deceased residents. The Acting DON, who was responsible for Resident #113 at the time of his death, could not recall if she had removed the medications as required. The Administrator confirmed that the expectation was for controlled medications to be removed within 24 hours and returned to the pharmacy within 72 hours, a procedure that was not followed in this case.
Deficiency in Vaccine Documentation
Penalty
Summary
The facility failed to document the refusal or acceptance of influenza and pneumonia vaccinations for a resident reviewed for immunizations. The resident, who was cognitively intact, was admitted to the facility with no documentation regarding the receipt, offer, refusal, or education of the flu or pneumonia vaccinations. The resident mentioned usually refusing the flu shot but was uncertain about the pneumonia shot. Interviews with the Regional Nurse Consultant and Infection Preventionist, as well as the Administrator, revealed that the consent forms were lost during a company ownership transition, which led to the breakdown in maintaining proper documentation of vaccine consents.
Incomplete Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that daily nurse staffing sheets were filled out completely for 27 out of 123 days reviewed during the period from October 1, 2023, through January 31, 2024. The daily nurse staffing sheets were supposed to include the date, current resident census, and the number of staff and hours worked for RNs, LPNs, and CNAs for each 12-hour shift. However, for the specified dates, the columns indicating the number of staff and hours worked for each shift were left blank, with only the total daily number of hours worked noted at the bottom of the sheets. The Scheduling Coordinator, who took over the scheduling responsibilities on March 18, 2024, reported that she was unable to locate the completed nurse staffing sheets for the missing dates. As a result, sheets were filled out retroactively with only the total hours worked. The Regional Clinical Nurse Consultant acknowledged that it was the Scheduler's responsibility to ensure the completion and accuracy of these sheets. The consultant also noted that since a new corporation took over in September 2023, the facility had difficulty maintaining a stable nurse administration team, particularly in the Director of Nursing position, which contributed to the oversight.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan addressing the immediate needs of residents within 48 hours of admission, affecting two residents reviewed for dialysis and nutrition. Resident #22, admitted with diagnoses including diabetes and end-stage renal disease, did not have a baseline care plan that included goals or interventions for dialysis services, nutrition, or discharge plans. The resident, who had intact cognition, stated he discussed discharge goals with staff but did not recall discussing or receiving a written baseline care plan. The Regional Clinical Nurse Consultant and Administrator identified a breakdown in the process, as nurses were unaware that the baseline care plan needed to be printed and reviewed with the resident or their Responsible Party (RP). Similarly, Resident #25, admitted with diabetes mellitus and severe protein-calorie malnutrition, did not have a baseline care plan completed within the first 48 hours of admission. Nurse #3, responsible for the admission evaluation, confirmed that the computer system did not trigger her to complete the baseline care plan for this resident. The Regional Nurse Consultant and Administrator reiterated that it was the admitting nurse's responsibility to complete and review the baseline care plan with the resident or their RP within the required timeframe. The absence of a baseline care plan for these residents highlights a systemic issue in ensuring timely and comprehensive care planning upon admission.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to obtain weekly weights as ordered by the physician and did not implement the recommendation for a nutritional supplement to promote weight stability for a resident with significant weight loss. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease, and cerebral vascular accident with hemiplegia, was supposed to receive weekly weights and various nutritional supplements. However, the facility did not follow through with these orders, leading to a significant weight loss that was not properly addressed or monitored. The resident's weight fluctuated significantly, with documented weights showing a drop from 124 pounds to 97 pounds over a short period, raising concerns about the accuracy of the weights and the effectiveness of the interventions in place. The Registered Dietitian's recommendation to add a health shake with breakfast was not implemented, and there was no physician's order to support this recommendation. The care plan indicated that the resident's nutritional status should be monitored, but the facility failed to report significant weight loss to the Medical Doctor as required. Interviews with staff revealed confusion and lack of follow-up on the resident's weights, with some weights being crossed out and marked as incorrect without proper reweighing. The Nurse Practitioner and Medical Doctor both expressed doubts about the accuracy of the documented weights and the significant weight loss reported. The Director of Nursing, who took over the position recently, was unaware of the Registered Dietitian's recommendation and confirmed that the weight of 97 pounds was accurate after reweighing. The resident's diet order was changed to a regular pureed diet with thin liquids, but the facility's failure to obtain weekly weights and implement nutritional interventions as ordered by the physician contributed to the resident's significant weight loss. Interviews with family members and staff highlighted the resident's poor appetite and need for encouragement during meals, further emphasizing the facility's shortcomings in addressing the resident's nutritional needs.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to complete and submit an Initial Allegation Report within 2 hours to the State Regulatory Agency for two residents involved in an abuse incident. Resident #2, who was severely cognitively impaired, was found in Resident #3's room and had grabbed Resident #3's arm, causing redness and bruising. The incident occurred on 03/09/24 at 5:15 PM, and the Administrator was notified immediately by Nurse #1. However, the Initial Allegation Report was not faxed to the State Agency until 03/10/24 at 3:06 PM, which was 21 hours and 51 minutes after the facility became aware of the allegation of abuse. The Administrator confirmed that he was notified of the incident on the evening of 03/09/24 and considered it an allegation of abuse. However, he did not initiate the Initial Allegation Report until the following day because he believed he had 24 hours to submit the report unless there was significant bodily harm. Since Resident #3 only sustained bruising, the Administrator did not consider it significant bodily harm and delayed the report submission. Nurse #1 also revealed that she had not received any education on how to report resident-to-resident altercations other than ensuring the residents' safety and notifying the Administrator.
Failure to Conduct Thorough Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of resident-to-resident abuse involving two residents. Resident #2, who was severely cognitively impaired, was found in Resident #3's room, grabbing Resident #3's left arm, which resulted in a small bruise. The incident was reported by Nurse #1, who separated the residents and notified the Administrator. The Administrator then informed Buncombe County Adult Protective Services and Asheville Police, who initiated their investigations. However, the facility's internal investigation was found lacking in several areas, including the failure to interview relevant staff and residents who were present during the incident and the lack of thorough documentation of the interviews conducted. The investigation file contained unsigned and undated questionnaires from staff and residents who were not present during the incident. Additionally, the residents interviewed resided in the Assisted Living unit rather than the skilled nursing unit where the incident occurred. The Administrator admitted to not specifying which units should be interviewed and relied on shower sheets to assess potential injuries among cognitively impaired residents. The Administrator also failed to provide documentation of interviews with the Nurse Aides assigned to the involved residents on the evening of the incident. This lack of thoroughness and proper documentation led to the deficiency in the facility's investigation process.
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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