Riverpoint Crest Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bern, North Carolina.
- Location
- 2600 Old Cherry Point Road, New Bern, North Carolina 28563
- CMS Provider Number
- 345211
- Inspections on file
- 23
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Riverpoint Crest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was transported in a geriatric wheelchair by an OT who pulled the chair from behind, preventing the resident from seeing where he was going. This action did not respect the resident's dignity, as confirmed by staff interviews and facility training expectations.
A resident with severe cognitive impairment had a family member designated as their Resident Representative (RR), but there was no documentation of care plan meetings or attempts to contact the RR since admission. The RR reported not being invited to participate in care planning and expressed a desire to be included. The Administrator, responsible for sending care plan invitations after the Social Worker left, could not provide evidence that the RR had been contacted.
A resident with moderate cognitive impairment and chronic pain was found to be self-administering arthritis creams, antacid tablets, and cough drops kept at her bedside without a clinical assessment or physician orders. Facility staff, including nursing and administration, were unaware of the resident's possession and use of these medications, and no care plan or documentation addressed self-administration.
A nurse failed to provide privacy for a resident with severe cognitive impairment and an indwelling urinary catheter by leaving the door open and not pulling the privacy curtain during a catheter assessment, resulting in the resident being exposed and visible from the hallway while staff passed by.
A resident with Diabetes Mellitus II received daily insulin as ordered, but the MDS assessment did not accurately reflect the use of hypoglycemic medication during the required lookback period. Staff confirmed the omission was due to human oversight.
A resident with a diagnosis of PTSD did not have a person-centered care plan addressing this condition, despite a trauma-informed assessment and staff awareness of potential triggers. Nursing staff confirmed that no care plan was developed for PTSD because the resident had not exhibited related problems since admission, resulting in a deficiency.
Two residents prescribed psychotropic medications did not have comprehensive care plans developed within the required timeframe after their assessments. Both had diagnoses such as dementia, anxiety, and depression, and their assessments triggered the need for care planning related to psychotropic medication use. Staff interviews revealed that care plans were not created due to human error and unclear responsibility among staff for updating care plans.
A treatment cart containing wound care medications was left unlocked and unattended in a hallway, accessible to staff, visitors, and a resident. The cart contained topical medications that could be dangerous if accessed by residents. Additionally, Astelin nasal spray was found stored horizontally in two medication carts, contrary to manufacturer instructions requiring upright storage. Nursing staff were unaware of the proper storage requirements, and the DON confirmed expectations for compliance with manufacturer guidelines.
Two staff members failed to follow the facility's Enhanced Barrier Precautions policy by not wearing gowns while providing high-contact care to a resident with an indwelling urinary catheter. Both the nurse aide and the nurse performed catheter care and assessment using only gloves, despite the policy requiring both gowns and gloves for such procedures. Both staff later acknowledged the omission and recognized that gowns were required for this type of care.
The facility failed to accurately code MDS assessments for three residents, resulting in deficiencies related to falls, oxygen use, and discharge status. A resident with a fall was not recorded in the MDS, another resident's continuous oxygen use was omitted, and a third resident's discharge status was incorrectly coded. These errors were attributed to human error, despite daily discussions of resident conditions with the IDT.
A resident with diabetes mellitus was not provided with a comprehensive care plan addressing their condition and hypoglycemic medication. Despite having a physician's order for metformin, the care plan lacked focus areas, goals, or interventions related to diabetes. Interviews with the MDS Coordinator and DON confirmed the oversight, acknowledging it as a human error.
A resident with severe cognitive impairment and incontinence was not provided timely incontinence care, as required, during a shift at an LTC facility. The resident's incontinence pad was found wet, and the responsible nurse aide admitted to not checking or providing care due to being occupied with another resident. The DON confirmed the oversight, and other staff members were unaware of the situation as the aide did not seek assistance.
The facility failed to attempt alternatives before installing siderails for two residents. One resident with vascular dementia and COPD, and another with end-stage renal disease and a femur fracture, had siderails installed without prior attempts at alternative interventions. Observations and staff interviews confirmed that alternatives were not considered, and the facility's practice was to use siderails unless contraindicated or declined by the resident.
A facility failed to handle soiled linen properly, as observed when a nurse aide picked up soiled linen from the floor and placed it into a laundry hamper without bagging it first. This action was against the facility's policy, which requires soiled linen to be bagged to prevent microorganism transfer. Interviews with the DON and Administrator confirmed the non-compliance with infection control practices.
Resident Transported in Wheelchair Without Regard for Dignity
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired, was transported in a geriatric wheelchair by an occupational therapist (OT) in a manner that did not honor the resident's right to dignity. The OT pulled the wheelchair from behind, positioning the resident so that he was unable to see where he was being taken. This action was observed by surveyors and was confirmed during interviews with the OT, who stated she was unaware that this method of transport was a dignity issue and explained she pulled the chair because it was difficult to push. The resident had an active order for occupational therapy evaluation and treatment. The incident was witnessed during a routine observation, and the OT involved was an agency staff member who had received facility training on treating residents with dignity and respect. The Rehabilitation Manager and the DON both acknowledged that staff should have known this method of transport was inappropriate and a concern for resident dignity.
Failure to Include Resident Representative in Care Planning
Penalty
Summary
The facility failed to include the Resident Representative (RR) of a severely cognitively impaired resident in the care planning process. The resident, who was admitted with severe cognitive impairment, had a family member designated as her RR. Review of the medical record showed that the care plan was last revised on 8/18/25, but there was no documentation of care plan meetings, attempts to contact, or conversations with the RR since admission. During a telephone interview, the RR stated he did not recall being invited to any care plan meetings and expressed a desire to be included. The Administrator confirmed that, following the departure of the Social Worker in June 2025, she was responsible for sending care plan meeting invitations but could not provide documentation that the RR had been invited for this resident.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, resulting in the resident keeping several medications at her bedside without clinical evaluation or physician orders. The resident, who was moderately cognitively impaired and had diagnoses including non-Alzheimer's dementia and chronic pain syndrome, stored and self-administered arthritis cream with 25% capsaicin, arthritis pain relief gel with 2% menthol, chewable antacid tablets, and cough drops. There was no documentation in the medical record of an assessment for self-administration, no physician orders for these medications, and no care plan addressing self-administration. Multiple staff members, including a nurse, unit manager, nurse aide, DON, and the administrator, were unaware that the resident kept and used these medications at her bedside. The nurse reported applying arthritis cream from the medication cart, but was unaware of the resident's personal supply. The DON and administrator confirmed that no assessment for self-administration had been conducted and were unsure how the facility would have known about the medications at the bedside. The lack of assessment and oversight led to the deficiency.
Failure to Provide Privacy During Catheter Assessment
Penalty
Summary
Nurse #2 failed to provide personal privacy for a resident with severe cognitive impairment and an indwelling urinary catheter during a catheter assessment. The nurse entered the resident's room, applied gloves, and proceeded to pull up the resident's gown and pull down his brief to assess the catheter insertion site without closing the door or pulling the privacy curtain. As a result, the resident's bare stomach and penis were visible from the hallway, and staff were observed passing by the open door during the assessment. Prior to this, a nurse aide had performed catheter care for the same resident, closing the door but not pulling the privacy curtain. The resident was in the bed closest to the door, with a roommate present whose privacy curtain was closed. After noticing bloody urine in the catheter tubing, the nurse aide informed Nurse #2, who then entered the room and conducted the assessment without ensuring privacy, leading to the resident's exposure.
Failure to Accurately Code MDS for Hypoglycemic Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of hypoglycemic medication use. The resident was admitted with a diagnosis of Diabetes Mellitus II and had active physician orders for both long-acting and sliding scale insulin, which were administered daily as documented in the Medication Administration Record. Despite this, the resident's admission MDS assessment did not reflect the use of hypoglycemic medications, including insulin, during the required 7-day lookback period. Staff interviews confirmed that the omission was due to human oversight and that the MDS should have been coded to indicate the resident's receipt of hypoglycemic medication. The deficiency was identified through record review and staff interviews, which established that the resident received insulin as ordered but the MDS assessment failed to accurately capture this information.
Failure to Develop Person-Centered Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), despite the resident having a documented history of PTSD, delusional disorders, mood disorder, and major depressive disorder. A trauma-informed assessment was completed, and the resident was found to be cognitively intact with no behaviors noted during the assessment period. However, review of the care plan revealed there was no plan of care addressing the resident's PTSD diagnosis. Staff interviews confirmed that while the resident had some behaviors such as refusal of care and paranoid behavior, these were care planned separately and not specifically linked to PTSD. Nursing staff, including the MDS Nurse and the Director of Nursing, acknowledged that a person-centered care plan should have been developed for the resident's PTSD, including identification of triggers such as loud noises. The MDS Nurse stated that a care plan was not created because the resident had not exhibited any PTSD-related problems since admission. Despite this, the expectation was that staff should be aware of appropriate interventions should a PTSD episode occur. The lack of a specific care plan for PTSD constituted the deficiency identified during the survey.
Failure to Timely Develop Comprehensive Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completing the comprehensive assessment for two residents who were prescribed psychotropic medications. For one resident with non-Alzheimer's dementia, anxiety, and major depressive disorder, the admission MDS assessment indicated the use of antianxiety and antidepressant medications, and the Care Area Assessment (CAA) was triggered for psychotropic medication use. However, the comprehensive care plan created did not address psychotropic medication use. Staff interviews revealed that the care plan was not created due to human error, and there was confusion among staff regarding responsibility for care plan updates. Similarly, another resident with anxiety, depression, and Alzheimer's dementia was prescribed antianxiety medication, and the CAA was triggered for psychotropic medication use. The care plan for this resident also failed to address psychotropic medication use. Staff interviews indicated that the lack of a clearly identified person responsible for updating care plans after new medication orders contributed to the deficiency. Both the DON and Administrator acknowledged that psychotropic medication use should have been included in the care plans for these residents.
Unsecured Treatment Cart and Improper Medication Storage
Penalty
Summary
Surveyors observed that a treatment cart containing medications used for wound care was left unattended and unlocked in a hallway for 25 minutes. During this time, no staff were present with the cart, and several staff members, visitors, and a resident in a wheelchair passed by the unlocked cart. Upon inspection, the cart was found to contain several topical medications, including antiseptic solution, medical grade honey, hydrocortisone cream, corticosteroid cream, and a cream for skin conditions. The Wound Care Nurse acknowledged forgetting to lock the cart and confirmed that these medications could be dangerous if accessed by a cognitively impaired resident. Both the DON and the Administrator confirmed that the cart should have been locked at all times when not in use, as the medications could pose a danger if ingested. Additionally, surveyors found that Astelin nasal spray, which must be stored upright according to manufacturer instructions, was stored horizontally in two separate medication carts. Nurses responsible for these carts admitted they had not read the manufacturer's instructions and were unaware of the proper storage requirements. The DON stated that nursing staff are expected to check carts and follow all manufacturer guidelines for medication storage, including storing the nasal spray upright if indicated.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control policy regarding Enhanced Barrier Precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter. During an observation, a nurse aide entered the resident's room, washed her hands, and applied gloves but did not don a gown, despite gowns being available and required by the facility's EBP policy for catheter care. The nurse aide proceeded to provide catheter care, noted the presence of bloody urine, and completed the task without ever applying a gown. Upon interview, the nurse aide acknowledged forgetting to put on the gown and recognized, after reviewing the posted signage, that a gown was required for this type of care. A similar observation occurred with a nurse who assessed the same resident's indwelling urinary catheter. The nurse entered the room, washed her hands, and applied gloves but did not wear a gown while lifting the resident's gown and lowering the brief to assess the catheter insertion site. After completing the assessment, the nurse disposed of her gloves and washed her hands. In an interview, the nurse admitted to forgetting to apply a gown and confirmed that it was required for catheter care. Both the Staff Development Coordinator and the Director of Nursing confirmed that the staff should have worn gowns during these high-contact care activities, as outlined in the facility's EBP policy.
Inaccurate MDS Coding for Falls, Oxygen Use, and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the areas of falls, oxygen use, and discharge status. Resident #17, who was admitted with diagnoses including diabetes, chronic kidney disease, and hypertension, experienced a fall on 4/2/24, as documented in a nurse's progress note. However, this fall was not recorded in the Quarterly MDS assessment dated 6/20/24. Interviews with MDS Nurses #1 and #2 revealed that the omission was due to human error, despite the fact that changes in resident conditions were discussed with the interdisciplinary team (IDT) each morning. The Director of Nursing (DON) and the Administrator both acknowledged that the MDS should have accurately reflected the fall. Resident #56, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had a physician's order for continuous oxygen use at 2 liters per minute via nasal cannula. Despite this, the admission MDS did not indicate oxygen use, although the Medication Administration Record confirmed continuous oxygen delivery since admission. MDS Nurse #1 admitted the oversight was due to human error. Similarly, Resident #93, who was discharged home, was incorrectly coded in the discharge MDS as being discharged to a short-term general hospital. MDS Nurse #2 acknowledged the error, and the Administrator confirmed that the MDS should have accurately reflected the resident's discharge status.
Failure to Include Diabetes Management in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with diabetes mellitus, who was taking hypoglycemic medication. The resident was admitted with this diagnosis, and a physician's order was in place for the administration of metformin, a hypoglycemic medication. However, upon review of the resident's comprehensive care plan, there was no mention of the diabetes diagnosis or the use of hypoglycemic medication, indicating a significant oversight in the care planning process. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the omission was an error. The MDS Coordinator acknowledged that it was her responsibility to include the resident's diabetes and medication in the care plan during the last review, but she missed it. The Director of Nursing and the Administrator both agreed that these elements should have been included in the comprehensive care plan, highlighting a lapse in the facility's care planning procedures.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a severely cognitively impaired resident, identified as Resident #45, who was dependent on staff for activities of daily living. Resident #45 was admitted with a diagnosis of cerebral infarction and was always incontinent of bowel and bladder. Despite having no pressure ulcers or skin conditions, the resident was at risk for skin integrity impairment due to the lack of incontinence care. Observations revealed that the resident's incontinence pad was wet, and there was a slight odor of urine, indicating that care had not been provided as required. On the day of the incident, Nurse Aide (NA) #1, who was responsible for Resident #45's care during the 7 AM to 3 PM shift, admitted to not checking or providing incontinence care since the start of her shift. She cited being occupied with another demanding resident and did not seek assistance from other staff members, such as the nurse or unit manager, who were available and willing to help. The Director of Nursing (DON) confirmed the resident's incontinence brief was saturated with urine and expressed disappointment in NA #1's failure to provide necessary care. Interviews with other staff members, including Nurse #4 and Unit Manager #2, revealed that they were unaware of the lack of care provided to Resident #45, as NA #1 did not communicate her inability to attend to the resident. Both Nurse #4 and Unit Manager #2 had been in the resident's room for other duties but did not check for incontinence or notice any issues. The facility's administrator stated that the resident should have received incontinence care every two hours, highlighting the oversight in care provision.
Failure to Attempt Alternatives Before Siderail Use
Penalty
Summary
The facility failed to attempt alternatives before installing siderails for two residents reviewed for accidents. Resident #27, who was admitted with vascular dementia and COPD, was found to have siderails installed without any prior attempts at alternative interventions. The physical device use evaluation completed by the Unit Manager indicated that no alternatives were tried before the use of one-quarter siderails. Observations revealed that the siderails were consistently in the raised position, and interviews with nursing staff confirmed that alternatives were not considered before siderail use. Similarly, Resident #56, admitted with end-stage renal disease, COPD, and a femur fracture, also had siderails installed without prior attempts at alternatives. The physical device use evaluation for this resident also showed no alternatives were attempted, and no medical symptom justified the use of siderails. Observations confirmed the siderails were in use, and interviews with nursing staff and the Director of Nursing revealed a lack of awareness regarding the requirement to try alternatives before siderail implementation. Interviews with the Director of Nursing and the Administrator further confirmed that the facility's practice was to use siderails unless they were contraindicated or declined by the resident or their representative. Both the DON and the Administrator were unaware that alternatives needed to be attempted before using siderails, indicating a systemic issue in the facility's approach to siderail use.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to handle soiled linen in a manner that prevents the spread of infection, as observed during a bathing activity for a resident. Nurse Aide #1 was seen removing soiled gloves, performing hand hygiene, and applying clean gloves before picking up soiled linen from the floor. She then transported the linen out into the hallway and placed it into the soiled laundry hamper without bagging it first. This action was contrary to the facility's policy, which requires soiled linen to be bagged or placed in containers at the location where it is used to avoid the transfer of microorganisms. Interviews with the Director of Nursing, who also serves as the facility's Infection Preventionist, and the Administrator confirmed that the practice observed was not in compliance with the facility's infection control policy. The Director of Nursing stated that soiled linen should not be placed directly on the floor, as it could lead to cross-contamination of microorganisms. The Administrator also indicated that soiled linen should be bagged for transportation unless it can be placed directly into the soiled linen hamper.
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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