Rockwell Park Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 1930 West Sugar Creek Road, Charlotte, North Carolina 28262
- CMS Provider Number
- 345489
- Inspections on file
- 35
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 17 (2 serious)
Citation history
Health deficiencies cited at Rockwell Park Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with a right upper tibia fracture had a physician’s order for a right lower extremity knee immobilizer to be worn continuously, removed only for skin checks and hygiene, with skin integrity documented twice daily and the leg maintained in extension. However, the comprehensive care plan contained no goals or interventions related to the immobilizer. The assigned nurse was unaware whether the device was care planned, the Unit Manager stated all care needs from orthopedic orders should appear on the care plan, and the MDS Coordinator acknowledged that immobilizer interventions should have been included but were omitted as an oversight. The DON confirmed that the immobilizer was a significant aspect of the resident’s care that should have been reflected in the comprehensive care plan.
Surveyors identified expired OTC bisacodyl suppositories and expired calcium tablets in two medication storage rooms, as well as an opened, undated vial of tuberculin PPD in a medication refrigerator. A unit manager and central supply staff member reported that the OTC room was stocked and checked regularly, and unit managers stated they were responsible for weekly checks of all medication rooms and refrigerators, with night-shift nurses also expected to check medication rooms. The DON and administrator confirmed that unit managers were responsible for monitoring expiration dates, that nursing staff were expected to verify expiration dates before use, and that opened vials were required by facility policy to be dated and used within a set timeframe.
A resident on Contact Precautions for an ESBL urinary infection had a Contact Precaution sign and PPE available at the room entrance requiring all staff to wear gloves and a gown upon entry. A nurse aide was observed completing incontinence care for this resident while wearing gloves but no gown, later stating she was moving quickly and forgot the gown despite knowing the resident’s precaution status. Facility leadership, including the ADON/IP, DON, the assigned nurse, and the Administrator, all confirmed that policy and door signage required both gown and gloves for any entry or care activity in such rooms.
A resident with dementia, severe cognitive impairment, and total ADL dependence was under a 30‑day discharge notice indicating his needs could not be met and listing his home as the discharge location, later amended to allow earlier transfer to a memory care facility. After the resident exhibited increased agitation, wandering, and unsteady gait, an RN obtained an order to send him to the ER, where he was medically cleared the same day and documented as not an imminent threat. When the hospital attempted to return him, the DON refused readmission due to safety concerns, despite the Regional Ombudsman’s communication that the facility was obligated to readmit him unless the family chose direct transfer to memory care. Email exchanges show the Administrator and DON maintained that the facility could not take him back, resulting in the resident remaining in the ER for several days before being discharged home with family and later placed in another memory care setting.
A resident with a right BKA, impaired mobility, and muscle weakness, who required two-person assistance and a mechanical lift for transfers, was being moved from a wheelchair to a bed by two NAs. The mechanical lift was positioned beside the bed with its legs parallel instead of under the bed and widened as required by the manufacturer’s instructions. Before the lift was correctly positioned, one NA began pulling on the lift sling from the opposite side of the bed to center the resident, causing the lift to tilt sideways. The lift arm struck the NA in the chest and came to rest on the resident’s leg while the resident was slightly above the mattress, after which the resident was lowered onto the bed without reported pain or visible injury. Interviews and a reenactment confirmed that improper lift positioning and pulling on the sling, contrary to manufacturer guidance, led to the unsafe transfer and tipping incident.
A resident with stroke, osteoporosis, muscle weakness, vascular dementia, and bilateral lower extremity ROM impairment, who was dependent for transfers and mobility and used a manual wheelchair, was transferred from bed to a wheelchair using a mechanical lift at the request of visiting family. The resident complained of leg pain and was unable to bend her legs to place her feet on the wheelchair footrests, leaving her legs extended straight out. An RN, feeling rushed because family was waiting, instructed the resident to hold her legs up and then pushed the wheelchair about 30 feet toward the medication cart. During this transport, the resident’s left leg dropped between the footrests and became caught under the wheelchair, causing severe pain and swelling. ED x‑rays confirmed an acute proximal tibia fracture of the left leg, and interviews with facility leadership and the medical director acknowledged that transporting the resident without her feet on the footrests and with improper positioning was unsafe and contributed to the injury.
The facility did not honor resident choice by prohibiting tobacco cigarette use and requiring all residents who smoked to switch to vaping devices, despite several residents expressing a preference for cigarettes and reporting dissatisfaction or adverse effects with vaping. Residents with a history of tobacco use and varying cognitive status were not given the option to continue smoking cigarettes, even though their care plans included interventions for safe smoking.
A resident with dementia and anxiety disorder had the frequency of a psychotropic medication increased without the responsible party being informed of the change or the associated risks and benefits. The responsible party was unaware of the medication and the change in frequency, and staff interviews confirmed that consent was not obtained prior to the medication adjustment.
A resident with a history of hemiplegia, COPD, and diabetes was initially care planned as a supervised smoker, but after quitting smoking, the care plan was not updated to reflect her new non-smoking status, despite documentation in the EMR and MDS assessments.
A nurse, unfamiliar with the assigned unit, attempted to administer medications to the wrong resident, resulting in a medication error rate of 7.69%. The nurse relied on door names and MAR photos but did not verify the resident's identity by asking their name, and only stopped when the resident refused the medication. This failure led to the administration of medications being nearly given to the wrong individual.
A cognitively impaired resident with a history of wandering and an elopement risk care plan exited the facility at night through an employee entrance that lacked a wanderguard alarm. The resident was found outside after approximately 15 minutes, lying on the ground with a tipped wheelchair, in a dark area near a cracked sidewalk. Staff did not observe the resident leaving, and the door required a keycode but was not alarmed for elopement risks.
Surveyors found that the facility failed to accurately code MDS assessments for four residents, including errors in discharge status, PASRR level, fall history, and physical restraint use. For example, a resident discharged to an ALF was incorrectly coded as discharged to a hospital, another with a Level II PASRR was not coded as such, a resident with multiple falls was marked as having none, and a resident was coded for bed rail use when none were present. These deficiencies were confirmed through record review, staff interviews, and observation.
A resident with a colostomy did not have any problems or interventions related to colostomy care included in their comprehensive care plan, despite this being a significant aspect of their care. Staff interviews confirmed the omission was an oversight.
A resident with hemiplegia following a CVA did not have a physician-ordered right-hand splint applied as required, despite documentation indicating otherwise. Observations showed the resident without the splint, and staff interviews revealed confusion over responsibility for its application, with nursing and therapy staff each believing the other was responsible. The DON and Administrator confirmed that nursing staff were expected to apply the splint.
Two residents experienced inaccurate medical record documentation: one had a right-hand splint recorded as applied on the MAR despite repeated observations and staff confirmation that it was not in use, and another received a prescribed medication for constipation that was not documented on the MAR after administration. Nursing staff admitted to assumptions and omissions in documentation, and leadership confirmed the expectation for accurate record-keeping.
A Unit Manager failed to perform hand hygiene before donning clean gloves while providing wound care to a resident, contrary to facility policy. The staff member also placed a soiled dressing on a clean bedside table with wound care supplies instead of disposing of it properly. The deficiency was confirmed through observation and staff interviews, with the Unit Manager acknowledging the lapse in infection control practices.
A resident was transferred to the hospital multiple times for medical reasons and later readmitted, but the facility failed to provide written notification of these transfers and discharges to the Ombudsman. Staff interviews revealed that the social worker responsible for this task was unaware of the requirement, and the Ombudsman did not receive the necessary information.
A resident with a traumatic brain injury was not immediately assessed by a medical provider after being hit on the head by a roommate, leading to a significant change in condition. Despite staff observing the resident's decline, including confusion and inability to transfer independently, the on-call provider was not promptly notified. The resident was eventually sent to the hospital for evaluation after falling from his wheelchair.
A resident with a history of traumatic brain injury was physically abused by a roommate, resulting in a significant decline in the resident's condition. Despite the resident losing consciousness and exhibiting increased confusion and decreased mobility, the facility did not immediately send the resident to the hospital. The resident's condition worsened, leading to further hospitalizations for post-concussive symptoms.
A resident with a history of traumatic brain injury was hit in the head by another resident, leading to a significant change in condition that was not promptly recognized or assessed by facility staff. Despite initial assessment, there was a lack of comprehensive follow-up, and the resident was not provided with necessary care until hours later, resulting in hospitalization. Additionally, another resident was improperly handled after a fall in a facility van, leading to a head injury. These incidents highlight failures in assessment, communication, and emergency response training within the facility.
A resident suffered a head injury when their wheelchair was not properly secured in a transport van, causing them to fall and hit their head. The driver, who had recently been trained and evaluated for competency in securing wheelchairs, failed to follow the manufacturer's instructions, leading to the incident.
A resident with bipolar disorder did not receive her prescribed monthly Aripiprazole injection from July to November, leading to emotional distress. The MAR showed inconsistencies, and interviews revealed communication lapses among nursing staff regarding the medication's unavailability. The Psychiatric NP confirmed that missing the medication could cause mood swings, highlighting a significant medication error.
The facility failed to provide RN coverage for at least 8 hours a day on 13 occasions due to staff turnover after a change in ownership. The facility relied on agency staff but struggled to fill RN positions, as confirmed by the Scheduler, DON, and prior Administrator.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing medical needs. A resident with multiple diagnoses lacked care plans for diabetes and medication use due to a lack of a full-time MDS Coordinator and transition issues. Another resident with a suprapubic catheter and pressure ulcers had no care plans for their management. A third resident's care plan did not include medication use or assistance with ADLs, attributed to a recent EMR system switch.
A resident's request to change her code status to DNR was not updated in the facility's records, leading to inconsistencies in her medical documentation. Despite the resident's expressed wishes during a care plan meeting, the MOST form, physician order, and EMR continued to indicate a Full Code status. Interviews revealed a communication breakdown between the Social Service Director and nursing staff, resulting in the failure to update the resident's code status across all records.
A resident's financial privacy was compromised when their name and amount owed for beauty/barber services were displayed on a sign-up sheet in a common area. Staff interviews revealed a lack of awareness and coordination regarding the sheet's content, and the Administrator acknowledged the breach of confidentiality.
A facility failed to thoroughly investigate an incident where one resident with a traumatic brain injury hit another during an argument. The investigation lacked necessary witness statements and staff interviews, as required by the facility's policy. The Administrator, who was responsible for the investigation, was unaware of a change in the condition of the resident who was hit, highlighting a deficiency in the investigation process.
The facility failed to accurately code the MDS for three residents, leading to deficiencies in assessing pain, ADLs, and pressure ulcers. A resident with chronic pain syndrome did not have a completed pain assessment. Another resident with neuropathy was inaccurately coded for ADLs, despite reporting improvements. A third resident with quadriplegia and stage 3 pressure ulcers was incorrectly coded as not at risk for pressure ulcers. MDS Coordinators working remotely did not address discrepancies, and the DON expected accurate assessments.
A resident receiving Quetiapine for anxiety and major depressive disorder did not have the required quarterly AIMS assessments to monitor for abnormal movements due to system errors and staff confusion. The last assessment was conducted in May 2024, despite the need for regular monitoring of psychotropic medication effects.
The facility failed to document Monthly Medication Reviews (MMRs) for two residents, leading to a deficiency in maintaining medical records. One resident with PTSD and dementia was missing MMRs for several months, while another with anxiety and depression had no MMRs documented for multiple months. Changes in ownership and the computer system contributed to the documentation lapse.
The facility failed to provide outside group activities for residents due to transportation issues, despite residents expressing the importance of such activities for their independence and socialization. The activity calendar showed only inside activities, and residents had not participated in outings for over a year. The previous administrator and Activity Director cited a broken van and lack of corporate approval for repairs or alternative transportation as reasons for the deficiency.
The facility failed to consistently provide evening snacks to residents, particularly those with type 2 diabetes, due to a lack of available snacks in nourishment rooms and insufficient communication between dietary and nursing staff. Residents reported having to purchase their own snacks or rely on family, while staff were unaware of the need to offer snacks. The interim Administrator and DON were not informed of the issue, expecting snacks to be readily available and offered.
The facility failed to maintain accurate temperature monitoring in refrigerators, adhere to QUAT sanitizer concentration guidelines, and ensure cleanliness of a condiment cart. Additionally, a dietary aide was observed without a beard restraint, violating hygiene policies.
The facility failed to maintain proper waste management, with an open dumpster exposing odorous trash and broken equipment around it. Insufficient dumpster capacity led to trash being stored in open utility trucks, attracting flies. Staff interviews revealed that the facility was transitioning ownership, affecting dumpster availability, and a third dumpster was awaited to address the issue.
A resident with bilateral lower extremity edema did not receive TED stockings as ordered by the physician. Despite documentation indicating their application, interviews revealed that the stockings were never received or applied. Staff assumed others had completed the task, leading to the resident not receiving the prescribed care.
The facility failed to provide food per resident preference for taste and temperature, affecting four residents. A resident with diabetes and hypertension found her meal unsatisfactory due to temperature, while another with similar conditions disliked the cold spinach. A third resident with renal failure and hypertension did not eat her meal, citing lack of seasoning. A fourth resident with hypertension reported ongoing dissatisfaction with food quality and temperature. A test tray confirmed the food was not served hot, and the facility was transitioning to new management to address these issues.
A resident with bilateral lower extremity edema had a physician's order for TED stockings, but the facility failed to apply them as ordered. The MAR inaccurately documented their application and removal, despite the resident not having received the stockings. Interviews revealed that nurses assumed nurse aides were handling the stockings, leading to inaccurate documentation without verification.
A facility did not allow a resident to return after hospitalization, citing behaviors and refusal of care as reasons. The resident, with a history of dementia and other conditions, was involuntarily committed due to self-harm statements and medication refusal. The facility's new guidelines deemed the resident inappropriate for return, and the hospital case manager was informed of the need for alternative placement.
A resident with bipolar disorder and blindness was allowed to self-administer medications and use an outside pharmacy, but the facility failed to update the care plan accordingly. Despite being cognitively intact, the resident's refusal to use the facility's physician and pharmacy was not reflected in the care plan. Interviews with the DON, MDS Coordinator, and interim Administrator confirmed the oversight.
A resident was not assessed for the ability to self-administer medications, despite having intact cognition and no functional limitations. The resident had medications on her overbed table, including Aspirin and Lactulose, without a physician's order for self-administration. Nursing staff were unaware of the resident's self-administration practices, and the facility failed to follow its policy requiring an assessment, physician notification, and secure medication storage.
The facility failed to accurately code MDS assessments for two residents, leading to deficiencies in care documentation. One resident with bipolar disorder and conduct disorder exhibited care refusal behaviors not reflected in the MDS. Another resident admitted to hospice care was not coded as such in the MDS. These inaccuracies were due to oversight and inexperience of the MDS Coordinator.
Expired over-the-counter medications were found in two medication storage rooms during a survey. In the south side room, an unopened bottle of Vitamin D expired in January 2024 and six bottles expired in May 2024 were discovered. The responsible Unit Manager admitted to missing the expiration dates. Similarly, in the west side room, four bottles of Vitamin D expired in May 2024 were found, with the Unit Manager also failing to notice the expiration. The DON confirmed that staff had checked the rooms recently but missed the expired medications.
A nurse failed to wear a gown while providing tracheostomy care to a resident, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. The policy requires gowns and gloves for high-contact care activities, including tracheostomy care. Despite receiving training, the nurse did not consider tracheostomy care as high-contact, leading to non-compliance with the EBP policy.
Three residents requiring assistance with meals experienced delays in receiving help, resulting in a lack of dignified dining. One resident with severe cognitive impairment waited for staff assistance while his roommate fed himself. Another resident with vision impairment expressed hunger while waiting for help, and a third resident with cognitive impairment felt sick and hungry during the delay. These incidents highlight the facility's failure to ensure timely and dignified dining for residents needing assistance.
A resident reported being hit by a Nurse Aide with a bed remote, but the LTC facility failed to follow its abuse policy. Despite the resident's intact cognition and the seriousness of the allegation, the incident was not reported or investigated as required. Staff were aware of the complaint, but no formal action was taken until later, and the facility's procedures were not followed.
A resident with a stage 3 sacral pressure ulcer was found without a dressing, contrary to physician orders, due to lapses in communication and adherence to care protocols. Staff interviews revealed a lack of awareness and communication about the resident's wound care needs, contributing to the deficiency. Medical professionals expressed concern over the risk of contamination and infection due to the uncovered ulcer.
A resident with anxiety and dementia was prescribed both Ativan and clonazepam due to a transcription error by a unit manager who failed to discontinue Ativan as ordered. The resident received both medications until hospitalization, where the error was discovered. The DON and Medical Director confirmed the error, noting potential risks but no confirmed adverse effects.
The facility failed to maintain daily nurse staffing sheets for 244 days from August 2023 to May 2024. The staffing coordinator did not have records from October 2023 to May 2024, as the previous Administrator had collected them. The new Administrator, who started in June 2024, could not locate the missing sheets despite searching the office.
Instances of physical and sexual abuse were reported involving cognitively impaired residents. One resident experienced physical abuse twice, including a chokehold by another resident. Another resident faced sexual abuse when touched inappropriately. The facility failed to protect these residents, highlighting a deficiency in ensuring their safety. Additionally, a resident with major depressive disorder and PTSD was involved in the physical abuse, with inadequate behavior care planning to address her needs and triggers, contributing to the deficiency.
A facility did not report two incidents of physical abuse involving a resident with dementia and multiple psychiatric conditions. The first incident occurred in the dining room following a verbal altercation, and the second incident took place in the hallway later the same day. Staff members, including the Activity Director, Activity Assistant, Nurse, and Human Resources Director, were aware of the incidents but did not promptly inform the facility administration. The DON and Administrator were only notified after the second incident. The facility's policies requiring prompt reporting and resident protection during abuse investigations were not followed.
Failure to Care Plan for Knee Immobilizer Use and Monitoring
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan that included immobilizer care for a resident with a right upper tibia fracture. The resident was admitted with a physician’s order for a right lower extremity knee immobilizer to be worn at all times, removed only for skin checks and hygiene, with the extremity maintained in extension. The order also required staff to document skin integrity every morning and at bedtime and to notify the provider if the skin was not intact. Record review showed that the comprehensive care plan dated the same day as the order contained no goals or interventions related to the right knee immobilizer, despite the resident being cognitively intact per the admission MDS. During interviews, the nurse assigned to the resident stated she did not know if the resident was care planned for the knee immobilizer and acknowledged that the resident should have a care plan in place. The Unit Manager explained that, upon admission, the admitting nurse, MDS Coordinator, and DON review orthopedic orders to determine care needs and that anything related to the resident’s care should be reflected in the care plan; she was not aware the immobilizer was omitted and did not know how it was missed. The MDS Coordinator confirmed he develops care plans based on diagnoses, MDS triggers, medical records, and resident interviews, stated he did not recall seeing a knee immobilizer on the resident, and acknowledged that interventions for the immobilizer should have been included, calling its absence an oversight. The DON stated that the MDS Coordinator develops care plans that are reviewed by the interdisciplinary team and confirmed the knee immobilizer was a significant part of the resident’s care and should have been included in the comprehensive care plan.
Expired and Undated Medications Found in Medication Storage Areas
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored, monitored for expiration, and labeled in accordance with professional standards. During an observation of the Over the Counter (OTC) Medication Storage room with a unit manager, surveyors found four boxes of bisacodyl 10 mg suppositories, each box containing 12 suppositories, with an expiration date of November 2025. The unit manager confirmed the expiration date and stated that the OTC room was checked frequently by central supply, and that nurses were expected to verify expiration dates before administering medications. The central supply staff member later reported that he stocked the OTC room weekly, checked for expiration dates, and had checked the room the prior week but did not identify the expired bisacodyl. In a separate medication storage room for another hall, surveyors found two bottles of Calcium 600 mg (60 tablets per bottle) with an expiration date of February 2026, which the unit manager confirmed. In the same medication room’s refrigerator, surveyors observed an opened, undated vial of Aplisol (tuberculin PPD, diluted) 5 TU/0.1 mL. The unit manager confirmed the vial was opened and undated and stated that unit managers were responsible for weekly checks of medication rooms and refrigerators for expired medications, and that a night shift nurse should also check the medication room each night. The DON stated that unit managers were responsible for checking expiration dates weekly in all medication rooms and the OTC room, that nursing staff were expected to check expiration dates before placing medications on carts or administering them, and that all vials should be dated when opened and were only good for 28 days per facility policy. The administrator similarly stated that medication storage rooms should be checked weekly for expiration dates and that opened vials should be dated when opened.
Failure to Follow Contact Precautions During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection control policy and procedures for Contact Precautions when a nurse aide did not wear all required personal protective equipment (PPE) while providing incontinence care. The facility’s Contact Precautions policy, revised in October 2018, required staff and visitors to wear clean, non-sterile gloves and a disposable gown upon entering the room of a resident on Contact Precautions, to change gloves after contact with infective material, and to remove gloves and gown with hand hygiene before leaving the room. On the date of survey, a Contact Precaution sign was posted on the door of a resident’s room, with PPE available next to the sign, and the sign specified that all healthcare personnel must wear gloves and a gown when entering the room and remove them before leaving. Surveyors observed a nurse aide completing incontinence care for this resident while wearing gloves but without a gown, despite the resident being on Contact Precautions for an ESBL (Extended Spectrum Beta-Lactamase) urinary infection. In an interview immediately after the observation, the nurse aide acknowledged awareness that the resident was on Contact Precautions, confirmed she had just completed incontinence care, and stated she was moving fast and forgot to put on a gown. The ADON/Infection Preventionist, DON, the assigned nurse, and the Administrator each confirmed in separate interviews that staff were required to follow the posted Contact Precaution signage and wear both gown and gloves for any entry or care activity in such rooms, including incontinence care, and that there was no acceptable reason for not following the policy.
Failure to Readmit Hospitalized Resident Under 30‑Day Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to readmit a resident after a hospital transfer while the resident was under a 30‑day discharge notice. The resident had dementia with behavioral disturbances, dysphagia, and chronic kidney disease, was severely cognitively impaired, and required staff assistance with all ADLs. The admission MDS indicated no coded behaviors and documented that the resident wished to remain in the facility long term. Care plans created earlier in the month identified the resident’s need and preference for long‑term care placement and documented risks for wandering and elopement, with interventions such as purposeful activities, de‑escalation strategies, and reorientation. On 2/26, the facility issued a 30‑day discharge notice stating that discharge was necessary for the resident’s welfare and that his needs could not be met in the facility, listing his home address as the discharge location. A revised notice the same day added a handwritten note that discharge could occur sooner if appropriate placement was found at a named memory care facility, while still listing the home address as the discharge location. The resident’s family reported that the memory care facility that assessed the resident was not acceptable to them, and they were working to find another placement. Despite this, the 30‑day discharge notice remained in effect. On 2/28, Nurse #5 documented that the resident had increased confusion, agitation, wandering, unsteady gait, and was at one point falling into the wall while walking. The nurse reported that the resident attempted to swing at staff, contacted the medical provider, obtained an order to send the resident to the ER, and notified the responsible party. Hospital records show the resident was brought to the ER for abnormal gait and increased agitation and was medically cleared for discharge later that day, with documentation that he was not an imminent threat to himself or others. When the hospital attempted to return the resident to the facility, the Former DON told the Hospital Case Manager that the resident would not be returning due to safety concerns and documented that the Regional Ombudsman was involved. Email communications among the social worker, Administrator, Former DON, and Regional Ombudsman show that the social worker sent the amended 30‑day discharge notice to the Ombudsman on 2/28 after the resident’s transfer. The Regional Ombudsman later relayed that the Hospital Case Manager reported the resident was in the ER, not admitted, and that unless the family chose to move him directly to memory care, the facility was obligated to readmit him and provide a sitter until transfer. The Administrator acknowledged that the resident had been accepted to memory care and that the family was considering options, and later indicated that the family wanted to appeal the 30‑day discharge notice. When the Ombudsman asked if the resident would return to the facility, the Administrator suggested he would, but the Former DON responded that the facility was not able to take him back. Hospital records and interviews confirm that the resident remained in the ER from 2/28 until 3/6 because the facility would not readmit him while the 30‑day discharge notice was in effect. The Hospital Case Manager stated that when the facility was contacted on 2/28 to readmit the resident, the Former DON refused. The Regional Ombudsman stated she informed facility management of the resident’s right to return and that the Former DON maintained the facility would not readmit him. The resident was ultimately discharged from the hospital to his home with a family member and later placed in another memory care facility. These actions and inactions demonstrate that the facility did not ensure the resident’s transfer and discharge were consistent with his needs and preferences and did not readmit him after hospital evaluation despite his being medically cleared and under an active 30‑day discharge notice.
Improper Mechanical Lift Positioning Causes Tipping Incident During Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe mechanical lift transfer for a resident, resulting in the lift tipping during a bed transfer. The resident had end stage renal disease, a right below-knee amputation, bilateral lower extremity range of motion impairment, and muscle weakness. An annual MDS showed the resident was cognitively intact but required substantial to maximal assistance with transfers. The care plan documented a need for two-person assistance and use of a mechanical lift for transfers due to an ADL self-care deficit related to the amputation. On the day of the incident, two nurse aides were transferring the resident from a wheelchair to the bed using a mechanical lift. Manufacturer instructions for the lift specified that, for bed transfers, the lift legs should be positioned under the bed, widened for stability, and that staff should not push or pull on the lift arm or the patient. Contrary to these instructions, the lift was positioned beside the bed with the legs parallel to the bed rather than horizontally underneath it. During the transfer, one aide was on the side of the bed with the lift, and the other was on the opposite side attempting to position the resident over the center of the bed. According to interviews and the subsequent reenactment, before the lift was correctly positioned with its legs under the bed, one aide began pulling on the lift sling to center the resident over the bed. This action, combined with the improper positioning of the lift legs, caused the lift to tilt sideways. As it tipped, the arm of the lift struck one aide in the chest and came to rest on the resident’s left leg/knee while the resident was approximately two inches above the mattress. The resident, the aides, and the former DON all reported that the resident was then lowered onto the bed and had no complaints of pain or visible injury at that time. An x-ray of the resident’s left knee later showed an intact knee arthroplasty with no acute fracture or injury. The facility’s investigation, including statements from the aides and a reenactment, confirmed that the mechanical lift had been placed with its legs parallel to the bed instead of under it and that the aides were pulling on the lift sling to position the resident, both of which were inconsistent with the manufacturer’s instructions. The former DON stated that the lift legs should have been placed horizontally under the bed and widened to provide stability before attempting to position the resident, and that staff should not have been pulling on the lift sling. These actions and inactions directly led to the lift tipping during the transfer, constituting the unsafe transfer and accident hazard cited in the deficiency. Subsequent interviews with the resident and involved staff corroborated the sequence of events. The resident recalled the lift tipping sideways during the transfer, the lift arm striking the aide, and coming to rest on his left knee while he was slightly above the bed, after which he was placed onto the mattress without pain or injury. Both aides described the lift tipping as they attempted to center the resident over the bed, with one aide specifically attributing the tilt to the lift being off balance due to incorrect positioning and pulling on the sling. These consistent accounts, along with the manufacturer’s instructions and the facility’s own findings, establish that the improper positioning and handling of the mechanical lift during the transfer led to the cited deficiency in maintaining a safe environment and preventing accidents.
Unsafe Wheelchair Transport Leading to Tibia Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide safe wheelchair transport and adequate supervision to prevent an accident for a resident with significant mobility and cognitive impairments. The resident had diagnoses including cerebral infarction, osteoporosis, muscle weakness, vascular dementia, and bilateral lower extremity range of motion impairment, and was dependent on staff for transfers and mobility. A quarterly MDS showed the resident was moderately cognitively impaired, used a manual wheelchair, and required staff assistance for all ADLs, with a care plan noting dependence for all ADLs and a pattern of often refusing to get out of bed. On the day of the incident, 15–20 family members arrived to celebrate the resident’s birthday and requested that she be transferred out of bed to a larger area because her room was too small to accommodate them. The resident initially refused to get out of bed but later agreed after continued encouragement from family and staff. Nurse #1 and Nurse #2 used a mechanical lift to transfer the resident from bed to her personal wheelchair. During this transfer, the resident complained of leg pain and was unable to bend her legs to place her feet on the wheelchair footrests due to stiffness and pain, resulting in her legs being extended straight out rather than supported on the footrests. Despite recognizing that the resident could not bend her legs and was complaining of pain, Nurse #1 proceeded to transport her in the wheelchair by asking the resident to hold her legs up while being pushed approximately 30 feet to the medication cart for pain medication. As Nurse #1 was approaching the medication cart, the resident yelled out about her leg; Nurse #1 then observed that the resident’s left leg had dropped down between the wheelchair footrests and become caught underneath the wheelchair. The resident was found to have swelling and severe pain in the left shin, and subsequent ED evaluation and x‑rays revealed an acute fracture of the left proximal tibia. Interviews with Nurse #1, the DON, the Medical Director, and the Former Administrator confirmed that transporting the resident in the wheelchair with her legs extended and not on the footrests was unsafe and that the positioning in the wheelchair contributed to the injury. Title: Unsafe Wheelchair Transport Leading to Tibia Fracture
Failure to Honor Resident Choice in Smoking Policy
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice by implementing a policy that prohibited the use of tobacco cigarettes and only allowed vaping or e-cigarettes. This policy change affected all residents who smoked, as they were no longer permitted to smoke tobacco cigarettes in the designated smoking area. Observations and interviews confirmed that multiple residents, including those who were cognitively intact or moderately impaired and had a documented history of tobacco use, were required to use vaping devices despite their expressed preference for tobacco cigarettes. Residents reported dissatisfaction with vaping, with some stating it made them sick or that they did not like it, and indicated they were not given the option to continue smoking tobacco cigarettes as they had previously. The facility's records, including care plans and safe smoking evaluations, showed that residents had previously been assessed for safe tobacco use and had interventions in place such as supervision and the use of smoking aprons. Despite these measures, the facility's new policy was implemented due to concerns about residents' ability to safely handle lit cigarettes and challenges with staff supervision during smoking times. Residents were informed of the policy change through meetings, but those who did not wish to switch to vaping were only offered smoking cessation support or the option to transfer to another facility that allowed tobacco cigarettes.
Failure to Obtain Informed Consent for Psychotropic Medication Change
Penalty
Summary
The facility failed to obtain informed consent and adequately inform the resident's responsible party (RP) about the risks and benefits of a psychotropic medication prior to increasing its frequency for a resident with dementia and anxiety disorder. The resident, who had severely impaired cognitive skills and exhibited behavioral symptoms, was receiving antipsychotic and antianxiety medications, including ABH gel. The physician order for ABH gel was changed from twice daily to three times daily, but there was no documented evidence that the RP was informed of this change or provided with information about the medication's risks and benefits before the change was implemented. Interviews with the RP revealed she was unaware of what ABH gel was, had not been informed about the medication or its increased frequency, and had not discussed its risks and benefits with staff. The unit manager acknowledged completing a consent form after a care conference but did not recall discussing the risks and benefits or the frequency increase with the RP at the time of the order change. The DON confirmed that the facility's process required obtaining consent prior to starting or changing psychotropic medications, but also acknowledged that consents were not consistently obtained prior to therapy changes during the relevant period.
Failure to Update Care Plan After Change in Smoking Status
Penalty
Summary
The facility failed to revise the care plan for a resident when her smoking status changed. The resident, who had a history of hemiplegia, hemiparesis following cerebral infarction, COPD, and type 2 diabetes mellitus, was initially care planned as an unsafe and supervised smoker, with interventions including a smoking safety evaluation and use of a smoking apron. However, subsequent documentation in the electronic medical record and a recent assessment indicated that the resident had quit smoking in the previous month and wished to remain a non-smoker. The annual MDS also reflected that the resident was cognitively intact and not coded for tobacco use. Despite these updates, the care plan continued to list tobacco use as a focus area and was not revised to reflect the resident's new non-smoking status.
Medication Error Rate Exceeds 5% Due to Resident Misidentification
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 26 opportunities, resulting in a 7.69% error rate. During a medication pass, a nurse prepared to administer medications intended for one resident but attempted to give them to another resident. The nurse was unfamiliar with the residents on the assigned unit and relied on names on the door and pictures in the Medication Administration Record (MAR) for identification. Despite these resources, the nurse attempted to administer the wrong medications, and only stopped when the resident pushed the medication cup away. The nurse admitted she would have given the medications to the wrong resident if not for the resident's refusal. The resident involved had a history of polyosteoarthritis and constipation, with active orders for Polyethylene Glycol and Acetaminophen. The nurse did not verify the resident's identity by asking for their name before attempting to administer the medication. Interviews with facility staff confirmed that the nurse was not familiar with the residents on the unit and did not follow established procedures for verifying resident identity prior to medication administration.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a cognitively impaired resident, who was care planned as an elopement risk and known wanderer with impaired safety awareness, exited the facility at night without staff knowledge. The resident was last seen at 9:00 PM and was discovered missing at approximately 9:30 PM. Staff conducted a search of the building before checking the back employee entrance, which required a keycode for exit and was not equipped with a wanderguard alarm. The resident was found outside, lying on his left side with his wheelchair on top of his lower back, approximately 30 feet from the exit door in a dark area near a dumpster. The area where the resident was found had a large crack in the pavement, which likely contributed to the wheelchair tipping over. The resident had a history of heart failure, metabolic encephalopathy, and non-Alzheimer's dementia, and was assessed as severely cognitively impaired, requiring moderate assistance for transfers. The care plan included interventions such as distraction, increased supervision, and a wanderguard bracelet, which was to be checked every shift. However, the back employee entrance did not have a wanderguard alarm system, and staff interviews indicated that the resident may have followed someone out of the door or exited when the door was left open. The resident was found outside after being missing for approximately 15 minutes, and staff noted that he was confused and stated he was looking for the kitchen. Interviews with staff and the DON revealed that the resident was known to follow staff closely and wander the facility in his wheelchair. The back employee entrance, used by staff for entry and exit, was not protected by a wanderguard alarm, and staff did not observe the resident exiting. The resident's elopement risk assessment was scored as low after the incident, and there was no documentation of wandering behaviors in the medical record prior to the event. The incident resulted in the resident being found outside at night, unsupervised, and in a potentially hazardous area.
Removal Plan
- Staff conducted a facility-wide search and located Resident #1 outside the employee exit door after being reported missing.
- A head-to-toe skin assessment, neurological checks, and range of motion were completed for Resident #1; no concerns identified.
- The Director of Nursing notified the on-call Nurse Practitioner and Resident #1's responsible party.
- The Regional Clinical Director reviewed Resident #1's care plan and physician orders to ensure proper documentation and interventions for wandering/elopement and wanderguard use.
- The Director of Nursing verified all doors were secure and locked, including performance test of wanderguard door.
- The Director of Nursing completed an elopement risk assessment for Resident #1 and verified wanderguard placement and battery function.
- Resident #1 was placed on 1:1 supervision.
- A 100% resident count was completed to ensure all residents were present.
- The Director of Nursing/Designee verified all residents with wanderguards had them in place and functioning.
- The policy and procedure for Wandering and Elopement was reviewed.
- The Maintenance Director checked all exit doors for proper functioning and performed a function test on the wanderguard door.
- Stop signs were placed on all exit doors as visual reminders for residents and staff.
- The Director of Nursing/Designee completed elopement assessments for all residents and evaluated interventions for those at risk.
- The Regional Clinical Director reviewed/updated care plans and NA's kardex's for all residents at risk for elopement/with a wanderguard.
- The Regional Clinical Director reviewed physician orders for all residents with wanderguards to ensure proper orders were in place.
- The Assistant Director of Nursing updated elopement books with pictures of residents at risk for elopement; books are maintained at nurse stations and reception.
- An elopement drill was conducted with all staff on duty using the facility Elopement Drill Documentation Audit Form.
- Staff were educated on the policy and procedure for Wandering and Elopement, including the elopement drill process and specific safety measures (e.g., not allowing residents to sit at exit doors, ensuring doors are closed/locked, monitoring whereabouts of wandering residents, reporting new behaviors, completing risk assessments, verifying wanderguard function, reviewing kardex, and responding to elopement/missing person).
- Education was added to the facility orientation program for all new hires, with validation by the Human Resource Director.
- An ADHOC QAPI Committee Meeting was held to review and approve the corrective plan and monitor its implementation.
- Root Cause Analysis was completed to determine the cause of the incident.
- The Director of Nursing/Designee and/or Human Resources Director/Designee will randomly observe staff entering/exiting employee entrance/exit doors (not wanderguard protected) to ensure compliance with safety protocols.
- The Maintenance Director/Designee will perform door checks on all exit doors and function tests on the wanderguard door.
- The Director of Nursing/Designee will verify wanderguards are functioning properly weekly.
- Elopement drills will be conducted on each shift, then additional drills monthly.
- The Director of Nursing/Designee will review all new admissions elopement assessments weekly to ensure proper interventions are implemented.
- The Director of Nursing/Designee will review progress/behavior notes to ensure wandering behaviors are addressed with proper interventions.
- The Director of Nursing/Designee and Maintenance Director will report audit results to the facility's QAPI committee meeting for review and recommendations.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in several key areas, including discharge status, PASRR level, fall history, and use of physical restraints. In one case, a resident was discharged to an assisted living facility, but the MDS incorrectly indicated a discharge to a short-term hospital. Another resident with a documented Level II PASRR was not coded as such on the MDS, despite having a diagnosis of schizophrenia and a valid Level II PASRR determination. Additionally, a resident with a history of multiple falls was coded as having no falls since admission, contrary to incident reports and nursing notes. Finally, a resident was coded as using bed rails as a physical restraint, but observations and staff interviews confirmed that no bed rails were present and the facility was restraint-free. These inaccuracies were identified through record reviews, staff interviews, and direct observation. The MDS Coordinator, who had recently started at the facility, acknowledged the errors and attributed them to oversight or lack of accurate information at the time of assessment. The DON and Administrator both confirmed that MDS assessments are expected to be coded accurately to reflect each resident's actual status and history.
Failure to Include Colostomy Care in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing colostomy care for a resident who was admitted with a colostomy. Record review showed that the resident's Minimum Data Set (MDS) assessment identified the presence of a colostomy, but the care plan dated 2/18/25 did not include any problems or interventions related to colostomy care. Interviews with the MDS Coordinator, DON, and Administrator confirmed that the omission of colostomy care from the care plan was an oversight and that the resident's colostomy status was a significant aspect of her care that should have been addressed in the care plan.
Failure to Apply Physician-Ordered Hand Splint for Resident with Limited ROM
Penalty
Summary
A deficiency occurred when staff failed to apply a physician-ordered right-hand splint for a resident with a history of cerebrovascular accident (CVA) resulting in hemiplegia and hemiparesis. The resident had an active order for a right resting hand splint to be worn daily after AM care and removed after PM care, with occupational therapy recommending up to 8 hours of daily use. Despite documentation in the Medication Administration Record indicating the splint was applied, multiple observations over several days showed the resident without the splint, and the device was not present in the resident's room. The resident, who was unable to communicate verbally, indicated through gestures that staff did not apply the splint and that he could not apply it himself. Interviews with staff revealed confusion regarding responsibility for applying the splint. Nurse aides reported not having seen the splint for weeks and believed therapy staff were responsible, while nursing staff thought therapy applied the splint or that the resident removed it himself. The Therapy Director clarified that therapy services had been discontinued and that nursing staff were responsible for the splint application, with education provided at the time of therapy discharge. The Director of Nursing and Administrator both confirmed that nursing staff should have been applying the splint as ordered.
Failure to Accurately Document Medical Records and Medication Administration
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents, specifically regarding the documentation of a right-hand splint application and the administration of a prescribed medication. For one resident, the Medication Administration Record (MAR) indicated that a right-hand splint was applied every morning over a three-week period, with specific documentation by a nurse on several dates. However, multiple observations by surveyors revealed that the resident was not wearing the splint during these times, and both the resident (using non-verbal cues) and a nurse aide confirmed that the splint had not been applied for several weeks. The nurse responsible for the documentation admitted to recording the splint as applied based on the assumption that therapy staff had done so, rather than direct observation or action. In a separate incident, another resident was prescribed Polyethylene Glycol 3350 for constipation, to be administered as needed. A nurse's progress note indicated the medication was given after three days without a bowel movement, but there was no corresponding documentation on the MAR for the entire month. The nurse involved acknowledged during an interview that she had forgotten to chart the medication administration on the MAR, despite her responsibility to do so. Both the Director of Nursing and the Administrator confirmed that nursing staff are expected to accurately document all medication administration in the MAR.
Failure to Follow Hand Hygiene Policy During Wound Care
Penalty
Summary
A deficiency occurred when the Unit Manager failed to follow the facility's Hand Hygiene policy during wound care for a resident. The Unit Manager was observed cleaning the bedside table, donning a clean gown and gloves, and removing the old dressing from the resident's sacrum. After doffing her gloves, she did not perform hand hygiene before donning new gloves and continued with the wound care procedure, including applying a collagen sheet and dry dressing. The Unit Manager also placed the soiled dressing onto the clean bedside table with wound care supplies instead of disposing of it in the trash can. She only washed her hands with soap and water after completing the procedure and before leaving the room. The facility's policy required hand hygiene immediately before touching a resident, before performing an aseptic task, after glove removal, and in other specified situations. The Unit Manager acknowledged during an interview that she was aware of the hand hygiene requirements and recognized her failure to sanitize her hands between glove changes. The Infection Preventionist and Director of Nursing both confirmed that the expectation was for staff to perform hand hygiene after glove removal and before donning new gloves, especially during wound care procedures.
Failure to Notify Ombudsman of Resident Hospital Transfers and Discharges
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding a resident's transfer and discharge to the hospital. Record review showed that a resident was admitted to the facility and subsequently transferred to the hospital on two separate occasions for further medical evaluation and treatment, including lack of appetite, generalized weakness, and urinary retention. The resident was readmitted to the facility after each hospital stay. Despite these transfers and discharges, there was no documentation that the Ombudsman was notified in writing as required. Interviews with facility staff revealed a lack of awareness and implementation of the requirement to notify the Ombudsman. The Ombudsman confirmed she did not receive a hospital transfer and discharge list for the relevant month. The DON indicated that social work was responsible for this communication, but the assigned social worker was unaware of the requirement and had not sent any such notifications since starting employment. The Administrator also confirmed that the process had not been followed, as no one at the facility was currently sending the required information to the Ombudsman.
Failure to Notify Medical Provider After Resident Injury
Penalty
Summary
The facility failed to immediately consult with the on-call medical provider when a resident with a pre-existing traumatic brain injury lost consciousness after being hit on the back of the head by his roommate. The incident occurred when a nurse heard a loud thud and observed the resident being struck. Although the nurse notified the on-call nurse practitioner about the altercation, she did not report the resident's loss of consciousness and slumping in the chair. This oversight led to a significant change in the resident's condition, including confusion and altered mental status, which was not immediately addressed by medical staff. Throughout the day, the resident's condition continued to decline. He was unable to transfer himself, became incontinent, and required increased assistance from staff. Despite these changes, the on-call provider was not contacted again until much later in the day, after the resident had fallen from his wheelchair. The resident was eventually sent to the hospital for evaluation due to concerns about a concussion, but only after several hours had passed since the initial incident. Interviews with staff revealed a lack of communication and failure to recognize the severity of the resident's condition. Multiple staff members noted the resident's altered state and increased care needs, but there was confusion about who was responsible for notifying the medical provider. This deficiency affected the resident's care and highlighted a breakdown in the facility's protocol for handling changes in a resident's condition.
Removal Plan
- Nurse #3 was re-educated on notification of medical provider per the policy and procedure for a resident with a change in condition based on the urgency of the situation to include but not be limited to falls, resident to resident altercations, injuries, unstable vital signs, head trauma and indwelling catheter with recurrent symptomatic urinary tract infections, or recurrent pneumonia, changes in skin color or condition.
- All licensed nurses, agency/contract staff, and all newly hired licensed nursing employees along with Certified Nurse Aides will be educated on proper notifications to the Medical Provider or to the On Call Provider after hours and on weekends when a resident has a change in condition or incident, immediately after the incident or immediately at the time when a change in condition occurs. The On Call After Hours provider numbers are posted at each nurses' station. Education will be completed by the DON/Nurse Manager. Nursing staff not educated will be educated prior to the start of their next scheduled shift. This education will be completed in person or by telephone. Education for newly hired staff will be completed by the Director of Nursing/Nurse Manager during the orientation period. Staff who were not educated either in person or by telephone will be educated prior to the start of their next scheduled shift. The DON is responsible for tracking staff who still require education. The DON/Licensed Nurse Manager will provide education to staff not educated prior to the start of the next scheduled shift.
- The Administrator will be responsible for the completion of the immediate jeopardy removal plan.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a significant change in the resident's condition. On the morning of September 14, 2024, a nurse heard a loud thud and observed a resident being hit in the back of the head by his roommate. The resident, who had a history of traumatic brain injury, lost consciousness briefly and exhibited a change in condition, including increased confusion and decreased mobility. Despite these changes, the resident was not immediately sent to the hospital for evaluation. The resident's condition continued to deteriorate throughout the day, with staff noting increased weakness and inability to perform activities of daily living independently. The resident eventually slid out of his wheelchair and was sent to the hospital later that evening. A CT scan showed no acute findings, and the resident was discharged back to the facility with instructions to return if symptoms worsened. However, the resident returned to the hospital a few days later with symptoms consistent with post-concussive changes. Interviews with facility staff revealed that the resident's condition was not adequately assessed or addressed following the incident. The nurse practitioner initially did not deem it necessary to send the resident to the hospital, despite reports of a significant decline in the resident's baseline condition. The facility's response to the incident was insufficient, as the resident's change in condition was not promptly recognized or acted upon, leading to further complications and hospitalizations.
Removal Plan
- Resident #49 was separated from his roommate and moved to another room to ensure safety.
- 15-minute safety checks were initiated for both Resident #49 and his roommate.
- Skin checks were performed by a licensed nurse for both Resident #49 and his roommate after the event.
- The Nurse Manager and the Social Services Director completed interviews with residents with a BIMS of 13 and above to ensure no abuse or neglect.
- Current residents with a BIMS of 12 and below had skin checks performed by a licensed nurse to ensure no suspicious injuries or indication of abuse or neglect.
- The Administrator and the Director of Clinical Services reviewed the incident log for any other potential abuse allegations needing to be self-reported.
- Current residents with targeted physical behaviors were identified by the Interdisciplinary Team.
- Care plans and behavior monitoring tools for residents with targeted physical behaviors were reviewed and updated as needed.
- The Regional Director of Clinical Services reviewed the policy and completed re-education of the facility's policy and procedures for abuse and neglect with the Administrator and the Director of Nursing.
- The Director of Nursing and Nurse Managers completed re-education with all current staff on the facility's policy and procedure for abuse and neglect.
- Education for the nursing staff will be the responsibility of the DON/Licensed Nurse Manager for current staff.
- Education will be done by the DON/RN Nurse Manager during the orientation period for any newly hired staff ongoing, including agency staff for abuse and neglect.
- An Ad-Hoc Quality Assurance Performance Improvement Committee was held to formulate and approve a plan of correction for the deficient practice.
Failure to Recognize and Respond to Significant Changes in Resident Condition
Penalty
Summary
The facility staff failed to recognize the seriousness of a significant change in condition for Resident #49, who had a history of traumatic brain injury, after being hit in the head by another resident. Despite initial assessment by Nurse #3, which noted no acute distress, there was a lack of comprehensive assessments and neurological checks following the incident. Resident #49 exhibited a change in condition, including confusion, inability to self-propel in his wheelchair, and increased assistance needed for transfers. However, effective communication between staff was lacking, and no further care or assessments were provided until several hours later, leading to Resident #49 being sent to the hospital for evaluation. Additionally, the facility failed to assess Resident #55 for injury before moving him after he fell in the facility van and hit his head. Driver #1, who had not been trained on how to respond in emergency situations, lifted Resident #55 back into an upright position without a medical assessment. Resident #55 was later diagnosed with a closed head injury, scalp abrasion, and strained neck muscles after being transported to the hospital for further evaluation. These incidents highlight the facility's failure to complete comprehensive and ongoing assessments, recognize the need for urgent medical attention, and ensure effective communication among staff. The deficient practices resulted in Immediate Jeopardy for both residents, which was later removed after the facility implemented an acceptable credible allegation. However, the facility remains out of compliance at a lower scope and severity level, indicating the need for further education and monitoring systems to ensure effectiveness.
Failure to Secure Wheelchair in Transport Van
Penalty
Summary
The facility failed to provide safe van transportation for a resident when the driver did not secure the resident's wheelchair in the facility van according to the manufacturer's instructions. During transport from a dialysis center, the resident fell backward in the wheelchair and hit their head on the van floor, resulting in an abrasion, swelling, and severe head pain. The resident was subsequently diagnosed with a closed head injury, scalp abrasion, and strained neck muscles at the emergency department. The incident occurred despite the driver having completed a competency evaluation for securing wheelchairs in the van just days prior. The driver had been trained by the former administrator, who observed the driver securing a wheelchair and confirmed competency. However, during the incident, the driver noted that one of the tie-down straps had come loose, which led to the resident's fall. Interviews with the resident and staff revealed that the resident had previously felt insecure during transport but did not report it. The driver admitted to not properly securing the wheelchair, which resulted in the accident. The facility's failure to ensure the wheelchair was secured according to the manufacturer's instructions directly led to the resident's injury.
Removal Plan
- Immediate education was provided via phone by the Regional Director of Clinical Services to the Administrator and Director of Nursing. This education included Vehicle Driver Safety Program, proper use of wheelchair securement devices per manufacturer's instructions, vehicle lift competency evaluation, placing the van out of service immediately, and not allowing the facility transportation driver to drive until investigation completed.
- Immediate education provided by the Director of Nursing to the facility Transportation Driver. This written and verbal education included Vehicle Driver Safety Program, proper use of wheelchair securement devices as per manufacturer's instructions, vehicle lift competency evaluation, placing the van out of service immediately, not allowing the facility transportation driver to drive until investigation completed.
- The Contracted Transportation company provided the facility with their policy and procedures for securing and strapping a wheelchair and competencies for the 2 current drivers. The education and competencies are completed upon hire and annually.
- The facility Transportation Driver, Maintenance Director and Maintenance Assistant were re-educated by the Regional Maintenance Director on the Facility Vehicle Driver Safety Program, including proper use of wheelchair securement devices ensuring proper tension of devices per manufacturer's instructions, with return demonstration, and competency check off completion, and validated facility Transportation Driver was able to safely operate facility van. This education will be added to the facility orientation program for new Transportation Drivers, Maintenance Director or Maintenance Assistant. This education and competencies will be completed annually for the current Transportation Driver, Maintenance Director and Maintenance Assistant.
- The Regional Maintenance Director inspected the facility van. The Regional Maintenance Director placed the facility van back in service.
- The facility Transportation Driver resumed transportation for the facility.
Failure to Administer Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Aripiprazole, an antipsychotic medication. Resident #2, who was diagnosed with bipolar disorder, was supposed to receive a monthly intramuscular injection of Aripiprazole. However, from July 2024 through November 2024, the medication was not administered as prescribed. The Medication Administration Records (MAR) for these months showed inconsistencies, with some entries left blank, others incorrectly marked as administered, and one instance where the medication was noted as unavailable. Interviews with nursing staff revealed a lack of communication and follow-up regarding the medication's unavailability. Nurse #6 documented the medication as not administered in October 2024 due to its absence from the medication cart and was unsure if the pharmacy had been contacted for a reorder. Nurse #8, who took over the shift, did not recall being informed about the missing medication. Nurse #1 mistakenly marked the medication as administered in November 2024, despite knowing it was unavailable, and admitted to forgetting to reorder it due to the workload. Resident #2 experienced emotional distress, including uncontrollable crying and waking up at night in tears, which she attributed to not receiving her medication. The facility's Activities Director and Social Workers noted the resident's depressive symptoms and reported them to the nursing staff. The Psychiatric Nurse Practitioner confirmed that the lack of Aripiprazole could lead to increased crying and mood swings, highlighting the significance of the medication error. The Pharmacist confirmed that the medication had not been refilled since July 2024, indicating a failure in the facility's medication management process.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, on 13 specific days between June 22, 2024, and November 22, 2024. This deficiency was identified through a review of daily assignment schedules and staff interviews. The absence of RN coverage on these days was confirmed by the facility Scheduler, who reported that the lack of RNs was due to significant staff turnover following a change in facility ownership in June 2024. The facility had been relying on staffing agencies but was unable to secure RN coverage when needed. Interviews with the Director of Nursing (DON) and the prior Administrator revealed awareness of the RN staffing issues. The DON, who joined the facility in August 2024, acknowledged the lack of RNs in supervisory roles and mentioned ongoing efforts to hire RNs, including for the positions of Assistant Director of Nursing (ADON) and Unit Manager. The prior Administrator confirmed that RN coverage had been problematic since the ownership change, with many nurses being let go and the facility operating primarily with agency staff.
Deficiencies in Care Plan Development for Residents
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their medical needs. Resident #9, who had multiple diagnoses including diabetes mellitus type 2, dementia, and atrial fibrillation, did not have care plans related to her diabetes or the use of various medications such as insulin, antidepressants, and anticoagulants. Despite receiving these medications as ordered, the care plans were not updated due to a lack of a full-time MDS Coordinator and the transition from paper to electronic records, as reported by the MDS Coordinator and Regional MDS Coordinator. Resident #199, who was readmitted with urinary retention and had a suprapubic catheter and pressure ulcers, also lacked appropriate care plans. The care plans did not address the management of his catheter or the treatment of his pressure ulcers, despite physician orders and observations indicating the need for such plans. The Regional MDS Coordinator acknowledged the oversight, attributing it to the absence of a full-time MDS Coordinator and the challenges of updating care plans during the facility's ownership change. Resident #1, diagnosed with major depressive disorder and diabetes mellitus, was receiving psychotropic and diabetes medications as ordered. However, her care plan did not include details on her medication use, assistance with activities of daily living, or diabetes therapy. Interviews with the MDS Consultant and the Director of Nursing confirmed that these aspects should have been included in the care plan. The facility's recent switch in electronic medical record systems contributed to the failure to update the care plans, as noted by the MDS Consultant.
Failure to Update Advanced Directive Information
Penalty
Summary
The facility failed to ensure that the advanced directive information for a resident was consistent and correctly updated throughout the medical record. The resident, who was moderately cognitively impaired, had expressed a desire to change her code status to Do Not Resuscitate (DNR) during a care plan meeting attended by her and her Resident Representative (RR). Despite this, the Medical Orders for Scope of Treatment (MOST) form, the physician order, and the electronic medical record (EMR) continued to reflect a Full Code status, indicating a failure to update the resident's wishes across all relevant documentation. Interviews with facility staff revealed a breakdown in communication and procedure. The Social Service Director, responsible for updating the MOST form and notifying the nurse manager of any changes, did not recall the resident's request to change her code status. Consequently, the nurse manager was not informed, and the physician's order and EMR were not updated. The Director of Nursing confirmed that the medical record should have been updated to reflect the resident's current code status, highlighting a lapse in the facility's process for managing and documenting advanced directives.
Resident's Financial Privacy Compromised
Penalty
Summary
The facility failed to protect the financial privacy of a resident, identified as Resident #67, by displaying their name and an amount owed on a sign-up sheet for the beauty/barber shop in a common area. This sign-up sheet was observed on a bulletin board in the [NAME] Hall common area, visible to staff, visitors, and other residents. The sheet included a price list for services and indicated that Resident #67 owed $15. This information was accessible to anyone passing by, compromising the resident's financial privacy. Interviews with staff revealed a lack of awareness and coordination regarding the sign-up sheet's content. Nurse Aide #1 confirmed the sheet had been displayed for weeks, while the Activity Director stated that staff were instructed only to list names of residents requesting services, not amounts owed. The Business Office Manager was unaware of the sign-up sheet's presence in the common area. The Administrator acknowledged that the resident's financial information should not have been publicly visible, indicating a lapse in maintaining confidentiality protocols.
Incomplete Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an allegation of resident-to-resident abuse involving two residents with traumatic brain injuries. The incident occurred when one resident hit another on the back of the neck/head during an argument. Although the residents were separated and monitored, the investigation was incomplete as it lacked witness statements and interviews with staff involved in the incident. The facility's policy required a comprehensive investigation, including interviews with all relevant parties, which was not adhered to. The Director of Nursing was out of town at the time of the incident, and the Administrator, who was notified, delegated the investigation to a Unit Manager. However, the necessary interviews and documentation were not completed. The Administrator was unaware of a change in condition for the resident who was hit, indicating a lack of communication and thoroughness in the investigation process. This oversight led to the deficiency in addressing the alleged abuse incident properly.
Inaccurate MDS Coding for Pain, ADLs, and Pressure Ulcers
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in the assessment of pain, activities of daily living (ADL), and pressure ulcers. Resident #9, who was admitted with chronic pain syndrome and osteoarthritis, had a severe cognitive impairment. The pain assessment interview was not completed, nor was the staff assessment for pain conducted. MDS Coordinator #2, who worked remotely, stated that the pain assessments were supposed to be completed by the nurse in the facility by the assessment reference date (ARD). However, these assessments were not completed timely, and the coordinator could not use the information from the medication administration record (MAR) for the pain interview. Resident #69, admitted with depression, neuropathy, and a diabetic ulcer, was inaccurately coded in the MDS assessment. The resident was marked as dependent on staff for certain ADLs, but during an interview, the resident reported being able to walk to the bathroom using a walker, indicating an improvement in ADLs. MDS Coordinator #2 admitted that the coding for walking and eating was not accurate and that discrepancies were not addressed before completing the assessment. The Director of Nursing (DON) expected MDS assessments to be completed accurately for all residents. Resident #199, readmitted with quadriplegia and stage 3 pressure ulcers, was incorrectly coded in the MDS assessment. The resident was marked as not at risk for developing pressure ulcers, despite having three stage 3 pressure ulcers. The Wound Nurse confirmed the presence of three pressure areas and stated that the resident did not have pressure areas on the back or right heel, contrary to what was coded. MDS Coordinator #1 noted that obsolete diagnoses should not be coded if the resident was not receiving treatment for them. The DON reiterated the expectation for accurate and timely MDS assessments.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving antipsychotic medication, Quetiapine, as part of their treatment for anxiety and major depressive disorder. The resident was admitted with these diagnoses and had been receiving the medication since April 2024. Despite the requirement for quarterly AIMS assessments to monitor for abnormal bodily movements associated with the use of psychotropic medications, the last recorded assessment was in May 2024. This lapse was identified during a review of the resident's medical records, which showed no AIMS assessments had been completed after May 2024. Interviews with facility staff, including the Regional MDS Coordinator, Unit Manager, and Director of Nursing (DON), revealed confusion and system errors as contributing factors to the oversight. The Regional MDS Coordinator noted that AIMS assessments were referred to as User-Defined Assessments (UDAs) in the computer system and should be completed quarterly. However, the assessments were not scheduled, and a glitch in the system caused some scheduled UDAs to disappear. The DON acknowledged the importance of completing AIMS assessments quarterly and with any medication changes, especially for residents on antipsychotic medications, but admitted to confusion over responsibility for triggering these assessments.
Failure to Document Monthly Medication Reviews
Penalty
Summary
The facility failed to maintain documentation of the pharmacist's Monthly Medication Reviews (MMRs) in the medical records for two residents, leading to a deficiency in safeguarding resident-identifiable information and maintaining medical records according to professional standards. Resident #9, who was admitted with diagnoses including PTSD, dementia, anxiety disorder, and depression, was receiving medications such as Lorazepam, Depakote, and Sertraline. Although a Pharmacy Medication Regimen Review (MRR) report dated September 25, 2024, was available, there were no MMR reports for July, August, or October. The report indicated that a dose reduction was contraindicated, and the provider had reviewed and signed the recommendation. However, the absence of MMRs for other months indicates a lapse in documentation. Similarly, Resident #69, admitted with anxiety and major depressive disorder, was receiving medications like Buspirone, Quetiapine, and Duloxetine. The resident's care plan included monitoring for side effects related to psychotropic medications, but there were no available Pharmacy MMRs for several months, including July through November. Interviews with the Nurse Practitioner and Consultant Pharmacist revealed that MMRs were supposed to be printed and placed in the system, but due to changes in ownership and the computer system, the MMRs were not consistently documented. The Director of Nursing confirmed that MMRs were only written if a medication was changed, contributing to the lack of documentation.
Lack of Outside Activities Due to Transportation Issues
Penalty
Summary
The facility failed to provide group activities outside of the facility for residents who expressed the importance of such activities for their independence and socialization. This deficiency was identified for four residents who were reviewed for activities. These residents reported feeling more dependent, less social, and sad due to the lack of opportunities to leave the facility for group activities, which they had not been able to do for over a year. The facility's activity calendar for June 2024 showed only inside activities, with no scheduled outings. The facility is located in an area with accessible shops and restaurants, yet residents had not participated in outside activities due to transportation issues. Interviews with residents revealed that they had repeatedly requested outings during resident council meetings, but were told by the previous administrator that the facility's van was broken and no alternative transportation was available. The previous administrator confirmed that during his tenure, residents were unable to participate in outside activities due to the broken van and lack of corporate approval for repairs or alternative transportation. The Activity Director also reported being unable to schedule outside activities due to these transportation issues, despite residents' requests. The interim administrator, who began working in June 2024, was unaware of the situation and stated he would investigate transportation options.
Failure to Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to provide evening snacks to residents when requested, affecting four residents who were reviewed for snack frequency. These residents, all diagnosed with type 2 diabetes and cognitively intact, reported inconsistencies in receiving evening snacks. They expressed that they either had to purchase their own snacks or rely on family members to provide them. When they requested snacks from the staff, they were often told that no snacks were available in the nourishment room, and staff did not have access to the kitchen to obtain more. Observations of the nourishment rooms confirmed the absence of snacks, sandwiches, or drinks available for residents. Interviews with nursing assistants revealed that they had never been instructed to offer evening snacks and were unaware of the need to do so. They also noted that the nourishment rooms did not stock snacks or drinks, and the kitchen did not provide diabetic-friendly options. The dietary manager stated that snacks were supposed to be provided to nursing staff, but it appeared that snacks were only given to residents upon request, and there was a lack of sugar-free options. The interim Administrator and the Director of Nursing were unaware of the issue, expecting that snacks and drinks should always be available and offered to residents. The deficiency highlights a lack of communication and coordination between dietary and nursing staff, resulting in residents not receiving the necessary evening snacks, particularly those with dietary restrictions like diabetes.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to maintain accurate temperature monitoring in its kitchen and nourishment room refrigerators. During an observation, the thermometer in the kitchen reach-in refrigerator showed a temperature of 28 degrees Fahrenheit, while a carton of milk inside registered 38.5 degrees Fahrenheit. Similarly, the thermometer in the south unit nourishment room refrigerator also showed 28 degrees Fahrenheit. The Certified Dietary Manager (CDM) replaced the faulty thermometers, but it was noted that the dietary staff did not regularly check the thermometers for accuracy. The facility also did not adhere to the manufacturer's recommendations for the concentration of quaternary ammonia (QUAT) sanitizer used in the three-compartment sink for manual dishwashing. The QUAT sanitizer concentration was found to be greater than 400 parts per million, exceeding the recommended maximum. The Training District Dietary Manager set up the sink, but the water level was not filled to the designated line, and the concentration was not checked before use. Additionally, the facility's condiment cart was observed to be soiled with food debris, despite a cleaning schedule indicating it should be cleaned weekly. Furthermore, a dietary aide was observed working without a beard restraint, contrary to the facility's policy requiring hair and beard restraints for kitchen staff. These deficiencies were identified during a lunch meal tray line observation.
Improper Waste Management and Exposed Trash
Penalty
Summary
The facility failed to maintain proper waste management practices, as observed by surveyors. On June 20, 2024, the lid of one of the two commercial trash dumpsters was found open, exposing multiple bags of odorous trash and broken cardboard boxes. The area surrounding the dumpster was cluttered with broken equipment, including two motorized wheelchairs, a bed, a plastic table, and two wooden pallets. Additionally, two large utility trucks without lids were filled with exposed trash bags, attracting flies. A second dumpster was also full, indicating insufficient capacity to manage the facility's waste. Interviews with facility staff revealed that the facility was undergoing a transition in ownership, which affected the availability of trash dumpsters. The Certified Dietary Manager and the Training District Dietary Manager confirmed that the existing dumpsters were inadequate for the facility's needs. The Maintenance Director, who had recently returned to his role, stated that there were no dumpsters when he arrived, and two were delivered on June 18, 2024. He had advised against placing trash outside until a third dumpster arrived, but staff did not comply. The Administrator confirmed that the previous contract's dumpsters were removed on June 17, 2024, and new ones were delivered the following day, with a third expected to resolve the issue.
Failure to Provide TED Stockings as Ordered
Penalty
Summary
The facility failed to provide Thrombo-Embolic Deterrent (TED) stockings as ordered by the physician for a resident with bilateral lower extremity edema. The resident, who was admitted with diagnoses including hypertension, lower extremity edema, and paraplegia, had physician orders for TED stockings to be applied in the morning and removed at bedtime. Despite these orders, the resident reported not receiving the stockings and was observed without them, with swollen lower legs, ankles, and feet. Interviews with the Director of Nursing and the Central Supply clerk revealed that although the stockings were ordered, they were never received, and no follow-up was conducted with the supplier. The facility's previous owners restricted the use of alternative suppliers, contributing to the delay. Nurses documented the application and removal of the stockings on the Medication Administration Record (MAR) without verifying their presence, relying on assumptions that nursing aides had completed the task. Nursing staff, including nurses and nurse aides, admitted to assuming the TED stockings were applied and removed by others, without personally verifying this. Interviews with the nursing aides confirmed they had never seen or applied the TED stockings on the resident. This lack of communication and verification among staff led to the resident not receiving the prescribed care for his edema, as documented in the physician's orders.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food per resident preference for taste and temperature, affecting four sampled residents on the south unit. Resident #4, who was admitted with diagnoses including type 2 diabetes mellitus and hypertension, received a lunch meal that was not to her liking, stating the macaroni was not good and not hot. Similarly, Resident #70, with diagnoses of type 2 diabetes mellitus and hyperlipidemia, expressed dissatisfaction with the temperature of the spinach served, stating it was not hot. Both residents did not consume the food items they found unsatisfactory. Resident #153, with chronic renal failure and hypertension, did not eat her lunch meal, stating it lacked seasoning and was not to her taste. She expressed that the food quality could be improved, suggesting that more seasonings should be added. Resident #65, diagnosed with hypertension, reported ongoing dissatisfaction with the taste and temperature of the food since the fall of 2023. He mentioned that the facility served cold food and that the quality was not up to his expectations, leading him to rely on food provided by his family or ordered from outside. A test tray observation revealed that the food served was not at the appropriate temperature, with the Certified Dietary Manager (CDM) noting that the macaroni and ham casserole was only slightly warm and the spinach was not hot. The CDM acknowledged resident complaints about cold food and stated that the facility followed corporate menus, which limited their ability to make changes. The Director of Nursing and the Administrator noted that the facility was transitioning to new management and working on improving meal service logistics to ensure residents received hot and palatable meals.
Inaccurate Documentation of TED Stockings Application
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected the application and removal of Thrombo-Embolic Deterrent (TED) stockings as ordered by the physician. The resident, who was admitted with bilateral lower extremity edema, had a physician's order for TED stockings to be applied in the morning and removed at night. However, the Medication Administration Record (MAR) inaccurately documented that the stockings were applied and removed as ordered, despite the resident not having received them. Observations and interviews revealed that the resident was not wearing TED stockings, and the staff had not received them from the durable medical equipment company. Interviews with nursing staff and nurse aides indicated a lack of communication and verification regarding the application of the TED stockings. Nurses assumed that the nurse aides were applying and removing the stockings, and they documented this on the MAR without verifying. Nurse aides reported never having seen or applied the TED stockings on the resident. The Director of Nursing was unaware of the inaccurate documentation and acknowledged the need for staff education on accurate record-keeping.
Facility Fails to Allow Resident Return Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, citing behaviors prior to discharge as the reason. The resident, who had a history of dementia with severity and agitation, metabolic and hepatic encephalopathy, and acute metabolic acidosis, was involuntarily committed to the hospital after expressing self-harm and refusing medication. The facility's Admission Director and interim Administrator decided not to allow the resident to return, citing new company admission guidelines and the resident's verbal aggression and refusal of care as reasons. The Director of Nursing (DON) confirmed that the resident had a pattern of refusing medication and making self-harm statements to be sent to the hospital, and the family always wanted him to return. Despite these behaviors, the facility had not previously issued a 30-day discharge notice. The DON mentioned that the facility's new admission guidelines deemed the resident inappropriate for return, and it was easier to send him to the hospital than to find alternative placement. The hospital case manager was informed of the facility's decision, and the resident remained in the hospital while alternative placement was sought.
Failure to Update Care Plan for Self-Administering Resident
Penalty
Summary
The facility failed to update the care plan for a resident who was readmitted with diagnoses including bipolar disorder, blindness, and conduct disorder. The resident had a physician's order allowing self-administration of medications and the ability to pick up medications from an outside pharmacy. However, the care plan was not updated to reflect these changes, nor was it revised when the medications were discontinued. The resident was cognitively intact and had not rejected care, yet the care plan did not account for the resident's refusal to use the facility's physician, nurse practitioner, and in-house pharmacy. Interviews with the Director of Nursing (DON), MDS Coordinator, and interim Administrator revealed that the care plan should have been revised to reflect the resident's self-management of medications and use of an outside pharmacy. The DON was aware of the resident's outside primary care physician and pharmacy by August or September 2023, but this information was not added to the resident's face sheet until October 2024. The MDS Coordinator, who was new to the role, acknowledged the need for care plan updates based on changes discussed in meetings or noted in nurse and physician documentation. The interim Administrator also recognized the necessity for accurate care plan updates.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess Resident #153 for the ability to self-administer medications, which is a requirement for residents who wish to manage their own medication intake. Resident #153, who was readmitted to the facility from the hospital, had several diagnoses including urea cycle metabolism disorder, osteoarthritis, congestive heart failure, and chronic pain. Despite having intact cognition and no functional limitations, there was no documented assessment or physician order allowing Resident #153 to self-administer medications such as Aspirin and Lactulose. During observations and interviews, it was discovered that Resident #153 had two bottles of medication on her overbed table. One bottle was labeled as Sodium Chloride but contained a pale, yellow-colored liquid, which the resident identified as Lactulose. The resident explained that when she was not ready to take Lactulose, the nurse left it in a medicine cup for her to take later, and she would pour it into the Sodium Chloride bottle. Additionally, the resident had a bottle of Aspirin that she brought from the hospital and took for pain, without a physician's order for self-administration. Interviews with nursing staff revealed a lack of awareness and communication regarding the resident's self-administration of medications. Nurse #8 and Nurse #9 were unaware of the resident's self-administration practices, and Unit Manager #1 and the Director of Nursing confirmed that no assessment had been conducted for self-administration. The facility's policy requires an assessment, physician notification, and a locked box for medication storage, none of which were in place for Resident #153.
Inaccurate MDS Coding for Resident Behaviors and Hospice Care
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their care documentation. Resident #353, who was readmitted with diagnoses including bipolar disorder and conduct disorder, exhibited behaviors such as refusing care and assistance, as well as rejecting psychiatric consultations and medication. Despite these ongoing behaviors, the quarterly MDS assessment did not reflect these issues, indicating the resident was cognitively intact and had no behaviors or care refusals. Interviews with the MDS Coordinator and the interim Administrator revealed that the MDS should have been coded to reflect the resident's refusal of care, but this was not done due to the MDS Coordinator's inexperience and oversight. Similarly, the facility failed to accurately code a significant change MDS assessment for Resident #35, who was admitted with diagnoses including senile degeneration of the brain and vascular dementia with behavioral disturbance. Although the resident was admitted to hospice care as per a physician's order, the MDS assessment did not indicate this. The MDS Coordinator acknowledged the oversight, despite being aware of the hospice care order from a manager's meeting. The Director of Nursing confirmed that the MDS should have been coded to reflect the hospice care. These inaccuracies in MDS coding highlight deficiencies in the facility's assessment processes.
Expired Medications Found in Facility's Storage Rooms
Penalty
Summary
The facility failed to remove expired over-the-counter medications from two medication storage rooms, as observed during a survey. In the south side medication room, an unopened bottle of Vitamin D with an expiration date of January 2024 and six unopened bottles with an expiration date of May 2024 were found. Unit Manager #1, responsible for checking the medication storage room, admitted to missing the expiration dates, acknowledging that the expired medications should have been discarded. Similarly, in the west side medication room, four unopened bottles of Vitamin D with an expiration date of May 2024 were discovered. Unit Manager #2, who was responsible for this room, also failed to notice the expired medications. The Director of Nursing confirmed that the facility staff had checked the rooms a few days prior but did not find the expired medications, indicating a lapse in the monthly checking process.
Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy when a nurse did not wear a gown while providing tracheostomy care to a resident. The facility's policy, last revised in October 2018, mandates the use of gowns and gloves for high-contact resident care activities, including tracheostomy care. During an observation, it was noted that the nurse performed hand hygiene and donned gloves but did not wear a gown while providing tracheostomy care to the resident, despite EBP signage on the resident's door indicating the requirement for both gloves and a gown. Interviews with the nurse and the Director of Nursing (DON) revealed that the nurse had received training on the EBP policy and was aware of the requirement to wear a gown for high-contact care activities. However, the nurse mistakenly believed that tracheostomy care was not considered high-contact care. The DON, who also serves as the facility's Infection Preventionist, confirmed that the policy requires gowns and gloves for tracheostomy care and that all staff had been trained on this policy. The Administrator, who was new to the facility, was not yet familiar with the EBP policy but acknowledged that staff should follow infection precautions and wear appropriate PPE.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for three residents who required assistance with their meals. Resident #74, who had severe cognitive impairments and required maximal assistance with eating, was observed waiting for staff assistance while his roommate fed himself. The staff member responsible for feeding Resident #74 did not assist him until after all other residents who could feed themselves had received their meals. This delay in assistance resulted in Resident #74 eating separately from his peers, which was contrary to the facility's previous practice of having residents eat together. Resident #88, who had severe vision impairment and required substantial assistance with eating, was also affected by the facility's failure to provide timely assistance during meals. She was observed waiting for staff to assist her while other residents around her were eating. Despite expressing her hunger and preference to eat with others, she had to wait for a staff member to become available to help her, which delayed her meal and separated her dining experience from that of her peers. Similarly, Resident #16, who had severe cognitive impairment and was dependent on staff for eating, experienced a delay in receiving assistance with her meal. She was observed waiting while other residents were served and fed. During this time, she expressed feelings of sickness and hunger. The staff member responsible for assisting her was delayed due to attending to another resident's needs, further prolonging her wait. These instances highlight the facility's failure to ensure that residents requiring assistance with meals were able to dine with dignity and in a timely manner.
Failure to Implement Abuse Reporting Procedures
Penalty
Summary
The facility failed to implement its abuse policy and procedure when a resident reported an incident involving a Nurse Aide. The resident, who had a history of making false accusations, reported that a Nurse Aide intentionally hit her on the hand with a bed remote. Despite the resident's intact cognition and the seriousness of the allegation, the facility did not report or investigate the incident as required by their policy. The policy mandates immediate reporting to the Administrator, Director of Nursing, and the applicable State Agency, with an investigation to be conducted within five working days. Interviews with staff revealed that the incident was communicated internally, but no formal report or investigation was initiated. A Nurse Aide and a Medication Aide were aware of the resident's complaint, and the Social Work Assistant was involved in an initial discussion with the resident. However, the facility's records showed no formal action was taken until much later, and the Administrator, who was not employed at the time of the incident, confirmed that the facility's procedures were not followed. This deficiency was identified for one of the five residents reviewed for abuse.
Failure to Maintain Dressing on Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to maintain a dressing on a stage 3 sacral pressure ulcer for a resident, leading to a deficiency in pressure ulcer care. The resident, who was admitted to the facility with multiple diagnoses including vascular dementia, Alzheimer's disease, and mild protein calorie malnutrition, had a care plan that required staff assistance with activities of daily living and wound care per physician orders. Despite these interventions, the resident was found without a dressing on the pressure ulcer during an observation, indicating a lapse in the prescribed wound care protocol. The deficiency was further highlighted by interviews with staff and medical personnel. A nurse aide reported that the resident was often found without a dressing during incontinence care, and there was a lack of communication between shifts regarding the resident's wound care needs. The assigned nurse for the resident was unaware of the missing dressing, and other staff members could not recall providing the necessary wound care. This lack of communication and adherence to the care plan contributed to the resident's pressure ulcer being left uncovered, increasing the risk of infection and hindering the healing process. Medical professionals, including the wound physician and hospice nurse, expressed concern over the uncovered pressure ulcer, emphasizing the risk of contamination from urine and feces. The wound physician noted that the resident's pressure ulcer had been stagnant, attributing this to the resident's poor nutritional status and the lack of consistent wound care. The director of nursing confirmed that residents with wound care orders should have dressings in place to prevent infection, underscoring the facility's failure to adhere to established care protocols.
Medication Error: Failure to Discontinue Ativan
Penalty
Summary
The facility failed to discontinue a benzodiazepine medication, Ativan, as ordered by the physician for a resident who was also prescribed clonazepam for anxiety. The resident was admitted with diagnoses including anxiety and unspecified dementia with other behaviors. Physician orders indicated that Ativan was to be discontinued and clonazepam started on a specific date. However, the resident continued to receive both medications for several days, contrary to the physician's orders. The error occurred when the Former Unit Manager, who was also serving as a hall nurse, received and transcribed the physician's order but failed to enter the discontinuation of Ativan into the electronic health record. This oversight resulted in the resident receiving both Ativan and clonazepam from the date the order was given until the resident was sent to the hospital. The responsible party of the resident was informed by the hospital about the concurrent administration of both medications, which was concerning given the care plan meeting discussions. Interviews with the Director of Nursing and the Medical Director confirmed the medication error. The Director of Nursing noted that the Former Unit Manager had written both orders on one form but overlooked entering the discontinuation of Ativan. The Medical Director acknowledged the risks associated with taking both medications but could not determine if the resident experienced adverse effects. The resident was hospitalized for heart-related issues, and the error was identified during this hospitalization.
Failure to Maintain Daily Nurse Staffing Sheets
Penalty
Summary
The facility failed to maintain daily nurse staffing sheets for 244 out of 305 days during the period from August 2023 to May 2024. This deficiency was identified through record reviews and staff interviews, revealing that no staffing information was available for the months of October 2023 through May 2024. The Director of Nursing indicated that the staffing coordinator was responsible for maintaining these records. However, the staffing coordinator admitted to not having any daily staff posting sheets from October 2023 through May 2024, as the previous Administrator had collected and kept them in his office. The new Administrator, who assumed the role on June 1, 2024, confirmed that the staffing coordinator was responsible for the daily nurse staffing sheets. Despite searching the office, the new Administrator could not locate the missing sheets. The Administrator acknowledged the regulatory requirement to maintain 18 months of daily nurse staffing sheets and noted that a change in ownership had occurred on June 1, 2024, which contributed to the inability to locate the records from October 2023 to May 2024.
Deficiency in Resident Safety and Behavior Management
Penalty
Summary
The report details instances of physical and sexual abuse involving several residents at the facility. Resident #5, a severely cognitively impaired individual, experienced physical abuse twice on a specific date, including being placed in a chokehold by another resident. Additionally, Resident #3, also severely cognitively impaired, experienced sexual abuse when another resident touched and rubbed her pubic area. The report highlights failures in protecting these residents from physical and sexual abuse, indicating a deficiency in ensuring their safety and well-being. The report further reveals that Resident #4, who had a history of major depressive disorder and PTSD, was involved in the physical abuse of Resident #5. Despite Resident #4's documented mental health conditions and history, there was a lack of comprehensive person-centered behavior care planning in place to address her needs and potential triggers. The facility's failure to address Resident #4's behavioral issues and prevent her from engaging in abusive behavior towards other residents contributed to the deficiency in protecting residents from harm.
Failure to Report Physical Abuse Incidents Between Residents
Penalty
Summary
The facility failed to report an incidence of physical abuse involving Resident #4 and Resident #5, leading to a deficiency in protecting Resident #5 from further physical abuse. Resident #5, diagnosed with dementia, agitation, anxiety disorder, mood affective disorder, psychosis, and major depressive disorder, experienced physical abuse twice on 12/27/23. The first incident occurred in the dining room when Resident #4 physically assaulted Resident #5 after a verbal altercation. This initial abuse was not reported to facility administration, resulting in a second physical assault by Resident #4 on Resident #5 in the hallway later that day. Multiple staff members, including the Activity Director, Activity Assistant, Nurse #1, and Human Resources Director, were aware of the altercations between Resident #4 and Resident #5 but failed to report the incidents to facility administration promptly. The Director of Nursing (DON) and Administrator were only made aware of the physical abuse after the second incident in the hallway. Despite policies in place requiring prompt reporting and protection of residents during investigations of abuse, the staff did not follow proper procedures to ensure Resident #5's safety and prevent further abuse.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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