Rocky Mount Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rocky Mount, North Carolina.
- Location
- 160 S Winstead Avenue, Rocky Mount, North Carolina 27804
- CMS Provider Number
- 345260
- Inspections on file
- 23
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Rocky Mount Rehabilitation Center during CMS and state inspections, most recent first.
Two residents were involved in a physical altercation in a common area, during which one resident was reportedly struck in the face by another while a third resident encouraged the aggression. CNAs observed the incident, separated the residents, and notified the nurse, but the RN on duty did not immediately notify the Administrator despite acknowledging she should have. The weekend Administrator on Duty learned that one resident may have hit another and that the alleged victim reported being hit by a man, yet the incident was still communicated to the Administrator as a non‑physical, verbal altercation. A written CNA statement describing the hitting was not reviewed by the Administrator for several days, the DON was not promptly informed, law enforcement was not notified within 24 hours, and key witnesses were not interviewed in a timely manner, resulting in delayed and incomplete implementation of the facility’s abuse reporting and investigation procedures.
The facility failed to maintain complete medical records related to an altercation between two residents and a subsequent clinical assessment. Staff witness statements described both residents hitting each other, and the assigned nurse reported she checked both residents and found no visible injuries but did not document the incident or her assessment in either record. Days later, a bruise below one resident’s eye was noted on a skin audit, and a PA evaluated the resident, confirming the eye was not painful, not shut, and without vision problems, and that the resident reported being hit in another room. The PA did not document this assessment in the medical record.
A staff member was employed and worked as an RN without a valid nursing license, as the facility failed to properly verify her credentials. Despite documentation showing competency and no performance issues, subsequent checks revealed she was only licensed as a CNA, not an RN, and her name did not match any active RN license in Maryland or North Carolina. The facility's HR process did not identify the discrepancy, and the staff member continued to work in the RN role until her departure.
Surveyors identified expired medications in the medication refrigerator and on a medication cart, as well as unopened insulin pens that were not refrigerated according to manufacturer instructions. The DON and nursing staff confirmed these findings, with staff interviews revealing inconsistent checks for expired medications and a lack of awareness regarding proper storage and discard timelines.
A resident's medical record was incomplete and inaccurate after a physician order for tracheostomy care was entered incorrectly in the electronic system, preventing the order from appearing on the TAR/MAR. As a result, nurses were unable to document the tracheostomy care provided, and some only realized the omission during the investigation. The DON confirmed the order was not entered properly, and the Administrator acknowledged the need to review the process.
Two residents with chronic pain conditions had narcotic pain medications go missing from the facility. The discrepancy was discovered during a routine narcotic count by nursing staff, and subsequent investigation confirmed that medication cards and countdown sheets for both residents were unaccounted for. The missing narcotics were reported to authorities, but the facility was unable to determine how the medications were removed or by whom.
A resident with a tracheostomy did not receive consistent or properly documented respiratory care due to missing orders on the TAR, leading to lapses in tracheostomy care and skin assessments. Nursing staff were unclear about care responsibilities and failed to inspect for moisture-associated skin damage in the neck folds, which was only discovered incidentally. Infection control practices were also breached when a nurse reattached oxygen tubing that had fallen on the floor.
A nurse did not remain at the bedside to confirm that a resident with renal dialysis dependence took all prescribed Lanthanum Carbonate tablets, resulting in a pill being left in a cup on the bedside table. The resident's care plan did not include self-administration, and no assessment for self-administration safety was documented. Staff interviews confirmed that the nurse was expected to observe medication administration but failed to do so.
A resident with an indwelling urinary catheter and significant cognitive and physical impairments was observed with her catheter collection bag touching the floor while in bed. Staff interviews confirmed awareness that the bag should not contact the floor, but adjustments to bed height had allowed this to occur, and the duration of the contact was unknown. Facility leadership acknowledged the bag should have been properly positioned to prevent floor contact.
A resident with severe cognitive impairment and multiple medical conditions did not receive enteral nutrition via g-tube as ordered, when staff failed to ensure the tube feeding pump was operating during a scheduled feeding period. Nursing staff were unaware of the interruption, and documentation did not reflect the actual administration of the feeding.
Nursing staff failed to demonstrate competency in tracheostomy care, as evidenced by improper handling of oxygen tubing and lack of facility-specific training or competency evaluation. Several nurses had not attended required training, and the facility could not provide documentation of tracheostomy care competencies for its staff. Leadership interviews revealed inconsistent protocols and missing records related to tracheostomy care education.
A nurse administered incorrect medications and dosages to a resident, including giving vitamin B12 instead of vitamin D3, providing double the ordered dose of a nasal spray, and administering levothyroxine while the resident was eating despite instructions to give it on an empty stomach. These actions resulted in a medication error rate of 12%, exceeding the acceptable threshold.
The facility did not consistently post daily nurse staffing sheets at the start of each shift, with instances of outdated or missing postings. The Scheduler was unclear about procedures for printing and posting staffing information for days other than the current day, and it was uncertain whether weekend staff had access to the required information.
The facility did not maintain an accurate facility-wide assessment, as it listed former administrative and clinical leaders rather than current staff. The assessment had not been updated to reflect recent changes in key positions, as confirmed by the interim Administrator, potentially affecting all residents.
Two residents and their responsible parties were not provided with required information about the facility's bed hold policy during hospital transfers. Medical records lacked documentation of this notification, and interviews with the responsible parties and the Admission Director confirmed that the policy was not discussed or provided at the time of transfer.
A resident with diabetes experienced a delay in treatment for hypoglycemia due to a nurse's failure to recognize symptoms and follow physician orders. The nurse, unaware of the resident's diabetes, did not check blood sugar levels or administer necessary medication, leading to a critical delay. EMS was called under the assumption of a stroke, and upon arrival, found the resident with a critically low blood glucose level. The lack of documentation and communication further exacerbated the situation.
A resident with Diabetes Mellitus Type 2 experienced a critically low blood glucose level, requiring EMS intervention. The primary nurse called EMS but failed to notify the physician of the incident. Subsequent staff notified the on-call physician for further orders, but the Physician Assistant and Medical Director were not informed of the EMS involvement. The DON was also unaware of the situation, highlighting a communication breakdown in the facility.
A resident with Diabetes Mellitus Type 2 experienced a critically low blood glucose level, prompting EMS intervention. Despite the resident's condition and subsequent treatment, the primary nurse failed to document the incident in the medical record, as confirmed by the DON.
A resident on anticoagulation medication experienced significant post-operative bleeding, but the LTC facility failed to ensure effective communication among staff and with the provider. The resident was not sent to the hospital promptly, and vital signs were not assessed. The on-call physician was not informed of the bleeding severity, leading to inappropriate treatment orders. The resident required a blood transfusion after being sent to the hospital.
A resident experienced significant post-operative bleeding while on an anticoagulant, but the facility failed to notify the physician appropriately. Despite the bleeding, the resident was administered Eliquis without consulting a physician. Miscommunication between nursing staff and the on-call physician led to inappropriate treatment orders, and the resident was eventually sent to the hospital after family intervention.
A resident with a history of blood clots and recent surgery experienced excessive bleeding while on Eliquis, an anticoagulant. Despite the bleeding, the medication was administered without proper monitoring or communication with the physician. The facility failed to document the administration and did not have a clear protocol for managing the situation, leading to a deficiency in care.
A resident in a LTC facility, who preferred showers and was dependent on staff for bathing, was not provided with a bariatric shower bed. The existing shower bed was deemed unsafe, and the resident only received bed baths. Despite approval to purchase a new bed, it was not yet available, leading to the resident not receiving showers as scheduled.
A resident's hearing assessment was inaccurately coded as adequate without hearing aids, despite multiple consultations indicating the need for hearing aids. Staff interviews revealed inconsistencies in awareness of the resident's hearing needs, with the resident expressing difficulty hearing and preferring a hearing amplifier over the hearing aid due to fit issues.
A resident with major depressive disorder and dementia was not referred for a PASRR after being diagnosed with an anxiety disorder. Despite having a care plan addressing cognitive impairment and using psychotropic medications, the facility failed to submit a new PASRR application. The Social Worker and Administrator acknowledged the oversight.
A resident's care plan was not updated to reflect their hearing impairment, despite multiple consultations indicating the need for hearing aids. Staff were unaware of the resident's hearing aids or alternative devices, and the care plan lacked necessary interventions. Interviews revealed a communication gap among staff regarding the resident's hearing needs.
A facility failed to obtain necessary orders for oxygen and respiratory therapy for a resident with acute respiratory failure and a tracheostomy. The resident's care plan included tracheostomy care and respiratory therapy but lacked interventions for oxygen use. Despite receiving oxygen at 2.5 liters per minute, there were no physician orders for oxygen in the records. Staff confirmed the resident had been on oxygen since admission, yet it was undocumented. Additionally, there was no physician order for respiratory therapy, although the resident received it regularly.
The facility did not have the Infection Preventionist (IP) present at one of the six Quality Assessment and Assurance (QAA) committee meetings, specifically the meeting held in June 2024. The absence was confirmed by the IP due to illness, and the Administrator noted a lack of documentation of her participation. This could potentially impact all 110 residents.
Failure to Timely Report and Thoroughly Investigate Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and federal requirements for reporting and investigating alleged abuse following a resident‑to‑resident altercation. The facility’s Abuse and Neglect Prohibition policy, revised in 8/2023, stated that the center would investigate any alleged abuse, neglect, or misappropriation of resident property and report all allegations and substantiated occurrences to state/federal agencies and law enforcement. However, the policy did not specify that the Administrator must be notified immediately of alleged abuse, and it referenced reporting to the corporate office via “Risk Guide” without defining what that entailed. Surveyors found that after an altercation between Resident #1 and Resident #2, the facility did not report the incident to local law enforcement within 24 hours and did not initiate a timely, thorough investigation. The incident occurred in the activity room on the evening of 2/14/26, when Resident #1, Resident #2, and Resident #3 were watching television. NA #1, seated at the nursing desk with a direct view into the activity room, heard Resident #1 yelling, “Stop. Leave me alone,” and heard Resident #3 say, “Hit her again.” As NA #1 entered the room, she saw Resident #2 hit Resident #1 in the face with his fist and then swing again, with Resident #1 raising her arm to block the second blow. NA #1 reported that she did not see Resident #1 provoke or hit Resident #2. NA #2 entered with NA #1 and later stated she saw both residents hitting each other but did not know who started it or where the blows landed. That night, Resident #1 had no visible marks, but within a couple of days she developed a black eye. NA #1 wrote a statement on 2/14/26 describing the incident and placed it under the Administrator’s door as instructed, and later added that before bed Resident #1 said Resident #2 had hit her in the eye. Nurse #1, the 3–11 PM nurse on 2/14/26, reported that a NA told her the two residents were in an altercation and that Resident #1 had started hitting Resident #2, who eventually hit back. She assessed both residents and found no marks but did not notify the Administrator, acknowledging she knew she should have. The Scheduler, acting as Administrator on Duty that weekend, overheard NA #1 say that Resident #2 had hit Resident #1, confirmed with the nurse that the nurse was aware, and assessed Resident #1, finding no marks. Resident #1 told the Scheduler that a man had hit her and described a male resident; Resident #2 denied involvement. The Scheduler called the Administrator at home and reported that Resident #2 may have hit Resident #1 and that there were no injuries, and was told to have NA #1 write a statement and place it under the Administrator’s door. The Administrator later stated she understood this to be a verbal, non‑physical altercation and did not review NA #1’s statement until 2/17/26, did not speak with NA #1 until 3/4/26, and did not begin the investigation until 2/17/26. By 2/16/26, the DON had not been informed of any alleged abuse, learning only that Resident #1 had darkening under her eye after the Administrator had already noticed it. On 2/17/26, the Administrator observed discoloration under Resident #1’s eye and obtained differing accounts from Resident #1, who first attributed it to a branch hitting her on the way to dialysis and then to a male resident who pushed her, pointing to her right anterior shoulder. The Administrator also interviewed Resident #2, who denied hitting anyone, and Resident #3, who stated that Resident #1 started hitting Resident #2 and that Resident #2 only pushed her away defensively. The facility’s initial allegation report to the state agency, submitted on 2/17/26, incorrectly listed the incident date as 2/17/26, later corrected in the five‑day investigation report to 2/14/26 with acknowledgment that the facility became aware on 2/17/26. Local law enforcement confirmed they did not receive a report of the alleged assault until 2/17/26 at 12:17 PM, indicating the facility did not notify law enforcement within 24 hours of the 2/14/26 altercation. The Administrator acknowledged that the incident was not reported to her as abuse initially, that the investigation was delayed because details were not clearly communicated and she had not read NA #1’s statement promptly, and that not all witnesses, including NA #1, were interviewed in a timely manner. The facility’s investigative file contained conflicting witness accounts and documentation indicating that alleged abuse occurred on 2/14/26, while the initial report to the state agency cited 2/17/26 as the occurrence date. NA #1 reported that no one spoke with her about the incident after she submitted her statement until she was interviewed by the surveyor on 3/4/26, and the Administrator confirmed she did not interview NA #1 until that date. The DON reported that no one notified her of alleged abuse during the days immediately following the incident. These findings demonstrate that the facility failed to follow its own abuse policy and federal requirements by not ensuring immediate Administrator notification of alleged abuse, not reporting the alleged crime to law enforcement within 24 hours of the altercation, and not conducting a prompt and thorough investigation that included timely interviews of all witnesses.
Failure to Document Resident Altercation and Subsequent Clinical Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for two residents involved in an altercation. An investigation file regarding an alleged abuse incident on 2/14/26 documented witness statements from two nurse aides, one reporting that Resident #2 hit Resident #1, and another reporting that both residents were hitting each other. Nurse #1, who was assigned to both residents that day, stated she had been informed that Resident #1 hit Resident #2 and that Resident #2 hit Resident #1 back. She reported she checked both residents, saw no injuries or marks, but did not document the altercation or her assessment in either resident’s medical record. The Administrator stated that Nurse #1 should have made a notation in each resident’s record that they had been involved in an altercation. The deficiency also includes the lack of documentation by a Physician Assistant (PA #1) following an assessment of Resident #1 after the same altercation. On 2/17/26, Resident #1 was noted on a skin audit report to have bruising to the cheek area below the left eye. PA #1 reported that she assessed Resident #1 after staff reported the altercation and the bruise, recalling that the resident’s eye was not painful or shut, there were no vision problems, and the resident stated she had been hit in another room without giving details. PA #1 acknowledged that she did not document her assessment in Resident #1’s medical record. The Administrator reported that PA #1 should have made a notation in the record about this assessment following the bruised eye and altercation.
Failure to Verify RN Licensure for Nursing Staff
Penalty
Summary
A facility failed to verify that a staff member hired as a Registered Nurse (RN) possessed an active professional nursing license in accordance with state laws. The staff member, identified through employment records and licensure verification, worked as an RN for several months. The personnel file included a Maryland Board of Nursing (MBON) licensure verification with the same first and last name as the staff member, but the middle name was missing, and subsequent checks revealed discrepancies. The staff member's competencies were reviewed and no performance issues were documented during her employment. Further investigation revealed that the staff member did not have an active RN license but was registered as a Certified Nursing Assistant (CNA) in Maryland, with her middle name included in the registry. Attempts to verify her RN license in both Maryland and North Carolina were unsuccessful, and the North Carolina Board of Nursing did not have her listed. Interviews with facility staff and external parties, including a staffing agency and another facility, highlighted concerns about the staff member's credentials, particularly regarding inconsistencies in her name and the absence of a valid nursing license. Despite these concerns, the facility's Human Resources process failed to detect the lack of a valid RN license, relying instead on incomplete or mismatched documentation. The staff member continued to work as an RN until she left the facility, and no further investigation was conducted by facility staff when questions about her licensure arose. The deficiency was identified through a review of employment records, licensure verification, and staff interviews, confirming that the facility did not ensure all nursing staff were properly licensed as required by state regulations.
Expired and Improperly Stored Medications Identified During Survey
Penalty
Summary
Surveyors observed that expired medications were not removed from the medication refrigerator in the medication storage room at the nursing station. Specifically, a box containing five expired COVID-19 mRNA vaccine injections, an open bottle of cephalexin oral suspension, and an open bottle of vancomycin hydrochloride oral solution were found past their expiration dates. The DON confirmed these findings prior to removal and stated that the Unit Manager was responsible for checking and removing expired medications, but checks were only performed every few weeks. Additionally, on the Hall 100 medication cart, an open inhalation powder medication used for COPD and asthma was found to have exceeded the six-week discard period after opening, which Nurse #1 was unaware of. The DON, who was new to the facility, had not yet implemented a process for regular checks of medication carts for expired medications. Further observations revealed that unopened insulin lispro injector pens, which require refrigeration according to manufacturer recommendations, were stored at room temperature on the Hall 200 medication cart instead of in the refrigerator. Both Nurse #2 and the Pharmacist confirmed that the insulin pens should have been refrigerated until opened, as indicated by clear labeling on the packaging. The DON also acknowledged that the insulin pens should have been placed in the refrigerator upon delivery from the pharmacy.
Incomplete Medical Record for Tracheostomy Care Due to Documentation Error
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate regarding tracheostomy care. Upon review, it was found that a physician order for tracheostomy care every shift and as needed was entered into the electronic medical record using an option that did not populate the Treatment Administration Record (TAR) or Medication Administration Record (MAR). As a result, the order was only visible in the orders section and not accessible for nurses to document the care provided. Multiple nurses who cared for the resident reported either forgetting to document tracheostomy care or being unable to do so because the order did not appear in the TAR/MAR. The Director of Nursing confirmed that the order was not entered properly, preventing appropriate documentation. The deficiency involved a resident who had been readmitted to the facility and required regular tracheostomy care. Despite the presence of a physician order, the improper entry into the electronic system led to a lack of documentation for tracheostomy care over several months. Staff interviews revealed that nurses performed the care but did not document it due to the missing order in the documentation system, and some only realized the omission during the investigation. The Administrator acknowledged the issue but did not provide an explanation for the failure.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of narcotic medications for two residents. Both residents had physician orders for opioid pain medications, which were delivered to the facility and documented as administered according to their Medication Administration Records. However, it was later discovered that one medication card containing 30 tablets for each resident was missing and could not be located within the facility. The issue was identified when a nurse noticed a discrepancy in the narcotic medication card count during her shift. She recalled that the number of narcotic cards had decreased unexpectedly and questioned another nurse, who denied removing any narcotics. After further investigation and a search of the medication cart, it was confirmed that the medication packs and their corresponding countdown sheets for both residents were missing. The facility's pharmacist confirmed the delivery process and the expectation for the facility to notify the pharmacy of any discrepancies, which was done after the issue was identified. Interviews with staff involved in the medication administration and narcotic count process revealed that the missing narcotics were not accounted for by any of the nurses on duty. The nurse who was named in the investigation as potentially involved was placed on a do not return list, but attempts to interview her were unsuccessful. The facility was unable to substantiate the allegation internally, but the missing narcotics were confirmed as removed from the facility and reported to the appropriate authorities.
Failure to Ensure Safe and Documented Tracheostomy Care and Skin Assessment
Penalty
Summary
The facility failed to implement effective systems for entering and documenting tracheostomy care orders, resulting in the absence of tracheostomy care orders on the Treatment Administration Record (TAR) for several months. This led to inconsistent and undocumented tracheostomy care for a resident with a history of anoxic brain damage, tracheostomy status, and severe cognitive impairment. Multiple nurses reported that they did not document tracheostomy care because there was no order on the TAR, and some were unsure of the required frequency or specific procedures for tracheostomy care, such as changing the inner cannula or inspecting the skin under the collar. During direct observation, a nurse was seen picking up oxygen tubing from the floor and reattaching it to the resident's respiratory equipment, which was immediately corrected by another nurse due to infection control concerns. The nurse admitted that she typically reconnected tubing without replacing it when it became disconnected, not recognizing the need for sterility at the connection site. Additionally, the facility did not have effective systems in place to identify and assess avoidable moisture-associated skin damage (MASD) in the resident's neck folds. The MASD was only discovered incidentally during tracheostomy care, and prior skin assessments had not included the neck area unless staff were alerted to a problem. Interviews with nursing staff revealed a lack of clarity regarding responsibilities for tracheostomy care, with some nurses stating they had never performed the care or were unsure which shift was responsible for specific tasks. The wound nurse confirmed that skin folds, especially in heavier residents, should be assessed regularly, and that the MASD was found in a moist, sweaty area under the tracheostomy ties. The respiratory therapist and medical director both described appropriate tracheostomy care procedures and assessment expectations, but these were not consistently followed or documented by nursing staff due to the missing orders and lack of clear protocols.
Failure to Ensure Medication Administration at Bedside
Penalty
Summary
A deficiency occurred when a nurse failed to remain at the bedside to ensure a resident took all prescribed medications. The resident, who was cognitively intact and dependent on renal dialysis, had a physician's order for Lanthanum Carbonate 500 mg chewable tablets to be taken before meals. The resident's care plan did not include self-administration of medication, and there was no assessment in the medical record to determine if self-administration was safe for this resident. During observation, a large white pill was found in a cup on the resident's bedside table. The resident reported taking the medication before meals and stated she intended to take the pill but had forgotten. Interviews with the nurse, DON, and administrator confirmed that the nurse was expected to watch the resident take all medications before leaving the room, but this did not occur, resulting in the medication being left at the bedside.
Catheter Bag Found Touching Floor During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a history of urostomy, spina bifida, seizures, and chronic kidney disease, who had an indwelling urinary catheter, was observed with her catheter collection bag touching the floor while lying in bed. The resident's care plan included specific instructions regarding catheter care, and her assessment indicated she required substantial to maximal assistance with all activities of daily living due to severely impaired cognition. During the observation, approximately three inches of the catheter bag were in contact with the floor, which was confirmed by staff interviews. Nurse Aide #1, responsible for the resident's care, acknowledged that the catheter bag should not be touching the floor and explained that the bag could touch the floor if the bed was set too low. The aide was unsure how long the bag had been in contact with the floor, as she typically emptied it at the end of her shift. Both the interim DON and the interim Administrator confirmed in interviews that the catheter bag should not have been on the floor and should have been positioned to prevent such contact, regardless of bed height adjustments.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when staff failed to provide enteral nutrition via a gastrostomy tube as ordered by the physician for a resident with significant medical needs. The resident, who had diagnoses including anoxic brain damage, dysphagia, quadriplegia, and was severely cognitively impaired, was dependent on staff for all activities of daily living and received the majority of nutrition and hydration through tube feedings. The care plan and physician orders specified continuous tube feeding at a set rate for 22 hours daily, with a scheduled hold from 12:00 PM to 2:00 PM. However, during an observation period, the tube feeding pump was found not infusing between 11:08 AM and 11:48 AM, outside the scheduled hold time, with the pump screen off and the formula bottle nearly full. Nurse documentation indicated the feeding was administered as scheduled, but direct observation contradicted this. The nurse assigned to the resident was unaware that the feeding was not infusing during the observed period and suggested that a nurse aide may have turned off the pump and forgotten to restart it. The nurse aide interviewed stated she typically only placed the pump on hold during care and did not recall turning it off. Facility leadership confirmed that the feeding should not have been interrupted during this time and that physician orders were not followed.
Failure to Ensure Nursing Staff Competency in Tracheostomy Care
Penalty
Summary
Nursing staff at the facility were found to lack appropriate competencies in providing tracheostomy care, as evidenced by direct observation, record review, and staff interviews. One nurse was observed picking up oxygen tubing from the floor and reattaching it to equipment connected to a resident's tracheostomy humidifier, a practice that was immediately corrected by another nurse who instructed her to replace all tubing. The nurse admitted to routinely reconnecting tubing that had fallen on the floor without replacing it, and also stated she had not attended the facility's tracheostomy care training. Another nurse, who was an agency staff member, reported having prior tracheostomy care experience but had not received any facility-specific education or training on the procedure, despite having performed tracheostomy care for a resident during her shift. A third nurse, who had recently returned to the facility, stated that her performance in tracheostomy care had not been evaluated since her return and that she had not received any training or education on the subject in the past two months. The facility was unable to provide documentation of tracheostomy care competencies or training for any of the nursing staff reviewed. The only documented training was a skills fair conducted by a respiratory therapist, but attendance records showed that not all relevant staff participated, and there was no evidence that the nurses involved in the deficiency attended the session. Interviews with facility leadership revealed a lack of consistent protocols and documentation regarding tracheostomy care education and competency evaluation. The Staff Development Coordinator position had experienced high turnover, resulting in gaps in training oversight. Although orientation was supposed to include tracheostomy care skills evaluation, no documentation could be found to confirm that this had occurred for the nurses in question. The deficiency was identified for three of eight nursing staff reviewed for tracheostomy care competencies.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 25 observed opportunities, resulting in a 12% error rate. During medication administration, a nurse gave a resident two vitamin B12 tablets instead of the prescribed cholecalciferol (vitamin D3) tablets for vitamin D deficiency. The nurse admitted to not verifying the medication against the physician's order and assumed vitamin B12 was correct. Additionally, the nurse administered two sprays per nostril of fluticasone propionate nasal spray for allergies, contrary to the physician's order of one spray per nostril, based on her belief that the full dose was not being delivered with a single spray. In another instance, the nurse administered levothyroxine sodium 50 mcg to the same resident while the resident was eating breakfast, despite the medication blister pack being labeled to give the medication on an empty stomach. The nurse acknowledged awareness of the administration instructions but did not check if any medications needed to be given before breakfast and proceeded to administer the medication after the resident had started eating. Interviews with the DON and pharmacist confirmed that the medications were not administered as ordered and that the nurse did not follow proper verification and administration procedures.
Failure to Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post daily nurse staffing sheets at the beginning of each shift, as required. On one of the five days surveyed, the posted staffing sheet in the lobby was outdated, displaying information from two days prior. Additionally, a review of records revealed that the staffing sheet for one day within a 31-day period was missing. Interviews with the Scheduler indicated a lack of understanding regarding the process for printing and posting staffing information for days other than the current day, and uncertainty about whether staffing information was posted during weekends or throughout the month. The interim Administrator confirmed that weekend nursing staff should have access to the necessary information to ensure timely and accurate posting.
Inaccurate Facility Assessment Due to Outdated Leadership Information
Penalty
Summary
The facility failed to maintain an accurate and up-to-date facility-wide assessment that reflected the current administrative and clinical leadership, including the Administrator, DON, Infection Preventionist, Rehabilitation Manager, Staff Development Coordinator, and Maintenance Director. The last recorded update of the facility assessment was on 10/31/24, and since that time, there had been multiple changes in leadership positions. During an interview, the interim Administrator confirmed that the assessment still listed former staff members and had not been updated to reflect the current personnel since he began his role on 9/9/25. This deficiency was identified through staff interviews and record review, and it had the potential to affect all 109 residents in the facility.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation or notification regarding the bed hold policy to residents or their responsible parties during hospital transfers for two of four residents reviewed. For one resident, there were two separate hospital transfers, and in both instances, neither the resident nor the responsible party received information about the bed hold policy. Medical records lacked documentation of this notification, and both the resident and responsible party confirmed in interviews that they were not informed. The Admission Director, who was responsible for providing this information, acknowledged that she did not discuss the bed hold policy during these transfers unless she anticipated needing the room for another resident. The President of Operations confirmed that no documentation could be found regarding these notifications. Similarly, another resident was transferred to the hospital, and neither the resident nor the responsible party received information about the bed hold policy. The responsible party confirmed in a telephone interview that no notification was provided, and the Admission Director stated she did not contact the responsible party to discuss the bed hold policy for this transfer. The President of Operations again confirmed the absence of documentation regarding communication of the bed hold policy for this resident.
Failure to Implement Diabetes Care Orders Leads to Delay in Treatment
Penalty
Summary
The facility failed to implement physician orders for diabetes care for a resident diagnosed with diabetes, leading to a delay in treating hypoglycemia. On the morning of the incident, the resident exhibited symptoms such as slurred speech and a change in consciousness, which were not recognized by the attending nurse as signs of hypoglycemia. The nurse, unaware of the resident's diabetes diagnosis, did not check the resident's blood sugar or administer any medication to address the low blood sugar levels. This oversight resulted in a critical delay in treatment. The nurse called emergency medical services (EMS) under the assumption that the resident was experiencing a stroke, as she did not know the resident had diabetes. Upon arrival, EMS found the resident unresponsive with a critically low blood glucose level. After administering dextrose, the resident regained consciousness and began to speak. The nurse's failure to recognize the signs of hypoglycemia and her incorrect communication to EMS about the resident's diabetes status contributed to the delay in appropriate medical intervention. The medical record for the day of the incident lacked documentation, and the Director of Nursing was not informed of the resident's low blood glucose or the EMS call. The absence of documentation meant that the incident was not included in the 24-hour summary report, further highlighting the communication breakdown within the facility. Interviews with staff, including the Physician Assistant and Medical Director, confirmed that the nurse should have recognized the symptoms of hypoglycemia and taken appropriate action according to the existing physician orders.
Removal Plan
- Nurse #1 was given education on diabetic protocol and change in condition with MD notification by Director of Nursing.
- Education was initiated by the Director of Nursing to Licensed Nurses, including agency licensed nurses, related to the facility policy on hyperglycemia and hypoglycemia.
- Education included obtaining blood glucose levels as needed for signs and symptoms of hypo/hyperglycemia.
- Education included reviewing resident medication administration record and diagnosis list to determine residents with Diabetes Mellitus.
- Immediate action is required if signs and symptoms of hyperglycemic or hypoglycemic are identified.
- When EMS is called to the facility, it is vital that accurate information is communicated to EMS, including if the resident is Diabetic.
- Parameters for MD notification and follow-up for diabetic residents were established.
- Insulin hyperglycemic and hypoglycemic orders to include monitoring and when to obtain a re-check of blood glucose level per facility policy and/or physician order.
- Licensed staff and agency staff that don't receive the education will receive it prior to working the next scheduled shift.
- The Director of Nursing will track the training to ensure all staff are educated.
- Newly hired licensed staff will receive training during orientation by Director of Nursing.
Failure to Notify Physician of Critically Low Blood Glucose
Penalty
Summary
The facility failed to notify the physician of a critically low blood glucose level in a resident, which required Emergency Medical Services (EMS) intervention. The resident, who was admitted with a diagnosis of Diabetes Mellitus Type 2, experienced a significant drop in blood glucose to 46 mg/dL, well below the normal range of 70-100 mg/dL. EMS was called, and upon their arrival, they administered dextrose intravenously, which resulted in the resident regaining alertness and the ability to speak. Despite the critical nature of the situation, there was no documentation in the medical record indicating that the physician was notified of the incident on the day it occurred. Interviews with facility staff revealed that Nurse #1, who was responsible for the resident at the time, prioritized calling EMS over notifying the physician. Nurse #2, who worked the subsequent shift, did notify the on-call physician to obtain an order for more frequent blood glucose checks. However, the Physician Assistant and Medical Director confirmed that they were not made aware of the EMS intervention. The Director of Nursing also stated that she was not informed of the incident and emphasized that Nurse #1 should have notified the physician and followed up with her regarding the resident's condition.
Failure to Document Resident's Change in Condition and EMS Intervention
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who experienced a change in condition requiring Emergency Medical Services (EMS) intervention. The resident, who was admitted with a diagnosis of Diabetes Mellitus Type 2, had a critically low blood glucose level of 46, which is below the normal range of 70-100 mg/dL. On the day of the incident, EMS was contacted at 8:51 AM for a possible stroke, and upon arrival, they administered dextrose intravenously, which resulted in the resident becoming alert and communicative. Despite this significant medical event, there was no documentation in the resident's medical record regarding the low blood glucose level or the EMS intervention. The deficiency was further highlighted during an interview with Nurse #1, who was responsible for the resident's care on the day of the incident. Nurse #1 admitted to observing the resident's change in consciousness and calling 911 but failed to document the incident in the electronic medical record, citing being sidetracked and forgetting as the reason. The Director of Nursing confirmed the absence of documentation for the shift during which the incident occurred, acknowledging that Nurse #1 should have recorded the event in the nurse progress notes.
Failure in Communication and Care for Post-Operative Bleeding
Penalty
Summary
The facility failed to ensure effective communication among nursing staff and with the provider, resulting in a resident who was on anticoagulation medication not being sent to the hospital promptly when she experienced significant post-operative bleeding. The resident, who had a history of deep vein thrombosis, pulmonary embolism, anemia, and peripheral vascular disease, underwent Mohs surgery on her left lower extremity. Despite the resident's sheets being soaked with blood and the dressing on her leg saturated, the nursing staff did not immediately communicate the severity of the situation to the on-call physician, nor did they recognize the need for a higher level of care. The nursing staff also failed to assess vital signs and perform treatments as ordered. Nurse #3, who was not initially assigned to the resident, attempted to manage the bleeding by following wound care instructions and applying pressure, but the bleeding persisted. The on-call physician was contacted, but due to incomplete information provided by the nursing staff, the physician ordered Bumex for edema rather than addressing the bleeding issue. The resident expressed a desire to go to the emergency department, and only after a second call to the physician was she sent to the hospital, where she required a blood transfusion due to low hemoglobin levels. Additionally, there was a failure to follow wound care orders accurately due to a lack of supplies. Nurse #6, who performed wound care on previous days, did not have access to hydrogen peroxide as specified in the wound care instructions and used normal saline instead. This deviation from the prescribed wound care protocol was not communicated to the physician for alternative orders. The Director of Nursing confirmed the absence of documentation for vital signs prior to the arrival of emergency medical services, indicating a lapse in monitoring the resident's condition effectively.
Failure to Notify Physician of Post-Operative Bleeding
Penalty
Summary
The facility failed to notify the physician when a resident, who was prescribed an anticoagulant, experienced significant post-operative bleeding. The resident had a history of deep vein thrombosis, pulmonary embolism, anemia, and peripheral vascular disease, and had recently undergone surgery for non-melanoma skin cancer. On the evening of the incident, Nurse #3 discovered that the resident's dressing was saturated with blood and attempted to control the bleeding by applying pressure and changing the dressing. Despite these efforts, the bleeding continued, and the resident's request to go to the emergency department was eventually honored after the on-call physician was notified. Nurse #3, who was not initially assigned to the resident, administered the resident's prescribed Eliquis, a blood thinner, without consulting a physician, despite the ongoing bleeding. Nurse #3 communicated the situation to Nurse #4, who then spoke with the on-call physician. However, Nurse #4 did not inform the physician about the resident's recent surgery or the use of Eliquis, leading to an order for Bumex, which was not appropriate for the bleeding condition. The resident's family was involved in the decision to send her to the hospital. Interviews with the on-call physician and the resident's primary physician revealed a lack of communication and understanding of the resident's condition. The on-call physician stated that if she had been informed of the blood thinner and recent surgery, she would have recommended immediate hospital evaluation. The primary physician did not believe immediate notification was necessary, nor did he see a reason to stop Eliquis. This miscommunication and lack of appropriate action contributed to the deficiency in care provided to the resident.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility failed to properly monitor and manage the administration of Eliquis, an anticoagulant, for a resident who was at high risk for bleeding. The resident, who had a history of deep vein thrombosis, pulmonary embolism, anemia, and peripheral vascular disease, underwent surgery for non-melanoma skin cancer on her left leg. Despite the known risks associated with Eliquis, the facility did not adequately monitor for signs of bleeding, as evidenced by the resident's bedsheet and dressing being saturated with blood. On the evening of the incident, Nurse #3 discovered the resident's dressing was soaked with blood and attempted to control the bleeding. Despite this, Nurse #3 administered Eliquis to the resident after explaining the potential for increased bleeding, as the resident agreed to take the medication. However, the bleeding continued, and the resident requested to be sent to the emergency department for further evaluation. The facility's Pharmacy Consultant later confirmed that the resident was at high risk for bleeding and should have been closely monitored. The physician for the resident indicated that Eliquis should not have been stopped before or after the surgery, as the wound was superficial. However, the lack of documentation on the Medication Administration Record and the failure to communicate the resident's bleeding condition to the on-call physician contributed to the deficiency. The facility did not have a clear protocol for managing such situations, leading to inadequate monitoring and communication regarding the resident's condition.
Failure to Provide Bariatric Shower Bed for Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who preferred to take showers, as they did not provide a bariatric shower bed. The resident, who was moderately cognitively intact and dependent on staff for bathing, expressed that showers were very important to her. Despite being scheduled for showers twice a week, she was only provided with bed baths during the review period due to the unavailability of a suitable shower bed. Interviews with staff revealed that the existing shower bed was too narrow and unsafe for the resident, and the shower chair was not an option due to her limited mobility. The Central Supply had discussed the need for a bariatric shower bed with the Administrator, who approved the purchase. However, the dimensions of the new bed were not compatible with the current shower room, and no updates were provided on the progress of acquiring a suitable bed. The Director of Nursing and other staff confirmed that the resident had not received a shower since her hospitalization, and the issue of the shower bed remained unresolved. The resident's Power of Attorney also confirmed her preference for showers and the facility's failure to provide them. The facility's President of Operations eventually purchased a bariatric shower bed, but it was not yet available at the time of the report.
Inaccurate Hearing Assessment Coding
Penalty
Summary
The facility failed to accurately code the resident assessment for hearing in the case of one resident. The resident, who was cognitively intact, was coded as having adequate hearing without the use of hearing aids in the Minimum Data Set (MDS) quarterly assessment. However, multiple hearing consultation reports indicated that the resident had been seen for hearing aid services, including a fitting for a replacement hearing aid and regular maintenance. During an observation and interview, the resident expressed difficulty hearing and mentioned needing to keep the television volume high. The resident also indicated uncertainty about the possession of hearing aids. Interviews with staff revealed inconsistencies in the understanding of the resident's hearing needs. A nurse acknowledged the resident's hearing difficulties but was unaware of any hearing aids. The Medical Records Clerk confirmed the resident had a hearing aid and a hearing amplifier, which the resident preferred due to fit issues with the hearing aid. The MDS Nurse responsible for the assessment was unaware of the hearing aids and did not perceive any hearing difficulties during the assessment. The Administrator noted that the MDS Nurse could have reviewed the resident's hearing consultations in the paper records to ensure accurate coding.
Failure to Refer Resident for PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly identified mental health diagnosis for a Preadmission Screening and Resident Review (PASRR). Resident #40, who was admitted with major depressive disorder and dementia, was initially given a Level I PASRR upon admission. However, after an additional diagnosis of anxiety disorder was added to the resident's medical record, the facility did not complete a PASRR referral for the newly identified serious mental illness. This oversight was identified during a review of the resident's records and staff interviews. The resident's care plan included treatment for impaired cognitive function and the use of psychotropic medication for agitation, depression, and anxiety. Despite these interventions, the facility did not submit a new PASRR application following the new diagnosis. The Social Worker, responsible for submitting PASRR referrals, acknowledged the oversight and stated that a new application should have been submitted. The Administrator also confirmed that the new mental health diagnosis required a PASRR referral, which was not completed due to an oversight.
Failure to Revise Care Plan for Hearing Impairment
Penalty
Summary
The facility failed to revise the care plan for a resident with hearing difficulties, despite multiple assessments and consultations indicating the need for hearing aids. The resident was admitted to the facility and had a series of hearing consultations, which noted the need for a replacement hearing aid and subsequent fitting. However, the care plan last reviewed did not include interventions for the resident's hearing impairment. During an observation and interview, the resident expressed difficulty hearing and mentioned the need to keep the television volume high. The resident was not wearing hearing aids at the time, and staff were unaware of the resident's hearing aids or any alternative devices. Interviews with various staff members, including a nurse aide, a nurse, the medical records clerk, the MDS nurse, and the Director of Nursing, revealed a lack of awareness and communication regarding the resident's hearing aids and the need for care plan updates. The medical records clerk confirmed the resident had a hearing aid and a hearing amplifier, but the resident preferred the amplifier due to poor fit of the hearing aid. The MDS nurse and the Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's hearing aid use, but this was not done, leading to the deficiency.
Failure to Obtain Orders for Oxygen and Respiratory Therapy
Penalty
Summary
The facility failed to obtain necessary orders for oxygen and respiratory therapy for a resident with acute respiratory failure and a tracheostomy. The resident's care plan, initiated in March 2022 and revised in June 2022, included interventions for tracheostomy care and respiratory therapy but did not include interventions for oxygen use. Despite the resident receiving oxygen at 2.5 liters per minute via a tracheostomy collar, there were no physician orders for oxygen use in the June and July 2024 records. Observations confirmed the resident was receiving oxygen, and staff interviews revealed that the resident had been on oxygen since admission, yet this was not documented or ordered. Additionally, the resident's care plan included respiratory therapy, but there was no corresponding physician order for this therapy in the records. The resident's MDS assessment indicated she received respiratory therapy, and staff interviews confirmed that a respiratory therapist visited the resident several times a month. However, the Director of Nursing acknowledged that an order for respiratory therapy should have been part of the physician's standing orders but was missing. This oversight resulted in a deficiency in providing appropriate respiratory care for the resident.
Infection Preventionist Absence at QAA Meeting
Penalty
Summary
The facility failed to ensure the presence of the Infection Preventionist (IP) at one of the six Quality Assessment and Assurance (QAA) committee meetings, specifically the meeting held on June 28, 2024. This deficiency was identified through a review of the facility's Monthly Meeting Agenda & Calendar QAA sign-in sheets from January through July 2024, which showed the absence of the IP at the specified meeting. The IP confirmed her absence due to illness during an interview on August 1, 2024. Additionally, the Administrator suggested that the IP might not have been in the facility or forgot to sign the attendance sheet, and there was no documentation of her participation as the committee was only reviewing existing plans at that time. This absence could potentially affect all 110 residents in the facility.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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