Roxboro Healthcare & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Roxboro, North Carolina.
- Location
- 901 Ridge Road, Roxboro, North Carolina 27573
- CMS Provider Number
- 345311
- Inspections on file
- 22
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Roxboro Healthcare & Rehab Center during CMS and state inspections, most recent first.
Nine ceiling vents in the dining room were observed with visible dust buildup and chipped paint, resulting in airborne particles over dining tables during multiple meal services. Staff and administrators confirmed the lack of vent cleaning and maintenance documentation, despite regular HVAC filter changes. No dust or paint chips were observed in residents' food.
Surveyors found that kitchen ceiling vents, ceiling fans, and industrial fans had visible dust, with particles blowing onto food preparation areas and clean dishes. The Dietary Manager and Maintenance Director confirmed the presence of dust and lack of documented cleaning, and maintenance logs only showed filter changes, not vent or fan cleaning.
A resident with multiple chronic conditions did not have a care plan meeting conducted or documented for an extended period, despite being cognitively intact and expressing a desire to participate. Although an invitation was sent to the resident's representative for a scheduled meeting, the resident was not invited, and the meeting did not occur due to lack of response. Facility staff acknowledged missed scheduling and failure to involve the resident in the care planning process.
The facility failed to address a buildup of dust and condensation on the kitchen HVAC vent, resulting in moisture damage to the ceiling. Observations showed a water puddle on the floor beneath the vent, which had a visible dust buildup and discoloration. The Dietary Manager was aware of the issue but did not report it to maintenance. The Maintenance Manager, unaware of the problem, noted that the thermostat was set too low, causing continuous operation and increased condensation. The Administrator confirmed these conditions led to the ceiling damage.
A resident with intact cognition and a history of diabetes and exocrine pancreatic insufficiency was observed self-administering Creon capsules without an active physician's order or care plan indicating it was clinically appropriate. The facility's interim DON confirmed that the resident had not been assessed or care-planned for self-administration, revealing a deficiency in medication management.
A resident with hemiplegia and contractures did not have a comprehensive care plan addressing the application and removal of splints. Despite receiving occupational therapy and recommendations for splint management, the care plan lacked necessary interventions. Interviews with facility staff confirmed that the interdisciplinary team missed including splint use in the care plan.
A resident with hemiplegia and contractures did not receive the prescribed splint application to prevent further contracture, as nursing staff failed to follow the physician's order. Despite education from the occupational therapist, staff were unaware of their responsibility, and the care plan lacked necessary details, leading to non-compliance with the order.
A resident with a history of UTIs and an indwelling urinary catheter was observed with the catheter bag touching the floor multiple times, contrary to infection control protocols. Despite staff involvement, the issue persisted until the bed was adjusted to prevent the bag from resting on the floor. The DON confirmed the expectation that catheter bags should not touch the floor.
The facility reported a medication error rate of 7.1% during a Medication Administration Observation, exceeding the acceptable threshold of 5%. Two residents were affected: one received the wrong formulation of aspirin, and another received an incorrect dosage of a calcium/Vitamin D combination. The errors were confirmed by the staff involved, and the interim DON emphasized the importance of following medication orders.
The facility failed to manage medication storage properly, with a stock bottle of cetirizine found with an illegible expiration date on the 200 Hall Med Cart and five loose, unidentified tablets discovered on the 100 Hall Med Cart. The interim DON acknowledged that nurses were responsible for checking expiration dates, yet these deficiencies were observed.
A resident with severely impaired cognition and a history of cerebral infarction and recurrent UTIs had consistently dirty fingernails, despite requiring substantial assistance for personal hygiene. Observations showed a dark brown/black substance under the nails over several days. The nurse aide responsible did not notice the issue, leaving the resident's family member to clean the nails. The interim DON confirmed that nail care should occur on shower days and as needed, indicating a lapse in care.
The facility failed to document the pharmacist's Monthly Medication Reviews and the physician's responses for two residents. The consultant pharmacist's recommendations were not uploaded into the electronic records, as they were kept in the DON's office. The interim DON noted that the previous DON did not ensure the recommendations were reviewed by the physician or uploaded, leading to missing documentation.
The facility failed to provide timely pain management for three residents, including one with a hip replacement, another with a severe ankle fracture, and a hospice patient with cancer. Delays in medication delivery, miscommunication, and incorrect allergy documentation led to unmanaged pain and inadequate care.
The facility failed to provide timely access to pain medications for three residents due to issues with backup supply access, prescription faxing errors, and untimely reordering. One resident experienced pain after hip surgery due to delayed Oxycodone administration, another faced a three-day delay due to allergy miscommunication, and a third ran out of medication due to untimely reordering.
A resident with multiple health conditions, including diabetes and Alzheimer's, had a reopened pressure sore on their thigh. The facility failed to document the sore's reopening and apply a dressing without obtaining orders. The treatment nurse discovered the issue and obtained necessary orders, but concerns about wound care practices were not addressed by the administration, leading to her resignation.
Failure to Maintain Clean and Intact Ceiling Vents in Dining Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in the dining room by not keeping nine ceiling vents free from dust buildup and chipped paint. Observations over several days revealed that all nine ceiling vents above resident dining tables had visible dust and chipped paint, with particles being blown into the air directly over areas where residents were eating. These conditions were consistently observed during multiple meal services, with staff serving meals to groups of residents while dust and paint chips were visibly airborne in the dining area. However, there was no observation of dust or paint chips directly in the residents' food. Interviews with the Maintenance Director, Regional Consultant, and Administrator confirmed the presence of dust and chipped paint on the vents. Maintenance logs showed that while HVAC filters had been changed regularly, there was no documentation of vent cleaning or maintenance. Both the Maintenance Director and Administrator acknowledged that the vents required cleaning and that the maintenance department was responsible for this task, but no cleaning schedule or records were provided.
Failure to Maintain Clean Kitchen Vents and Fans
Penalty
Summary
Surveyors observed that seven ceiling vents, two ceiling fans, and two industrial fans in the kitchen and dishwashing areas had visible dust particles on their blades and vent grates. During meal preparation, dust was seen blowing from these fixtures over the steam table, food preparation areas, uncovered dishes, and an uncovered pan of vegetables. In the dishwashing area, dust from the vents and fans was observed blowing over clean dishes. The Dietary Manager confirmed the presence of dust and stated that the maintenance department was responsible for cleaning these fixtures, but was unaware of when the last deep cleaning had occurred. The kitchen cleaning checklist did not assign responsibility for cleaning vents and fans to kitchen staff. A review of maintenance logs for the previous 90 days showed documentation of filter changes but no records of vent or fan cleaning. The Maintenance Director stated that vents were cleaned monthly, but could not provide documentation or a cleaning schedule for the ceiling vents, ceiling fans, or industrial fans. The Administrator also confirmed the need for cleaning and presented reports that documented filter inspections and changes, but not vent cleaning. These findings indicate that the facility failed to maintain kitchen ventilation and fan fixtures free of dust, resulting in dust particles blowing onto clean surfaces and food preparation areas.
Failure to Involve Resident and Representative in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or their representative in the care planning process as required. Specifically, a resident with diagnoses including type 2 diabetes mellitus, congestive heart failure, and atrial fibrillation, who had moderate cognitive impairment at one assessment and was later assessed as cognitively intact, did not have a care plan meeting conducted or documented since January 2025. Although a care plan meeting was scheduled and an invitation was sent to the resident's representative for a meeting in May 2025, there was no evidence that the resident was invited, and the meeting did not occur due to lack of response from the representative. The resident expressed that it had been a long time since any care plan meeting occurred and indicated a desire to participate in the development of his care plan and receive updates on his medical issues. Interviews with facility staff revealed that the Social Worker was responsible for scheduling care plan meetings and typically sent invitations to representatives based on the MDS assessment calendar. The Social Worker acknowledged that she missed scheduling the care plan meetings for this resident and that the resident, who was cognitively intact, could have participated in the meeting. The Administrator confirmed that care plan meetings and notifications should follow regulations and that residents and/or their representatives should be involved in care plan meetings, but acknowledged that the required meetings had not been held for this resident since January 2025.
HVAC Vent Condensation and Ceiling Damage in Kitchen
Penalty
Summary
The facility failed to prevent a buildup of dust and condensation on and around the kitchen HVAC vent, leading to moisture damage to the ceiling. Observations revealed a puddle of water on the kitchen floor, directly beneath the HVAC vent, which had a visible buildup of dust and a brownish-black discoloration around its edges. The condensation from the vent was dripping onto the floor, contributing to the water puddle. The Dietary Manager acknowledged that the vent dripped water during high humidity and had been doing so for several months. Despite being aware of the issue, the Dietary Manager had not reported it to maintenance, and the facility Administrator was also aware of the problem. Further observations showed that the ceiling paint near the vent was loose and sagging, with visible condensation and water stains. The Maintenance Manager, who was recently hired, stated he had not received any work orders or notifications about the vent or ceiling issues. He noted that the kitchen air conditioning thermostat was set too low, causing the equipment to run nonstop and contributing to the condensation problem. The Administrator confirmed that the low thermostat setting and frequent opening of the back door increased humidity, leading to the condensation and subsequent ceiling damage.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to determine whether the self-administration of medications was clinically appropriate for a resident who was observed to have a medication at bedside. The resident, who had intact cognition, was admitted with diagnoses including diabetes and exocrine pancreatic insufficiency. Upon re-entering the facility after a hospital stay, the resident had physician's orders for Creon capsules to be taken with meals and snacks. However, there were no active physician's orders or care plans indicating that it was clinically appropriate for the resident to self-administer the Creon capsules. Observations revealed that the resident had a bubble-pack card of Creon capsules on his nightstand, within reach, and was seen self-administering the medication without staff inquiry. Interviews with the resident and the facility's interim DON confirmed that the resident had not been assessed or care-planned for self-administration, and there was no active physician's order for this practice. The DON acknowledged that a resident should be assessed and care-planned for self-administration of medication, highlighting a deficiency in the facility's medication management process.
Failure to Include Splint Management in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with contractures and the need for splint application and removal. The resident, who was admitted with hemiplegia following a cerebral infarction affecting the right side, had contractures in the right elbow, wrist, hand, and fingers. Occupational therapy was provided, and upon discharge, recommendations were made for nursing staff to assist with self-care needs and perform a functional maintenance program for the resident's right hand and elbow splints. However, the resident's care plan did not include any interventions related to the contractures or the application and removal of splints. Interviews with the facility's MDS Nurse and Rehabilitation Director revealed that the interdisciplinary team was responsible for developing and revising care plans, which were updated quarterly. The Rehabilitation Director confirmed that the use of splints should have been included in the care plan, indicating that this intervention was overlooked. The deficiency was identified during a review of the resident's care plan, which lacked necessary information and interventions for managing the resident's contractures and splint use.
Failure to Apply Splints as Ordered for Resident with Contractures
Penalty
Summary
The facility failed to follow a physician's order to apply two splints to a resident's right hand and elbow to prevent further contracture. The resident, who was admitted with hemiplegia following a cerebral infarction affecting his right side, was assessed to have contractures in his right elbow, wrist, hand, and fingers. Occupational therapy services were provided, and upon discharge, the nursing staff was instructed to apply and remove the splints daily. However, observations revealed that the splints were not applied as ordered. During multiple observations, the resident was seen without the required splints on his right arm. Interviews with staff members, including nurse aides and the hall nurse, indicated a lack of awareness and responsibility regarding the application of the splints. The nurse aide assigned to the resident was unaware of the splint requirement, and the hall nurse incorrectly believed it was the rehabilitation department's responsibility. The occupational therapist confirmed that the nursing staff had been educated on the splint application process, and the splints were to be applied in the morning and removed in the afternoon. Further investigation revealed that the resident's care plan and Kardex did not include information about the splint application, leading to confusion among the staff. The interim Director of Nursing acknowledged the oversight and clarified that the responsibility for applying the splints had been transferred to the nursing staff. Despite this, the splints were not consistently applied, resulting in a failure to adhere to the physician's order and potentially compromising the resident's care.
Failure to Maintain Infection Control for Urinary Catheter
Penalty
Summary
The facility failed to prevent a urinary catheter bag from touching the floor, which is a deficiency in maintaining infection control standards. This issue was observed in the case of a resident who was admitted with a history of cerebral infarction and recurrent urinary tract infections. The resident required substantial assistance for daily activities and had an indwelling urinary catheter due to urinary retention. Observations revealed that the urinary catheter bag was repeatedly found resting on the floor, which was not in compliance with infection control protocols. The deficiency was noted during multiple observations where the urinary catheter bag was seen touching the floor, despite the expectation that it should be attached to the bed frame and positioned off the floor. The nursing staff, including a nurse aide and a nurse, were involved in the care of the resident, but the issue persisted until it was addressed by raising the bed slightly. The interim Director of Nursing confirmed the expectation that catheter bags should not touch the floor, indicating a lapse in adherence to this protocol.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.1% error rate during a Medication Administration Observation. This deficiency was identified through observations, staff interviews, and record reviews involving two residents. The first incident involved a nurse administering an 81 mg chewable aspirin tablet to a resident instead of the prescribed 81 mg enteric-coated delayed-release aspirin. The nurse confirmed the error after reviewing the medication orders and comparing the formulations available in the medication cart. The second incident involved a medication aide administering a combination medication of 600 mg calcium and 400 units of Vitamin D to a resident, contrary to the prescribed dosage of 600 mg calcium and 200 units of Vitamin D. The medication aide acknowledged the discrepancy after reviewing the stock bottle and stated she would report the issue to her Unit Manager. The interim Director of Nursing, along with the Unit Manager, discussed the findings and expressed the expectation that nursing staff should adhere to medication orders and seek clarification when necessary.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly manage medication storage on two medication carts, leading to deficiencies in drug labeling and identification. On the 200 Hall Med Cart, a stock bottle of cetirizine was found with an illegible expiration date. The bottle, which was opened on 6/11/24, contained approximately 20 tablets, but the manufacturer's expiration date was not readable. Both the Medication Aide and the Unit Manager confirmed the expiration date could not be determined, indicating a failure to ensure drugs were labeled in accordance with professional principles. Additionally, on the 100 Hall Med Cart, five loose, unidentified tablets of varying sizes were discovered in the top drawer. Neither the nurse nor the Unit Manager could identify these tablets, which included two large, two small, and one medium-sized white round tablets. The interim Director of Nursing acknowledged that nurses were responsible for checking expiration dates and that nurse management staff routinely followed up on medication storage, yet these deficiencies were still observed.
Failure to Maintain Resident's Nail Hygiene
Penalty
Summary
The facility failed to ensure proper nail hygiene for a resident with severely impaired cognition and a history of cerebral infarction and recurrent UTIs. The resident required substantial assistance for personal hygiene, as indicated in her care plan. Observations over several days revealed that the resident's fingernails were consistently dirty, with a dark brown/black substance underneath them. Despite the resident's need for assistance, the nurse aide responsible for her care did not notice the dirty nails and did not clean them, leaving the task to the resident's family member. The family member, upon visiting, found the resident's nails unclean and took it upon herself to clean them. The nurse aide later stated that she would clean nails when noticed or on scheduled bath days, but she had not observed the need in this case. The interim DON confirmed that nail care should be performed on shower days and as needed, indicating a lapse in the expected care routine. This deficiency highlights a failure in maintaining the resident's personal hygiene as per the care plan and facility expectations.
Failure to Document Medication Reviews and Physician Responses
Penalty
Summary
The facility failed to maintain proper documentation of the pharmacist's Monthly Medication Reviews (MMRs) and the physician's review and response to the pharmacist's findings for two residents. For one resident, the electronic medical record did not include the MMRs for specific months, nor did it contain the signed provider's review and response to the pharmacist's recommendations. Similarly, for another resident, the electronic medical record was missing MMRs and the signed provider's review and response for certain months. The consultant pharmacist stated that all recommendations after the monthly MMRs were sent via email to the Director of Nursing (DON), Administrator, and Pharmacy Nurse Consultant. However, these recommendations were not uploaded into the residents' electronic records, as they were kept in the DON's office. The interim DON, who was hired later, indicated that the previous DON did not ensure that the recommendations were reviewed by the physician or uploaded into the electronic records, leading to inconsistencies and missing documentation. Interviews with the Nurse Consultant and Administrator revealed that they were made aware of the pharmacy's concerns and discussed the issue with relevant staff. However, the plan of correction did not address the missing recommendations for the two residents involved in the deficiency.
Deficiencies in Pain Management for Residents
Penalty
Summary
The facility failed to provide appropriate pain management for three residents, resulting in deficiencies in care. Resident #10, who had undergone hip replacement surgery, did not receive her prescribed Oxycodone in a timely manner due to a delay in the medication's arrival and a lack of access to the facility's backup supply. Despite being in pain, the resident was not offered alternative pain relief, such as Acetaminophen, until the Oxycodone was available. The nursing staff failed to communicate effectively, leading to a delay in pain management. Resident #15, who had a history of substance abuse and had undergone multiple surgeries for a severe ankle fracture, also experienced a delay in receiving Oxycodone. The resident's allergy to Oxycodone was mistakenly noted, causing further delays in obtaining the medication. Despite the resident's reports of pain, the staff did not administer the prescribed Oxycodone until three days after admission, relying instead on Acetaminophen, which was not sufficient for the resident's pain management needs. Resident #5, who was on hospice care for colon cancer and chronic pain, missed doses of Oxycodone due to the facility running out of the medication. The staff failed to reorder the medication in a timely manner, resulting in the resident experiencing unmanaged pain. Although alternative pain medications were available, the resident reported that the Oxycodone was specifically effective for her cancer pain, highlighting the importance of timely medication management.
Deficiency in Pain Medication Management
Penalty
Summary
The facility failed to ensure that nurses had access to backup pain medications and that these medications were replenished and available for administration. This deficiency affected three residents who required narcotic pain medications. One resident, who had undergone hip replacement surgery, did not receive Oxycodone until several hours after admission due to the unavailability of the medication in the facility's backup supply. The resident experienced pain during this period, and the staff was not aware of the procedures to obtain the medication from the backup supply. Another resident, who had a history of substance abuse and depression, did not receive Oxycodone for three days following admission due to a miscommunication regarding an allergy and a delay in faxing the prescription to the pharmacy. The resident had been receiving Oxycodone in the hospital and clarified the allergy issue with the staff, but the medication was still not available in the facility's backup supply. The pharmacy records indicated that the prescription was not received until two days after the resident's admission. A third resident, with a history of chronic pain and opioid disorder, ran out of Oxycodone because the facility did not reorder the medication in a timely manner. The resident's Oxycodone was held until it arrived from the pharmacy, and the facility's backup supply was not utilized. The pharmacy manager reported that the facility had not replenished its backup supply of Oxycodone since March, and a required form for reordering was not properly submitted. The facility's accounting system for controlled substances did not accurately reflect the number of tablets on hand.
Failure to Document and Obtain Orders for Pressure Sore Care
Penalty
Summary
The facility failed to ensure proper documentation and orders for the care of a reopened pressure sore on a resident's right posterior thigh. The resident, who had a history of diabetes, Alzheimer's disease, stroke, neuropathy, and peripheral vascular disease, was under hospice care and required substantial assistance with hygiene and bed mobility. Despite being at risk for skin impairment, the resident's care plan was not followed when a dressing was applied to the reopened pressure sore without obtaining orders or documenting the change in the resident's record. The treatment nurse discovered the issue on June 26th when a Nurse Aide informed her of a dressing on the resident's thigh that needed changing. Upon inspection, the nurse found the dressing had drainage and an odor, indicating it needed attention. However, there was no record of the pressure sore reopening or any orders for the dressing. The nurse obtained the necessary orders and ensured the Wound Physician evaluated the resident the following day. Despite reporting the issue to the facility's resource nurse and the Director of Nursing, the treatment nurse felt her concerns about wound care practices were not addressed, leading to her resignation. Interviews with facility staff, including the DON, Administrator, and Nurse Consultant, revealed a lack of awareness about the dressing being applied without orders. The Wound Physician noted the resident's skin was prone to breakdown due to sweating and previous skin issues, and the Medical Director emphasized the importance of obtaining treatment orders when skin breakdown is first observed. The facility's failure to document and obtain orders for the pressure sore dressing led to a deficiency in the care provided to the resident.
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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