Royal Park Rehabilitation & Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Matthews, North Carolina.
- Location
- 2700 Roal Commons Lane, Matthews, North Carolina 28105
- CMS Provider Number
- 345026
- Inspections on file
- 21
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Royal Park Rehabilitation & Health Center during CMS and state inspections, most recent first.
A resident with a history of hydronephrosis and urological cancer had a urinary catheter removed by facility staff contrary to hospital discharge orders, leading to reinsertion, improper placement, and subsequent trauma requiring hospitalization. Staff did not reconcile the hospital discharge summary with EMR orders, resulting in the deficiency.
Surveyors found that staff did not consistently label, date, or discard expired food items in two nourishment rooms. Unlabeled and expired items such as coffee creamer, noodles, iced tea, prune juice, and pudding were observed. The Dietary Manager confirmed that all items should be labeled and expired items discarded, but checks were missed and procedures were not consistently followed.
A resident admitted for respite care with multiple chronic conditions did not receive several prescribed medications for multiple days due to the facility's lack of effective systems for obtaining and administering medications. Staff and pharmacy interviews revealed confusion and inconsistent procedures, resulting in numerous missed doses documented on the MAR.
Multiple residents consistently received meals that were not at appropriate temperatures, with hot foods served lukewarm or cold and beverages sometimes partially frozen. Residents and staff reported frequent reheating of meals, dissatisfaction with food quality, and ongoing complaints to facility leadership. Observations confirmed that food was often not served as ordered and lacked proper temperature control.
A resident with a gastrostomy tube and complex medical history received enteral feedings using a syringe that was not properly washed or dried after use. An RN stored the wet syringe with the plunger inside and residual formula present in a plastic bag at the bedside, contrary to facility protocol. Staff interviews confirmed a lack of awareness regarding the need to separate and air dry the syringe and plunger to prevent bacterial growth.
Surveyors identified an 11.5% medication error rate after observing three errors during medication administration. Errors included a resident with renal disease receiving sevelamer before the scheduled meal instead of with meals as ordered, and two residents receiving single-ingredient sennosides instead of the prescribed sennosides/docusate combination. Staff involved acknowledged the discrepancies after reviewing orders and medication labels.
A resident who was cognitively intact and had documented dislikes for certain breakfast items repeatedly received those items despite expressing her preferences for alternatives like yogurt to both dietary and nursing staff. Staff interviews revealed ongoing issues with tracking food preferences due to software problems, and communication lapses prevented the resident's preferences from being honored.
Two residents had inaccuracies in their MDS assessments: one was incorrectly coded as discharged to home when actually sent to the hospital, and another receiving hospice care was incorrectly coded as not having a prognosis of six months or less, despite physician documentation.
A resident was observed taking medications unsupervised, despite not being assessed for self-administration. The resident, who was cognitively intact, had medications left at the bedside on multiple occasions. Interviews revealed that the facility's protocol requires an assessment for self-administration, which was not conducted for this resident.
A nurse failed to follow the infection control policy by not performing hand hygiene after removing soiled dressings and before donning new gloves during wound care for a resident. Despite the facility's policy requiring hand hygiene after glove removal, the nurse changed gloves multiple times without sanitizing hands. Interviews with the nurse, Infection Preventionist, and Director of Nursing confirmed the expectation for hand hygiene, with the nurse attributing the lapse to forgetfulness.
A resident's oxycodone medication was misappropriated by a nurse, who forged a Medication Aide's signature to remove the drugs from the medication cart. The facility's investigation confirmed the nurse's involvement through video footage, leading to her termination. The resident continued to receive her medication without delay, and the facility implemented corrective measures to prevent future incidents.
Failure to Follow Hospital Discharge Orders for Urinary Catheter Management
Penalty
Summary
A deficiency occurred when the facility failed to follow hospital discharge orders regarding urinary catheter management for a resident with a complex urological history, including hydronephrosis, prostate and bladder cancer, and a recent sacral fracture. The hospital discharge summary specified that the urinary catheter was to remain in place until a follow-up with urology, but facility staff removed the catheter for a voiding trial based on orders entered into the electronic medical record (EMR). This removal was performed despite concerns voiced by the resident and their representative, who were informed by the nurse that the order to remove the catheter originated from the hospital. Within hours, the facility determined that the catheter should not have been removed and reinserted it per the Medical Director’s review of the hospital records. Following reinsertion of the urinary catheter, the resident began experiencing lower abdominal pain and blood in the catheter tubing. Nursing staff observed string-like blood clots and visible bleeding from the urethral meatus, prompting notification of the on-call provider and subsequent transfer to the emergency department (ED). The hospital urologist found that the catheter had not been advanced properly, with the balloon inflated in the prostate, resulting in trauma to the urethra and the creation of a false passage. The resident required cystoscopy for proper catheter placement, constant bladder irrigation, and antibiotics during a week-long hospitalization. Interviews with facility staff revealed that the discharge summary scanned into the EMR did not match the one reviewed by the nursing supervisor and nurse practitioner, leading to the incorrect order for catheter removal. The nurse who performed the removal did not compare the hospital discharge summary sent with the resident to the EMR orders, relying instead on the orders already verified and entered. The Medical Director and hospital urologist both confirmed that the catheter should have remained in place, and the urologist stated that the resident’s history made catheterization particularly difficult, suggesting that reinsertion should have been performed in a hospital setting.
Failure to Label, Date, and Discard Expired Food Items in Nourishment Rooms
Penalty
Summary
Surveyors observed that staff failed to consistently label and date food items and discard expired products in two of three nourishment rooms. Specifically, in the 300/400 hall nourishment room, there was an opened container of coffee creamer labeled with a name but no date, a container with noodles labeled with a resident's name but no date, a gallon of iced tea not labeled with the product or resident name and with a best by date that had already passed, and an opened bottle of prune juice not labeled with a resident's name. In the 500/600 hall nourishment room, a container of leftover pudding was found without any label or date. These findings were confirmed during interviews with the Dietary Manager, who stated that all items were expected to be labeled and expired items discarded. Further interviews revealed that although kitchen staff were supposed to check the nourishment rooms twice daily, the Assistant Dietary Manager admitted to not checking the rooms on a specific day when she was working as a dietary aide and forgot to perform the check. The Director of Nursing and the Administrator both stated that staff were educated to label and date residents' items in the nourishment rooms and that this was covered during orientation. However, the observations indicated that these procedures were not consistently followed, resulting in the presence of unlabeled and expired food items.
Failure to Provide Timely Medications for Respite Care Resident
Penalty
Summary
The facility failed to have effective systems in place to obtain and provide medications for a newly admitted respite care resident, resulting in multiple missed doses of eleven prescribed medications. The resident, who had complex medical needs including end stage renal disease requiring dialysis, glaucoma, GERD, and dementia, was admitted for a short-term stay. Despite having clear physician orders for a range of medications, including eye drops, oral medications, and a phosphate binder, the facility did not ensure these medications were available and administered as ordered. Nursing notes and interviews revealed that the resident's medications were not received or administered for several days after admission. Staff reported confusion regarding the process for obtaining medications for respite care residents, particularly those enrolled in a managed care program. The contracted pharmacy did not receive requests to fill the resident's medications until several days after admission, and the managed care pharmacy did not provide medications for respite stays. As a result, the resident missed multiple doses of critical medications, as documented in the Medication Administration Record (MAR), with many doses left blank, held, or otherwise not given. Interviews with nursing staff, the DON, and pharmacy representatives confirmed a lack of clarity and established procedures for obtaining and administering medications to respite care residents. The facility's staff gave inconsistent answers about whether medications should be brought from home or obtained from the contracted pharmacy, and there was no evidence that a consistent or effective process was followed. The resident's vital signs remained stable during the stay, and no harm was identified by the nurse practitioner, but the deficiency was due to the facility's failure to ensure medications were available and administered as ordered.
Failure to Serve Food and Beverages at Palatable and Safe Temperatures
Penalty
Summary
The facility failed to ensure that food and beverages were served at palatable and safe temperatures, resulting in multiple residents receiving lukewarm or cold hot foods and partially frozen beverages. Observations and interviews revealed that residents consistently received meals that were not at the appropriate temperature, with several residents reporting that their food was often cold upon delivery. Staff frequently offered to reheat food, but some residents declined due to concerns about food quality after reheating, such as eggs becoming too dry and difficult to chew. In some cases, residents expressed frustration and hesitancy to eat meals due to the persistent issue of cold food. Residents with various dietary orders, including cardiac, diabetic, pureed, and regular diets, were affected by the deficiency. Cognitively intact residents repeatedly voiced concerns about the temperature and quality of their meals, with some reporting that their complaints had been raised to the Resident Council and facility administration over several months without improvement. Observations included instances where hot foods arrived without visible steam, beverages were served cold or partially frozen, and meal items did not match the tray tickets. Staff interviews confirmed that reheating food was a common practice, and administrative staff were also involved in meal delivery and setup. Facility leadership, including the Dietary Manager, DON, and Administrator, acknowledged awareness of ongoing complaints regarding food temperature and palatability. The Dietary Manager stated that replacement trays should be offered instead of reheating, but there was no documented evidence of daily test tray records. Staff reported that meal trays were delivered promptly upon arrival to the units, yet the issue persisted, with many trays requiring reheating. The deficiency was further substantiated by staff and resident interviews, as well as direct observations of meal service and food temperatures.
Improper Storage and Handling of Enteral Feeding Syringe
Penalty
Summary
A deficiency was identified regarding the management of enteral feeding equipment for a resident with multiple medical conditions, including diabetes, stroke, malnutrition, and gastrostomy status. The resident was receiving scheduled bolus feedings and water flushes through a gastrostomy tube. During observations, it was noted that the syringe used for enteral feedings and medication administration was stored with the plunger inside the syringe, wet with condensation, and placed in a plastic bag on the bedside table. After administering a feeding and water flush, the nurse did not separate or wash the syringe and plunger, instead placing them back in the bag with residual formula present. Staff interviews revealed that the nurse was unaware of the requirement to dry the syringe and plunger separately to prevent bacterial growth, although she acknowledged the need to wash the syringe if residue was present. The DON confirmed that the protocol required washing and air drying the syringe and plunger separately, and that staff had been educated on this process. The administrator also stated that the nurse should have washed and dried the equipment properly to prevent bacterial growth.
Medication Error Rate Exceeds 5% Due to Incorrect Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 26 observed opportunities, resulting in an 11.5% error rate. Surveyors observed medication administration to five residents and identified errors involving three residents. The errors were identified through direct observation, staff interviews, and review of medication orders and administration records. One resident with end stage renal disease requiring hemodialysis was administered sevelamer, a phosphate binder, at a time not consistent with the physician's order, which specified the medication should be given with meals. The nurse administered the medication well before the scheduled dinner meal, providing only juice and crackers instead of a full meal, and was unaware that the medication was intended to be given specifically with meals. This action did not align with the prescribed instructions or the manufacturer's guidelines. Two other residents were administered a single ingredient medication containing only sennosides, rather than the prescribed combination medication of sennosides and docusate. In both cases, the staff members selected the incorrect medication from the stock bottles on the medication cart, failing to match the medication to the physician's order. Both the nurse and the medication aide involved acknowledged the error after reviewing the orders and the available medications, confirming that the combination medication should have been administered as ordered.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's documented food preferences, resulting in the resident repeatedly receiving breakfast items she disliked, specifically hot cereal and grits. The resident, who was cognitively intact according to her most recent MDS assessment, had an undated preference sheet indicating a dislike for grits and hot cereal and had communicated her preference for yogurt to both dietary and nursing staff on multiple occasions. Despite these communications, observations on two separate mornings confirmed that she continued to receive the unwanted food items. Interviews with staff revealed ongoing issues with tracking and honoring residents' food preferences. The nurse interviewed stated she had relayed the resident's concerns to dietary staff but could not recall to whom. The Dietary Manager acknowledged problems with the facility's meal program software, which contributed to the inability to consistently provide residents with their preferred food items. The DON was unaware of the issue, and the Administrator reported that no concerns had been brought to her attention, despite the resident's repeated complaints.
Inaccurate MDS Coding for Discharge and Hospice Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents in the areas of discharge and hospice status. For one resident, the discharge MDS was coded as a discharge to home based on information from the responsible party that the resident was sent home from the hospital and would not return to the facility. However, the resident had actually been sent to the hospital for evaluation following an episode of sudden confusion and shaking, and the discharge MDS did not accurately reflect the resident's discharge location from the facility. For another resident with Alzheimer's dementia and rheumatoid arthritis, who was under hospice care, the quarterly MDS assessment was incorrectly coded regarding the resident's prognosis. Although the hospice plan of care and physician documentation indicated a prognosis of six months or less, the MDS was coded as 'no' for this item. The MDS Coordinator acknowledged the error, stating it was a mistake and that the assessment should have been coded correctly.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of a resident, identified as Resident #42, to self-administer medications. Resident #42, who was cognitively intact according to the Minimum Data Set, was observed with a cup of medications left at his bedside on multiple occasions. Despite the resident's assertion that he knows his medications and takes them independently, there was no documented assessment or care plan focus area for self-administration of medications. The Medication Administration Record indicated that a medication aide had signed off on administering several medications to the resident, but the resident was observed taking the medications without supervision. Interviews with the medication aide and the Director of Nursing revealed that the facility's protocol requires a physician's order and an assessment for residents to self-administer medications. The medication aide admitted to leaving the resident with medications unsupervised, contrary to the facility's policy. The Director of Nursing confirmed that Resident #42 had not been assessed for self-administration and should have been supervised during medication administration. This lack of assessment and supervision led to the deficiency identified in the report.
Infection Control Policy Violation During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policy during wound care procedures, as observed in the actions of Nurse #1. During a continuous observation of wound care, Nurse #1 did not perform hand hygiene after removing soiled dressings and before donning new gloves. This occurred multiple times during the care of a resident with wounds on the left upper back and right heel. The facility's policy clearly states that hand hygiene should be performed after contact with body fluids, non-intact skin, wound dressings, and after removing gloves. Despite this, Nurse #1 was observed to change gloves several times without sanitizing her hands in between, which is a direct violation of the facility's infection control policy. Interviews with Nurse #1, the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed the expectation for hand hygiene to be performed after glove removal. Nurse #1 acknowledged her lapse in hand hygiene, attributing it to forgetfulness during the procedure. The IP confirmed that hand hygiene should be done after each glove change and noted that education on infection control, including hand hygiene, was provided to staff. However, the IP had not directly observed Nurse #1's wound care practices. The DON reiterated the importance of hand hygiene after glove removal, indicating that staff education on infection control is regularly conducted.
Misappropriation of Controlled Medications by Nurse
Penalty
Summary
The facility failed to protect a resident's rights by allowing the misappropriation of controlled medications. The incident involved a resident who was prescribed oxycodone for knee pain. The medication was found to be missing from the medication cart, along with the controlled medication count sheet. The facility's investigation revealed that Nurse #2 was allegedly responsible for removing the medication and the count sheet from the cart. Despite several attempts to contact Nurse #2, she did not respond, and video footage later confirmed her involvement in the diversion of the drugs. The investigation showed that Nurse #2 had forged the signature of a Medication Aide to sign out two medication cards, which included the missing oxycodone tablets. The facility's former Director of Nursing (DON) conducted a thorough audit of pharmacy packing slips, medication administration records, and controlled medication return sheets, confirming that 24 tablets of oxycodone were missing. The incident was reported to the Department of Health and Human Services, law enforcement, the North Carolina Board of Nursing, and Adult Protective Services. The affected resident was assessed and did not experience any adverse effects from the missing medication, as the facility promptly replaced the missing doses. Interviews with staff and the resident confirmed that the resident continued to receive her medication as prescribed without any delays. The facility took immediate action to address the issue, including terminating Nurse #2 and conducting in-service training for all nursing staff on narcotic accountability and the prevention of drug diversion. The facility also implemented a monitoring procedure to ensure compliance with controlled substance processes, which was reviewed by the Quality Assurance Performance Improvement Committee.
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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