Salisbury Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Salisbury, North Carolina.
- Location
- 635 Statesville Boulevard, Salisbury, North Carolina 28144
- CMS Provider Number
- 345115
- Inspections on file
- 29
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Salisbury Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of agitation was allowed unsupervised access to a courtyard, where he climbed onto the facility's roof after becoming upset about a potential move to a secured unit. Staff observed the resident on the roof and called the fire department for assistance. Prior to the incident, increased agitation and unsafe behaviors had been noted, but the resident's care plan and supervision level were not updated accordingly. The facility also failed to complete required smoking assessments for another resident.
Two residents experienced misappropriation of their prescribed Oxycodone when medication cards containing narcotic tablets went missing from locked medication storage. Staff discovered the discrepancies during routine narcotic counts, but documentation and narcotic counting procedures were not consistently followed, and the pharmacy was not notified of the missing medications. The responsible party for the missing narcotics could not be identified.
Two residents experienced separate incidents of missing oxycodone from the locked narcotic drawer, and staff identified that full or partial medication cards of oxycodone were no longer present during narcotic counts. In the first case, documentation showed two cards of oxycodone were delivered, but only one was found; the DON reported the loss initially but did not complete or provide evidence of a required 5‑day investigation report to the State Agency. In the second case, a hospice resident’s remaining oxycodone tablets were discovered missing during a count requested by a hospice nurse, and although the loss was reported internally to the DON, she did not submit the required 24‑hour or 5‑day reports to the State Agency or notify APS, law enforcement, or DEA, believing additional reporting was unnecessary after the first incident.
Multiple residents with prior Level I PASRR status were later diagnosed with serious mental disorders such as schizophrenia, bipolar disorder, dementia with behavioral disturbance, psychosis, and severe depression, and were receiving ongoing psychiatric treatment, including antipsychotic medications and regular psychiatric NP follow-up. Despite pre-admission PASRR instructions to resubmit for Level II upon new mental health diagnoses or significant changes in condition, the facility did not submit Level II PASRR requests for these residents. The MDS nurse identified residents with new psychiatric diagnoses and provided a handwritten list of 25 residents needing PASRR referrals to Social Services and the DON, but several residents remained on the list without completed referrals, and no documentation of Level II PASRR determinations was found in their records. Interviews with the MDS nurse, Social Work Director, and DON confirmed that the process to initiate and complete Level II PASRR evaluations after diagnosis changes was not carried out for these residents.
Surveyors found that the facility failed to consistently remove expired and unlabeled food items from the dry storage room, walk-in cooler, and nourishment rooms. In dry storage, multiple expired products and dented canned vegetables were stored with regular stock, and numerous single-use dressing packets were kept in mislabeled or unlabeled bins with no way to verify expiration dates. In the walk-in cooler, several large containers of chicken salad were past the manufacturer’s expiration date but remained available for use. In the 100 and 200 hall nourishment rooms, opened containers of nutritional supplements, thickened beverages, and sweet tea lacked opening dates despite manufacturer time-use limits, and several personal food items were unlabeled. The Dietary Manager and nursing staff shared responsibility for monitoring and labeling, but there was no designated schedule for checks, and assigned staff did not consistently remove outdated, mislabeled, or unlabeled items.
A resident assessed as safe for unsupervised smoking was prevented from accessing the smoking area after 8:00 PM due to facility policy, despite their care plan allowing independent smoking and the resident's expressed preference to smoke later in the evening. Staff enforced this restriction based on prior instructions and concerns about weather, limiting the resident's right to self-determination.
Survey results were not readily accessible because the survey binder, though referenced by a sign at the front desk, was kept behind the receptionist desk in a restricted area that residents and visitors could not access without asking. Several residents reported not knowing where the survey results were located. Staff interviews confirmed the book had always been stored behind the desk, that individuals were not allowed in that area, and that they had to request to see it. Leadership acknowledged awareness that survey results were required to be continuously available without residents or visitors having to ask.
A resident with cognitive impairment, emphysema, prior stroke, and a history of repeated falls was repeatedly observed in a reclining Broda wheelchair positioned at angles up to approximately 130 degrees, during which the resident at times attempted to sit up or stand. The readmission assessment left device and restraint sections incomplete, and the EMR contained no MD order or documentation identifying or assessing any restraint use. NAs and a nurse reported that the chair was reclined specifically to prevent falls, acknowledging the resident could get out of the chair when upright, while the rehab manager and DON recognized that reclining beyond about 110 degrees constituted a restraint and that the chair was not intended to be used that way. The MD stated there was no known medical indication for using the chair at a 130-degree recline and did not support restricting the resident’s movement.
A resident with dementia and alcohol abuse, assessed as severely cognitively impaired, was transferred to the hospital for evaluation after aggressive behavior, exit seeking, and attempts to access the facility roof. On the same day as a discharge-return-anticipated assessment, the social worker informed the guardian that the resident was being issued a 30‑day discharge notice and that the facility could no longer manage his behaviors, while the administrator signed a transfer/discharge notice citing danger to others. The guardian reported being told the resident was suicidal and that the facility would not accept him back, although the resident later stated he was not suicidal and only wanted to leave. The DON and nursing staff indicated the resident became more agitated after being told he would be moved to a secured dementia unit, that he needed 1:1 supervision or secured placement, and that the facility declined his return because he would not agree to transfer to the secured unit or wear a wander guard, leading to prolonged hospitalization until alternate placement was found.
A resident with non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and a psychotic disorder had a PASRR Level II Determination Notification indicating a halted Level II determination due to a primary dementia diagnosis, with a PASRR number ending in H. However, the resident’s most recent comprehensive significant change MDS assessment was coded as not having a PASRR Level II status. During interviews, the MDS nurse acknowledged the MDS coding was incorrect and that the resident should have been identified as PASRR Level II, and the DON stated she expected MDS assessments to be accurate.
A resident with multiple psychiatric and cognitive diagnoses, including dementia, had an existing PASRR Level II determination and later experienced a significant change in condition, including initiation of hospice care, as documented on a comprehensive MDS and CAA for cognitive loss/dementia. Although the MDS nurse recognized that this resident, listed as a PASRR Level II case, should have been referred for a PASRR re-evaluation after the significant change assessment, no referral was made. The Director of Social Services confirmed she did not submit a PASRR re-evaluation request, stating she believed it was unnecessary because the resident already had a Level II PASRR status, resulting in the facility’s failure to notify the appropriate authorities for a required PASRR Level II re-evaluation.
A resident with emphysema, prior CVA, and a history of repeated falls was readmitted, and staff completed a re-admission assessment that captured clinical and risk information but did not generate a baseline care plan. The DON and Unit Manager confirmed that the admitting nurse used the wrong assessment form, which lacked the baseline care plan component with focus areas, goals, and interventions, and a comprehensive care plan was not initiated until several days later and then only addressed nutrition.
A resident with emphysema, prior cerebral infarction, repeated falls, cognitive impairment, and probable inadequate intake was readmitted after a hospital stay with discharge instructions for a pureed diet with thin liquids. Nursing completed a re-admission assessment and a Unit Manager filled out a communication form to Dietary specifying a regular diet with pureed textures and thin liquids, but no provider diet order was entered into the EMR at admission. Despite this, the resident was observed receiving and consuming pureed meals at breakfast and lunch. The Dietary Manager, Regional Dietary Manager, Unit Manager, and DON all confirmed that a provider diet order was missing from the EMR and that it should have been entered upon admission.
A resident with severely impaired cognition, total dependence for ADLs, and an indwelling catheter for neurogenic bladder was observed in bed with the catheter drainage bag lying on the floor, despite a care plan requiring proper catheter positioning. A NA reported she had been taught to hang the bag on the bed frame but said it often slipped off when the bed was kept low. When a unit manager attempted to rehang the bag, it still touched the floor, and leadership, including the ADON and DON, confirmed that catheter drainage bags were expected to remain off the floor and that staff had been educated on this requirement.
A resident with COPD and anemia experienced low O2 saturation and was started on O2 via nasal cannula after a nurse contacted a provider, with documentation in a progress note that the provider ordered 2 L/min O2 later increased to 3 L/min. The resident was repeatedly observed on 3 L/min O2 and had provider notes describing upper respiratory infection symptoms, low O2 saturations, and initiation of oxygen, antibiotics, and nebulizers, yet no corresponding oxygen order was entered into the EMR over multiple days. The unit manager confirmed that the nurse documented receiving the oxygen order but did not create the required EMR order.
Surveyors identified a 7.6% medication error rate when a resident with COPD/asthma did not receive a scheduled morning dose of Breo Ellipta because the prior inhaler had expired and been removed from the cart and a replacement had not yet arrived, and when a nurse prepared an Insulin Lispro pen for another resident without initially priming it as required by the manufacturer’s instructions, only acknowledging and correcting this after being questioned; the DON confirmed expectations that medications be available as ordered and that staff follow clinical guidelines for administration.
The facility failed to ensure that daily nurse staffing sheets accurately reflected the actual nursing staff working across multiple days and shifts. Comparison of internal schedules with posted staffing sheets showed repeated discrepancies in the numbers of RNs, LPNs, CNAs, and CMAs listed for various shifts. Staff interviews revealed that a staff coordinator and receptionists posted the sheets, while nursing staff were sometimes expected to revise them for callouts or schedule changes. One receptionist reported that nursing staff did not always communicate changes, and another stated she had never been educated or instructed to revise the postings. The administrator stated that the staff coordinator was responsible for accurate postings and that he expected the sheets to be updated to show correct staffing for each shift.
A resident admitted with fractures to her left knee and right ankle did not receive the prescribed Oxycodone for pain management due to the absence of a prescription from the hospital. Instead, she was given Acetaminophen, which did not adequately relieve her pain. Staff interviews revealed that the facility's on-call service would not provide a narcotic prescription without one from the hospital, and the nursing staff did not contact the Physician or Nurse Practitioner to obtain the necessary prescription.
A resident with severe cognitive impairment and an indwelling urinary catheter missed a scheduled urology appointment for a catheter change. The appointment was not rescheduled, and the resident was later hospitalized with sepsis and a urinary tract infection. The facility's Appointment Coordinator and Urology Clinic's Scheduler provided conflicting information about the appointment's cancellation and rescheduling. The resident's decline was attributed to existing health conditions, and they were transferred for palliative care.
A resident admitted with leg fractures did not receive prescribed Oxycodone due to the facility's failure to obtain a necessary prescription. Instead, the resident was given Acetaminophen, which did not relieve her pain. The on-call provider would not issue a narcotic order without a hospital prescription, preventing the pharmacy from releasing the medication from the emergency back-up system.
The facility's kitchen was found to have a malfunctioning sink drain and leaking pipe, causing standing water on the floor. Additionally, dusty ceiling vents and improperly stored cereal bags were observed. Staff interviews revealed that maintenance had been notified of the sink issue, but it remained unresolved. The Maintenance Director admitted to previous repair attempts, and the Administrator was unaware of the ongoing problem.
The facility failed to maintain sanitary conditions around the outdoor trash receptacle area, with observations revealing loose garbage and debris on multiple occasions. Interviews with staff indicated ongoing issues and uncertainty about responsibility for cleaning the area. The Administrator acknowledged the problem and expected housekeeping and kitchen staff to maintain cleanliness.
The facility failed to conduct quarterly smoking assessments for two residents, one cognitively intact and the other moderately impaired, both of whom were allowed to smoke unsupervised. Despite being identified as smokers in their care plans, assessments were not completed for over a year. The nursing staff was responsible for these assessments, but the oversight was not recognized by the Administrator until the survey.
Failure to Prevent Accident Hazard Due to Inadequate Supervision of Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment, alcohol-induced dementia, and a court-appointed guardian was not provided with effective supervision, resulting in a serious incident. The resident, who had a history of confusion, agitation, and impaired judgment, was allowed unsupervised access to an enclosed courtyard where he was considered a safe smoker. On the day of the incident, the resident became upset after being told by staff that he would be moved to a secured unit. Subsequently, he stacked patio furniture, climbed onto an awning, and then accessed the facility's roof. Staff observed the resident running and sitting on the edge of the roof, prompting the fire department to be called for his safe removal. Prior to this event, the resident had not exhibited wandering or exit-seeking behaviors, but staff had noted increased agitation and unsafe behaviors, including attempts to take his non-smoking roommate outside to smoke. Despite these observations and discussions with the guardian about escalating behaviors and the potential need for a higher level of care, the resident remained in the unsecured unit. The resident's care plan had not been updated to reflect the increased risk, and he was not placed under enhanced supervision or restricted from unsupervised courtyard access until after the incident occurred. Additionally, the facility failed to complete a smoking assessment on admission and quarterly for another resident to determine if independent smoking was safe or if supervision was required. The lack of timely reassessment and supervision for residents with cognitive impairment and behavioral changes contributed to the occurrence of the incident and the identified deficiency.
Removal Plan
- Resident #120 was placed on enhanced supervision and restricted from unsupervised courtyard access after the incident.
- Resident #120 was reassessed and changed from a safe smoker to a supervised smoker.
- Resident #120 was relocated to a room closer to the nurses' station for increased observation.
- All residents with cognitive deficits and physical capabilities were assessed for wandering, change in behavior, increased agitation, and problematic behaviors.
- Wander guard transmitters were placed on all residents identified as having the ability to wander.
- The Interdisciplinary Team reviewed all residents to identify those with wandering or exit-seeking behavior.
- Staff members were assigned as wandering resident monitors on duty to monitor wandering residents and points of egress.
- All staff received in-service training on supervision of wandering residents, continuous observation, escalation of concerns, and environmental risk identification.
- Staff were instructed to relocate residents displaying exit-seeking or wandering behavior to the secure unit and notify the DON for evaluation.
- All employees were re-hired by new ownership and required to complete dementia and behavior management training to be eligible for rehire.
- All new hires receive training on dementia and care of wandering/behavioral residents during orientation and thereafter.
- Unsupervised courtyard access was restricted for residents with wandering or unsafe behaviors.
- Designated staff monitor the courtyard during resident use.
- Routine environmental rounds are conducted to identify elevated surfaces and climbing risks.
- Behavioral escalation triggers are incorporated into care planning.
- Nurse managers are to be notified immediately for new agitation, pacing, wandering, or exit-seeking behavior; a wandering assessment is completed, wander guard placed, provider and responsible party notified, and care plan updated.
- Residents with new wandering or exit-seeking behaviors are discussed in clinical meetings.
- The DON is responsible for ensuring wandering assessments, notifications, wander guard initiation, and care plan updates are completed.
- A list of exit-seeking/wandering residents is updated and reviewed by the DON and Social Worker.
- Resident wandering assessments and nursing documentation are audited by the DON/ADON to identify residents with increased agitation, exit-seeking, or wandering behavior.
- Audits ensure residents with these behaviors have wander guards and appropriate care plan interventions.
- Audit results are discussed at the clinical At-Risk IDT Meeting and presented to the QAPI Committee for review and revision as needed.
- All residents are assessed for wandering and exit-seeking and with any significant change in condition.
- Education on facility processes for residents with increased agitation, pacing, exit-seeking, or wandering behavior is provided to all staff and reviewed.
Failure to Protect Residents from Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic medications, specifically Oxycodone, for two residents. For one resident, physician orders indicated a prescription for Oxycodone 5 mg twice daily, with two medication cards of 30 tablets each delivered to the facility. However, during a routine narcotic count, staff discovered that one of the medication cards was missing from the locked narcotic box in the medication cart. The medication administration records showed the resident consistently received the prescribed doses and did not report pain, but the missing card was not accounted for, and the receiving nurse had not signed the pharmacy delivery slip. For another resident, who had a PRN order for Oxycodone 5 mg, a medication card of 28 tablets was found missing from the locked narcotic drawer. The resident rarely used the Oxycodone due to an alternative prescription for liquid Morphine Sulfate, and the medication administration record confirmed no doses had been administered. The discrepancy was identified during a narcotic count conducted by a medication aide and a hospice nurse, who noted the absence of the medication card that had previously contained 28 tablets. Interviews with staff revealed that narcotic counts were not consistently performed according to facility policy, and documentation of the number of medication cards was incomplete on several occasions. The pharmacy was not notified of the missing medications, and staff involved in the counts were not suspended or drug tested during the investigation. The facility was unable to determine who was responsible for the missing narcotic medication cards.
Failure to Report Misappropriation of Narcotic Medications to Required Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely and completely report suspected misappropriation of narcotic medications to the State Agency and other required authorities. For one resident with immobility and contractures who had an order for oxycodone 5 mg twice daily, pharmacy documentation showed two 30‑tablet cards of oxycodone were delivered, but only one card (labeled 1 of 2) was present in the locked narcotic drawer when a medication aide and a nurse counted narcotics at shift change. The missing 30‑tablet card was reported to the DON, who stated she submitted a 24‑hour report to the State Agency and notified law enforcement, Adult Protective Services, and the contracted pharmacist. However, she could not produce a 5‑day investigation report or proof it was sent, and the State Agency did not receive it, contrary to the facility’s Abuse Policy requiring reporting of misappropriation to the State Agency, Adult Protective Services, and law enforcement within 24 hours and completion of a 5‑day investigation report. The deficiency also includes the facility’s failure to report another incident of missing narcotics for a hospice resident with osteoporosis and chronic pain who had PRN oxycodone 5 mg and scheduled morphine sulfate. Pharmacy delivery records showed oxycodone tablets were supplied, and a medication aide recalled 28 oxycodone tablets present in the locked narcotic drawer on a prior workday. When asked by a hospice nurse to count narcotics, the aide found that the oxycodone card with 28 tablets was no longer in the locked narcotics box and reported this to the DON. The DON acknowledged that she did not initiate a 24‑hour or 5‑day report to the State Agency and did not notify police, Adult Protective Services, or the DEA about the 28 missing oxycodone tablets, stating she believed additional reporting was unnecessary because she had already investigated the earlier missing oxycodone for another resident. The administrator stated the DON should have ensured required notifications were made for both residents’ missing narcotics.
Failure to Request Level II PASRR Evaluations After New Serious Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to request Level II Preadmission Screening and Resident Review (PASRR) evaluations after new serious mental disorder diagnoses or significant changes in condition were identified for multiple residents who previously had Level I PASRR status. For one resident, a Level I PASRR completed prior to admission instructed that paperwork be resubmitted for a Level II evaluation if a new mental health diagnosis was suspected or if there was a significant change in condition. After admission, this resident was diagnosed with dementia with behavioral disturbance, schizophrenia, and anxiety, and was treated with olanzapine for schizophrenia, with ongoing psychiatric follow-up and consideration of gradual dose reduction. Despite these new diagnoses and ongoing psychiatric management, there was no documented evidence that a Level II PASRR evaluation was requested, and the resident’s name remained on an internal list of residents needing PASRR referrals without indication of completion. Another resident had a Level I PASRR completed prior to admission with the same instruction to resubmit for Level II if a new mental health diagnosis or significant change occurred. This resident was admitted with schizophrenia and later received additional diagnoses of severe depression, dementia, and bipolar disorder. Psychiatric notes documented that the resident was stable on the current regimen and would be seen routinely for schizophrenia, depression, and bipolar disorder. However, the medical record contained no documentation that a Level II PASRR evaluation was requested. The resident’s name also appeared on the handwritten list of residents needing PASRR Level II evaluations and was not crossed off, and facility staff could not provide a date when the submission would be completed. A third resident had a Level I PASRR completed prior to admission with instructions to resubmit for Level II if a new mental health diagnosis or significant change occurred. This resident was later diagnosed with psychosis, dementia, bipolar disorder, anxiety, and schizophrenia, and psychiatric documentation showed ongoing follow-up every four weeks for schizophrenia, bipolar disorder, and anxiety, including assessment for gradual dose reduction of psychiatric medications. Despite these multiple serious mental health diagnoses, there was no documented evidence of a Level II PASRR determination request, and the resident’s name remained uncrossed on the list of residents needing PASRR referrals. A fourth resident was admitted with a Level I PASRR status documented on an FL-2 form and a history of stroke; after admission, additional diagnoses of dementia with psychotic disorder, bipolar disorder, and unspecified psychosis were added. A significant change MDS assessment noted that bipolar disorder was diagnosed after admission and that a significant change in status assessment had been completed, yet the MDS still reflected a Level I PASRR status. The Director of Social Services confirmed this resident was on the list of those needing PASRR referral and that no referral had been initiated. Interviews with the MDS nurse, Social Work Director, and DON confirmed that residents with new mental health diagnoses or significant changes had been identified, but the process to submit Level II PASRR requests had not been carried out for these residents. Facility staff interviews further clarified the actions and inactions that led to the deficiency. The MDS nurse stated she understood that when a resident had a change in condition along with a new mental health diagnosis, she was to notify the Social Work Director for a Level II PASRR referral, and she had created and shared a handwritten list of 25 residents with new mental health diagnoses requiring referral. The Social Work Director reported that she was responsible for initiating Level I or Level II PASRR requests when notified by the MDS nurse of a significant change or new mental health diagnosis and acknowledged that the residents in question were on an audit list of names that still needed to be submitted for Level II evaluations. The list of 25 residents showed that the names of the affected residents were not crossed off, indicating that submissions had not been completed, and the Social Work Director was unable to provide dates when these submissions would occur. The DON, who had recently assumed the role, stated her understanding that Level II PASRR requests should be completed in a timely manner upon admission or readmission of residents with mental health diagnoses and whenever there was a change in condition or new mental health diagnosis, but she was not aware of the specific residents on the list and confirmed that the issue of missed PASRR screenings remained a concern.
Expired and Unlabeled Food Items in Storage, Cooler, and Nourishment Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure food was procured, stored, and maintained in accordance with professional standards, including removal of expired and improperly stored items. In the dry goods storage room, surveyors observed multiple expired products, including thickened orange juice cups, animal crackers, ground coffee packets, and vegetable soup base. There were also numerous single-use salad dressing packets stored in bins that were either mislabeled or unlabeled, with no way to determine their expiration dates because the original boxes had been discarded. Additionally, a case of dented canned vegetables was stored on a regular shelf with other canned goods instead of in the designated area for dented items, despite posted signage instructing staff not to use dented items and to store them separately for return or credit. The Dietary Manager acknowledged responsibility for inspecting storage areas and checking for expired items but reported having no designated schedule for these checks. In the walk-in cooler, surveyors found three containers of chicken salad that were past the manufacturer’s expiration dates, including two full 5-pound containers and one half-full 5-pound container. These items remained in the cooler instead of being discarded or otherwise removed from circulation. The Dietary Manager stated that his standard practice was to dispose of expired cold foods in the garbage, indicating that the presence of these expired items in the cooler was inconsistent with his stated practice. This demonstrated a failure to consistently monitor and remove expired refrigerated food items intended for resident use. In the nourishment rooms on the 100 and 200 halls, surveyors observed multiple opened and partially used containers of nutritional supplements, thickened beverages, and sweet tea that were not labeled with the date they were opened, despite manufacturer guidelines requiring use within a specified number of days after opening when refrigerated. In the 200-hall nourishment room, there were also several personal food items, including partially eaten foods and fast-food items, that were not labeled. Similarly, in the 100-hall nourishment room, opened thickened lemonade and nutritional supplement containers lacked opening dates, and personal food items were unlabeled. The Dietary Manager reported he was responsible for checking nourishment refrigerators for expired items but had no designated schedule, and he stated that nursing staff were responsible for checking nourishment rooms and that any staff placing residents’ personal food in the refrigerators were responsible for labeling it with the resident’s name and the date placed in storage. A Unit Manager later stated that two staff assigned to the nourishment room task were responsible for removing outdated, mislabeled, or unlabeled items at the end of their shift and that the policy for food storage and labeling was posted, but acknowledged that unlabeled items had been present and removed.
Failure to Honor Resident Choice for Independent Smoking
Penalty
Summary
A resident who was cognitively intact and assessed as safe to smoke without supervision was not allowed to smoke at their preferred times. The resident's care plan and smoking assessment indicated that they could smoke independently and unsupervised. However, the facility restricted the resident from accessing the designated smoking area after 8:00 PM by locking the doors, despite the resident's expressed desire to smoke later in the evening. The resident reported this restriction to staff, and staff interviews confirmed that the policy of not allowing residents outside to smoke after 8:00 PM was enforced, even for those assessed as safe to smoke independently. Staff indicated that this restriction was due to instructions from department heads and concerns about cold weather, as well as a lack of available staff for supervised smokers. The Director of Nursing acknowledged that independent smokers should be allowed to smoke at their preferred times, and the Administrator was unaware of the restriction for independent smokers, attributing it to previous administration practices. The facility's actions failed to honor the resident's right to self-determination and choice regarding smoking, as required by their care plan and assessment.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to make survey results readily accessible to residents and visitors without requiring them to ask, as required. During a Resident Council meeting, multiple residents reported they did not know where the survey results were located. An observation showed a sign on the receptionist desk stating that the survey binder was located at the front desk, but the actual survey results book was kept behind the reception desk in a small room near the entrance. This area was restricted by walls and a desk, closed off to residents and visitors, and while the book was visible behind the receptionist, it was not within reach from the front of the desk. Interviews with two receptionists confirmed that the survey results book had always been kept behind the desk in a restricted area and that residents and visitors were not allowed behind the desk, but instead had to request access to review the book. The receptionists also described their work hours, indicating that access to the book depended on their presence. The ADON acknowledged she had not noticed that the survey results book was not in a public area and stated she was aware it needed to always be available without residents or visitors having to ask. The Administrator reported that the book had previously been placed in front of the desk but was moved behind the desk a few weeks earlier after residents had taken and misplaced it, and he acknowledged knowing that the survey results needed to be always available and not require a request to view.
Improper Use of Reclining Wheelchair as Undocumented Restraint
Penalty
Summary
The deficiency involves the facility’s failure to identify and manage a reclining Broda wheelchair as a physical restraint when used in a manner that restricted a resident’s ability to rise independently, and without medical justification or required documentation. The resident involved had emphysema, a history of cerebral infarction, repeated falls, and cognitive impairment, being oriented to person only and confused. On readmission, the Nursing Re-admission Assessment Tool completed by a nurse included sections for Device Assessment and Restraint Identification, but these sections were left blank. The resident’s EMR contained no physician orders for any device that would restrict movement and no documentation of identification, assessment, or use of a restraint. Surveyors observed the resident on multiple occasions seated in a reclining Broda wheelchair at varying back angles, including approximately 110 degrees and 130 degrees. At several observations when the chair was reclined to about 130 degrees, the resident appeared to be attempting to sit up or stand by pulling her upper body forward, including while near the nursing station, in a hallway, and in her room. At other times, when the chair was reclined to about 110 degrees, the resident appeared comfortable, content, and able to feed herself or participate in activities. During therapy, the same chair was observed in an upright position while the resident engaged in therapeutic exercise. Interviews with staff revealed that the chair was intentionally reclined to prevent falls rather than for a documented medical treatment purpose. Two NAs stated that the chair was reclined that far because the resident was at high risk for falls and agreed that the recline was intended to prevent her from falling, noting it could be less reclined when someone was close by. A nurse reported that during a prior admission the resident used the same type of reclined wheelchair, that the resident had multiple falls, and that the resident could get out of the wheelchair when it was in a normal sitting position, which is how she fell. The Rehab Therapy Manager acknowledged that reclining the chair beyond approximately 110 degrees would make it a restraint and stated that the 130-degree position was not typically used except for rest. The DON stated she understood that a 130-degree recline would be considered a restraint and that the Broda chair was never to be used as a restraint. The Medical Director reported he was not aware of any medical symptoms that would warrant use of a 130-degree reclined wheelchair for this resident and did not recommend restricting or restraining the resident’s movements.
Failure to Readmit Hospitalized Resident After Transfer for Behavioral Concerns
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return following a hospital transfer, despite the transfer/discharge being identified as a discharge-return-anticipated. The resident had diagnoses of alcohol abuse and dementia and was assessed as severely cognitively impaired. A quarterly MDS and a discharge-return-anticipated MDS were completed, and on the same day the social worker documented that the guardian was notified the resident was being issued a 30‑day discharge notice for behaviors the facility stated it could not manage, and that the facility was going to proceed with involuntary committal because it could no longer keep the resident safe. Later that day, a nurse documented that the resident was transferred to the hospital for evaluation after aggressive behavior and extreme exit seeking, and that the resident was calm at the time of discharge. A written Nursing Home Notice of Transfer/Discharge, signed by the administrator, cited endangerment to the safety of individuals in the facility due to the resident’s clinical or behavioral status and indicated the guardian was notified of the transfer. Interviews and record review showed that the resident had previously climbed onto the facility roof and later attempted again by stacking lawn furniture in the courtyard. The social worker reported that the guardian was told the facility could no longer handle the resident’s behaviors and that he was sent to the hospital after a second roof attempt. The guardian stated she had not been informed of the first roof incident, but had been told previously that the resident was pushing other residents in wheelchairs and that the facility wanted to move him to a secured dementia unit, which she refused. The guardian reported being told by the social worker that the resident was sent to the hospital because he was suicidal and that the facility refused to accept him back on the grounds that they were unable to keep him from harming himself. The resident later told the guardian from the hospital that he was not suicidal and just wanted to leave the facility. Nursing and administrative staff interviews further described the events leading to the transfer and the refusal to readmit. A nurse stated the resident had always walked around the facility and had not attempted to leave until he was told he was being moved to the secured dementia unit, after which he became more agitated and was perceived as potentially harmful to others, though not suicidal. The nurse stated the resident needed one‑to‑one supervision or placement on the secured dementia unit, but the facility did not have staff for one‑to‑one care. The former DON stated the resident was exit seeking and became more aggressive after the initial roof incident, and that the facility refused to take him back because he would not agree to placement on the secured dementia unit or to wearing an electronic wander guard bracelet. The hospital discharge summary documented that the resident was medically stable, did not meet criteria for inpatient psychiatric admission, and that his hospitalization was prolonged because his original facility declined his return, with eventual placement arranged at another facility with a secured dementia unit.
Inaccurate MDS Coding of PASRR Level II Status
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) assessment for a resident’s Preadmission Screening and Resident Review (PASRR) status. The resident was admitted with multiple psychiatric and cognitive diagnoses, including non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and psychotic disorder. A PASRR Level II Determination Notification letter dated 11/14/23 documented that the resident had a PASRR number ending in the letter H, indicating a halted PASRR Level II determination due to a primary diagnosis of dementia. Despite this, the resident’s most recent comprehensive significant change MDS assessment reported that the resident was not determined to have a PASRR Level II status. During an interview, the MDS nurse reviewed this assessment and confirmed it was incorrect and should have indicated a PASRR Level II status, and the DON stated she would expect residents’ MDS assessments to be accurate. This inaccurate coding of the PASRR Level II status on the MDS, despite existing documentation of the resident’s PASRR determination and diagnoses, constitutes the cited deficiency.
Failure to Request PASRR Level II Re-evaluation After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) re-evaluation after a significant change in condition for a resident with a prior Level II PASRR determination. The resident was admitted with multiple psychiatric and cognitive diagnoses, including non-Alzheimer’s dementia, anxiety disorder, bipolar disorder, and psychotic disorder, and had a PASRR Level II Determination Notification dated 11/14/23, with a PASRR number ending in H indicating a halted Level II determination due to a primary dementia diagnosis. The resident’s electronic medical record showed a hospitalization and a subsequent significant change comprehensive MDS assessment, which documented that the resident was receiving hospice care. The Care Area Assessment for Cognitive Loss/Dementia also noted that the resident was now under hospice care. The facility’s current list of PASRR Level II residents identified this resident as having Level II status. During interviews, the MDS nurse acknowledged awareness that the resident was a Level II PASRR resident and stated that the resident should have been referred for a PASRR re-evaluation when the significant change MDS was completed, and that the resident had been on the original list of those needing a PASRR referral. However, the MDS nurse did not know whether Social Services had actually made the referral. The Director of Social Services reported that she did not submit a PASRR re-evaluation request for this resident following the significant change MDS, explaining that she believed a referral was unnecessary because the resident already had a Level II PASRR status. As a result, no PASRR Level II re-evaluation was requested despite the documented significant change in the resident’s physical and/or mental status and initiation of hospice care.
Failure to Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a newly admitted resident. The resident, who had emphysema, a history of cerebral infarction, and repeated falls, was readmitted to the facility and had a Nursing re-admission Assessment Tool completed by a nurse. This assessment included information on mental and physical health, pain, Braden Scale, tuberculosis screening, fall risk/medication, smoking safety, device/air mattress safety, and elopement risk. However, review of the electronic medical record showed that no baseline care plan was completed following this admission. A comprehensive care plan was not initiated until several days after admission and, as of the survey review date, contained only one focus area related to nutritional status. During interviews, the DON stated that a baseline care plan was normally completed by the admitting nurse within 24 hours of admission and confirmed that none was present for this resident. The Unit Manager reported that the admitting nurse completed a re-admission assessment instead of the required admission assessment, and that the re-admission form did not include the baseline care plan component with focus areas, goals, and interventions. The admitting nurse stated she completed the forms that were auto-populated in the electronic system and did not know that the admission Nursing Collection Tool form was required to generate a baseline care plan.
Failure to Obtain and Enter Provider Diet Order for Readmitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a provider’s diet order into the electronic medical record (EMR) for a newly readmitted resident. The resident, who had emphysema, a history of cerebral infarction, repeated falls, cognitive impairment, confusion, and was oriented only to person, was discharged home and later hospitalized before being readmitted to the facility. Her hospital inpatient discharge summary specified a pureed diet with thin liquids. Upon readmission, a Nursing Re-admission Assessment Tool completed by a nurse documented her nutritional status, including that her usual food intake pattern was probably inadequate, that she had some or all natural teeth, and that she required partial to moderate assistance with eating. However, no provider diet order was entered into her EMR at the time of readmission. Surveyor observations on multiple occasions showed the resident receiving meals despite the absence of a provider diet order in the EMR. At breakfast, she was served a regular, pureed diet and consumed about 25% of the meal. At lunch, she was again served a regular diet with pureed foods and was observed feeding herself while seated in a reclining wheelchair. Review of the EMR confirmed there was no provider diet order in place. The Dietary Manager and Regional Dietary Manager verified that a diet order was missing and that a Communication Form from Nursing to Dietary, completed and signed by a Unit Manager, directed dietary staff to provide a regular diet with pureed textures and thin liquids based on the hospital discharge information. The Unit Manager acknowledged she had relied on the hospital discharge information and the Communication Form to Dietary, but confirmed that a provider’s diet order should have been entered into the EMR upon admission. The DON also stated that the diet order should have been entered into the EMR at admission and identified the lack of a provider diet order as a significant problem.
Failure to Keep Indwelling Catheter Drainage Bag Off the Floor
Penalty
Summary
The deficiency involves the facility’s failure to maintain a urinary catheter drainage bag off the floor for a resident with an indwelling urinary catheter. The resident had neuromuscular dysfunction of the bladder and a physician’s order for an indwelling catheter due to neurogenic bladder with urinary retention. The resident’s MDS documented severely impaired cognition and total dependence for most ADLs, and the care plan specified that the catheter tubing should be free of kinks or obstruction and the drainage bag kept in the proper location. During an observation, the resident was found in bed with the bed in a low position and the urinary catheter drainage bag lying flat on the floor. In a subsequent observation and interview, a nurse aide acknowledged that the catheter drainage bag was on the floor and stated she had been educated to hang the bag on the metal bed frame but reported it often fell off when the bed was in a low position. When the unit manager attempted to hang the bag on the bed frame, the drainage bag still touched the floor, and the manager stated the bed would need to be raised to prevent this and that the bag should never touch the ground due to possible contamination and germs. The ADON and DON both stated that it was never acceptable for a urinary catheter drainage bag to touch the ground and that staff had been educated on catheter care, confirming that the observed condition did not meet the facility’s expectations for catheter bag positioning.
Failure to Enter Physician Order for Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a physician’s order for oxygen therapy for a resident who was receiving supplemental oxygen. The resident was admitted with COPD, tobacco use, and anemia. On 12/15, the resident was observed asleep in bed on 3 L/min O2 via nasal cannula from a portable tank, without signs of discomfort or respiratory distress. A nurse progress note from earlier that afternoon documented that the nurse notified the provider of abnormal vital signs, including an O2 saturation of 64% on room air, and that the provider ordered oxygen at 2 L/min. The note further stated that the resident’s O2 saturation increased to 89% on 2 L/min, and oxygen was then increased to 3 L/min with saturation rising to 91%. Despite this, review of the electronic medical record that day showed no corresponding oxygen order entered. On the following day, the resident was again observed resting in bed on 3 L/min O2 via nasal cannula, alert and oriented to self and without signs of discomfort or difficulty breathing. A provider progress note documented upper respiratory infection symptoms with difficulty breathing and an O2 saturation of 90% while on 3 L/min O2. Review of the electronic medical record that afternoon again revealed no oxygen order. A subsequent provider note on 12/17 stated the resident had mild upper respiratory infection symptoms during the week, that O2 saturations had dipped below 90%, and that oxygen, antibiotics, and nebulizers were started with improvement in O2 saturation into the low 90s on room air. However, review of the chart at midday on 12/17 still showed no oxygen order. The unit manager, upon reviewing the record with the surveyor, confirmed that the nurse had documented receiving an oxygen order from the provider on 12/15 but had failed to create the required oxygen order in the electronic medical record by 12/17.
Medication Error Rate Above 5% Due to Omitted Inhaler Dose and Improper Insulin Pen Preparation
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 26 opportunities (7.6%) during a medication administration observation. For one resident with an order for Breo Ellipta 200-25 mcg per actuation, to be given as one puff by mouth once daily at 8:00 AM for shortness of breath and wheezing related to COPD and/or asthma, the medication was not administered during the observed morning medication pass. The medication aide reported that the Breo Ellipta inhaler was not available on the medication cart, and the unit manager stated that the prior inhaler had been identified as expired and removed from the cart, and that a replacement had been ordered but not yet delivered. The DON stated she would have expected the inhaler to have been ordered before it was out or expired so it would have been available as scheduled. In a separate incident, surveyors observed a nurse preparing to administer Insulin Lispro via a prefilled insulin pen to another resident. The manufacturer’s Full Prescribing Information for the Insulin Lispro pen required priming with 2 units of insulin prior to each injection to ensure the pen was ready to dose and to remove air from the cartridge. The nurse attached a needle to the pen and dialed 15 units for administration but did not prime the pen before walking toward the resident’s room. When stopped outside the room and questioned, the nurse acknowledged she had not primed the pen and confirmed she was supposed to prime it before each injection. The DON confirmed that the Insulin Lispro pen needed to be primed with 2 units prior to each use and that she expected nursing staff to follow clinical guidelines for each medication administered.
Inaccurate Daily Nurse Staffing Postings Across Multiple Shifts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that daily nurse staffing sheets accurately reflected the actual nursing staff who worked on 6 of 7 reviewed days. Surveyors compared the posted daily nurse staffing sheets with the internal nursing staff schedules and found multiple discrepancies. On one day, the schedule showed 5 LPNs and 11 CNAs on first shift and 1 LPN, 8 CNAs, and 3 CMAs on second shift, while the posted sheet showed only 4 LPNs and 9 CNAs on first shift and 2 LPNs, 9 CNAs, and 1 CMA on second shift. On another day, the schedule listed 4 LPNs on first shift, but the posted sheet showed only 3 LPNs. On a third day, the schedule showed 4 LPNs and 1 CMA on first shift, while the posted sheet showed 3 LPNs and 2 CMAs. Additional discrepancies included a day when the schedule showed 7 CNAs on third shift but the posted sheet showed 6 CNAs, another day when the schedule showed 5 LPNs on first shift but the posted sheet showed 4 LPNs, and a day when the schedule showed 1 RN on third shift but the posted sheet showed 3 RNs. Interviews with facility staff revealed confusion and inconsistent practices regarding responsibility for posting and updating the daily staffing sheets. The staff coordinator and two receptionists were identified as responsible for posting the sheets, typically in the morning for all three shifts, and for updating them to reflect callouts or schedule changes. The staff coordinator stated she worked weekdays and expected assigned nurses to make revisions after hours and on weekends, but she was not aware that the sheets had not been updated on the identified dates. One receptionist reported assisting with posting and stated that she, the staff coordinator, and nursing staff were responsible for revising the postings, but noted that nursing staff sometimes failed to communicate changes when staff called out. The other receptionist stated she never made revisions, had not been educated to do so, and had never been told it was her responsibility. The administrator stated that the staff coordinator was responsible for posting and updating the sheets and that he expected the sheets to be updated as needed to reflect the correct number and hours of nursing staff for each shift, and he assumed nursing staff made revisions when the staff coordinator was unavailable.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident who was admitted with fractures to her left knee and right ankle. The resident had undergone surgical repair of the right ankle and was prescribed Oxycodone Hydrochloride for pain management. However, upon admission, the resident did not receive the prescribed narcotic pain medication due to the absence of a prescription from the hospital. Instead, the resident was given Acetaminophen, which did not adequately relieve her pain, as she rated her pain at an 8 or 9 on a scale of 1 to 10 until she received the ordered medication the following evening. Interviews with staff revealed that the Unit Manager was unable to obtain a prescription for the narcotic pain medication on the evening of the resident's admission. The Director of Nursing confirmed that the facility's on-call service would not provide a prescription for a narcotic without one from the hospital. The Pharmacy Consultant indicated that the ordered narcotic would have been beneficial for managing the resident's pain. The Administrator acknowledged that the nursing staff should have contacted the Physician or Nurse Practitioner to obtain the necessary prescription to ensure the resident's comfort.
Missed Urology Appointment for Catheter Change
Penalty
Summary
The facility failed to ensure that a resident was transported to a scheduled urologist appointment for a suprapubic indwelling urinary catheter change. The resident, who was severely cognitively impaired and required an indwelling urinary catheter, was scheduled for a catheter change at the urologist's office. However, there was no evidence in the medical record that the resident attended the appointment, and the appointment was not rescheduled. Interviews with the Appointment Coordinator and the Urology Clinic's Scheduler revealed discrepancies regarding the cancellation and rescheduling of the appointment. The Appointment Coordinator stated that the appointment was canceled, but the Urology Clinic's Scheduler confirmed that the appointment was not canceled and the resident was not brought to the appointment. The Director of Nursing acknowledged that the appointment was not placed on the transportation schedule and should have been rescheduled promptly. The resident was later admitted to the hospital with sepsis due to pneumonia and a urinary tract infection, and the suprapubic catheter was changed at the hospital. The Nurse Practitioner stated that the missed appointment did not cause the resident's decline or sepsis, attributing the decline to the resident's existing health conditions. The resident was eventually transferred to another facility for palliative care.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide necessary pain medication to a resident who was admitted with fractures in both legs. The resident had a physician's order for Oxycodone Hydrochloride, a narcotic pain medication, which was not administered as prescribed on the evening of admission and the following morning. Instead, the resident received Acetaminophen, which did not adequately control her pain. The resident reported experiencing significant pain until the ordered medication was finally administered the next evening. The deficiency occurred because the facility did not obtain a prescription for the narcotic pain medication from the hospital or the on-call provider. The Unit Manager and Director of Nursing stated that the on-call provider would not issue a narcotic order without a prescription from the hospital. Consequently, the pharmacy could not release the medication from the electronic emergency back-up system. The facility's failure to secure the necessary prescription resulted in the resident experiencing unmanaged pain for an extended period.
Kitchen Deficiencies: Sink Leak and Improper Food Storage
Penalty
Summary
The facility was found to have several deficiencies in the kitchen area, including a malfunctioning sink drain and leaking pipe, which resulted in a large amount of standing water on the floor. This issue was observed during a survey, and it was noted that the problem had been ongoing for several weeks despite maintenance being notified multiple times. Additionally, the ceiling vents above the dry station and stove area were found to be dusty and dirty, which could potentially affect the food served to residents. Furthermore, four bags of cereal were observed to be unlabeled and improperly stored next to the tea and coffee station. Interviews with staff revealed that the maintenance department was responsible for cleaning the vents, but this had not been done in a while. The Dietary Aide mentioned that the cereal bags were usually used within a couple of days and were not stored properly. The Maintenance Director admitted to attempting to fix the sink issue previously but was unaware that it was still malfunctioning. The Administrator was not initially aware of the ongoing sink issue but acknowledged that a plumber had been contacted to address the problem.
Failure to Maintain Sanitary Conditions Around Trash Receptacles
Penalty
Summary
The facility failed to maintain sanitary conditions around the outdoor trash receptacle area, which was observed to have loose garbage and debris on multiple occasions. Observations on three consecutive days revealed masks, water bottles, debris, gloves, and bags of trash on the ground around the trash receptacles. Additionally, the staff break area, located near the trash receptacle area, was also observed to have food wrappers and drink bottles scattered on the ground. Interviews with facility staff, including two dietary aides, indicated that the issue of trash and debris around the receptacle area was ongoing. The dietary aides expressed uncertainty about who was responsible for keeping the area clean, despite their attempts to maintain it. A joint interview with the Administrator and Maintenance Director confirmed the ongoing issue, with the Administrator acknowledging a lack of clarity regarding responsibility for the area’s cleanliness. The Administrator expected housekeeping and kitchen staff to maintain the area free of trash and rodents.
Failure to Complete Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #67, who was cognitively intact and had a history of heart failure and diabetes, was admitted to the facility and identified as a smoker. Despite being coded for smoking in the Minimum Data Set (MDS) and having a care plan that allowed unsupervised smoking, Resident #67 did not receive a quarterly smoking assessment from April 2023 until July 2024. The assessment completed in July 2024 confirmed the resident as an unsupervised smoker. Similarly, Resident #91, who was moderately cognitively impaired, was also identified as a smoker upon admission. The resident's care plan, revised in July 2024, permitted unsupervised smoking. However, like Resident #67, Resident #91 did not receive a quarterly smoking assessment from April 2023 until July 2024. Interviews with the Nurse Unit Manager and the Director of Nursing revealed that the responsibility for completing these assessments lay with the nursing staff, and both residents should have had their assessments completed quarterly. The Administrator was unaware of the missed assessments until the survey.
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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