Signature Healthcare Of Kinston
Inspection history, citations, penalties and survey trends for this long-term care facility in Kinston, North Carolina.
- Location
- 907 Cunningham Road, Kinston, North Carolina 28501
- CMS Provider Number
- 345365
- Inspections on file
- 23
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Signature Healthcare Of Kinston during CMS and state inspections, most recent first.
Lunch was served approximately two hours late to all dining areas after kitchen staffing shortages led to unwashed dishes from the previous dinner service, which delayed both breakfast and lunch meal times. The interim dietary manager confirmed the delays were due to staff quitting without notice, and the administrator was aware of prior late meal services but had not previously identified staffing as the cause.
A resident admitted with multiple serious mental health diagnoses, including bipolar disorder, PTSD, depression, and anxiety, did not receive a required Level II PASRR evaluation despite ongoing psychiatric symptoms and medication changes. The facility relied on a prior Level I screening and did not reassess the need for a Level II evaluation, as confirmed by staff interviews and record review.
A resident with a tracheostomy did not have an Ambu bag at the bedside as required by policy and physician orders, and nursing staff were unable to immediately locate the Ambu bag on the crash cart. Additionally, a nurse performed tracheostomy care without maintaining sterile technique after contaminating her gloves, and staff training and competency checks were found to be insufficient.
A resident with dysphagia and physician orders for a pureed diet did not receive the required pureed bread item as specified on the dietitian-approved menu. Staff confirmed the omission during meal service, and the issue was only addressed after surveyor intervention.
A resident who was cognitively intact and independently mobile in a wheelchair was verbally abused and threatened by a housekeeper, who used profane and racially charged language and physically pushed her cart into the resident's wheelchair. Multiple staff witnessed the incident, intervened to separate the individuals, and confirmed the abusive behavior, which was substantiated by the facility's investigation.
Two residents experienced misappropriation and exploitation when staff solicited and used their funds for personal gain. One resident with dementia lost over $2,200 after giving her debit card to a nurse aide, who made unauthorized purchases. Another cognitively intact resident gave $65 to a nurse aide who requested money for her children and was not reimbursed. Both incidents were substantiated, and the staff involved were terminated.
The facility did not notify Adult Protective Services (APS) of substantiated cases of misappropriation of property and verbal abuse involving three residents, despite facility policy requiring such reporting. Incidents included a resident's debit card being misused by a nurse aide, another resident being verbally abused and physically threatened by a housekeeper, and a third resident reporting a missing valuable ring. Documentation and staff interviews confirmed APS was not notified in these cases.
A resident's MDS assessment was inaccurately coded when a physician-documented contraindication to gradual dose reduction (GDR) of a psychotropic medication was not properly recorded. The MDS nurse acknowledged the error during an interview, confirming that the section should have indicated the GDR was clinically contraindicated as documented by the physician.
The facility failed to accurately code MDS assessments for several residents, including a resident with diabetes not coded for hypoglycemic medications, a smoker not coded for tobacco use, a resident with a colostomy not coded for an ostomy, and a resident with dementia not coded for a gradual dose reduction of antipsychotic medication. These errors were acknowledged by the MDS Nurse and confirmed by the Interim Director of Nursing and the Administrator.
A resident was left with medications on her overbed table without an assessment for self-administration. The resident, who was cognitively intact, had Acetaminophen and Ciprofloxacin left in medication cups to take at her discretion. Nurse #1 admitted to leaving the medications unsupervised, and both the Assistant Director of Nursing and the Interim Director of Nursing confirmed the lack of assessment and supervision.
A facility failed to provide the required CMS Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for a resident with moderate cognitive impairment. The resident's Medicare Part A skilled services ended, but the benefit was not exhausted, and there was no evidence that the necessary notices were given. The Business Office Manager indicated that the former Receptionist was responsible for the forms, but they were not completed or uploaded.
A facility failed to refer a resident with a new PTSD diagnosis for a PASARR evaluation. The resident, initially admitted with adjustment disorder, was not screened for PASARR despite a new PTSD diagnosis. The Social Worker did not make the referral, believing the resident was doing well and unaware of her nightmares. The Administrator confirmed that a new psychiatric diagnosis should have prompted a referral.
A facility failed to document the administration of Acetaminophen for a resident with peripheral vascular disease. A nurse administered 650 mg of Acetaminophen, but this was not recorded in the resident's MAR. The nurse believed he had documented it, and the Interim DON confirmed it should have been documented.
A resident's room in the facility was found to have a scuffed bathroom door with peeling paint and a buildup of black debris on the grout at the base of the doorway. Despite the resident's complaints to staff, no maintenance work order was found, and staff interviews revealed a lack of awareness of the issues. The facility's maintenance and housekeeping procedures failed to address the resident's concerns.
Delayed Meal Service Due to Staffing and Dishwashing Issues
Penalty
Summary
The facility failed to serve lunch at the scheduled times for all dining areas on 12/01/25, with meals being delivered approximately two hours later than the posted mealtimes. The posted schedule indicated lunch service was to begin at 12:00 PM in the dining room and continue in staggered intervals across the 500, 400, 300, 200, and 100 halls, but actual service did not begin until 2:15 PM in the dining room and was completed at 2:40 PM on the 100 hall. The Regional Dietary Manager, acting as interim dietary manager, confirmed that the delay was due to staffing issues in the kitchen, specifically that dietary aides had quit without notice on the night of 11/20/25, resulting in unwashed dishes that had to be cleaned the morning of 12/01/25. This caused breakfast to also be served two hours late, which in turn delayed lunch service. The Administrator acknowledged awareness of previous late dining services but had not identified staffing as the cause prior to this incident.
Failure to Submit PASRR Level II Evaluation for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who was admitted with multiple serious mental health diagnoses. Documentation showed that the resident had a history of bipolar disorder, post-traumatic stress disorder (PTSD), depression, and anxiety, and was receiving several psychiatric medications, including antidepressants, antianxiety medications, and an antipsychotic. Despite these diagnoses and ongoing psychiatric symptoms, such as hallucinations, there was no evidence in the medical record that a Level II PASRR evaluation had been requested or completed. The resident's care plan addressed mood alterations, PTSD, and the risk of drug-related side effects, and included interventions such as psychiatric consultations and monitoring for medication effects. However, the care plan did not reference the need for a PASRR Level II evaluation. Medical and psychiatric notes documented ongoing symptoms, medication adjustments, and the addition of antipsychotic and antianxiety medications, but there was no indication that these changes prompted a reassessment of the resident's PASRR status. Interviews with facility staff revealed that the social worker relied on the hospital's PASRR Level I screening, which did not identify a serious mental illness, and assumed that all relevant diagnoses had been entered into the screening tool. The social worker acknowledged not submitting a Level II PASRR request after admission, despite the resident's diagnoses, medication changes, and reports of hallucinations. The administrator deferred to the social worker regarding PASRR requirements, and the clinical coordinator confirmed that no Level II evaluation had been submitted, as the Level I determination did not indicate a serious mental illness and there was no significant change in the resident's condition.
Failure to Maintain Emergency Tracheostomy Equipment and Sterile Technique
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not ensuring that required emergency tracheostomy equipment, specifically an Ambu bag, was kept at the bedside as ordered and as required by facility policy. Observations revealed that while spare trach tubes and an obturator were present at the bedside, the Ambu bag was missing from the resident's room and could not be located by nursing staff on the crash cart. The Director of Nursing (DON) was also unaware of the facility's trach policy and confirmed the absence of the Ambu bag at the bedside after searching the room and surrounding areas. The Ambu bag was eventually found inside the crash cart, which was located 143 feet away from the resident's room, and staff were unable to immediately locate it when needed. Additionally, the facility failed to ensure proper infection-control practices during tracheostomy care for the resident. During an observed tracheostomy care procedure, a nurse contaminated her sterile gloves by holding the resident's hands and moving non-sterile items, but did not change gloves or reestablish sterility before continuing the procedure. The nurse proceeded to complete the tracheostomy care, including cleaning the stoma site and changing the inner cannula, while wearing contaminated gloves. The nurse reported having received training from another nurse on the floor and had shadowed for several days prior to performing tracheostomy care independently. Interviews with the Medical Director and Staff Development Coordinator confirmed concerns regarding the lack of sterile technique and the adequacy of staff training. The Staff Development Coordinator stated that new nurses were trained by more experienced floor nurses and received annual refresher training, but did not follow up to ensure correct training unless a deficiency was brought to her attention. The DON, who was new to the facility, acknowledged the importance of following proper protocol but was not familiar with the exact policy.
Failure to Serve Dietitian-Approved Pureed Bread Item
Penalty
Summary
The facility failed to follow the approved menu for a resident on a pureed diet. The dietitian-approved menu for Week 2 specified that residents requiring a pureed diet should receive pureed cornbread. One resident, admitted with dysphagia and physician orders for a pureed diet, was observed during tray line service to have received pureed chicken, pureed broccoli, and pureed candied yams, but no pureed cornbread or any pureed bread product was included on the tray. Staff confirmed that a pureed bread item was not prepared or served, and the omission was only addressed after surveyor intervention. Attempts to contact the Registered Dietitian at the time were unsuccessful.
Resident Subjected to Verbal Abuse and Threats by Housekeeper
Penalty
Summary
A resident with a history of cerebral vascular accident (stroke), who was cognitively intact and able to independently propel himself in a wheelchair, was subjected to verbal abuse by a staff member. The incident occurred when the resident was moving down a crowded hallway and was confronted by a housekeeper who became upset that the resident was blocking her cart. Multiple staff members witnessed the housekeeper cursing at the resident in a threatening tone, using profane and racially charged language, and physically pushing her housekeeping cart into the back of the resident's wheelchair. The housekeeper also yanked the resident's wheelchair and continued to verbally threaten and insult him, escalating the situation and causing the resident to become visibly upset. Witness statements from two nurse aides confirmed the sequence of events, including the housekeeper's repeated use of profanity, threats to physically harm the resident, and physical contact with the resident's wheelchair. The incident was substantiated as verbal abuse by the facility's investigation, with corroborating accounts from staff who intervened to separate the housekeeper from the resident and de-escalate the situation. The resident was taken to his room and calmed down after the incident. The facility's investigation confirmed the occurrence of verbal abuse and threats by the housekeeper toward the resident.
Failure to Protect Residents from Misappropriation and Exploitation
Penalty
Summary
The facility failed to protect residents from misappropriation of property and exploitation in two separate incidents involving two residents. In the first case, a resident with a diagnosis of dementia, assessed as moderately cognitively impaired, reported that her debit card account was depleted after she gave her card to a nurse aide to pay a utility bill. The nurse aide used the card for unauthorized purchases totaling over $2,200, including groceries, retail items, and rent payments. The resident became aware of the missing funds after checking her account balance and confronted the aide, who did not provide an explanation. Multiple staff members were informed of the incident, and the matter was reported to local law enforcement. The aide was suspended and later terminated following the investigation, and the resident was reimbursed for the unauthorized transactions. In the second incident, another resident, who was cognitively intact and had multiple medical diagnoses, was approached by a nurse aide who requested money to feed her children. The resident gave the aide $65 after being told $20 would not be sufficient. The aide promised to repay the money but did not do so and instructed the resident to misrepresent the reason for the transaction to other staff. The aide was suspended and subsequently terminated after the incident was reported and substantiated by facility staff. However, the facility did not reimburse the resident for the money given to the aide, with the administrator stating that the money was given voluntarily. Both incidents were substantiated through staff interviews, resident statements, and review of facility records. The facility's failure to prevent staff from soliciting or misusing residents' funds resulted in financial loss and emotional distress for the residents involved. The facility's policies defined such actions as exploitation and misappropriation of property, yet the protections in place were insufficient to prevent these occurrences.
Failure to Notify APS of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and misappropriation of property/exploitation to Adult Protective Services (APS) for three residents. According to the facility's policy, the Administrator is responsible for reporting all investigation results of such incidents to the appropriate state agencies as required by law. However, documentation and staff interviews revealed that APS was not notified in several substantiated cases involving misappropriation of property and verbal abuse. In one case, a resident alleged that a nurse aide borrowed her debit card under the pretense of paying a bill, but subsequently, nearly the entire balance was depleted without authorization. The facility substantiated the misappropriation, reimbursed the resident, and notified law enforcement and the state agency, but there was no documentation that APS was informed. In another incident, a resident with a history of stroke was verbally abused and threatened by a housekeeper, who also physically pushed a cart into the resident's wheelchair. The facility substantiated the verbal abuse, but again, APS was not notified as required. A third resident, diagnosed with bipolar disorder and anxiety, reported a valuable ring missing after showing it to a nurse aide. The investigation noted the resident did not witness the theft but believed the aide was the only person aware of the ring's location. The facility's investigation report documented that APS was not notified of this allegation either. Interviews with former administrators and nursing staff confirmed a lack of clarity and adherence to the policy regarding APS notification in these cases.
Inaccurate Coding of Physician-Documented GDR Contraindication on MDS
Penalty
Summary
The facility failed to accurately code a physician-documented gradual dose reduction (GDR) as clinically contraindicated on the Minimum Data Set (MDS) assessment for one resident. Record review showed that the psychiatric provider documented that a dosage reduction to the resident's psychotropic regimen was likely to impair function and worsen the underlying psychiatric condition. However, the annual MDS assessment did not reflect that the physician had documented the GDR as clinically contraindicated. During interviews, the MDS nurse confirmed she completed the relevant section of the MDS and acknowledged that she incorrectly marked the GDR as not clinically contraindicated, which was an error. The administrator confirmed the expectation for MDS assessments to be accurate.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in various areas, including medications, smoking, elimination, and behaviors. Resident #14, who was diagnosed with Diabetes Mellitus, was not coded for receiving hypoglycemic medications despite having multiple physician orders for insulin and other diabetes medications. The MDS Nurse acknowledged the error, attributing it to human error, and both the Interim Director of Nursing and the Administrator confirmed that the MDS should have been coded accurately. Resident #17, who had a history of smoking, was not coded for tobacco use in the MDS assessment, despite being cognitively intact and actively using the facility's designated smoking area. The MDS Nurse admitted to clicking the wrong answer on the MDS screen, and both the Interim Director of Nursing and the Administrator agreed that the assessment should have reflected the resident's smoking status. Resident #2, with a diagnosis of colostomy, was not coded for an ostomy in the MDS assessment, which was acknowledged as an error by the MDS Coordinator and the Interim Director of Nursing. Additionally, Resident #13, who had dementia, was not coded for a gradual dose reduction attempt of antipsychotic medication, despite documentation in the care plan and a pharmacy consultant report indicating such an attempt. The MDS Nurse recognized this as an oversight, and the Interim Administrator confirmed the assessment should have been coded to reflect the dose reduction attempt.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications before leaving medications on the overbed table in the resident's room. The resident, who was cognitively intact, had medications left on her overbed table to take at her discretion, without a documented assessment or physician's order for self-administration. The medications included Acetaminophen and Ciprofloxacin, which were left in separate medication cups on the overbed table. Nurse #1 admitted to leaving the medications on the overbed table after observing the resident with a medication cup at her mouth. The nurse acknowledged that he should have stayed with the resident to ensure the medications were taken. The Assistant Director of Nursing and the Interim Director of Nursing confirmed that the resident had not been assessed for self-administration and that the nurse should have supervised the medication administration.
Failure to Provide Required CMS Notices
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) for a resident reviewed for beneficiary protection notification. The resident was admitted with Medicare Part A skilled services and had moderate cognitive impairment. Her Medicare Part A skilled services ended, but her benefit was not exhausted, and she remained in the facility. There was no evidence that the resident or her responsible party received the necessary NOMNC or ABN notices. The Business Office Manager stated that the former weekday Receptionist was responsible for completing the required forms, but the Receptionist was no longer employed, and the forms were not uploaded to the facility system. Blank forms were found in the resident's folder. The Administrator confirmed that the resident should have received the CMS-10123-NOMNC and CMS-ABN as required by federal guidelines.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident with a new diagnosis of mental illness for a Preadmission Screening and Resident Review (PASARR) evaluation. Resident #33, who was admitted with a diagnosis of adjustment disorder, was newly diagnosed with post-traumatic stress disorder (PTSD) on June 27, 2024. Despite this new diagnosis, the resident's quarterly Minimum Data Set (MDS) assessment did not indicate that she was screened for a PASARR evaluation. The resident's care plan, last reviewed on July 29, 2024, included interventions for behaviors related to a traumatic event, but did not include a referral for a PASARR evaluation. Interviews conducted during the investigation revealed that the facility's Social Worker did not refer Resident #33 for a PASARR evaluation because she believed the resident was doing well and was unaware of the resident's nightmares. The resident reported experiencing nightmares after being contacted by a family member who had previously assaulted her. The facility Administrator confirmed that a new psychiatric diagnosis should have prompted a referral to the North Carolina Medical Uniform Screening Tool (NC MUST) for a PASARR application, which the Social Worker failed to do.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, specifically in documenting the administration of medication. Resident #18, who was admitted with a diagnosis of peripheral vascular disease, had a physician's order for Acetaminophen 325 mg tablets, to be given as needed for pain or fever. On October 14, 2024, Nurse #1 was observed administering 650 mg of Acetaminophen to Resident #18, but this administration was not recorded in the resident's Medication Administration Record (MAR) for October 2024. Additionally, there was no nursing documentation in the medical record indicating that the medication was administered. In a subsequent interview, Nurse #1 stated that he believed he had documented the administration on the MAR, while the Interim Director of Nursing confirmed that the documentation should have been completed after the medication was given.
Failure to Maintain Safe and Clean Environment in Resident's Room
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as evidenced by the condition of the bathroom door and doorway in the resident's room. Observations revealed that the bathroom door was scuffed and had peeling paint, exposing a wood-like color underneath. Additionally, there was a buildup of black debris on the grout at the base of the bathroom doorway. The resident expressed dissatisfaction with the condition of the bathroom and reported having informed staff about these issues multiple times, although she could not recall specific staff members or dates. Interviews with facility staff, including the Assistant Maintenance Director, Housekeeping Supervisor, Maintenance Director, Administrator, and interim Director of Nursing, revealed a lack of awareness and documentation regarding the resident's complaints. The Assistant Maintenance Director confirmed that room inspections were conducted monthly, and maintenance issues were logged in a book at the nurse's station and an electronic work order system, both checked weekly. However, no work order for the resident's room was found. The Housekeeping Supervisor was unaware of the discoloration, and the Administrator, who conducted daily ambassador rounds, did not notice any issues. The interim DON stated that nursing staff were expected to notify housekeeping and maintenance of any cleaning or repair needs.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
