Signature Healthcare Of Roanoke Rapids
Inspection history, citations, penalties and survey trends for this long-term care facility in Roanoke Rapids, North Carolina.
- Location
- 305 East Fourteenth Street, Roanoke Rapids, North Carolina 27870
- CMS Provider Number
- 345336
- Inspections on file
- 29
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Signature Healthcare Of Roanoke Rapids during CMS and state inspections, most recent first.
The facility failed to accurately document and reconcile controlled medications for multiple residents, including those receiving hydrocodone-acetaminophen, oxycodone, and Oxycontin for pain. For one resident with metastatic cancer and severe pain, controlled drug records showed more doses removed from locked storage than were documented as administered on the MAR, and several nurses admitted to forgetting MAR documentation, misdating removals, or signing out doses without times to correct off-counts. On one unit, the controlled substance count sheets over several days lacked required dual signatures, omitted counts of cards and sheets, and contained undocumented additions and subtractions of medication cards, with some shifts showing no recorded reconciliation at all. For another resident on chronic Oxycontin, the pharmacy’s dispense and return records did not match the facility’s controlled drug records, and neither the pharmacist nor the corporate nurse consultant could reconcile the discrepancies. A third resident on scheduled Oxycontin and PRN oxycodone had MAR entries indicating doses were given without corresponding removals on the controlled drug record, and nurses later reported holding doses without correcting the MAR, giving PRN oxycodone instead of scheduled Oxycontin without clear documentation, or being unable to explain mismatched records.
The facility failed to maintain accurate and complete medical records for two residents, including documentation of bowel movements and administration of controlled pain medications. One resident with advanced cancer had bowel movements under-documented despite staff acknowledging more frequent occurrences, and multiple doses of hydrocodone-acetaminophen and oxycodone were signed out on the controlled drug record without corresponding entries on the MAR, even though nurses stated the medications were given. Another resident with vertebral osteomyelitis and chronic low back pain had a scheduled Oxycontin dose documented as administered when it was actually held due to sedation, and the nurse involved did not know how to correct the electronic MAR. The DON and interim Administrator both acknowledged that these records were incomplete or inaccurate.
A resident with Stage IV cancer and Stage IV kidney disease was admitted from the hospital with a discharge summary listing multiple scheduled follow-up appointments, including a PET scan and oncology and nephrology visits. The facility’s process required nursing staff to review the discharge summary and provide it to the Transportation Nurse Aide to arrange transport, but this did not occur. The family member went to the oncology appointment expecting to meet the resident, believing transportation had been arranged, but the resident never arrived and all appointments were missed. The Transportation Nurse Aide and Social Worker reported they were unaware of the appointments, and the DON confirmed the discharge summary had not been given to the Transportation Nurse Aide as expected.
A resident with metastatic cancer, an open malignant shoulder wound, neuropathy, and a history of spine surgery had PRN hydrocodone, PRN oxycodone, and scheduled gabapentin ordered for pain and was care-planned to request and receive pain meds as needed. On one evening shift, the resident requested pain medication early in the shift, but the assigned nurse did not administer any opioid analgesic, could not be located by the NA, and was later found asleep in a car with the med cart keys. Another nurse, working on a different unit, and other staff repeatedly attempted to wake the assigned nurse and contacted the DON, but the resident’s first documented oxycodone dose on that shift was not given until the early morning hours, at which time the resident was tearful and reported extreme pain. The MAR showed no hydrocodone given that shift and no documented time for the evening gabapentin dose, demonstrating a significant delay in providing ordered pain management.
A resident with multiple comorbidities and severely impaired cognition experienced two falls in one day. After the second fall, an RN assessed new left leg pain and obtained a STAT order for x‑rays of the left hip and femur, but the mobile x‑ray was not completed that night due to access issues and lack of staff response. The next morning, the resident’s representative reported the resident was in pain and requested Tylenol before dialysis; an RN performed a limited assessment, relied on the prior evaluation and pending STAT x‑ray, and allowed the resident to attend dialysis, while the DON, seeing the resident laughing in a wheelchair, did not assess pain. When the x‑ray technician arrived later, the resident was already at dialysis, and the exam was again delayed. Dialysis documentation showed ongoing left lower extremity pain and early termination of treatment, and the resident was later found to have a hip fracture requiring surgery. The deficiency centers on the failure to ensure timely completion of the ordered STAT x‑ray and prompt diagnostic evaluation of the resident’s post‑fall leg pain.
Surveyors identified significant medication errors involving two residents who did not receive scheduled rapid-acting insulin doses due to a staffing shortage, and another resident who continued to receive prednisone despite a pulmonologist's recommendation to discontinue it. The errors were linked to missed medication administration, lack of timely communication, and failure to implement consultation recommendations.
Due to insufficient nursing staff coverage, two residents with diabetes did not receive their scheduled morning doses of rapid-acting insulin. The absence of a medication aide and a unit manager resulted in delayed medication administration, and communication lapses among staff further contributed to the missed doses. The incident was confirmed through medication records and staff interviews.
A resident with hemiplegia and transfer dependence was manually transferred from a wheelchair to bed by an agency CNA without the required mechanical lift, despite clear care plan instructions and available assistance. The resident reported being handled roughly and experienced severe pain, later found to be due to a comminuted, displaced femur fracture. Staff interviews and documentation confirmed the transfer was not performed per protocol.
The facility did not update its facility-wide assessment to reflect the needs of all residents, including two who required tracheostomy care. The assessment inaccurately stated no residents needed such care, and the Administrator admitted to not reviewing the assessment in the previous year.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with improved kidney function was incorrectly coded for dialysis, another with vascular dementia was not coded for a wander guard alarm, and a diabetic resident was not coded for hypoglycemic medication. Additionally, a resident dependent on dialysis was not correctly coded upon readmission. The MDS Nurse was responsible for these inaccuracies.
The facility failed to properly label and store medications, with an insulin pen and albuterol inhaler found unlabeled on Unit 3, and a netarsudil solution unrefrigerated on Unit 1. Additionally, a wound treatment cart on Unit 3 was left unattended and unlocked, containing resident treatment supplies. The DON confirmed that all staff were responsible for ensuring proper labeling, storage, and security of medications and treatment carts.
The facility failed to maintain sanitary conditions in the kitchen, with observations revealing unclean equipment such as a plate dispenser with dried food particles and a steam table shelf covered in food debris. Despite having a cleaning schedule, these areas were overlooked, as confirmed by the dietary managers and the Administrator.
The facility failed to properly dispose of garbage in the dumpster area, with observations of an open dumpster lid, scattered litter, and uncollected waste. The Dietary District Manager noted the area was cleaned earlier, but the waste company did not pick up dropped items. The Administrator stated all staff were responsible for maintaining cleanliness, and the Corporate Administrator suggested daily inspections.
A facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for a resident who was admitted with a diagnosis of malignant neoplasm and later admitted to hospice. Despite a physician order indicating the resident's terminal status and hospice admission, no MDS assessment was completed to reflect this change. Interviews with the MDS Nurse and Administrator confirmed the oversight.
A resident with severe cognitive impairment and specific activity preferences did not have a person-centered care plan developed by the facility. Despite expressing interest in activities like reading and music, the resident's care plan lacked these provisions. Observations showed the resident often in their room with the TV on, and interviews revealed confusion among staff about responsibility for care plan development.
A facility failed to obtain a physician order for tracheostomy care for a resident with a tracheostomy. Although nursing staff provided care, including cleaning and suctioning, there was no documented physician order for tracheostomy site care. The Unit Manager acknowledged the oversight, and the DON could not explain how the order was missed.
A facility failed to ensure a resident receiving dialysis had a physician's order for the service. The resident, dependent on renal dialysis, was readmitted from the hospital without the dialysis order being reinstated. Staff interviews confirmed the oversight, with the Unit Manager and DON acknowledging the failure to reestablish the order. The Administrator also noted that staff should have ensured the presence of a physician's order.
The facility failed to notify the Ombudsman of hospital transfers for two residents. The Social Service Director was running incorrect reports, leading to missed notifications. Interviews revealed that the Director of Nursing and interim Administrator were unaware of the issue, which was identified through record reviews and staff interviews.
Failure to Accurately Document and Reconcile Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to accurately document and reconcile controlled medications for multiple residents, and to follow its system for accounting for controlled substances between shift changes and upon receipt or removal from locked storage. For one resident with metastatic cancer, open malignant wound, neuropathy, and a history of spine surgery, hydrocodone-acetaminophen and oxycodone orders were in place for pain management. The hydrocodone-acetaminophen controlled drug record showed 11 removals from storage, while the MAR reflected only one administered dose. The oxycodone controlled drug record showed 13 removals, while the MAR reflected 11 administered doses. Several nurses signed out controlled medications without corresponding MAR documentation, left times blank, or misdated removals. One nurse reported he arrived late for his shift, did not believe a narcotic count was done at shift change, and later signed out additional doses without times to correct an off count, intending another nurse to fill in the times. Another nurse admitted she often became busy and forgot to document administrations on the MAR after removing doses from storage, and another nurse stated she administered a dose but forgot to sign the MAR. The facility’s unit-level controlled substance count sheets also showed multiple deficiencies in reconciliation practices. On one unit, over a period of several days, the controlled substance count sheet documented 20 instances where medication cards were added to or subtracted from the total count. For 11 of these, only one nurse’s signature was present, and for seven there were no nurse signatures at all. In two instances, there was only a notation of “+1” without any information about which medication, which resident, or which nurse was involved. Across multiple days and shifts, required signatures of off-going or on-coming nurses were missing, the number of cards/containers and count sheets was left blank, and there were gaps of up to 36 hours with no documented count or reconciliation. The DON later reported that a count had been reconciled in her presence during one of these undocumented periods, but this reconciliation was not reflected on the count sheet. For another resident with chronic pain receiving Oxycontin twice daily, discrepancies existed between the pharmacy’s records and the facility’s records regarding dispensed and returned doses. The pharmacy’s system showed that 28 Oxycontin tablets were dispensed on one date, that 17 doses from that fill were returned the following day, and that another 28 tablets were sent on the same day as the recorded return. The pharmacist stated they had no record of returned Oxycontin from the later dispense and were still awaiting unused doses. In contrast, the facility’s controlled drug records showed all 28 doses from the first fill were used with none returned, and that 17 doses from the second fill remained after discharge and were returned on a later date. The Corporate Nurse Consultant stated that the facility’s return documentation was pulled directly from the pharmacy’s system and could not explain why the pharmacy’s internal records and the facility’s records could not be reconciled. A third resident with vertebral osteomyelitis and low back pain had orders for scheduled Oxycontin and PRN oxycodone. For this resident, the March MAR and Oxycontin controlled drug record did not consistently match. On one date, a nurse initialed the 10:00 AM Oxycontin dose as given on the MAR, but no corresponding removal was documented on the controlled drug record; the nurse later stated she had not administered the dose because the resident appeared sedated, and that she had signed the MAR before deciding to hold the dose and did not know how to correct the entry. On another date, a nurse documented administration of PRN oxycodone and placed initials with an asterisk and the comment “RC” by the 10:00 PM Oxycontin dose, but no Oxycontin removal was documented; the nurse later stated she had not realized the resident had Oxycontin ordered, gave oxycodone instead, and did not document an explanation for not giving the Oxycontin. On a separate date, another nurse initialed the 10:00 AM Oxycontin dose as administered on the MAR, but there was no corresponding removal on the controlled drug record, and the nurse could not recall why the documentation did not match. The DON stated she expected removal documentation from locked storage to coincide with MAR documentation of administration.
Inaccurate Documentation of Bowel Movements and Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for two residents, specifically regarding bowel movement documentation and controlled medication administration. One resident with Stage IV basal cell carcinoma had only three bowel movements documented over a nineteen-day stay, despite nursing staff and the DON acknowledging that the resident had more bowel movements than recorded. The facility’s system was designed to flag when a resident went three days without a bowel movement so that medications could be administered if needed, but the actual frequency of bowel movements was not accurately reflected in the medical record. For the same resident, record review showed multiple instances where hydrocodone-acetaminophen and oxycodone were removed from controlled drug storage, as documented on the Controlled Drug Record, but there was no corresponding documentation of administration on the MAR. Nurse #1 confirmed that she had administered both hydrocodone-acetaminophen and oxycodone at the times she signed out the medications but failed to document these administrations on the MAR. Another nurse (Nurse #6) also reported administering a dose of hydrocodone-acetaminophen that she removed from storage but forgot to sign for on the MAR. The DON stated that the resident was at risk for constipation due to pain medications and acknowledged that the record was incomplete and did not accurately reflect the resident’s status. A second resident with vertebrae osteomyelitis and low back pain had an order for scheduled Oxycontin and PRN oxycodone for breakthrough pain. Review of this resident’s MAR and Oxycontin Controlled Drug Record showed that a nurse (Nurse #13) initialed that a scheduled Oxycontin dose was given, even though she did not administer it because the resident appeared sedated. Nurse #13 explained that she had signed the MAR before deciding to hold the dose and was unfamiliar with how to correct the electronic MAR to show that the medication was not actually administered. She confirmed that the medical record was therefore not accurate. The interim Administrator stated an expectation that medical records be complete regarding documentation of bowel movements and controlled medications.
Failure to Arrange Transportation for Critical Follow-Up Appointments
Penalty
Summary
The facility failed to ensure that transportation was arranged for a resident’s scheduled follow-up oncology and nephrology appointments after discharge from the hospital and admission to the facility. The resident had Stage IV basal cell carcinoma with metastatic disease to the lung and bone, as well as Stage IV kidney disease. The hospital discharge summary included multiple diagnostic and physician appointments for a specific date, including a preclinical PET scan and visits with an oncologist and nephrologist, with times, departments, and locations clearly listed. A physician progress note documented that the resident’s family member informed the physician that an oncology follow-up was scheduled in about 10 days and asked whether transportation could be arranged. On the day of the scheduled appointments, the family member went to the oncology appointment expecting to meet the resident there, believing the facility had arranged transportation, but the resident did not arrive and all appointments were missed. Interviews and record review showed that the facility’s internal process for reviewing hospital discharge summaries and arranging transportation was not followed for this resident. The Transportation Nurse Aide stated that nursing staff are supposed to read the discharge summary for new admissions and then give it to her so she can identify and arrange transportation for any listed appointments. She reported that she never received this resident’s discharge summary, was not informed of the scheduled appointments, and therefore did not arrange transport, although she could have taken the resident if she had known. The Social Worker stated she was unaware of the missed appointments and that the Transportation Nurse Aide routinely checked discharge summaries and arranged transport, with the Social Worker assisting if the aide was absent. The DON confirmed that the Transportation Nurse Aide should have been given the discharge summary to arrange transportation but this did not occur, and the admitting nurse who might have provided further information was unavailable for interview due to a personal emergency.
Failure to Provide Timely Pain Medication to Resident With Metastatic Cancer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, ordered pain management to a cognitively intact resident with stage IV basal cell carcinoma metastatic to lung and bone, an open malignant wound to the posterior left shoulder, neuropathy, and a history of cervical and thoracic spine surgery. The resident’s admission MDS documented frequent moderate pain interfering with daily activities, with reported pain up to 7/10, and the care plan directed staff to encourage the resident to request PRN pain medication and to offer it as ordered. Physician orders included hydrocodone 5-325 mg every four hours PRN, oxycodone 10 mg every six hours PRN, and gabapentin 800 mg three times daily. The resident’s family member reported that the resident had told him it often took a couple of hours after calling before staff administered pain medication, describing this as a general problem rather than a single incident. On the evening in question, assignment sheets showed that one nurse was assigned to the resident beginning at 7:00 PM. The MAR for that date showed the evening gabapentin dose was documented with another nurse’s initials, with no time of administration, and the first oxycodone dose on that shift was not given until 1:48 AM the following day, with no hydrocodone documented for that shift. A nurse aide who cared for the resident that evening reported that during initial rounds between 7:00 PM and 7:30 PM, the resident requested pain medication, and she relayed this to the assigned nurse, who said she would get to it. Around 8:30 PM, the resident again reported he still had not received pain medication, and the aide stated she could not locate the assigned nurse despite repeatedly looking for her and observing that the nurse’s medication cart remained in the same place. The aide reported the resident repeatedly called out that he was in pain and that he did not go to sleep because he was hurting. Another nurse, assigned to a different unit, reported being alerted by staff that the assigned nurse was asleep in her car while residents on that unit, including this resident, needed medications. She stated she could not access the resident’s medications because the assigned nurse had the keys to the medication cart. She contacted the on-call nurse and the DON for assistance and was instructed multiple times to try to awaken the assigned nurse in her car. She and other staff attempted to wake the assigned nurse, who briefly cracked the car door but did not return to the building and went back to sleep. The DON reported receiving calls about the situation later that night, directing staff to awaken the assigned nurse and instructing her to return inside, and then ultimately coming to the facility after midnight, having the assigned nurse reconcile controlled substances, and sending her home. The assisting nurse stated that by the time the DON arrived, the resident still had not received pain medication, and that she was only able to administer oxycodone around 2:00 AM, at which time the resident had tears in his eyes and rated his pain as 20/10. The assigned nurse later stated she had not been feeling well, had gone to her car for a break, and was not aware the resident was in pain or that he had not received pain medication.
Failure to Complete STAT X‑Ray After Fall With New Left Leg Pain
Penalty
Summary
The deficiency involves the facility’s failure to obtain a STAT mobile x‑ray as ordered after a resident fall and subsequent complaint of left leg pain. The resident had multiple significant diagnoses, including end stage renal disease, pulmonary hypertension, COPD, chronic respiratory failure, CHF, atrial fibrillation, sick sinus syndrome with pacemaker, hypertension, Type 2 diabetes, osteoarthritis, gait difficulty, muscle weakness, and disability-related activity limitations. An admission MDS showed severely impaired cognition but ability to understand and be understood, no prior falls since admission, and receipt of dialysis and multiple therapies. The care plan identified the resident as at risk for falls related to debility and difficulty walking, with a goal to remain free from falls with major injury. On the morning of 02/16, the resident was found on the floor by nurse aides after reportedly sliding off the bed while trying to sit on the edge. The wound care nurse (Nurse #2) assessed the resident, documented no injuries, and the resident denied pain; range of motion of all extremities was reportedly normal, and the resident was talking about going shopping. Nurse aides who assisted confirmed that the resident did not complain of pain and was able to move all extremities. Nurse #2 stated she notified the resident’s representative (RR) about this first fall, although the event report erroneously documented notification of the resident instead of the RR. Later that day, the NP assessed the resident for gout pain in the left great toe and also checked her leg because of the earlier fall, finding normal range of motion and no signs of pain or suspicion of hip fracture at that time. Late that night on 02/16, a second fall was documented by Nurse #1 as a late entry. Nurse #1 recorded that the resident was found on the floor at the bedside, denied hitting her head, and had no bruising or bleeding, but did complain of left leg pain on assessment with range of motion, though no deformity was noted. Nurse #1 notified the on‑call physician and obtained a STAT order for x‑rays of the left femur and hip related to the fall, and documented notifying the RR. The DON later stated that STAT mobile x‑rays were normally completed within four hours. However, the ordered STAT x‑ray was not completed that night. The DON reported that the mobile x‑ray company indicated the responding technician was new, did not have the door code, and was unable to reach staff by doorbell or phone, so the exam was not performed. On the morning following the second fall, the RR arrived and reported the resident was moaning in pain and requested Tylenol before dialysis. Nurse #3 stated she initially did not perform a full assessment because she relied on Nurse #1’s prior assessment and the existing STAT x‑ray order, but later recalled that, after the RR voiced concern about pain, she assessed the resident by listening to lungs, palpating the abdomen and both hip areas, and bending both legs at the knees. She reported the resident denied pain, did not verbalize pain during the assessment, and only grimaced or closed her eyes with movement; she stated she administered Tylenol but failed to document it on the MAR, and she considered the resident appropriate to attend dialysis. The DON stated she saw the resident sitting in a wheelchair laughing while waiting for transport and did not assess pain at that time, and that she contacted the NP, who reportedly said that if the resident was not in distress it was acceptable to proceed with dialysis and obtain the x‑ray later. The mobile x‑ray technician arrived later that day to perform the STAT x‑ray but the resident had already left for dialysis, and the technician indicated the exam would be rescheduled. Nurse #3 documented that the RR reported the resident was having left leg pain when being repositioned before dialysis, that the resident grimaced with movement, and that Tylenol was given. The DON stated she had delegated a call to the dialysis unit to check on the resident’s status; the dialysis nurse reportedly told facility staff that the resident was sleeping and had no complaints of pain, although the dialysis provider’s documentation showed the resident continued to complain of left lower extremity pain during dialysis and requested to end treatment early. The NP later reviewed the case and noted that, given the resident’s diagnoses and the presence of a hip fracture, she had been at risk for shortness of breath or a cardiovascular event during transfer to dialysis, but that she had not experienced these outcomes. The RR reported she believed the resident should have been sent to the hospital after the second fall and that she learned at the hospital that the resident required surgery for a hip fracture. The facility’s failure to ensure that the ordered STAT x‑ray was obtained promptly after the second fall, and to complete timely diagnostic evaluation of the resident’s reported left leg pain, constituted the deficiency.
Significant Medication Errors Due to Missed Insulin Doses and Failure to Discontinue Steroid
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by missed doses of scheduled rapid-acting insulin for two residents and a failure to discontinue a steroid medication as recommended for another resident. For two residents with diabetes, scheduled doses of insulin aspart were not administered in the morning due to a staffing issue. The Medication Administration Records (MAR) indicated that the morning doses were missed, and there was no documentation of blood sugar readings prior to the scheduled administration times. The nurse on duty reported that he was only notified of the need to pass medications after arriving late, and by that time, it was already time for the next scheduled insulin doses. The physician was informed and directed staff to hold the missed doses and proceed with the next scheduled administration. Both residents did not experience adverse events from the missed doses, but the medications were not given as ordered. Another resident with a diagnosis of pulmonary sarcoidosis continued to receive prednisone, a corticosteroid, despite a pulmonologist's consultation recommending discontinuation of the medication. The consultation report was signed by the unit manager, but the order to discontinue prednisone was not implemented until several months later. The MAR showed that the resident continued to receive prednisone every other day until the order was finally discontinued. Interviews with the previous DON and medical directors revealed that the consultation report was either not reviewed with the physician or the recommendation was not acted upon in a timely manner. The administrator was unaware that the consultation report had not been reviewed and that the medication had not been discontinued as recommended. These deficiencies were identified through record review, staff and resident interviews, and review of consultation reports. The facility's failure to administer medications as ordered and to follow up on consultation recommendations resulted in significant medication errors for three residents. The events were attributed to staffing issues, lack of communication, and failure to implement physician recommendations in a timely manner.
Insufficient Nursing Staff Leads to Missed Insulin Doses
Penalty
Summary
The facility failed to ensure sufficient nursing staff were present to meet the needs of all residents, resulting in significant medication errors for two residents with diabetes. On the morning in question, two of three assigned staff members, a Medication Aide and a Unit Manager, did not report to work as scheduled. This left only one nurse on duty for the three units, and the absence of staff was not promptly addressed, leading to a delay in medication administration. As a result, two residents who required scheduled morning doses of rapid-acting insulin did not receive their medication as ordered. One resident, who was cognitively intact, reported not receiving his insulin after breakfast due to the absence of the assigned staff member. The other resident, who had severe cognitive impairment, also missed the scheduled insulin dose. The Medication Administration Records confirmed that the insulin was not administered, and notes indicated the missed doses were due to overlapping doses from late administration, with the physician being made aware. Interviews with staff revealed that the scheduler was aware of the staffing shortage early in the shift and attempted to find replacements but was unsuccessful. The previous DON and other nursing staff arrived later in the day, but by that time, the morning medications had already been missed. Communication lapses among staff contributed to the delay in addressing the staffing issue, and the absence of key personnel directly led to the failure to administer critical medications as scheduled.
Failure to Follow Care Plan for Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident, who had a history of cerebral vascular accident, hemiplegia, hemiparesis, heart failure, and diabetes mellitus, was transferred from a wheelchair to a bed by a nurse aide without the use of a mechanical lift, as required by the resident's care plan. The resident was documented as cognitively intact but dependent on staff for transfers and had range of motion impairment on one side. The care plan specifically indicated the need for a mechanical lift for all transfers. On the day of the incident, the agency nurse aide performed a one-person assist transfer, lifting the resident manually from the wheelchair to the bed. The aide did not use the mechanical lift, despite being instructed by another nurse aide to do so and being informed that assistance was available if needed. The resident reported being picked up and thrown onto the bed, resulting in immediate pain. The aide acknowledged performing the transfer alone and stated that the resident complained of mild pain, which was reportedly relieved with repositioning. Following the transfer, the resident experienced significant pain and swelling in the left knee, which was assessed by nursing staff. The pain persisted despite administration of acetaminophen and other interventions. The resident was eventually sent to the emergency department, where imaging revealed a comminuted and displaced fracture of the distal femur. The incident was confirmed through interviews with staff and review of documentation, which showed that the transfer was not performed according to the resident's care plan and that the required mechanical lift was not used.
Failure to Update Facility Assessment for Tracheostomy Care
Penalty
Summary
The facility failed to annually review and update its facility-wide assessment, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. This oversight had the potential to affect all 80 residents in the facility. Specifically, the facility assessment inaccurately indicated that there were no residents requiring tracheostomy care, despite medical records showing that two residents had tracheostomies and required such care. The facility was unable to provide documentation demonstrating that the facility assessment had been reviewed and updated since 2023. During an interview, the Administrator acknowledged that it was her responsibility to ensure the facility assessment was current and admitted she was unaware that the assessment was outdated, having forgotten to conduct a review in 2024.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their medical records. Resident #15, who was admitted with end-stage renal disease and initially required dialysis, had improved kidney function and no longer needed dialysis upon discharge back to the facility. However, the MDS assessment incorrectly indicated that the resident was still receiving dialysis due to an assumption made by MDS Nurse #1 based on a physician order for monitoring the shunt site. Resident #57, diagnosed with vascular dementia, had an active physician order for a wander guard alarm, which was in place as per the Medication Administration Record (MAR). Despite this, the MDS quarterly assessment failed to reflect the use of the wander guard alarm. MDS Nurse #1 acknowledged missing this detail during the assessment process. Similarly, Resident #44, who had diabetes and was on insulin glargine, was not coded for the use of hypoglycemic medication in the MDS assessment, an oversight admitted by MDS Nurse #1. Resident #70, who was readmitted to the facility with end-stage renal disease and dependence on dialysis, was not correctly coded in the MDS assessment to reflect his dialysis treatment. The resident had been hospitalized for sepsis and returned without dialysis orders, but the MDS should have indicated the ongoing need for dialysis. The Director of Nursing noted that the dialysis order was not reinstated upon the resident's return from the hospital. In all cases, the Administrator confirmed that the MDS Nurse was responsible for ensuring accurate coding of resident assessments.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to properly label and store medications on two separate medication carts, leading to deficiencies in medication management. On Unit 3, an insulin lispro injector pen was found open without a date or resident identifiers, and an albuterol inhaler was similarly unlabeled. The Unit Manager confirmed these findings, and the Director of Nursing acknowledged that all nurses were responsible for ensuring medications were labeled and dated. Additionally, on Unit 1, a netarsudil ophthalmic solution was found unrefrigerated, contrary to the manufacturer's storage recommendations. The Director of Nursing stated that nurses were responsible for checking medication storage. Furthermore, the facility failed to secure a wound treatment cart on Unit 3, which was found unattended and unlocked. The cart contained resident creams, ointments, medicated dressings, and treatment supplies. The Administrator and Nurse #2 were present at the nursing station but did not notice the unlocked cart until it was pointed out by the surveyor. The Director of Nursing confirmed that the cart should have been locked when unattended, and all nursing staff were aware of this requirement.
Failure to Maintain Sanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain kitchen equipment in a clean and sanitary condition, which could potentially lead to cross-contamination of food served to residents. During a lunch meal observation, the two-cylinder plate dispenser was found with dark dried food particles at the bottom of both cylinders, and the plate tray had dried liquid stains. This condition was observed on two consecutive days, indicating a lack of regular cleaning. The District Dietary Manager acknowledged that the plate dispenser was kept plugged in at all times, and staff had overlooked cleaning inside the cylinders. Additionally, the shelf under the steam table was observed to be covered with dark dried food particles during kitchen inspections. Despite having a weekly cleaning schedule that included the steam table, the Certified Dietary Manager admitted that the cleaning was not adequately performed. The Administrator confirmed that the dietary staff should maintain cleanliness in all kitchen areas, including the plate dispenser and steam table shelves, but these areas were neglected in the cleaning routine.
Improper Garbage Disposal in Dumpster Area
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed in the dumpster area. On the morning of January 7, 2024, a large bag of garbage was seen hanging out of the lid of Dumpster #1, and two disposable gloves were found on the ground behind it. Later that afternoon, the lid and right-side door of Dumpster #1 were open, with additional litter, including three disposable gloves, a soda bottle, and straw papers, scattered around the area. The Dietary District Manager confirmed that the area had been cleaned earlier that day, but the waste company did not pick up the dropped items. The facility's Administrator stated that all staff were responsible for maintaining the cleanliness of the dumpster area, and the Corporate Administrator suggested assigning a staff member to inspect the area daily.
Failure to Complete MDS Significant Change Assessment for Hospice Admission
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment for a resident who was admitted with a diagnosis of malignant neoplasm. The resident was initially identified as cognitively intact, had a tracheotomy, and was not receiving hospice services at the time of admission. However, a physician order dated 11/21/24 indicated that the resident was to be admitted to hospice due to the terminal diagnosis, with a life expectancy of six months or less. Despite this significant change in the resident's status, there was no documentation in the medical record that an MDS significant change in status assessment had been completed to reflect the initiation of hospice services. Interviews with the MDS Nurse and the Administrator confirmed that the assessment should have been completed when the resident began receiving hospice services. The MDS Nurse acknowledged the oversight, and the Administrator stated that the MDS Nurse should have reviewed the resident for a significant change in status assessment upon the election of hospice services.
Failure to Develop Person-Centered Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with severe cognitive impairment, who had expressed specific activity preferences. The resident, admitted with diagnoses including stroke and dementia, indicated that activities such as reading, listening to music, attending religious services, and being outdoors were very important. However, the resident's care plan, last reviewed in early January 2025, did not include any provisions related to these activity preferences. Observations over several days showed the resident consistently in their room with the television on, and the responsible party was unaware of any activities provided by the facility. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and implementation of the resident's activity care plan. The Activity Director, who had been in the role for over a year, admitted to not having created care plans previously and only recently being shown how to do so. The MDS Nurse indicated that the Activity Director was responsible for the activity-focused care plan, while the Administrator expected the MDS Nurses to assist when needed. This lack of coordination and clear responsibility led to the deficiency in providing a person-centered care plan for the resident.
Failure to Obtain Physician Order for Tracheostomy Care
Penalty
Summary
The facility failed to obtain a physician order for tracheostomy care for a resident who was admitted with a tracheostomy. The resident, identified as Resident #35, was admitted with a diagnosis that included a tracheostomy and had physician orders for oxygen via tracheostomy collar and suctioning needs. However, there was no physician order documented for tracheostomy site care, and the Treatment Administration Record for December 2024 and January 2025 lacked documentation of such care. Interviews with nursing staff revealed that tracheostomy care was being provided at least once per shift, including cleaning around the tracheostomy site and suctioning as needed. Despite this, the Unit Manager confirmed that a physician order for tracheostomy care was not entered upon the resident's admission, and the Director of Nursing was unable to explain how this oversight occurred. The deficiency was identified during a survey, highlighting a lapse in ensuring proper documentation and physician orders for necessary respiratory care.
Failure to Ensure Physician's Order for Dialysis
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis had a physician's order for dialysis. This deficiency was identified for a resident who was admitted with end-stage renal disease and was dependent on renal dialysis. The resident's care plan included specific instructions for managing dialysis-related care, such as coordinating with the dialysis center and monitoring the shunt site. However, after the resident was readmitted from the hospital, the dialysis order was not reinstated, and this oversight was confirmed through staff interviews. The deficiency was further highlighted when the resident was sent to dialysis without a documented physician's order. Interviews with the Unit Manager and the Director of Nursing revealed that the staff failed to reestablish the dialysis order upon the resident's return from the hospital. The Administrator also acknowledged that the staff should have ensured the presence of a physician's order for dialysis. This lapse in documentation and communication led to the deficiency being cited during the survey.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman in writing of resident transfers to the hospital for two residents. Resident #35 was transferred to the hospital on two occasions, but the Ombudsman was not notified of these transfers. The Social Service Director, who started in the position in July 2024, was running the wrong report, which did not show any resident transfers or discharges. This error was discovered during interviews with the Ombudsman and the Social Service Director, who admitted to not knowing how to run the correct report until recently. Similarly, Resident #11 was transferred to the Emergency Department on two occasions due to changes in condition, but there was no documentation that the Ombudsman was notified of these transfers. The Director of Nursing and the interim Administrator confirmed that it was the responsibility of the Social Service Director to send these notifications, but they were unaware that the notifications were not sent. The deficiency was identified through record reviews and staff interviews, highlighting a lapse in the facility's notification process to the Ombudsman.
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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