Silver Bluff
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, North Carolina.
- Location
- 100 Silver Bluff Drive, Canton, North Carolina 28716
- CMS Provider Number
- 345341
- Inspections on file
- 22
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Silver Bluff during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to follow food safety and sanitation standards, including storing an opened container of soy sauce beyond its usable date in a walk-in refrigerator. During tray line service, a kitchen worker touched their hair with bare hands, did not perform hand hygiene before putting on gloves, and moved between the dining room and kitchen without washing hands while plating hot tray liners and handling covered desserts. An air vent directly above the tray line was also observed to be covered with thick, gray debris, and the Dietary Manager could not state when it was last cleaned.
A resident with severe cognitive impairment, total dependence for ADLs, and multiple pressure injuries had a right hip wound with purulent drainage, odor, and unstable eschar. A wound NP documented that the wound had declined and showed signs of infection and recommended that staff contact the PCP about possible antibiotic treatment, ordering Santyl for debridement. The wound nurse reported verbally mentioning antibiotics to an NP who did not assess the wound, while that NP later stated she was never informed. The EMR contained no documentation that the PCP or any provider was contacted and no antibiotic order, despite the care plan requiring staff to monitor wounds and report declines to the MD and the wound NP’s clear note about suspected infection and need for provider follow-up.
A medication error rate above 5% was identified when a resident with COPD and other chronic conditions received a crushed dose of Oxybutynin XL despite an order specifying it should not be crushed, and ordered doses of Refresh Tears eye drops and a Fluticasone-Salmeterol inhaler were not administered. A medication aide reported crushing the extended-release tablet based on the resident’s preference and not noticing the "do not crush" instruction, and also stated the resident self-administered the eye drops and inhaler from the bedside. The resident denied keeping or self-administering these medications, and the DON confirmed there were no self-administration orders and that facility medication administration protocols were not followed.
Surveyors found multiple medication management failures, including an opened, undated Novolog insulin pen and an expired bottle of Acidophilus tablets left available for use on a medication cart, as well as a partially full heparin lock flush syringe left unsecured on a resident’s bedside shelf after the related order had been discontinued. A nurse acknowledged administering insulin from the undated pen and stated she only checked expiration dates on stock medications she used during her shift, while the DON and Administrator confirmed that medications should not be left in resident rooms or at bedside without a self-administration order.
A resident with heart disease, severe protein-calorie deficiency, and significant dental problems had a standing, year-long consent and order to hold aspirin prior to dental extractions. Aspirin was correctly held for an earlier visit, allowing extraction of several teeth, but for a subsequent scheduled extraction visit, staff did not obtain or act on the existing order to hold the blood thinner, and the medication was administered as usual. The dentist documented that the resident could not be treated because the blood thinner had not been held, and the resident reported ongoing tooth pain and that the appointment was canceled due to the medication not being stopped.
The facility failed to secure medications properly, leaving an unopened vial and an opened ointment unattended in a resident's room. Additionally, opened medications, including eye drops and insulin pens, were not dated across multiple medication carts, and a medication cart was left unlocked and unattended. Staff interviews revealed a lack of awareness and responsibility for medication management, highlighting significant gaps in the facility's practices.
A resident with dementia and severe cognitive impairment was subjected to physical restraint during incontinence care when a nurse aide held her wrists and later smacked her wrist. The incident was witnessed by other staff, who reported feeling uncomfortable with the actions, which they did not perceive as defensive. Despite this, the facility's investigation concluded the actions were defensive and unsubstantiated the abuse allegation.
The facility failed to serve food at an appetizing temperature for three residents, with reports of cold meals at lunch and dinner. Observations confirmed the food was cold and unappealing, attributed to inadequate steam table temperatures and lack of plate warmers. The Administrator was unaware of these issues until informed by the Corporate Dietary Manager.
Expired Food Storage, Poor Hand Hygiene, and Dirty Air Vents in Kitchen Tray Line Area
Penalty
Summary
Surveyors identified deficiencies in food storage and kitchen sanitation practices. In the walk-in refrigerator, an opened 1-gallon container of soy sauce was observed on a top shelf with a written date range of 6/11–12/11. The Dietary Manager stated that the soy sauce had been opened on 6/11/25 and that its useful date range was 6 months after opening, meaning it should have been disposed of after 12/11/25. The Administrator later confirmed that food stored past its usable date should have been discarded. During tray line service, surveyors observed a kitchen staff member remove his hat and rub his hair with bare hands, then fail to wash his hands before donning gloves. The same staff member left the kitchen wearing gloves, entered the dining room, and returned to the kitchen without handwashing, then proceeded to plate hot tray liners into plate covers and onto trays, and handle covered dessert containers. Additionally, an air vent located directly above the tray line was observed to be covered in thick, clumpy, grayish debris. The Dietary Manager acknowledged that the staff member should have washed his hands after touching his hair and each time he entered the kitchen and changed gloves, and stated that kitchen air vents were supposed to be cleaned every 3 to 4 months but did not know when they were last cleaned.
Failure to Follow Up on Wound NP Recommendation for Possible Antibiotics for Infected Pressure Wound
Penalty
Summary
The deficiency involves the facility’s failure to follow up on a wound care nurse practitioner’s recommendation to contact the primary care provider regarding possible antibiotic treatment for a resident’s pressure-related hip wound that showed signs of infection. The resident had severe cognitive impairment, required extensive to total assistance with all ADLs and mobility, and was identified as at risk for pressure ulcers, with existing unhealed stage 3 and unstageable pressure ulcers and a pressure-reducing device in use. A care plan directed staff to administer treatments as ordered, monitor wound healing weekly, and report improvements or declines to the MD. On 12/31/25, Wound Care NP #2 evaluated the resident’s right hip wound, which had declined, and documented that there were positive signs and symptoms of infection, recommending that staff contact the primary care physician for possible antibiotic treatment. NP #2 ordered Santyl for debridement because the wound was covered with unstable eschar and reported that the wound was bad, with moderate purulent drainage and odor, leading her to believe there was likely infection present. She stated that her process was to notify the primary care provider and defer to them for the antibiotic decision, and she discussed with the facility’s wound care nurse that the resident had symptoms of infection and needed follow-up with the primary care provider, which she also documented in her note. Despite this recommendation and documentation, review of the electronic medical record showed no antibiotic orders and no progress note indicating that the primary care provider had been contacted. The facility’s wound care nurse (Nurse #2) stated she was aware of NP #2’s note and said she mentioned the possible need for antibiotics to NP #1 when NP #1 was at the facility, but NP #1 allegedly did not think the resident needed an antibiotic and did not examine the wound; NP #1, however, reported she had not been informed and did not recall being contacted about the wound or need for antibiotics. On observation by the surveyor, the right hip wound had copious purulent brown drainage saturating the dressing and under-pad, a malodorous smell, a visible cavity, and remaining eschar, and was measured at 4 cm by 5 cm by 5.5 cm. The Medical Director later stated he had not been contacted about the wound or antibiotics and that someone should have followed up on the wound NP’s recommendation. The DON and Regional Nurse acknowledged that information about the possible need for antibiotics should have been communicated to the primary care provider and that outside provider notes were expected to be reviewed and addressed by the clinical team, but the DON did not recall reviewing the 12/31/25 wound note, and there was no evidence that the recommendation for possible antibiotics was acted upon prior to the surveyor’s involvement. The deficiency therefore centers on the facility’s failure to implement and act upon the wound care NP’s documented recommendation to contact the primary care provider regarding possible antibiotic therapy for a wound with documented signs and symptoms of infection, and the lack of documented communication or follow-up with any provider despite the resident’s high-risk status, existing pressure injuries, and care plan requirements to monitor and report wound changes to the MD.
Medication Error Rate Exceeded Due to Improper Crushing and Omitted Doses
Penalty
Summary
A medication error rate of 8.82% was identified during a medication pass observation involving one resident with COPD, benign prostatic hyperplasia, and age-related bilateral cataracts. The resident had an active order for Oxybutynin Chloride XL 5 mg, an extended-release tablet to be given once daily with instructions not to crush. During the observed medication pass, the medication aide crushed the Oxybutynin along with other medications, stating the resident preferred medications crushed. She administered the crushed medications, including the extended-release Oxybutynin, with water. In a subsequent interview, the medication aide acknowledged she had not noticed the "do not crush" instruction in the electronic order and stated she did not know why Oxybutynin could not be crushed. The nurse practitioner and pharmacist both confirmed that extended-release Oxybutynin should not be crushed because it is designed to release medication over 24 hours and crushing would release the dose at one time. The same resident also had active orders for Refresh Tears ophthalmic solution to be instilled in both eyes three times daily and for Fluticasone-Salmeterol inhalation aerosol to be administered twice daily for COPD. During the same medication pass observation, the medication aide did not administer the ordered eye drops or inhaler. She later stated she did not give these medications because she believed the resident kept them at the bedside and self-administered them. However, when the resident was interviewed, he reported that he did not keep these medications at the bedside and denied self-administering them. The interim DON confirmed there were no physician orders authorizing the resident to self-administer medications and stated he did not know why the medication aide believed the medications were at the bedside. He also stated that the medication aide should have followed the medication administration protocol, including not crushing medications that were ordered not to be crushed.
Improper Medication Labeling and Unsecured Heparin Syringe
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications on a medication cart and in a resident room. During an observation of the 500 hall long-side medication cart with a nurse, surveyors found an opened and undated Novolog insulin flex pen in the top drawer, with a pharmacy label showing it was filled on 11/10/25. Manufacturer instructions indicated the pen was usable for 28 days after first use, but the nurse stated she did not know whether the expiration was 28 or 30 days after opening and confirmed it should have been dated. She reported she had administered insulin from this pen that morning and had not noticed it was undated. The same cart also contained an open bottle of Acidophilus tablets with a manufacturer’s expiration date of 11/25 and approximately 40 tablets remaining, indicating the stock medication was expired but still available for use. The nurse stated she had not administered any of the Acidophilus and that she only checked expiration dates on stock medications she used during her shift, rather than all stock medications in the cart. In a separate incident, the facility failed to secure a heparin flush syringe, leaving it accessible in a resident’s room. A resident with a prior physician’s order for heparin lock flush solution 10 units/mL, 5 mL IV every shift for PICC line patency, had that order discontinued on 12/15/25. On observation of the resident’s room, surveyors found a syringe in a sealed bag on a shelf next to the resident’s chair, labeled as heparin lock flush solution 5 mL and partially full. A nurse confirmed the syringe contained medication and removed it from the room, stating he had given the resident medications earlier that day but had not seen the syringe on the shelf and did not know who had left it there. The DON later stated that medications should never be left in a resident’s room and the Administrator stated that medications should not be kept at bedside unless there was an order for self-administration of medication.
Failure to Hold Antiplatelet Medication Resulting in Missed Dental Extractions
Penalty
Summary
The deficiency involves the facility’s failure to hold an ordered antiplatelet medication (aspirin) prior to a scheduled dental extraction, resulting in a resident being unable to receive planned dental services. The resident was admitted with severe protein-calorie deficiency and heart disease and had an active order for aspirin 81 mg at bedtime. He was care planned for dental health problems, including broken teeth, poor repair, tooth pain, and abscesses, and his MDS documented mouth or facial pain and discomfort with chewing. A dental extraction consent form, signed by the resident and the Medical Director, specified that because the resident was on a blood thinner, the medication needed to be held 24–48 hours prior to dental procedures, and that this order was valid for one year. Following this, the dentist documented that no remaining teeth were restorable and that a full mouth extraction was planned. A physician’s order was written and implemented in October to hold the aspirin for several days, and the resident successfully had four teeth extracted at that time. The social worker reported that after the October visit, the dentist scheduled the resident for additional extractions at the next clinic visit in November and that she informed the former DON of this upcoming extraction. However, there were no physician’s orders to hold aspirin in November, and the MAR showed the aspirin was not held on the days preceding or on the date of the scheduled November dental visit. On that date, the dentist documented that the resident could not be seen because the blood thinner had not been held and that he would be seen at the next visit if the medication was held. The resident reported ongoing intermittent tooth pain, especially with tougher foods, and confirmed that the November appointment was canceled because his medication had not been stopped beforehand. The former DON acknowledged that the consent form, which included the standing order to hold blood thinners for one year, had been scanned into the chart but was missed by nursing staff, who were looking for a new order and were not aware of the dentist’s return date.
Medication Management Deficiencies
Penalty
Summary
The facility failed to properly secure and manage medications, leading to several deficiencies. During a medication storage audit, an unopened vial of DuoNeb solution and an opened tube of zinc oxide ointment were found unattended in a resident's room. The Unit Manager and Staff Development Coordinator acknowledged that these medications should not have been left in the room, especially since the resident had not been assessed for self-administration of medication. This oversight indicates a lapse in medication management and security protocols. Additionally, the facility did not date opened medications, including a bottle of latanoprost eye drops and several insulin pens, across multiple medication carts. These medications were found without opening dates, making it impossible to determine their usability according to manufacturer guidelines. Interviews with nursing staff revealed a lack of awareness and responsibility for ensuring medications were dated, with some staff not authorized to administer insulin and therefore not checking the medications properly. Furthermore, a medication cart was left unlocked and unattended in a hallway, with keys left on the countertop. Nurse #1 admitted to being distracted by nursing students, which led to the oversight. The Director of Nursing and the Administrator both expressed that it was their expectation for staff to follow proper procedures for medication management, including dating medications and securing them appropriately. These incidents highlight significant gaps in the facility's medication management practices.
Resident's Right to Be Free from Physical Restraint Violated
Penalty
Summary
The facility failed to protect a resident's right to be free from physical restraint during incontinence care. A nurse aide (NA #2) held the resident's wrists/hands in front of her chest when the resident began swinging her arms and kicking her legs. This incident involved a resident with severe cognitive impairment and dementia with behavioral disturbances, who was known to exhibit physical and verbal behaviors directed toward others. The resident was dependent on staff for toileting hygiene and personal care. During the incident, NA #2, along with NA #1 and a student nurse aide, were providing incontinence care to the resident. The resident became combative, swinging her arms and kicking, prompting NA #2 to hold her hands. After the care was completed, NA #2 was observed smacking the resident on the wrist. NA #1 and the student nurse aide witnessed the incident and reported feeling uncomfortable with NA #2's actions, which they did not perceive as defensive. The facility conducted an investigation, including interviews with the involved staff and a reenactment of the event. Despite the witnesses' accounts, the facility concluded that the abuse allegation was unsubstantiated, determining that NA #2's actions were defensive. However, the report highlights discrepancies in the staff's accounts and the facility's conclusion, as NA #1 and the student nurse aide did not agree with the facility's assessment that the actions were defensive.
Facility Fails to Serve Food at Appropriate Temperature
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature for three residents who had food concerns. Resident #59, with severely impaired cognition, required assistance with eating and reported through a representative that the food was often cold at lunch and dinner. Resident #103, who was cognitively intact, also required setup assistance and reported that the food was cold about half the time. Resident #42, also cognitively intact and requiring setup assistance, mentioned that the food was cold sometimes. An observation of the lunch tray line revealed that the test tray, which was the last to be plated and delivered, contained food that was not at the appropriate temperature. The pork chop and beets were cold, while the stuffing was warm, and the overall appearance of the plate was mostly brown. The Corporate Dietary Manager and facility Dietary Manager confirmed the food was cold and unappealing, attributing the issue to the steam table temperature not being set high enough, lack of plate warmers, and absence of insulated meal tray carts. The Administrator was unaware of these concerns until informed by the Corporate Dietary Manager.
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.
