Surry Community Health Center By Harborview
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Airy, North Carolina.
- Location
- 542 Allred Mill Road, Mount Airy, North Carolina 27030
- CMS Provider Number
- 345191
- Inspections on file
- 24
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Surry Community Health Center By Harborview during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of anxiety and depression was started on Lorazepam without documented consent or prior notification to their representative regarding the risks and benefits. The DON confirmed that the facility's consent process only covered antipsychotic medications, not all psychotropic medications, due to outdated forms.
A resident with anxiety and severely impaired cognition received PRN lorazepam without a required 14-day stop date, resulting in the medication being administered multiple times over two months. The NP and DON acknowledged the oversight, with the NP typically writing such orders for 14 or 30 days but not specifying a stop date in this instance.
Two residents' MDS assessments were inaccurately coded: one resident receiving an antipsychotic was marked as not having received such medication, and another receiving hospice care was not marked as having a life expectancy of less than six months. Errors were acknowledged by the MDS nurse and coordinator, who cited mistakes and unavailable documentation at the time of assessment.
An unsecured, partially full oxygen cylinder was found stored in a resident's room despite no physician order for oxygen therapy. The resident, who had moderately impaired cognition, was unaware of the cylinder's presence or purpose. Nurse aides and the DON confirmed that oxygen cylinders should be stored and secured in the designated storage room, not in resident rooms.
Two residents experienced medication administration errors when a medication aide failed to follow physician orders, resulting in a medication error rate above 5%. One resident received a gastrointestinal medication at the wrong time in relation to meals, and another received an incorrect dosage of an antidepressant. Both errors were attributed to the aide not carefully reading medication cards.
A resident with multiple diagnoses, including chronic pain syndrome and opioid dependence, reported severe pain and anxiety due to not receiving her Methadone as prescribed. Despite the medication being present and documented as administered, the DON did not conduct a thorough investigation. The facility's grievance policy, which mandates prompt investigation and resolution, was not followed. Interviews revealed a lack of proper follow-up and communication, resulting in ongoing distress for the resident.
A resident with a complex medical history, including paralysis, anxiety disorder, and chronic pain syndrome, reported not receiving prescribed Methadone for pain relief during the night shift. Despite physician orders, the resident experienced severe pain, anxiety, nausea, and headaches due to missed doses. Staff, including a Medication Aide, cited reasons such as medication shortages and pharmacy issues. The resident's representative also raised concerns about the facility running out of Methadone. The facility's lack of oversight, documentation discrepancies, and inadequate communication between staff members contributed to the resident not receiving essential pain relief medication as prescribed.
Facility staff failed to disinfect shared glucometers properly, using non-approved disinfectant wipes and not following manufacturer guidelines, leading to potential exposure to bloodborne pathogens among residents.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in areas such as abuse and neglect, accuracy of assessments, nutrition and hydration, nurse staffing, pharmacy services, and significant medication errors. These failures included not implementing physician orders, not following abuse policies, and not providing sufficient nursing staff.
The facility failed to ensure proper urinary catheter care for two residents, leading to incidents where catheter bags were not drained in a timely manner. Both residents reported that their catheter bags were not emptied regularly, causing discomfort and potential health risks. Staff interviews and observations confirmed that night shift staff frequently neglected to empty the catheter bags, leaving the task for the morning shift.
The facility failed to update the posted nurse staffing information on each shift for 2 of 5 days during the onsite recertification survey. The ADON and Administrator confirmed that the staffing sheet was only updated every 24 hours, not at each shift change, and the ADON admitted to forgetting to update the information on specific dates.
The facility failed to accurately complete the discharge MDS assessment for a resident. The resident was discharged to the community, but the MDS incorrectly indicated a discharge to a hospital. Interviews revealed the error was due to a mis-click during data entry.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent and inform a resident or their representative in advance about the risks and benefits of initiating a psychotropic medication, specifically Lorazepam, for anxiety. The resident in question was admitted with diagnoses including generalized anxiety disorder and depression, and was assessed as severely cognitively impaired with no behavioral symptoms. Despite the initiation of Lorazepam as needed for anxiety, the medical record did not contain documentation that the resident's representative was informed or provided consent prior to starting the medication. During an interview, the DON confirmed that consents were only being obtained for antipsychotic medications, not for all psychotropic medications, due to the limitations of the facility's existing consent forms.
Failure to Include Required Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as needed (PRN) psychotropic medication, lorazepam, prescribed for a resident with anxiety, included a required stop date of 14 days as per regulations. The resident, who had a diagnosis of anxiety and severely impaired cognition, was readmitted to the facility and had a physician's order for lorazepam 0.25 mg every 8 hours PRN for anxiety, but the order did not specify a stop date. Review of the resident's medication administration records showed that the medication remained active and was administered multiple times over two months without a stop date. Interviews with the Nurse Practitioner revealed that she typically wrote PRN psychotropic medication orders for 14 days and then evaluated the resident's need, but in this case, she usually wrote the lorazepam order for 30 days due to the resident's behaviors. However, she was unaware of why there was no stop date on the order in the system. The Director of Nursing acknowledged awareness of the requirement for a physician-designated stop date for PRN psychotropic medications and stated that staff were educated on this, but indicated that the lack of a stop date for this resident's lorazepam was an oversight.
Inaccurate MDS Coding for Hospice and Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents in the areas of hospice care and antipsychotic medication use. For one resident with major depressive disorder and Alzheimer's disease, the medical record showed an active order and administration of quetiapine, an antipsychotic medication. However, the quarterly MDS assessment incorrectly indicated that the resident had not received any antipsychotic medication since the last assessment. The MDS nurse acknowledged marking the wrong answer in the Antipsychotic Medication Review section, stating it was a mistake. For another resident with chronic obstructive pulmonary disease who was certified for hospice care, the quarterly MDS assessment indicated the resident was receiving hospice care but did not mark that the resident had a condition or chronic disease that might result in a life expectancy of less than six months. The MDS Coordinator explained that the hospice recertification was not available at the time of the assessment and was uploaded later, which led to the incorrect coding. The Administrator confirmed that the MDS should have been coded correctly regarding life expectancy and hospice care.
Unsecured Oxygen Cylinder Improperly Stored in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen cylinder was found stored upright and unsecured in a resident's room. The resident, who had moderately impaired cognition, stated she did not know why the oxygen cylinder was in her room and was unaware if she was supposed to be receiving oxygen. Review of her medical records, including the quarterly MDS assessment, care plan, and current physician orders, confirmed that she was not receiving oxygen therapy and had no order for oxygen. The oxygen cylinder was observed to be approximately three-quarters full and remained in the resident's room over multiple observations. Nurse aides responsible for the resident acknowledged that the oxygen cylinder should have been stored in the designated oxygen storage room and secured in a holder to prevent it from falling. They could not recall how long the cylinder had been in the resident's room and stated they had not noticed it previously. The Director of Nursing confirmed that oxygen cylinders should not be stored in residents' rooms and should be secured in the storage room until needed.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 31 observed opportunities, resulting in a 6.45% error rate. In the first instance, a resident with gastroesophageal reflux disease was prescribed metoclopramide 5 mg to be administered by mouth before meals. During a medication pass, the medication aide gave the medication while the resident was already eating breakfast, contrary to the physician's order specifying administration before meals. The aide acknowledged not reading the medication card directions closely enough prior to administration. In the second instance, a resident with depression was prescribed escitalopram 20 mg by mouth once daily. During medication administration, the aide prepared and administered only 5 mg of escitalopram instead of the ordered 20 mg. Upon review, the aide realized the error was due to not carefully reading the directions on the medication cards, as there were two cards for different dosages. Both errors were confirmed through staff interviews and direct observation.
Grievance Policy Implementation Failure Leading to Medication Issues
Penalty
Summary
The facility failed to implement its grievance policy and procedures when a resident (Resident #21) reported on 11/30/23 that the facility was running out of her Methadone. The Director of Nursing (DON) did not conduct a thorough investigation despite confirming that the Methadone was present in the medication cart and documented as administered. This lack of investigation led to ongoing issues for Resident #21, who reported experiencing severe pain, anxiety, and withdrawal symptoms due to not receiving her medication as prescribed. The deficiency was identified when Resident #21 filed a grievance, and immediate jeopardy was determined to have begun on 11/30/2023. Resident #21, admitted to the facility with diagnoses including paralysis affecting the lower half of the body, anxiety disorder, neuropathy, major depressive disorder, insomnia, headache, chronic pain syndrome, and opioid dependence, reported significant distress and physical discomfort due to the facility's failure to ensure the availability of her Methadone medication. Despite being cognitively intact as per a quarterly Minimum Data Set (MDS), Resident #21 suffered from severe pain and anxiety when faced with medication supply issues. The facility's grievance policy required the investigation and resolution of grievances promptly, with clear communication of outcomes to residents or their representatives. Interviews with Resident #21, the DON, Resident Representative, Social Worker, and Administrator revealed a lack of proper follow-up and communication regarding Resident #21's grievance. The DON acknowledged not speaking directly with Resident #21 about the issue and failing to follow the grievance process outlined in the facility's policy. The Resident Representative highlighted the emotional toll on Resident #21 and her family due to the ongoing medication supply issues. The facility's failure to address Resident #21's grievance in a timely and thorough manner resulted in a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.
Pain Management Deficiency Due to Medication Administration Issues
Penalty
Summary
The facility failed to address a resident's pain management needs, specifically for Resident #21, who reported not receiving her Methadone as prescribed for pain relief during the night shift. Resident #21 had a complex medical history including paralysis affecting the lower body, anxiety disorder, neuropathy, neuromuscular dysfunction, major depressive disorder, insomnia, chronic pain syndrome, and opioid dependence. Despite physician orders for Methadone administration at specific times, Resident #21 reported experiencing severe pain, anxiety, nausea, and headaches when her medication was not given. The resident consistently reported this issue to staff, including the Physician Assistant (PA) and nurses, but the problem persisted for an extended period. Multiple staff members, including Medication Aide (MA) #3, were implicated in the deficiency. MA #3 was reported to have frequently not administered Resident #21's Methadone, citing reasons such as the facility running out of medication or pharmacy issues. Resident #21's representative also raised concerns about the facility running out of Methadone and the lack of follow-up on the reported grievances. Despite Resident #21's consistent reports of increased pain and anxiety due to missed medication doses, the facility did not take adequate action to address the issue, leading to prolonged suffering for the resident. The facility's lack of oversight and failure to investigate and address Resident #21's pain management concerns resulted in a deficiency in providing safe and appropriate pain management. The facility's medication administration practices, including documentation discrepancies and staff behavior, contributed to the resident not receiving essential pain relief medication as prescribed. The deficiency was further exacerbated by inadequate communication between staff members, lack of follow-up on reported grievances, and a failure to ensure consistent and appropriate pain management for Resident #21, highlighting systemic issues within the facility's medication management processes.
Failure to Properly Disinfect Shared Glucometers
Penalty
Summary
The facility staff failed to disinfect a shared blood glucose meter (glucometer) after use and before placing it back in the medication cart. This deficiency was observed in three different staff members who did not follow the proper disinfection protocol for the glucometer between residents. Specifically, Nurse #1, Medication Aide #4, and Nurse #7 were involved in this practice, which occurred while there was a resident with known bloodborne pathogens in the facility. The failure to use an EPA-approved disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer posed a high likelihood of exposing residents to bloodborne pathogens. Nurse #1 was observed collecting supplies and using a glucometer to check Resident #60's blood glucose level. After obtaining the results, Nurse #1 placed the glucometer back into the medication cart without disinfecting it. When questioned, Nurse #1 admitted to forgetting to clean the glucometer due to nervousness. Similarly, Nurse #7 used a non-approved disinfectant wipe to clean the glucometer after checking Resident #47's blood glucose level. Nurse #7 was unaware that different disinfectant products had different kill times and believed any disinfectant that claimed to kill germs was sufficient. Medication Aide #4 also used a non-approved disinfectant wipe to clean the glucometer after checking Resident #54's blood glucose level. MA #4 was not aware of the specific cleaning time required to disinfect the glucometer until informed by another nurse. The facility's policies and procedures on cleaning and disinfection of resident-care equipment were not followed, leading to the potential for cross-contamination and exposure to bloodborne pathogens among residents. The facility's staff, including the ADON and DON, acknowledged the failure to use the correct disinfectant product and the need for proper training and adherence to manufacturer guidelines.
Facility's QAA Committee Fails to Maintain Procedures and Monitor Interventions
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following the recertification survey and complaint investigation. This failure resulted in five deficiencies being recited during the current recertification and complaint investigation. These deficiencies included issues related to abuse and neglect, accuracy of assessments, nutrition and hydration status maintenance, sufficient nurse staffing, pharmacy services and procedures, and significant medication errors. The repeat deficiencies indicated a pattern of the facility's inability to sustain an effective QA program. One of the deficiencies involved the facility's failure to implement a physician order for intravenous fluids for a resident, leading to neglect. Another deficiency was the failure to implement the facility's abuse, neglect, and exploitation policy, which included incidents of involuntary seclusion and unauthorized use of physical restraints by staff. Additionally, the facility failed to accurately complete the discharge Minimum Data Set (MDS) assessment for a resident reviewed for hospitalization. Further deficiencies included the failure to carry out nutritional interventions recommended by the Registered Dietician for a resident with significant weight loss and the failure to provide sufficient nursing staff to honor residents' preferences for showers and incontinence care. The facility also failed to have systems in place for accurately receiving and reconciling controlled medications from the pharmacy, leading to a possible drug diversion. Lastly, the facility failed to prevent significant medication errors, such as not administering medications as ordered by the physician.
Failure to Ensure Proper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper urinary catheter care for two residents, leading to incidents where catheter bags were not drained in a timely manner. Resident #4, who has a diagnosis of Neuromuscular Dysfunction of the Bladder, reported that her catheter bag was not emptied regularly, causing it to become so full that it burst open on two occasions. Observations confirmed that her catheter bag was often full, and staff interviews revealed that night shift staff frequently neglected to empty the catheter bags, leaving the task for the morning shift. Despite the facility's policy that only med aides and nurses should perform catheter care, this protocol was not consistently followed, leading to the resident's discomfort and potential health risks. Similarly, Resident #52, also diagnosed with Neuromuscular Dysfunction of the Bladder, experienced issues with his catheter bag not being emptied regularly. The resident reported that his catheter bag was not emptied during the night shift, causing it to become overfilled and leak. Observations and staff interviews corroborated the resident's claims, with staff noting that the night shift often failed to monitor and empty catheter bags, resulting in overfilled bags that had to be addressed by the day shift. The facility's policy requiring only med aides and nurses to handle catheter care was not adhered to, contributing to the resident's distress and potential health complications. Interviews with the Medical Director and Director of Nursing confirmed that improper catheter care could increase the risk of infection and harm to the residents. Both residents' care plans included specific instructions for catheter care, which were not consistently followed by the staff. The facility's failure to ensure that catheter bags were regularly emptied and properly monitored led to significant issues for both residents, highlighting a deficiency in the facility's adherence to its own care protocols.
Failure to Update Nurse Staffing Information on Each Shift
Penalty
Summary
The facility failed to update the posted nurse staffing information on each shift for 2 of 5 days during the onsite recertification survey. On 3/17/24, the daily posted nurse staffing and information sheet was observed to be dated 3/14/24. On 3/19/24, the sheet was not updated at the 7:00 PM shift change and contained the same information as earlier in the day. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that the facility's practice was to update the staffing sheet every 24 hours, not at each shift change, and that the ADON was unaware of the requirement to update the information on each shift. The ADON admitted to forgetting to update the information on 3/16/24 and 3/17/24, and the Unit Manager was unavailable for an interview to explain why the information was not updated on 3/15/24. The Administrator confirmed that the facility operates on 12-hour shifts and that the posted nurse staffing and information sheet was only changed out every 24 hours. The Administrator also stated that the nursing management department was responsible for posting the daily nurse staffing information and that they worked as a team to ensure it was updated daily. However, the posted nurse staffing sheet was only updated throughout the day to reflect actual working hours when there were call outs. The ADON and Unit Manager were identified as the individuals responsible for posting the nurse staffing and information sheet daily.
Inaccurate Discharge MDS Assessment
Penalty
Summary
The facility failed to accurately complete the discharge Minimum Data Set (MDS) assessment for a resident reviewed for hospitalization. The resident was admitted to the facility and later discharged to the community. However, the discharge MDS incorrectly indicated that the resident was discharged to a short-term general hospital. Interviews with the MDS/Resident Assessment Directors revealed that the error was due to a mis-click when entering data into the computer program. The Director of Nursing confirmed that the MDS Nurses were responsible for completing the discharge MDS assessments and acknowledged the error in coding the discharge status.
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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