The Carrolton Of Dunn
Inspection history, citations, penalties and survey trends for this long-term care facility in Dunn, North Carolina.
- Location
- 711 Susan Tart Road, Dunn, North Carolina 28335
- CMS Provider Number
- 345325
- Inspections on file
- 22
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at The Carrolton Of Dunn during CMS and state inspections, most recent first.
The facility did not maintain the required 8 hours of RN coverage on two reviewed days when the scheduled weekend RN called out and no replacement RN was provided. Review of daily staffing postings confirmed there was no RN scheduled for those days. The DON reported not being notified of the RN call‑outs and only learned of the lack of RN coverage afterward, despite knowing the requirement for daily RN coverage and expecting to be informed of such absences. The Administrator also stated an expectation that RN coverage be provided 8 hours a day, 7 days a week.
The facility failed to provide required CMS Skilled Nursing Facility Advanced Beneficiary Notification (SNF-ABN) forms to two residents when their Medicare Part A skilled services were discontinued before all covered days were used, while they remained in the facility. In both cases, the insurance company initiated the end of Part A coverage and sent a CMS Notice of Medicare Non-Coverage (NOMNC), which the facility completed and issued, but no SNF-ABN was given. The BOM and SW reported they were unaware that both a NOMNC and a SNF-ABN were required and that the SNF-ABN includes estimated out-of-pocket costs, and the Administrator stated he expected appropriate notices to be provided but had not seen the SNF-ABN used at the facility.
Surveyors found that dietary staff failed to properly store and monitor food and ensure dish cleanliness. Spoiled produce with visible mold and slime was present in the walk-in cooler, and open bags of frozen meatballs, French fries, and peas in the freezer were left unsealed, undated, and covered with ice crystals. On the tray line, multiple bowls, pans, plates, and plate covers labeled as clean were stacked while still wet, and several plates and covers had visible black, yellow, and brown spots. The Dietary Manager reported she had recently started in the role, that the dishwashing staff member was new, and that she personally checked for dating and spoilage on a set schedule, without identifying other staff responsible. The Administrator stated he had been informed of wet dishes and undated food but was not aware of spoiled food and expected dietary staff to label and date open items, keep dishes dry, and discard spoiled food.
The facility removed a microwave that residents and families had previously used to heat outside food, and staff refused to heat any food not prepared by the kitchen, citing safety and temperature-monitoring concerns. Cognitively intact residents with conditions such as diabetes, GERD, and depression, who were independent with eating, reported they could no longer warm soups and other items brought by family and were told they must eat such food cold or not at all. Nursing staff, the Dietary Manager, the DON, and the Administrator confirmed that the microwave was removed for safety reasons, that no alternative method was provided for heating outside food, and that residents and families were upset about the loss of this choice.
A cognitively intact resident told the Admissions Director that a nurse aide had hit her in the face multiple times during bathing, but the Admissions Director only completed a grievance form and did not notify the DON or Administrator until the next morning. This delay caused the Administrator to document the facility’s awareness of the allegation as occurring later than it actually did and to submit an initial report to the State Agency that did not accurately reflect when the allegation was first made or include timely notification to APS and law enforcement as required by facility policy.
Staff failed to knock or request permission before entering the rooms of three residents, including individuals with varying levels of cognitive impairment, while delivering lunch trays. The nurse aide involved acknowledged awareness of the requirement but did not follow it, and other staff confirmed that knocking and announcing oneself is expected to maintain resident dignity.
A resident who was initially progressing in rehabilitation experienced a significant decline, including decreased responsiveness, poor oral intake, and new symptoms such as dizziness and dark stools. Despite multiple therapy and nursing staff observing and documenting these changes, there was a failure to notify the physician in a timely manner. The resident was later hospitalized in critical condition with sepsis and gastrointestinal bleeding.
A resident with a history of stroke and anemia experienced a significant decline in condition, including new symptoms and decreased responsiveness, which was observed by therapy and aide staff but not effectively communicated or acted upon by nursing. Physician-ordered labs were not completed, and after testing positive for COVID, the resident did not receive timely evaluation or treatment for her infection or decline until hospital transfer, where she was found to be septic and severely anemic.
A nurse in an LTC facility failed to follow physician orders for continuous tube feeding for two residents, turning off the pumps without authorization. This action deprived the residents of necessary nutrition and was not documented in their medical records. The facility's DON and RD were unaware of the nurse's actions, which placed the residents at risk of harm.
A nurse in an LTC facility turned off the feeding tube pumps for two residents without notifying the physician, deviating from continuous feeding orders. This action deprived the residents of their nutritional needs, as the nurse believed their stomachs needed a rest. The facility failed to ensure physician notification and adherence to prescribed orders, leading to a deficiency.
The facility failed to complete quarterly MDS assessments within the required 14-day timeframe for eight residents due to staffing issues. The assessments were either incomplete or completed late, with the facility relying on a part-time MDS nurse. The Administrator was aware of the backlog and had hired additional MDS nurses to address the issue.
Three residents in an LTC facility did not receive tube feedings as ordered by their physicians. A nurse turned off the feeding pumps for two residents without physician orders, believing their stomachs needed rest, and did not document these actions. Another resident's feeding pump was set at a lower rate than ordered, impacting their nutritional intake. The facility's staff failed to notify physicians of these changes, potentially affecting the residents' health.
A resident with cognitive impairment and incontinence was not provided timely incontinence care, resulting in a saturated adult brief. The resident's care plan required frequent checks, but staff failed to adhere to this due to misunderstandings and prioritization of other duties. The DON confirmed the need for two-hour checks due to the resident's health changes.
A facility failed to conduct and document an admission screening assessment for a resident readmitted after hospitalization. The resident, with non-Alzheimer's dementia and a hip fracture, required assistance with daily activities. The DON did not complete the assessment or communicate its necessity to the night shift nurse, resulting in a lack of documentation of the resident's cognitive and functional levels.
A facility failed to ensure a resident's code status was accurately documented, leading to potential misinterpretation of resuscitation orders. The resident's representative requested a DNR order upon admission, but the order was not properly recorded in the medical record. A nurse believed the resident had a full code status based on a report, but found conflicting information in the chart. The issue was identified by a surveyor, revealing a lapse in the facility's documentation process.
A facility failed to complete the admission MDS assessment within the required timeframe for a newly admitted resident. The delay was due to a lack of full-time MDS staff for about three months, resulting in a backlog of incomplete assessments. The MDS Nurse acknowledged the issue, and the Administrator confirmed that additional MDS nurses had been hired to address the backlog.
A facility failed to conduct a PASRR Level 2 for a resident with schizophrenia and bipolar disorder. The resident was admitted with a PASRR Level 1 assessment, which did not recognize their mental illness. Despite being prescribed Haloperidol, the PASRR Level 2 was not initiated until an inquiry was made. The Social Worker had not reviewed the resident's diagnoses upon admission, and the Clinical Nurse Consultant and Administrator acknowledged the oversight.
A facility failed to create a baseline care plan within 48 hours for a resident with significant medical needs, including a brain bleed, dysphagia, and an unhealed Stage IV wound. The resident was unable to speak or understand others and could not participate in assessments. The DON confirmed the absence of the required care plan, which should have been completed by the charge nurse.
The facility did not have an RN on duty for 8 consecutive hours daily on three occasions due to a lack of available RNs, despite offering overtime and bonuses. The schedule only included LPNs and medication aides, and the Administrator was unaware of this staffing deficiency.
A facility failed to address a Consultant Pharmacist's recommendation for an AIMS assessment for a resident on antipsychotic medication. Despite monthly reviews and communication from the pharmacist, the assessment was not conducted, and no response was documented. Interviews revealed communication lapses among the Interim DON, the new DON, and nursing staff, leading to the oversight.
An expired insulin aspart flex pen was found on a medication cart, despite being opened beyond the recommended 28-day period. The DON confirmed the oversight and removed the expired pen. Medication Aide #1 was unaware of the expiration period, and the Chief Clinical Officer stated that medication carts are regularly checked for expired medications.
The facility failed to maintain an effective pest control program, resulting in mice sightings and evidence of mice presence in two halls. Cognitively intact residents reported seeing mice and finding droppings in their rooms. Pest control logs showed treatments in 2023, but no documentation since October. The Maintenance Supervisor confirmed increased mice presence and acknowledged verbal complaints from staff, but no official work requests were made. The administrator confirmed ongoing reports of mice.
The facility failed to report allegations of abuse and neglect to APS for three residents. One resident alleged verbal abuse, another alleged neglect causing skin breakdown, and a third alleged neglect due to lack of hygiene care. The facility notified local law enforcement but did not notify APS, as confirmed by blank notification areas in the investigation reports. The Administrator was unaware of the requirement to notify APS.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of RN coverage per day on two days within a 30‑day staffing review period. Review of daily nurse staffing postings for 8/10/25 through 9/10/25 showed that no RN was scheduled for at least 8 hours on 8/30/25 and 8/31/25. During interview, the DON reported there was no RN coverage in the facility on those two days because the scheduled weekend RN called out, and the DON was not notified of the call‑outs at the time. The DON stated she did not learn that the facility had no RN coverage on those dates until the following Monday morning and acknowledged awareness of the requirement for 8 hours of RN coverage each day, as well as an expectation to be notified when an RN calls out. In a separate interview, the Administrator stated he expected the facility to have RN coverage 8 hours a day, 7 days a week. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Issue Required SNF-ABN Notices When Medicare Part A Services Ended
Penalty
Summary
The deficiency involves the facility’s failure to provide required Centers for Medicare & Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notification (SNF-ABN) forms when Medicare Part A skilled services were discontinued before the exhaustion of the 100 covered days, while the residents remained in the facility. For one resident whose Medicare Part A skilled stay began on 5/19/25 and ended on 5/30/25, record review showed no evidence that a SNF-ABN was issued, even though the resident had remaining covered days and continued to reside at the facility. The Business Office Manager (BOM) stated that the resident’s discharge from Medicare Part A services was initiated by the insurance company, which emailed a CMS Notice of Medicare Non-Coverage (NOMNC) for the facility to present, and acknowledged she was not aware that a SNF-ABN also needed to be provided. The Social Worker (SW) interviewed, who was not employed at the time of this resident’s NOMNC issuance, reported that the SW role had been limited to providing the NOMNC and that she had never provided a SNF-ABN, and was unaware that both notices were required. A second resident was admitted under Medicare Part A skilled services beginning 8/19/25, with covered services ending on 9/5/25, and also remained in the facility with Medicare days still available. Review of this resident’s record likewise revealed no SNF-ABN. The BOM reported that this resident’s discharge from Medicare Part A services was also initiated by the insurance company, which sent a blank NOMNC form for completion and delivery to the resident, and again stated she did not know a SNF-ABN was required. The SW confirmed she had issued the NOMNC for this resident at the time Part A services ended, but was not aware she was required to provide both a NOMNC and a SNF-ABN and did not know about the SNF-ABN form that includes an estimated out-of-pocket cost. The Administrator acknowledged awareness of both the SNF-ABN and NOMNC forms and stated his expectation that appropriate notices would have been given, but indicated he had not seen the SNF-ABN form used at this facility.
Improper Food Storage and Dishwashing Practices in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, and monitoring of food items, as well as inadequate dishwashing practices. During an observation of the walk-in cooler with the Dietary Manager, all five cantaloupes were found with soft, brown and black spots and white fuzz, and all fourteen heads of lettuce were brown, slimy, and had spots of white fuzz, indicating spoilage that had not been discarded. In the walk-in freezer, surveyors observed partially used bags of meatballs, French fries, and peas that were open to the air, undated, and had a layer of ice crystals, showing that open frozen foods were not being properly sealed and dated. On the tray line, surveyors observed that dishes and service ware that were designated as clean and ready for use were not properly dried or clean. Eleven of twelve bowls, two of three quarter pans, ten of ten divided plates, and thirty-one of fifty-seven plate covers were stacked while still wet. Additionally, seven of ten divided plates and two of fifty-seven plate covers had visible black, yellow, and brown spots on them. In interviews, the Dietary Manager reported she had been in her role for about three months and that the dishwashing staff member was new; she stated she had educated him that dishes must be dry before stacking and checked for cleanliness before being placed on the tray line. She also stated she personally went through the kitchen on Mondays to ensure items were dated and that spoiled food was discarded, and did not identify other staff responsible for this task. The Administrator stated he had been informed of wet dishes and undated food but was unaware of food with signs of spoilage, and he expected dietary staff to label and date open food items, stack dishes dry, and dispose of spoiled food.
Failure to Honor Resident Choice to Heat Outside Food After Microwave Removal
Penalty
Summary
The deficiency involves the facility’s failure to honor resident choice regarding warming meals brought from outside the facility after the removal of a resident-accessible microwave. Three cognitively intact residents who were independent with eating, some with diagnoses including type 2 diabetes mellitus, anxiety disorder, GERD, and depression, reported that they had previously used a microwave in the dining room to heat soups and other foods brought by family. About a month to a month and a half before the survey, the microwave was removed from the dining room. Residents stated they were told by kitchen staff that personal food items could not be brought into the kitchen to be heated and that the change was due to safety concerns. As a result, residents who did not like the facility’s meals or alternatives, or who wished to save outside food for later, were left with food they could only eat cold or not at all. Staff interviews confirmed that there was no longer any access to a microwave for residents’ food and that the microwave had been removed for safety reasons, including concerns about monitoring food temperatures and the possibility of residents burning themselves. Nurse staff acknowledged that residents and families were upset about the change and that families were informed they would need to bring food already warmed. The Dietary Manager stated she was told by management that the microwave was removed due to safety concerns and that outside food could not be brought into the kitchen to be heated, even though comparable soup could be provided from the kitchen. The DON and Administrator both stated the microwave was removed from the dining room for safety reasons, including inability to monitor temperatures of microwaved foods and concerns about burns, and confirmed that no residents had been injured while using the microwave prior to its removal. These actions and inactions resulted in residents’ expressed dissatisfaction and loss of the ability to exercise choice in heating and consuming outside food items.
Failure to Timely and Accurately Report Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy requiring immediate reporting of abuse allegations to the Administrator, State Agency, Adult Protective Services (APS), and law enforcement when applicable, within two hours of the allegation. A cognitively intact resident reported to the Admissions Director that a nurse aide had hit her in the face multiple times during a shower/bed bath, describing the staff member as a Black woman with pearls in her hair. The Admissions Director documented the concern on a grievance form but did not notify nursing staff, the DON, or the Administrator until the following morning during a meeting, citing that it was late, had been a long day, and that she had not observed any visible injuries on the resident at the time. As a result, the Administrator recorded the facility’s awareness date and time of the allegation as the following day, rather than when the Admissions Director first received the report from the resident. The initial allegation report completed by the Administrator documented that the facility first became aware of the abuse allegation on the later date and did not reflect the actual date and time the allegation was first reported to staff. The initial report was faxed to the State Agency several hours after the Administrator was informed, and the initial documentation did not show that APS or law enforcement were notified at that time. A subsequent skin assessment by a nurse, completed at the request of the Facility Nurse Consultant, documented no signs of facial trauma or other skin issues aside from a pressure spot on the resident’s toe. Interviews with the DON and Administrator confirmed that staff were expected to report any abuse allegation immediately so it could be reported to the State Agency within two hours, and that the Admissions Director did not follow this requirement, resulting in delayed and inaccurate reporting of the abuse allegation.
Failure to Knock or Request Permission Before Entering Resident Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility's treatment of residents' dignity and rights, specifically related to staff failing to knock or ask permission before entering resident rooms. Observations revealed that a nurse aide entered the rooms of three residents without knocking on multiple occasions while delivering lunch trays. The nurse aide acknowledged during interviews that she was aware of the expectation to knock and announce herself but could not explain why she did not follow this protocol. Other staff, including the wound nurse and the administrator, confirmed that staff are expected to knock and introduce themselves before entering resident rooms. The residents involved included one with severe cognitive impairment, one who was cognitively intact, and one with moderate cognitive impairment. Attempts to interview two of the residents were unsuccessful, while the third resident did not express an opinion about the staff's actions. The deficiency was determined based on the reasonable person concept, as individuals generally expect staff to knock and identify themselves before entering their rooms.
Failure to Notify Physician of Resident's Significant Decline
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's condition, despite multiple staff members observing a marked decline. The resident, who was admitted for rehabilitation following a stroke and was initially making progress in therapy, began to exhibit symptoms such as dizziness, lightheadedness, nausea, altered responsiveness, decreased communication, dry mouth, poor oral intake, reduced urine output, dark stools, and eventually tested positive for COVID. Therapy and nursing staff documented and discussed the resident's decline, but there was no timely communication with the physician regarding these changes. Throughout the resident's stay, therapy staff and nurse aides noted a regression in the resident's functional abilities, including a loss of ability to feed herself, ambulate, and communicate as she had previously. Multiple therapy notes and staff interviews indicated that the resident required increasing assistance, became less responsive, and was unable to participate in therapy or self-care. Despite these observations and documentation of the resident's deteriorating condition, the physician was not notified for several days. The only documented physician notification prior to the resident's hospital transfer was related to facial twitching, for which a medication was ordered, but subsequent and more severe changes were not communicated. The lack of physician notification persisted even as the resident's symptoms worsened, including after a positive COVID test and the onset of gastrointestinal symptoms such as dark stools and decreased intake. Staff interviews revealed a breakdown in communication between therapy, nursing, and management, with several staff members assuming others had notified the physician or were unaware of the resident's previous progress. Ultimately, the resident was transferred to the hospital in a critical state, where she was found to be septic due to COVID and had gastrointestinal bleeding, resulting in a critical hemoglobin level and heart injury.
Failure to Obtain Ordered Labs and Recognize Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to obtain laboratory tests as ordered by the physician and did not ensure effective communication among staff to recognize and respond to a resident's change in condition. The resident, who had a history of stroke, anemia, and hypertension, was admitted for rehabilitation and initially made progress in therapy, including self-feeding, ambulating with assistance, and communicating needs through gestures. Despite a physician's documented plan for specific lab work, no orders were entered or completed for these labs during the resident's stay. In the days leading up to the resident's hospital transfer, multiple staff members—including therapists and nurse aides—observed a significant decline in the resident's functional status. Symptoms included dizziness, lightheadedness, nausea, altered responsiveness, poor appetite, dry mouth, and decreased ability to communicate or participate in therapy. These changes were reported to nursing staff, but there was a breakdown in communication, and the severity of the decline was not recognized or escalated appropriately. Nursing documentation was inconsistent, and some nurses were unaware of the resident's prior progress or the extent of her decline. After testing positive for COVID, the resident did not receive evaluation or medical treatment for her infection or her deteriorating condition until she was transferred to the hospital several days later. At the hospital, she was found to be septic due to COVID infection and had gastrointestinal bleeding resulting in critically low hemoglobin, requiring intensive care and blood transfusions. The lack of timely assessment, failure to follow physician orders for labs, and poor communication among staff contributed to the delay in recognizing and treating the resident's acute medical needs.
Neglect Due to Unauthorized Tube Feeding Cessation
Penalty
Summary
The facility failed to protect residents from neglect when Nurse #1 did not adhere to physician orders for continuous tube feeding for two residents. Nurse #1 independently decided to turn off the tube feeding pumps for Resident #60 and Resident #74, believing their stomachs needed a rest, despite being aware of the physician's orders for continuous feeding. This action deprived the residents of their assessed nutritional needs and was not documented in the residents' medical records. Resident #60, who was readmitted with diagnoses including anoxic brain damage and dysphagia, was dependent on tube feeding. The resident's care plan required continuous tube feeding, but Nurse #1 turned off the feeding pump without notifying the physician. Similarly, Resident #74, who had diagnoses including dysphagia and dementia, was also dependent on tube feeding. Nurse #1 turned off the feeding pump for Resident #74 without physician notification, despite the resident having specific orders for continuous feeding with scheduled downtime for activities of daily living. The facility's Director of Nursing and Registered Dietician were unaware of Nurse #1's actions, which disregarded physician orders. The physician expressed concerns about the residents not receiving necessary calories and nutrients due to the unauthorized cessation of tube feeding. Nurse #1 had a history of disciplinary action for substandard work, and her actions placed the residents at risk of serious harm.
Removal Plan
- Nurse #1 was removed from the facility.
- Nurse #1 was terminated.
- The Director of Nursing assessed the pump settings, dates and times of currently hung feedings, and ensured pumps were on appropriately and feedings were infusing accurately per MD orders.
- The Administrator, DON, and Corporate team will monitor the facility and patient care delivery every shift to ensure that the nutrition and hydration needs of all patients are met based on MD orders.
- The team will utilize newly hired administrative nurse managers, facility management team, and lead CNAs to accomplish shift to shift rounding.
- The DON, ADON, and nurse managers will review findings every morning to ensure appropriate and necessary action has been taken to remedy all identified negative findings.
- The Director will ensure that the MD is notified timely of all discrepancies and plans for correction.
- Education sessions on resident rights, reporting abuse and neglect, and facility policies on abuse, neglect, and exploitation began with all staff.
- No employee will be allowed to work until they have received the education.
- New hires are trained in orientation and education will continue within the facility to ensure understanding of abuse and neglect prevention.
- The Director of Nursing, ADON, and nurse managers will review education sessions daily to ensure that all staff have received it and that no staff members work prior to receiving it.
- Daily ongoing audits of all residents with an order for tube feeding to evaluate the status of the pump status/infusion rate and type of feed per physician order.
Failure to Notify Physician of Tube Feeding Deviations
Penalty
Summary
The facility failed to notify the physician of deviations from prescribed tube feeding orders for two residents, resulting in a deficiency. Nurse #1, who was responsible for the care of these residents, turned off their feeding tube pumps without physician notification or orders. This action was taken based on her belief that the residents' stomachs needed a rest, despite being aware that the tube feedings were ordered to be continuous. This deviation from physician orders deprived the residents of their assessed nutritional needs. Resident #60, who was readmitted to the facility with diagnoses including anoxic brain damage and dysphagia, had a continuous tube feeding order of 60 ml/hr. Observations revealed that the feeding tube pump was turned off for an undetermined amount of time, and Nurse #1 admitted to turning it off for 2 to 3 hours without notifying the physician. Similarly, Resident #74, with diagnoses including dysphagia and dementia, had a tube feeding order for 22 continuous hours. Nurse #1 also turned off this resident's feeding tube pump without physician notification, citing the same reasoning. Interviews with the Registered Dietician and the Director of Nursing confirmed that continuous tube feedings should not be turned off without a physician's order. The physician was not aware of the tube feedings being turned off and expressed concerns about the residents not receiving the necessary calories and nutrients. The facility's failure to ensure physician notification and adherence to prescribed orders for tube feedings led to the identification of this deficiency.
Removal Plan
- The facility confirmed that all residents with enteral feedings, including residents #60 and #74, were resumed and infusing at the rate ordered by the physician.
- Nurse #1 was notified of her failure to follow MD orders.
- The Board of Nursing Complaint Evaluation Tool was completed and reviewed with Nurse #1.
- Nurse #1 was suspended after consultation with the Chief Clinical Officer and the Chief Operating Officer.
- Education sessions were begun with all licensed nurses on consulting and notifying the MD of resident changes and need to alter treatments, and ensuring that MD orders are followed at all times, including orders for enteral feedings.
- The DON and Corporate Clinical Nurse and Chief Clinical Officer conducted the education sessions.
- Education sessions will continue with all staff members until 100% of the licensed nurses have received education.
- The Director of Nursing, ADON, and nurse managers will review education session sign-ins daily to ensure that all staff have received the material effectively and to ensure that no staff members worked prior to receiving it.
- No licensed nurses will be allowed to work until they have received the education.
- The Chief Clinical Officer notified the Facility Nurse Consultant that new licensed nursing staff will be trained in orientation and education will continue within the facility.
- The Chief Clinical Officer notified the Director of Nursing for the need and requirement to complete education prior to employees returning to work.
- The DON notified the hall nurses at the beginning of shifts that an inservice would be held prior to the shift beginning.
- These education sessions will continue until 100% of the licensed nurses have been trained.
Failure to Complete MDS Assessments Timely Due to Staffing Issues
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for eight residents. The assessments for these residents were either incomplete or completed past the regulatory deadline. The residents affected included those with ARDs ranging from mid-August to mid-September, with completion dates extending into late September and early October. This delay in completing assessments was identified during a review conducted on October 3, 2024. The deficiency was attributed to staffing issues within the MDS department. The facility lacked consistent MDS staff, relying on a part-time MDS nurse who worked only twice a week. The Resource Nurse and MDS Nurse #1 confirmed the backlog of incomplete assessments, which was acknowledged by the Administrator. Upon his arrival at the facility on August 30, 2024, the Administrator was aware of the backlog and had taken steps to address it by hiring additional MDS nurses and utilizing remote MDS nurses to assist in completing the overdue assessments.
Failure to Administer Tube Feedings as Ordered
Penalty
Summary
The facility failed to administer tube feedings via a gastrostomy tube as ordered by the physician for three residents, leading to deficiencies in nutrition maintenance. Resident #60, who was severely cognitively impaired and dependent on staff for all activities of daily living, had her feeding tube pump turned off by Nurse #1 without a physician's order. Nurse #1 believed the resident's stomach needed a rest, but this decision was made independently and not documented in the resident's electronic medical record. The Registered Dietician and the Director of Nursing were unaware of this action, and the physician was not notified, which could have contributed to the resident's weight fluctuations. Similarly, Resident #74, who was also severely cognitively impaired and required maximum assistance, had her feeding tube pump turned off by Nurse #1 for the same reason. Despite having a physician's order for scheduled downtime for activities of daily living, Nurse #1 turned off the pump outside of these parameters without notifying the physician or documenting the action. The Registered Dietician noted that the resident's weight had been stable, but the unauthorized action could have impacted the resident's nutritional intake. Resident #341, who had a gastrostomy tube and a tracheostomy, was found to have his feeding pump set at a lower rate than ordered. Nurse #2 admitted to setting the pump based on previous settings without confirming the current physician's orders. The resident's physician emphasized the importance of the ordered feeding rate for wound healing, as the resident had a Stage IV wound. The physician was not informed of any symptoms that would justify a reduced feeding rate, and the Director of Nursing was unaware of any distress that would necessitate such a change.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care to a resident who was dependent on staff for activities of daily living. The resident, who was moderately cognitively impaired and frequently incontinent of urine and stool, required partial assistance with toileting. The care plan for the resident included extensive assistance with toileting needs and monitoring for incontinence, but these interventions were not adequately followed. On the morning of the incident, the resident's roommate reported that the resident's adult brief had not been changed since the previous night. Upon checking, a nurse aide found the resident's brief saturated with urine, indicating a lack of timely incontinence care. The nurse aide assigned to the resident admitted she had not checked the resident for incontinence since the start of her shift, as she was attending to other residents and had planned to address the resident's needs later. Further interviews revealed that the resident's care needs had changed since readmission to the facility, requiring more assistance with feeding and incontinence care. The night shift nurse aide did not recheck the resident for incontinence after an initial change, based on a misunderstanding with the resident's roommate. The Director of Nursing confirmed that the resident should have been checked every two hours due to changes in her health condition.
Failure to Conduct Admission Screening Assessment
Penalty
Summary
The facility failed to conduct and document an admission screening assessment for a resident who was readmitted after hospitalization. The resident, who had non-Alzheimer's dementia and a recent hip fracture, was moderately cognitively impaired and required assistance with daily activities. Upon readmission, there was no documentation in the electronic medical record regarding the resident's cognitive state and functional level. The significant change Minimum Data Set (MDS) assessment was incomplete, and the quarterly MDS indicated the resident's need for assistance with meals, mobility, transfers, and toileting, as well as frequent incontinence. The Director of Nursing (DON) acknowledged that the admission screening assessment should have been completed within 24 to 48 hours of the resident's return. However, the DON did not complete the assessment and failed to communicate the need for it to Nurse #5, who was on the night shift. Nurse #5 was unaware of the requirement to complete the assessment, as it was not communicated to her, and she did not find the assessment packet at the nurse's station. The Clinical Nurse Consultant confirmed that the DON should have initiated the assessment and communicated its necessity to the night shift nurse.
Failure to Accurately Document Resident's Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status election was accurately documented throughout the medical record. This deficiency was identified for one of the two residents reviewed for advanced directives. The resident in question was admitted to the facility without a clear order for a code status in the physician's orders from 9/09/24 through 10/01/24. During an interview, a nurse indicated that she believed the resident had a full code status based on a report from another nurse, but upon reviewing the medical record, she could not find a code status order. Instead, she found a hospital note indicating a code with limitations, which she did not understand. The nurse stated that in the absence of a Do Not Resuscitate (DNR) order, the resident would have been treated as full code in an emergency. The Admission Director explained that upon admission, she met with the resident's representative (RR) to discuss advanced directives, and the RR requested a DNR order, which was documented and signed. However, the Admission Director was unaware of the follow-up actions taken by the charge nurse, who was new and no longer worked at the facility. The Director of Nurses (DON) confirmed that the resident did not have a DNR order in place until after the surveyor identified the concern, indicating a lapse in the facility's process for ensuring accurate documentation of code status orders.
Failure to Complete Timely MDS Assessment for New Admission
Penalty
Summary
The facility failed to complete the admission Minimum Data Set (MDS) assessment within the required timeframe for a newly admitted resident. The resident was admitted on a specific date, and their admission MDS, which was due, had not been completed by the time of review. Interviews with staff revealed that the facility had been without full-time MDS staff for approximately three months, leading to a backlog of incomplete assessments. The MDS Nurse acknowledged the delay and stated that efforts were being made to catch up on the pending assessments. The Administrator was aware of the issue and confirmed that additional MDS nurses had been hired to address the backlog.
Failure to Conduct PASRR Level 2 for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of mental disorders received a Level 2 Preadmission Screening and Resident Review (PASRR) after admission. The resident, who was admitted with schizophrenia and bipolar disorder, had a PASRR Level 1 assessment indicating they did not meet the federal definition for mental illness and mental retardation. Despite this, the resident was prescribed Haloperidol for paranoid schizophrenia, and their care plan included the use of antipsychotic medications. The admission Minimum Data Set (MDS) assessment noted that the resident was not considered by the state Level II PASRR process to have a serious mental illness. The deficiency was identified during a review of records and staff interviews, revealing that the Social Worker had not reviewed the resident's diagnoses upon admission and had only initiated the PASRR Level 2 screening process after an inquiry was made. The Clinical Nurse Consultant and the Administrator acknowledged that a PASRR Level 2 should have been submitted due to the resident's diagnoses. The Social Worker explained that the PASRR Level 1 determination was only valid for thirty days from hospitalization, and the oversight was discovered after the resident had been in the facility for some time.
Failure to Create Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to create a baseline care plan within 48 hours of admission for a resident diagnosed with nontraumatic intracerebral hemorrhage and dysphagia. The resident, who was unable to speak, rarely understood others, and could not participate in assessments, also had an unhealed Stage IV wound. Despite these significant medical needs, there was no documentation of a baseline care plan in the electronic medical record. The Director of Nursing confirmed that the baseline care plan, which should have been completed by the charge nurse within 48 hours of admission, was not done.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for 8 consecutive hours daily, 7 days a week, as required by regulations, for three specific dates within a 60-day review period. A review of the facility's daily nurse staffing totals and nursing clock-in sheets for August and September 2024 revealed that there was no RN present on 8/3/24, 8/18/24, and 9/15/24. During an interview, the Chief Clinical Officer confirmed the absence of an RN on these dates, citing a lack of available RNs despite offering overtime and bonuses to existing staff. The facility's schedule only included licensed practical nurses (LPNs) and medication aides on those days. The Administrator was unaware of the RN staffing deficiency on the specified dates.
Failure to Conduct AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist for a resident who was reviewed for unnecessary medications. The resident, who was admitted with diagnoses including dementia and Alzheimer's disease, was prescribed Quetiapine Fumerate, an antipsychotic medication. The Consultant Pharmacist conducted monthly Medication Regimen Reviews and recommended an Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for side effects associated with the antipsychotic medication. However, there was no written response to these recommendations, and no AIMS assessment was documented in the resident's electronic medical record. Interviews with the Consultant Pharmacist and nursing staff revealed communication lapses regarding the pharmacy's recommendations. The Consultant Pharmacist had identified concerns about AIMS assessments not being completed and had communicated these concerns to the facility's administration. Despite this, the Interim Director of Nursing (DON) and the new DON both failed to ensure the AIMS assessment was conducted. The Interim DON could not recall informing the nursing staff to complete the assessment, and the new DON acknowledged receiving the pharmacy recommendations but did not address them. This inaction resulted in the failure to monitor the resident for potential side effects of the antipsychotic medication.
Expired Insulin Aspart Flex Pen Not Discarded
Penalty
Summary
The facility failed to discard an expired insulin aspart flex pen from one of the medication carts, specifically the 300-hall medication cart. During an observation, a flex pen with a label indicating it was opened on 8/23 was found, despite the manufacturer's recommendation to discard it 28 days after opening. The expiration date on the pen was 8/31/26, but it should have been discarded by 9/19/24. Medication Aide #1, who was present during the observation, was unaware of the expiration period for the insulin aspart flex pen. The Director of Nursing (DON) later confirmed the oversight and removed the expired insulin aspart flex pen from the cart. The DON admitted to checking the cart for expired medications earlier in the week but could not explain why the expired pen was still present. The Chief Clinical Officer stated that medication carts are regularly checked for expired medications by nursing staff, pharmacy staff, and nursing administration, but the expired medication was not removed as required.
Deficient Pest Control Program Leads to Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in mice sightings and evidence of mice presence in two of the facility's halls. Residents who were cognitively intact reported seeing mice and finding mouse droppings in their rooms. One resident on the 300 hall reported seeing mice as recently as a week prior to the interview. Another resident on the 200 hall allowed an inspection of her dresser, where small black pellets, identified as mouse droppings, were found near an open package of clean briefs. A third resident, also on the 200 hall, reported ongoing issues with mice for the past year, including finding droppings in her dresser and hearing mice. Glue traps and a metal live mouse trap were observed in her room. The facility's pest control treatment logs indicated treatments for rats and mice in July, September, and October of 2023, but there was no documentation of treatments since October. The Maintenance Supervisor confirmed that exterminators had visited the facility since October but had not always documented their visits. He acknowledged the increased presence of mice this year and confirmed the interventions placed in the resident's room. Staff reported complaints of mice verbally to the Maintenance Supervisor, but there was not always an official work request. The administrator confirmed reports of mice in the facility, with staff and residents continuing to report sightings.
Failure to Report Allegations to APS
Penalty
Summary
The facility failed to report allegations of abuse and neglect to Adult Protective Services (APS) for three residents. The first incident involved a resident who alleged verbal abuse and intimidation by a staff member. The facility became aware of this incident and notified local law enforcement but did not notify APS, as indicated by the blank notification area in the investigation report. The second incident involved a resident who alleged neglect resulting in skin breakdown. Similar to the first incident, the facility notified local law enforcement but failed to notify APS, with the investigation report again showing a blank notification area. The third incident involved another resident who alleged neglect due to not receiving hygiene and incontinent care for over six hours. The facility was aware of this allegation and notified local law enforcement but did not notify APS, as reflected in the investigation report. During an interview, the Administrator admitted to not notifying APS, stating she was unaware of the requirement and believed only local police needed to be informed.
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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