The Carrolton Of Lumberton
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, North Carolina.
- Location
- 1170 Linkhaw Road, Lumberton, North Carolina 28358
- CMS Provider Number
- 345315
- Inspections on file
- 15
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Carrolton Of Lumberton during CMS and state inspections, most recent first.
The facility failed to maintain proper accountability and documentation for multiple residents’ controlled medications, including lorazepam, hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol. Pharmacy records showed that controlled drugs were delivered, but declining count sheets were missing, narcotic book entries were absent, and delivery receipts were often signed by only one nurse or not signed at all. For one resident, lorazepam tablets were delivered for a time-limited PRN order with no evidence of administration, no inventory log, and no return to the pharmacy after discontinuation. Interviews with the DON, a unit manager, the consultant pharmacist, the pharmacy nurse consultant, and the pharmacy director revealed that no one was consistently auditing controlled medications, second-nurse verification at receipt was not reliably performed, and discontinued controlled drugs were not systematically removed from carts and returned, leading to unaccounted-for controlled substances.
A resident with heart failure, HTN, and kidney disease had an order for Metolazone with instructions to hold the dose if SBP was below 110 or DBP below 60, yet an RN repeatedly administered the medication on multiple occasions when BP readings were outside these parameters over several months. The consultant pharmacist identified and reported these discrepancies in two consecutive monthly drug regimen reviews, but the facility’s follow-through was limited to a vague note that nursing staff were educated, without clear documentation that the responsible nurse was included. In subsequent months, the pharmacist’s reviews did not address the ongoing out-of-parameter administrations, and facility nursing leadership did not review the resident’s Metolazone use to ensure compliance with the ordered BP parameters, allowing the pattern of incorrect administration to continue.
A resident with heart failure, hypertension, and kidney disease received Metolazone with ordered blood pressure hold parameters that required the dose to be withheld if systolic BP was below 110 or diastolic BP was below 60. Over several months, an RN repeatedly administered the medication on multiple occasions when the resident’s BP readings were outside these parameters, totaling 57 doses given contrary to the order. The nurse later stated she misunderstood the parameters, believing both systolic and diastolic values had to be below 110/60 to hold the dose. The NP confirmed the correct interpretation of the order, and the consultant pharmacist noted that unnecessary Metolazone could cause hypotension and increase fall risk, although no change in the resident’s condition was documented.
Multiple residents with orders for tramadol, oxycodone, and hydrocodone-acetaminophen had controlled medications documented by the pharmacy as delivered, but the facility lacked required declining count sheets and complete nurse signatures on delivery receipts. Available nurses, rather than designated staff, distributed controlled medications from delivery totes to medication carts, and the DON did not verify that medications recorded as delivered were actually placed on carts or entered into narcotic logs. Internal audits initiated after one resident’s missing tramadol uncovered additional residents with missing controlled medications and a total of hundreds of unaccounted-for tablets, while staff interviews and drug testing linked a medication aide’s suspicious behavior and positive drug screen to the period of diversion. Ordering and refill practices by a NP and the pharmacy contributed to excessive quantities of controlled medications accumulating on carts without adequate tracking.
A resident with a history of traumatic brain injury and a left chest port-a-cath placed for long-term vascular access returned from the hospital with documentation that the device was available for use and had been flushed with saline and heparin, but the facility never obtained provider orders for its care or maintenance. Over an extended period, there were no physician orders or care plan addressing the port-a-cath, and staff, including LPNs and the Unit Manager, reported they did not realize orders were needed or believed only RNs could manage the device. The DON acknowledged the port-a-cath had never been accessed or maintained at the facility, and the NP confirmed she knew the device required routine flushing but had not written orders or ensured ongoing management, resulting in the port-a-cath remaining in place without scheduled access or flushing.
The facility failed to honor resident choice regarding storage and reheating of outside food. Several cognitively intact or moderately impaired residents who were independent with eating reported disliking facility food and preferring meals brought from home or restaurants, but stated they were told they could not store cooked foods in the refrigerator or have them reheated, and that purchased food was discarded. A posted sign on the nourishment room refrigerator and interviews with the Dietary Manager and Administrator confirmed a facility policy prohibiting storage and reheating of cooked foods and disallowing personal refrigerators, while the RD indicated cooked foods can usually be safely stored for several days and the DON stated residents should be allowed to choose to store leftovers.
Surveyors found that medications on two medication carts were not managed according to labeling and storage requirements. On one cart, opened bottles of Latanoprost and Rocklatan ophthalmic drops lacked opened dates, despite manufacturer directions limiting use to six weeks after opening. On another cart, Pyridium tablets and Dorzolamide ophthalmic drops were discovered past their expiration dates. The assigned nurse reported that nurses are responsible for checking carts for expired medications and dating eye drops when opened but acknowledged she had not checked expiration dates on the carts, and the DON confirmed that these responsibilities and expectations were not met.
The facility did not include the care needs of a resident with a port-a-cath or the related staff training and competency requirements in its facility-wide assessment, despite having updated the document to reflect other service changes. The assessment stated that staff education and competencies were completed for resident care needs but omitted port-a-cath care. A resident had a port-a-cath placed during a prior hospitalization, and at the time of survey this was the only resident with such a device. The DON confirmed nursing staff had not received training or competency checks for port-a-cath care, and the Administrator, responsible for updating the assessment, acknowledged being unaware of this lack of education.
A cognitively impaired resident with Lewy body dementia and known wandering and rummaging behaviors accessed an unlocked drawer in an unattended receptionist’s desk in a lobby common area, obtained a loose OTC cold and flu gel capsule containing acetaminophen, dextromethorphan, and phenylephrine, and ingested it before staff could intervene. Staff reported that residents frequently used the lobby, that there was no system for continuous monitoring in this area, and that the resident was difficult to redirect when wandering and rummaging. After ingestion, the resident became drowsy and lethargic and was evaluated in the ED for altered mental status. The DON and Administrator acknowledged that the resident should have been supervised and kept free from hazards and that unlocked drawers in the lobby had not previously been considered a potential hazard.
The facility failed to ensure 8 consecutive hours of RN coverage daily for 13 days due to unreliable RN Weekend Supervisor staffing. The DON worked additional hours as a staff nurse on some days, but these were not recorded due to his salaried status. A new RN Weekend Supervisor was hired to address the issue.
A resident with high blood pressure and cognitive impairment did not receive the ordered Midodrine medication six times in one month when blood pressure readings indicated it was needed. Medication Aides failed to notify the nurse to administer the PRN medication, and a nurse was unaware of the order. The Consulting Pharmacist noted the missed opportunities to administer the medication, and the DON expected staff to follow orders to prevent negative outcomes.
Two incidents of resident-to-resident abuse occurred in the facility. In the first, a cognitively impaired resident attempted to take items from another resident, leading to a physical altercation. In the second, a resident entered another's room and was slapped. Both incidents highlight the facility's failure to manage residents with behavioral issues and cognitive impairments.
A resident with schizoaffective disorder and a traumatic brain injury was involved in an altercation and sent to the hospital for evaluation. Despite being cleared as safe to return, the facility refused to readmit him, citing behavioral concerns. The ADON and hospital Case Manager had conflicting accounts, and the resident's representative faced challenges in providing care at home. The facility's failure to adhere to the bed-hold policy and ensure continuity of care constitutes a deficiency.
The facility failed to clarify a physician's order for a topical medication, leading to inconsistent dosing for a resident with osteoarthritis. Additionally, a lidocaine patch was not removed as ordered, and a resident received an incorrect dose of Vitamin D3 due to a pharmacy delay. Staff interviews revealed lapses in following the five rights of drug administration.
A resident with a stage IV sacral pressure ulcer and dementia had her urinary catheter tubing unsecured, leading to potential tension or trauma. Despite the resident's request for a stabilizing device, it was not provided until observed by the Wound Treatment Nurse. Staff interviews revealed a lack of consistent understanding of the facility's policy requiring catheter stabilization.
A resident with end-stage renal disease did not have their dialysis dressing removed as per physician's orders, leading to potential complications. Despite clear instructions and reminders, the dressing was observed still in place the day after dialysis. Nurse #5 did not remove the dressing, citing a lack of awareness of the order, which was documented in the MAR. The Dialysis Nurse and DON had communicated the importance of timely dressing removal to prevent access site damage.
A medication error rate of 8% was identified in an LTC facility when a nurse prepared two tablets of Ciprofloxacin instead of one and intended to crush Protonix despite 'do not crush' instructions. The resident involved was severely cognitively impaired, and the errors were observed during medication administration preparation. The DON acknowledged the nurse's failure to follow the complete order and special instructions.
Expired medications were found on two medication carts during a survey. An LPN admitted to overlooking expired Geri-dryl, Liquid Tylenol, and Simethicone, which were not administered that day. The DON confirmed that night shift nurses were responsible for checking for expired medications.
A facility failed to accurately document the removal of a Lidocaine patch and a fall mat for a resident, and the removal of a dressing for another resident post-dialysis. Staff signed off on tasks that were not completed, leading to inaccurate medical records. The DON acknowledged the deficiency and had previously addressed similar concerns with staff.
Two nurses failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for residents with tracheostomy and wound care. Despite EBP signage indicating the need for gowns, one nurse did not wear a gown during tracheostomy care, and another forgot to wear a gown during wound dressing changes.
Failure to Maintain Accountability and Documentation for Controlled Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to the accounting and handling of controlled medications for nine residents. For multiple residents with active or time-limited PRN orders for controlled substances such as lorazepam, hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol, pharmacy packing slips and proof-of-delivery records showed that controlled medications were dispensed and delivered to the facility. However, for these deliveries, the facility frequently lacked required documentation, including missing declining count sheets (narcotic inventory logs) and incomplete or absent nurse signatures on delivery receipts. In one case, a resident had an order for lorazepam 0.5 mg every 24 hours as needed for anxiety for 14 days, with 14 tablets delivered, but there was no declining count sheet, no narcotic book entry, and no MAR documentation that any doses were administered after delivery. For several other residents, similar documentation gaps were found. Residents with active orders for hydrocodone-acetaminophen, oxycodone, oxycodone-acetaminophen, and tramadol had controlled medications delivered in quantities ranging from 30 to 90 tablets, but there were no corresponding declining count sheets located for any of these medications. In many instances, the delivery receipts were signed by only one nurse, often the same nurse, or had no nurse signature at all, despite the presence of two signature lines intended for verification by two nurses. The DON later confirmed that declining count sheets were missing for nine residents whose controlled medications had been delivered during the review period, and that the missing lorazepam tablets for one resident had not been returned to the pharmacy and were not documented as administered. Interviews with facility and pharmacy staff further described how these documentation failures and lack of oversight contributed to the deficiency. The DON explained that prior to the discovery of missing medications, the process for receiving controlled drugs involved whichever nurse was available distributing medications from the delivery tote to the medication carts and signing the delivery sheet, without consistent second-nurse verification. The DON also stated she did not verify that medications documented on delivery sheets were actually present on the carts and did not identify the absence of declining count sheets until missing medications were reported. The Unit Manager reported that she did not audit controlled medications and believed the DON was responsible. The Consultant Pharmacist stated she did not conduct controlled medication cart audits and believed the pharmacy’s Nurse Consultant did random checks, while the Pharmacy Nurse Consultant stated he only verified that narcotic boxes were locked and did not review controlled medications or declining count sheets. The Pharmacy Director confirmed that the pharmacy did not track discontinued controlled medication orders and relied on the facility to remove and return discontinued medications, which did not occur for at least one resident’s discontinued lorazepam order.
Ongoing Administration of Metolazone Outside Ordered BP Parameters Despite Pharmacy Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist’s monthly drug regimen review and subsequent nursing actions prevented ongoing administration of a diuretic medication outside ordered parameters for one resident. The resident was admitted with diagnoses including heart failure, hypertension, and kidney disease and had a physician’s order for Metolazone 5 mg to be given orally on Mondays, Wednesdays, and Fridays for edema, with instructions to hold the medication if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Review of the September Medication Administration Record (MAR) showed that Metolazone was administered multiple times by one nurse when the resident’s blood pressure readings were below the ordered parameters, including systolic readings under 110 and diastolic readings under 60. In October and November, the Consultant Pharmacist identified that Metolazone had been administered outside the ordered blood pressure parameters and documented this in monthly medication regimen review reports sent to the DON. The October review noted that the resident had received Metolazone outside parameters on several occasions in September and October, and the November review again informed the DON that the resident continued to receive Metolazone outside the ordered parameters. On both reports, the Unit Manager documented that nursing staff had been educated, but did not specify whether the nurse who administered the medication in error received this education or what specific education was provided. Despite these pharmacist reports, MARs for October and November showed that the same nurse continued to administer Metolazone on multiple dates when the resident’s blood pressure readings were below the ordered hold parameters. In December and January, the Consultant Pharmacist’s monthly medication regimen reviews did not include any recommendations regarding the resident’s Metolazone, even though the MARs for those months showed that the same nurse continued to administer the medication on numerous dates when the resident’s blood pressure readings remained below the ordered parameters. The Consultant Pharmacist later stated that she did not address Metolazone in those months and that this was missed, and she typically did not go back to review prior recommendations. The DON stated that she and the Unit Manager shared responsibility for reviewing and acting on the pharmacy reports and that the Metolazone issue was not reviewed in December or January to ensure the medication was being held per parameters. The nurse who administered the medication stated she was new, misunderstood the hold parameters as applying only if both systolic and diastolic pressures were below 110/60, and was not aware of the medication error until it was brought to her attention during the survey, despite being consistently assigned to the resident and administering Metolazone in this manner since September. This sequence of events shows that the facility did not act effectively on the Consultant Pharmacist’s October and November findings and that the Consultant Pharmacist did not continue to identify and address the ongoing issue in December and January, resulting in the resident continuing to receive Metolazone outside the physician-ordered blood pressure parameters over multiple months.
Failure to Follow Blood Pressure Parameters for Metolazone Administration
Penalty
Summary
Surveyors identified a deficiency in which the facility failed to ensure a resident was free from significant medication errors related to administration of Metolazone, a diuretic prescribed with specific blood pressure hold parameters. The physician’s order dated 9/5/25 directed that Metolazone 5 mg be given orally on Monday, Wednesday, and Friday for edema, with instructions to hold the dose if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Despite these parameters, review of the Medication Administration Records (MARs) from September 2025 through February 2026 showed that the medication was repeatedly administered when the resident’s blood pressure readings were outside the ordered limits. The resident involved was admitted with diagnoses including heart failure, hypertension, and kidney disease, and received diuretic medications. MAR review revealed that Metolazone was documented as given on multiple dates over several months when either the systolic blood pressure was below 110 or the diastolic blood pressure was below 60. These administrations occurred on numerous specific dates in September, October, November, and December 2025, as well as January and February 2026, totaling 57 doses given contrary to the ordered hold parameters. Progress notes from 9/10/25 through 2/11/26 contained no documentation of any change in the resident’s condition during this period. During interviews, the nurse who administered the medication on all of the identified dates acknowledged giving Metolazone despite the blood pressure readings and stated she misunderstood the order, believing the medication should be held only if both systolic and diastolic pressures were below 110/60. The nurse reported she was new and consistently assigned to care for this resident. The resident was observed sitting in a wheelchair, in no distress, and voiced no concerns with care. The Nurse Practitioner confirmed that the order required holding Metolazone if either the systolic was less than 110 or the diastolic was less than 60 and stated she was not aware the medication had been given outside these parameters. The Consultant Pharmacist stated that taking Metolazone when not indicated could cause hypotension and increase fall risk. The Director of Nursing reported she was not aware that Metolazone had continued to be administered outside the ordered parameters and that the resident had no falls and no change in condition.
Failure to Safeguard and Account for Controlled Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their controlled pain medications and to maintain required controls over these drugs. For nine residents with active orders for narcotic or controlled pain medications (including tramadol, oxycodone, hydrocodone-acetaminophen, and oxycodone-acetaminophen), pharmacy records showed that multiple prescriptions were filled and delivered to the facility, but there were no corresponding declining count sheets or complete delivery documentation. In several instances, delivery receipts were signed by only one nurse instead of two, and in some cases there was no nurse signature at all. The Director of Nursing (DON) later confirmed that the medications for these residents were never entered into the narcotic records and that the declining count sheets were missing. For each of the nine residents, the surveyors verified that controlled medications had been ordered by a practitioner and dispensed by the pharmacy, but the facility lacked the required inventory logs to track receipt and use of these medications. For example, one cognitively intact resident with an order for scheduled tramadol had 30 tablets documented as delivered by the pharmacy, signed as received by a night-shift nurse, but no second nurse signature and no declining count sheet could be found. Another resident with severely impaired cognition and an as-needed oxycodone order had two separate deliveries of 60 tablets each documented by the pharmacy, yet there were no nurse signatures on one delivery sheet and no declining count sheets for either shipment. Similar patterns occurred for residents with diagnoses such as cancer, heart failure, CVA, arthritis, diabetes, renal disease, and deep vein thrombosis, all of whom had active controlled medication orders and documented pharmacy deliveries without corresponding facility inventory records. Interviews and record reviews showed that the facility’s process for handling controlled medication deliveries contributed to the deficiency. The DON stated that when controlled medications were delivered, whichever nurse was available would distribute medications from the delivery tote to the medication carts and sign the delivery sheet, even though the form had two signature lines intended for both the nurse checking in the medications and the nurse receiving them on the cart. The DON acknowledged that two nurses were not consistently signing the delivery sheets, that she did not verify that medications documented as delivered were actually placed on the carts, and that missing medications were not recorded in the narcotic book. An internal audit initiated after one resident’s tramadol could not be located revealed that eight additional residents had missing controlled medications for active orders, and the facility ultimately identified a total of 660 missing controlled tablets for active orders. Staff interviews indicated that a specific medication aide had been acting suspicious, and subsequent drug testing of staff showed that this aide tested positive for the missing medications, coinciding with the period in which the controlled medications and required documentation were absent. Additional interviews with the Chief Nursing Officer, Nurse Consultant, pharmacy director, and nurse practitioners further described how ordering and dispensing practices led to excessive quantities of controlled medications being present on medication carts without adequate tracking. One nurse practitioner reported that during monthly pain assessments she routinely ordered refills for controlled pain medications without first checking with nursing staff to determine if refills were needed, and the pharmacy director stated that the pharmacy would refill controlled medications when orders were received if they had not been filled in a while. These practices resulted in large amounts of controlled medications being stored on the carts. Although facility leadership and pharmacy representatives later described changes to ordering and refill processes, the surveyors noted that the facility-provided corrective action plan could not be validated.
Failure to Obtain Orders and Maintain a Resident’s Port-a-Cath
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement provider orders for the care and maintenance of a resident’s port-a-cath. The resident, who had a history of traumatic brain injury with a persistent vegetative state and severely impaired decision-making, was admitted with a left chest port-a-cath placed in the hospital for future vascular access. The hospital discharge summary documented that the port-a-cath was initially too immature to use and required 7 to 14 days to heal before use, and later hospital documentation indicated the port-a-cath was available for medication administration and had been flushed with normal saline and heparin prior to discharge back to the facility. Despite this, review of physician orders from the time of port placement through the survey period showed no orders related to accessing or maintaining the port-a-cath, and the resident’s care plan contained no plan of care addressing the device. Surveyor observation confirmed the presence of a left chest port-a-cath, and staff interviews revealed a lack of knowledge and action regarding its management. A nurse stated she did not know if there were orders for the port-a-cath and believed only RNs could access and flush it. The Unit Manager, who handled the resident’s readmission from the hospital, reported she did not realize orders were needed to access and flush the port-a-cath and noted that both nurses who reviewed the readmission orders were LPNs. The DON acknowledged that the resident had a port-a-cath due to poor vascular access, that orders should typically be obtained upon admission for care and maintenance, and that the facility had never accessed or maintained the resident’s port-a-cath since placement. The NP confirmed awareness that the resident had a port-a-cath for IV fluids, medications, and blood draws and stated that such devices are usually usable about two weeks after placement and should be accessed and flushed routinely. The NP acknowledged that the port-a-cath had not been accessed or flushed at the facility since its placement in December 2024 and that no orders had been written for its maintenance. She further stated she assumed the hospital had accessed and flushed the port during the resident’s hospitalizations and had only verbally mentioned ordering special needles to nursing staff without following through with orders or physician discussion. Collectively, these actions and inactions resulted in the absence of physician orders, care planning, and routine maintenance for the resident’s port-a-cath over an extended period.
Failure to Honor Resident Choice for Storage and Reheating of Outside Food
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ choices regarding storage and reheating of food brought from outside the facility, despite regulatory requirements to promote and facilitate resident self-determination and choice. One resident with acute unspecified protein calorie malnutrition, who was moderately cognitively impaired but independent with eating, reported that she did not like the facility’s food and preferred food from home or local restaurants. She stated that the facility would not allow her to store cooked foods in the refrigerator or have them reheated, and that she had been told such storage was not allowed. Another cognitively intact resident, independent with eating, reported that he previously ordered pizza monthly, ate part of it, and stored the remainder in the refrigerator to be reheated for later meals, but was recently told he could no longer store cooked food or have it reheated, and that staff threw away pizza he had purchased. A third cognitively intact resident with stroke and diabetes stated he did not like the facility’s food and preferred healthy, diabetic foods provided by his family, but was told he could not store cooked foods in the refrigerator or have them reheated, and that personal refrigerators in rooms were not allowed. Surveyors observed a sign on the nourishment room refrigerator stating that no cooked food may be stored and that no stored foods were allowed per facility policy. The Dietary Manager confirmed that the facility’s policy prohibited residents from storing food in the nourishment room refrigerator to prevent potentially hazardous food illnesses, allowing only drinks and nutritional supplements. The RD stated that previously cooked food items could usually be safely stored in the refrigerator for up to three days. The DON stated she expected residents to be allowed to make choices about their food, including storing leftovers for later consumption, while the Administrator confirmed the facility policy not to allow residents to store or reheat food and to discard any cooked foods not eaten within four hours, and that residents were not allowed personal refrigerators in their rooms.
Failure to Discard Expired Medications and Date Opened Ophthalmic Drops on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices on two of six medication carts reviewed. On the 200-hall medication cart #1, an opened bottle of Latanoprost 0.005% ophthalmic drops and an opened bottle of Rocklatan ophthalmic drops were found without any opened dates labeled on the bottles, despite manufacturer instructions that each product may be stored at room temperature for only six weeks after opening before being discarded. On the 200-hall medication cart #2, Pyridium (phenazopyridine) 95 mg tablets and a bottle of Dorzolamide 2% ophthalmic drops were found with expiration dates that had already passed. During interviews, the nurse assigned to both medication carts stated that all nurses were responsible for checking the carts for expired medications and for recording opened dates on eye drops, but acknowledged she had not checked expiration dates on either cart and had not administered the expired medications that day. She also stated she did not open the eye drops on medication cart #1 and that the drops should have been dated when opened. The DON confirmed that the assigned nurse is responsible for checking medication carts for expired medications and ensuring medications with shortened expiration dates are labeled with an opened date, and stated that the expired medications should have been discarded and the eye drops labeled with opened dates.
Failure to Include Port-a-Cath Care and Training in Facility Assessment
Penalty
Summary
The facility failed to ensure its facility-wide assessment identified and addressed the care needs of residents with a port-a-cath and the associated staff training and competencies. The facility assessment, last updated on 9/8/2025, stated that education, training, and competencies had been completed specific to resident care needs, but it did not include training or competency requirements for care of residents with a port-a-cath. The Administrator, who is responsible for updating the facility assessment with input from the DON and other administrative staff, had updated the assessment on 1/1/2026 to reflect a change in therapy providers but did not include the care needs related to port-a-caths, despite knowing that all resident care needs should be reflected in the facility assessment. Resident #1 was admitted to the facility with a port-a-cath that had been placed on 12/18/2024 during a hospitalization for pneumonia. At the time of the survey, the facility had one resident with a port-a-cath. During interviews, the DON confirmed that nursing staff had not received training or competencies regarding port-a-cath care. The Administrator confirmed there was one resident with a port-a-cath and stated he was not aware that nursing staff had not been educated or had competencies checked for providing care to residents with a port-a-cath.
Failure to Supervise Cognitively Impaired Resident and Control Access to Medication in Lobby Area
Penalty
Summary
The deficiency involves the facility’s failure to provide effective supervision and maintain an environment free from accident hazards for a cognitively impaired resident with known wandering and rummaging behaviors. The resident had Lewy body dementia and other significant medical diagnoses, including atrial fibrillation, hypertension, diabetes, COPD, heart failure, thyroid disease, and kidney disease. The resident’s care plan identified risk for cognitive decline related to delirium history and neurocognitive disorder with Lewy body dementia, with an intervention to monitor, document, and report changes in cognitive function. The quarterly MDS documented moderate cognitive impairment and wheelchair use, and staff interviews described a pattern of wandering throughout the facility, entering other residents’ rooms and common areas, and rummaging through belongings, with staff reporting difficulty redirecting the resident. On the day of the incident, the resident was in the lobby area, which is an open common area with television and seating where residents can freely sit and propel their wheelchairs. The receptionist’s desk is located in this lobby area near the facility entrance. The Unit Coordinator reported that the receptionist left her desk unattended, with an unlocked desk drawer containing a loose over-the-counter cold and flu gel capsule. As the receptionist returned to the desk, she observed from across the room that the resident had opened the unlocked drawer, found the loose gel capsule, and ingested it before staff could intervene. The Unit Coordinator stated that residents were frequently in the front common area and that most residents did not wander or go into things, but there was no system in place to ensure continuous monitoring of residents in that area. Following ingestion of the cold and flu gel capsule containing acetaminophen, dextromethorphan, and phenylephrine, the resident initially appeared to be okay but then became drowsy and lethargic, according to the Unit Coordinator and Weekend Supervisor. A nursing note documented that the resident went through the unattended receptionist’s desk, found the capsule, and ingested its contents. Another nursing note later documented that the resident was lethargic and not responding after ingesting the medication and was sent to the emergency department for evaluation of altered mental status. The emergency department record indicated the resident arrived with stable vital signs and a history that her altered mental status began after ingesting the over-the-counter cold and flu medication taken from the receptionist’s desk drawer. The DON and Administrator both acknowledged that the resident should have been supervised and kept free from hazards, and that prior to this incident the facility had not considered unlocked drawers in the lobby area as a potential hazard for cognitively impaired residents, and there was no system to ensure continuous monitoring of residents in common areas, including the lobby.
Failure to Provide Consistent RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage a day, 7 days a week for 13 of 139 days reviewed. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 2, 2024, and Quarter 3, 2024, documented several days where there was no RN coverage. Specifically, there was no RN coverage on multiple dates across January, February, March, April, and May 2024. The Director of Nursing (DON) worked as a staff nurse on some of these days after fulfilling his full-time obligations as the DON, but these hours were not reported due to his salaried status and not punching the time clock. Interviews with the facility's Administrator, Nursing Scheduler/Payroll Manager, and the DON revealed that the staffing issues were primarily due to the unreliability of the RN Weekend Supervisor. The DON confirmed that he worked additional hours as a staff nurse on certain days, but these were not reflected in the PBJ report. The facility had since hired a new RN Weekend Supervisor, which reportedly resolved the recent staffing issues, but the deficiency occurred due to the lack of consistent RN coverage on the specified dates.
Failure to Administer Hypotensive Medication as Ordered
Penalty
Summary
The facility failed to administer the physician-ordered hypotensive medication, Midodrine, to a resident with high blood pressure and Vitamin D deficiency, six times in one month. The resident was moderately cognitively impaired and had specific orders for Midodrine to be given when blood pressure was less than 110/60 mm/Hg. Despite the Metoprolol Tartrate being held due to low blood pressure readings, the Midodrine was not administered as required. This was evidenced by the absence of nursing initials or checkmarks on the Medication Administration Record (MAR) for the days in question. Interviews with staff revealed that Medication Aides were not allowed to administer PRN medications and failed to notify the charge nurse when the resident's blood pressure was within the parameters for Midodrine administration. Nurse #6 confirmed not administering the medication due to unawareness of the order. The Consulting Pharmacist indicated that the medication should have been given to prevent further drops in blood pressure. The Director of Nursing expected staff to follow medication orders and acknowledged that failure to do so could result in negative outcomes for the resident.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by two incidents involving resident-to-resident altercations. In the first incident, a resident with severe cognitive impairment attempted to take belongings from another resident's hat, leading to a physical confrontation. The second resident, who had a history of behavioral issues and was using a wheelchair, responded by shaking the first resident and attempting to run him over with the wheelchair. Despite the altercation, the first resident did not sustain any injuries. The facility's staff, including the Unit Manager and the Director of Nursing (DON), were not fully aware of the incident's details or the residents involved until after it occurred. In another incident, a resident with severe cognitive impairment entered another resident's room, resulting in the latter slapping the intruder on the cheek. The resident who was slapped experienced mild redness, which resolved quickly. The facility's staff, including a Medication Aide and the DON, were informed of the incident after it occurred. The resident who slapped the other had no prior history of physical aggression, and the incident was considered isolated by the staff. Both incidents highlight the facility's failure to adequately monitor and manage residents with known behavioral issues and cognitive impairments. The care plans for the involved residents did not effectively address their behavioral problems, and staff interventions were insufficient to prevent the altercations. The facility's response to these incidents was reactive rather than proactive, indicating a deficiency in protecting residents from abuse.
Facility Fails to Readmit Resident After Hospital Clearance
Penalty
Summary
The facility failed to permit a resident to return after hospitalization, violating the bed-hold policy. Resident #84, who had schizoaffective disorder and a traumatic brain injury, was involved in a resident-to-resident altercation and was sent to the hospital for evaluation. Despite being cleared by the hospital as safe to return, the facility refused to readmit him, citing concerns about his behavior. The Assistant Director of Nursing (ADON) and the hospital Case Manager had conflicting accounts, with the ADON claiming she might have told the hospital that the resident could not return, while the Case Manager confirmed the resident was safe for discharge. The Psychiatric provider confirmed that the only order given was to send the resident to the hospital for evaluation, and no order was given to refuse readmission. The Director of Nursing (DON) acknowledged the facility's obligation to hold the resident's bed for 30 days and to readmit him once cleared by the hospital. However, the resident was not readmitted, and the facility's Social Worker provided documentation to the resident's representative to seek placement elsewhere. The resident's representative expressed difficulties in caring for the resident at home and financial strain due to the facility's refusal to readmit him. The Administrator was unaware of the ADON's decision and believed it was a judgment call due to staff fears. The facility's failure to readmit the resident after hospital clearance constitutes a deficiency in adhering to the bed-hold policy and ensuring continuity of care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to clarify a physician's order for a topical medication for a resident with osteoarthritis, resulting in the medication being administered without a specified dose for 26 days. The order for Diclofenac Sodium External 1% did not indicate the number of grams to be applied, leading to inconsistent application by various nursing staff and medication aides. Interviews with the staff revealed that they applied varying amounts of the ointment without measuring, and none of them sought clarification of the order until a medication pass observation prompted a review and correction of the order. Another deficiency involved the failure to follow a physician's order for the removal of a lidocaine patch after 12 hours for a resident with pain. The patch was left on overnight, contrary to the order, and was only removed the following morning by a medication aide. The nurse responsible admitted to signing off on the removal without actually performing it, citing being busy as the reason for the oversight. The nurse practitioner confirmed that leaving the patch on longer than ordered could lead to skin irritation, although no irritation was observed in this instance. The facility also failed to administer the correct dose of Vitamin D3 to a resident due to a delay in receiving the correct medication from the pharmacy. The medication aides administered a lower dose than ordered, mistakenly believing it was the correct one. The consulting pharmacist noted that while the lower dose would not cause harm, the aides should have verified the medication label and informed the nurse of the discrepancy. The director of nursing emphasized the importance of adhering to the five rights of drug administration, which includes ensuring the right dose is given.
Failure to Secure Urinary Catheter Tubing
Penalty
Summary
The facility failed to secure a resident's indwelling urinary catheter tubing, which could prevent tension or trauma. The resident, who was admitted with diagnoses including a stage IV sacral pressure ulcer and dementia, was observed with her urinary catheter tubing hanging off the side of the bed without being secured. The catheter bag was hooked to the lower side of the bed, and the resident reported that she had requested a stabilizing device but had not received one. The Wound Treatment Nurse confirmed that the tubing should have been secured and proceeded to attach a stabilizing device to the resident's thigh. Interviews with staff revealed inconsistencies in understanding and implementing the facility's policy regarding catheter stabilization. Nurse #2 incorrectly stated that residents did not need a stabilizing device unless they wanted one, while the Assistant Director of Nursing and the Administrator both confirmed that the facility policy required a stabilizing device for all residents with an indwelling urinary catheter. This discrepancy in staff understanding and adherence to policy contributed to the deficiency observed during the survey.
Failure to Follow Dialysis Dressing Removal Orders
Penalty
Summary
The facility failed to follow the physician's orders regarding the care of a resident who required dialysis services. The resident, who was moderately cognitively impaired and diagnosed with end-stage renal disease, had a physician's order to have the dressing on their arterial venous fistula removed approximately one hour after returning from dialysis. This order was intended to prevent potential damage to the access site and to monitor for bleeding. However, the dressing was not removed as ordered, and it was observed still in place the following day. Nurse #5, who was responsible for the resident's care, did not remove the dressing, claiming there was no order to do so, despite the order being documented in the medication administration record (MAR). The Dialysis Nurse had previously communicated the importance of removing the dressing to prevent complications, and the Director of Nursing had addressed this issue with the staff, ensuring an order was in place to remind them. Despite these measures, the dressing remained on the resident's access site, which could potentially cause complications. The failure to remove the dressing as ordered was confirmed through interviews with the nursing staff and observations of the resident, highlighting a lapse in following established care protocols for dialysis patients.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Crushing Instructions
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 25 opportunities, resulting in an 8% error rate. The errors were observed during a medication administration preparation for a resident who was severely cognitively impaired. Nurse #7 prepared medications for the resident, including Allopurinol, Ciprofloxacin, Finasteride, Haldol, Protonix, Seroquel, Flomax, and aspirin. However, Nurse #7 incorrectly prepared two tablets of Ciprofloxacin instead of one and intended to crush all medications, including Protonix, which had a 'do not crush' instruction. During the observation, Nurse #7 admitted to not noticing the 'do not crush' instruction on the Protonix dispensing card and had been crushing it regularly. The Consulting Pharmacist later confirmed that administering more than the ordered dose of Ciprofloxacin could cause stomach discomfort, and crushing Protonix would make it less effective. The Director of Nursing acknowledged that Nurse #7 should have read the entire order and followed special instructions, such as 'do not crush,' to prevent such errors.
Expired Medications Found on Medication Carts
Penalty
Summary
The facility failed to discard expired opened multidose medications on two of the four medication carts reviewed. During an observation of the 300 Hall medication cart, an opened bottle of Geri-dryl with an expiration date of 10/24 was found. Nurse #5, who was present during the observation, admitted that the night shift nurses were responsible for checking the medication carts for expired medications, but she also checked her cart and overlooked the expired Geri-dryl. She confirmed that she did not administer this medication on the day of the observation. Similarly, an observation of the 400 Hall medication cart revealed an opened bottle of Liquid Tylenol with an expiration date of 09/24/24 and an opened bottle of Simethicone with an expiration date of 08/24/24. Nurse #5 again acknowledged that the night shift nurses were supposed to check for expired medications, but she missed the expired Liquid Tylenol and Simethicone. She confirmed that neither of these medications was administered on the day of the observation. The Director of Nursing stated that it was the facility's responsibility to ensure that all medications on the carts were not expired and reiterated that the night shift nurses were tasked with checking for expired medications due to their increased availability during downtime.
Inaccurate Documentation of Medical Orders
Penalty
Summary
The facility inaccurately documented the removal of a Lidocaine patch and the presence of a fall mat for a resident during a medication pass. The resident, who was admitted with diagnoses including stroke with left side weakness and pain, had a physician's order for a Lidocaine patch to be applied daily and removed after 12 hours. However, during a medication pass, it was observed that the patch from the previous day was still on the resident's back, despite being signed off as removed by a nurse. The nurse admitted to signing off the removal without actually performing the task due to being busy. Additionally, the medication aide signed off on the presence of a fall mat, which was not in place, admitting to clicking off the task in error. Another resident, who was admitted with end-stage renal disease and dependent on dialysis, had a physician's order to remove the dressing from the dialysis access site after each treatment. The order was signed off as completed by a nurse, but the dressing was found still in place the following day. The nurse claimed there was no order to remove the dressing, but upon review, confirmed the order existed and admitted to signing off without removing the dressing. The Director of Nursing (DON) expressed expectations that staff should follow physician orders accurately and document tasks only after completion. The DON acknowledged previous concerns about the removal of dressings post-dialysis and had implemented an order to remind staff of this requirement. The inaccurate documentation by the nursing staff was identified as a deficiency in maintaining professional standards for medical records.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement their Enhanced Barrier Precautions (EBP) policy when two nurses did not apply gowns before providing care to residents under EBP. Nurse #3 was observed providing tracheostomy care to Resident #40 without wearing a gown, despite the EBP sign on the resident's door indicating that a gown was necessary for high-contact care activities. Nurse #3 initially believed a gown was not required for tracheostomy care until he read the EBP sign and acknowledged the need for a gown. Similarly, Wound Nurse #1 was observed completing wound dressing changes for Resident #12 without wearing a gown, even though the EBP signage on the resident's door instructed staff to wear a gown and gloves during high-contact care activities. Wound Nurse #1 admitted to forgetting to put on a gown, despite being aware of the EBP requirements. The Assistant Director of Nursing, who also serves as the facility's Infection Control Preventionist, confirmed that both nurses should have worn gowns while providing care to the residents.
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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