The Carrolton Of Williamston
Inspection history, citations, penalties and survey trends for this long-term care facility in Williamston, North Carolina.
- Location
- 119 Gatling Street, Williamston, North Carolina 27892
- CMS Provider Number
- 345145
- Inspections on file
- 22
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at The Carrolton Of Williamston during CMS and state inspections, most recent first.
A resident with end-stage renal disease requiring dialysis was readmitted, but the subsequent quarterly MDS assessment, while noting the diagnosis, failed to indicate that dialysis services were being provided. The current MDS nurse acknowledged that the former MDS nurse should have coded the dialysis treatment and confirmed the assessment was inaccurate. The Administrator reported that the facility’s expectation is that all MDS assessments are coded accurately.
A resident with ESRD returned from a hospital stay with a permacath in place and an established outpatient dialysis schedule, but the facility did not obtain or enter a physician’s order for dialysis upon readmission. The resident’s care plan documented the need for dialysis and related interventions, including monitoring and dressing changes at the access site and encouraging attendance at thrice-weekly dialysis appointments, yet the MDS did not code the resident as receiving dialysis. Staff interviews confirmed the resident continued to attend dialysis, while the DON and Administrator acknowledged that the dialysis order was missing and should have been entered into the system.
The facility did not provide the required CMS SNF-ABN notification to two residents before ending their Medicare Part A skilled services, even though both remained in the facility. Record review and staff interviews confirmed that the notifications were not issued due to processing errors, and the responsible staff acknowledged the oversight.
A resident with dementia exhibited behaviors such as spitting, urinating on the floor, and refusing care, but the MDS assessment was inaccurately coded, omitting documented behavioral symptoms and rejection of care. Staff confirmed the error in coding during interviews.
Surveyors identified expired insulin pens, an expired bottle of docusate sodium, and an opened, expired vial of Pneumococcal vaccine that were not removed from medication carts and storage areas. Nursing staff and the interim DON acknowledged responsibility for checking and removing expired medications, but these items remained accessible beyond their expiration dates.
A resident with severe cognitive impairment and a history of stroke was found without access to their call light, which was placed out of reach on a light fixture. The resident, who was dependent on staff for all ADLs and had difficulty communicating, was observed in discomfort and unable to request assistance. Staff interviews confirmed the call light should have been accessible at all times.
A resident was placed in a room with damaged sheetrock, a broken dresser, and an unusable bathroom cabinet. Staff and maintenance were aware of the issues, but repairs were delayed for several months despite work orders and ongoing complaints. The resident experienced an injury from the faulty dresser, and the room remained in disrepair, failing to meet standards for a safe and homelike environment.
A nurse failed to follow enhanced barrier precautions for two residents with Stage 4 pressure ulcers. One resident's room lacked a precaution sign and PPE, leading the nurse to perform wound care without a gown. Another resident had a sign, but the nurse still did not wear a gown. The DON confirmed the nurse should have worn gowns in both cases.
A resident with Alzheimer's in a dementia unit was treated without dignity when a Nurse Aide forcibly pushed her into a chair, causing it to hit the wall. The incident was witnessed by a Med Aide who reported it immediately. The Nurse Aide admitted to the action, claiming it was to prevent the resident from disturbing others, although the resident typically did not bother anyone.
A resident with complex medical conditions and existing pressure sores was admitted to an LTC facility, where the initial skin assessment was incomplete, and treatment orders were not consistently documented or administered. The facility's DON and nursing staff failed to initiate treatment for a right buttock wound and omitted documentation for sacral wound care on specific dates. The facility's wound care consultant later found significant necrotic tissue, requiring surgical intervention. The facility administrator acknowledged the deficiency in treatment and documentation practices.
The facility failed to have an RN on duty for at least eight consecutive hours a day, seven days a week, and did not designate a full-time DON. The DON also served as a charge nurse despite the facility's census being greater than 60 residents. Interviews and timecard reviews confirmed the lack of RN coverage and improper assignment of the DON.
The facility failed to provide effective leadership and oversight, resulting in insufficient staffing, delayed medication administration, unmonitored nursing licenses and certifications, incomplete performance evaluations, and inadequate annual training for nurse aides. The Administrator cited staffing challenges and limited support for the DON.
The facility failed to obtain post-dialysis vital signs, record post-dialysis weights, and maintain communication with the dialysis facility for a resident requiring dialysis care. Interviews revealed that assigned nurses did not consistently follow protocols, leading to missing documentation and incomplete communication forms.
The facility failed to monitor the NC Nurse Aide Registry, resulting in five nurse aides working with expired certifications. This oversight was due to frequent changes in the DON position and a lack of clear communication regarding the responsibility for tracking certification expirations. An audit revealed the expired certifications, and the affected nurse aides were removed from their assignments until their certifications were renewed.
The facility failed to complete annual performance reviews for 4 of 5 nursing assistants reviewed. The DON was unaware of the requirement due to high turnover in her position, leading to the absence of performance evaluations and individual training based on these evaluations.
The facility failed to provide a smooth pureed food consistency for 9 residents with diet orders for a pureed diet texture. During a lunch meal tray line observation, pureed egg noodles were found to have a lumpy consistency. Cook #1 did not inspect the food before placing it on the tray line, and the Dietary Manager confirmed that the food was prepared by a recently re-hired Dietary Aide. The Speech Therapist indicated that lumpy pureed foods could be a choking hazard.
The facility failed to ensure that a nurse maintained a current and active professional nursing license, resulting in the nurse working without a valid license for an extended period. Staff interviews revealed a lack of clarity regarding the responsibility for monitoring license expirations.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in areas such as Resident Rights, Environment, Pressure Sores, Supervision, Medication Storage, and Medical Records. Issues included disrespectful communication, unclean bathrooms, improper wound care, inadequate supervision, unsecured medication carts, and inaccurate medical records.
The facility failed to ensure that four nursing assistants completed the required 12 hours of annual training, including dementia care and areas of weakness identified in performance reviews. High turnover in the DON position and the absence of a Staff Development Coordinator contributed to this deficiency.
A Medication Aide left the keys to a medication cart in a resident's room, which were later retrieved by the resident. The keys should have been kept in the aide's possession at all times, as confirmed by the Director of Nursing.
A facility failed to accurately document the treatment of a resident's pressure ulcer. The resident had specific physician orders for wound care, but an observation revealed that the treatment was not performed as documented by a nurse. The Director of Nursing confirmed the falsification of records, and the Administrator acknowledged the need for accurate documentation.
The facility failed to display accurate daily nursing staffing information and maintain the daily nurse staff posting on file for 39 days reviewed. Interviews with front desk staff revealed inconsistencies and a lack of clarity in the process of completing the daily nursing staff sheet, and the Administrator confirmed that the front desk staff were responsible for this task.
The facility failed to complete quarterly MDS assessments within the required 14-day timeframe for three residents. The MDS Nurse acknowledged awareness of the timeline requirements but could not explain the delays. The Administrator confirmed the missed deadlines during a spot check and admitted they should not have been missed.
Inaccurate MDS Coding for Dialysis Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate Minimum Data Set (MDS) assessment for a resident receiving dialysis. Record review showed that a resident was readmitted with end-stage renal disease requiring dialysis, yet the quarterly MDS assessment, dated after readmission, documented the diagnosis of end-stage renal disease but did not indicate that dialysis services were being provided. During an interview, the current MDS nurse stated that the former MDS nurse should have coded that the resident was receiving dialysis services and acknowledged that the MDS assessment was inaccurate. An attempted interview with the former MDS nurse was unsuccessful, and the Administrator stated that the expectation was for all MDS assessments to be accurately coded.
Failure to Maintain Physician Order for Dialysis Services
Penalty
Summary
The deficiency involves the facility’s failure to obtain and maintain a physician’s order for dialysis for a resident with end-stage renal disease who required ongoing dialysis treatments. The resident had been hospitalized for shortness of breath and progressive renal failure, had a permacath placed, and began dialysis in the hospital with a scheduled outpatient regimen on Tuesday, Thursday, and Saturday. Upon readmission to the facility with a diagnosis that included end-stage renal disease requiring dialysis, the physician’s orders did not include dialysis services, even though the resident continued to receive dialysis treatments. The resident’s care plan, updated shortly after readmission, documented the need for dialysis related to renal failure and included interventions such as checking and changing the dressing at the access site daily, monitoring the access site for signs of infection, and encouraging the resident to attend scheduled dialysis appointments three times a week. However, the quarterly MDS assessment did not code the resident as receiving dialysis services despite documenting end-stage renal disease. During interviews, a nurse confirmed the resident was at dialysis on the survey day, and the DON acknowledged being unaware that the dialysis order was missing and that staff likely failed to enter the order upon readmission. The Administrator also stated that the dialysis order should have been entered into the computer system when the resident returned from the hospital.
Failure to Provide SNF-ABN Notification Prior to Medicare Part A Discharge
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 to two residents prior to the termination of their Medicare Part A skilled services, despite both residents remaining in the facility after their skilled coverage ended. Record reviews showed no documentation that either resident or their responsible parties received the SNF-ABN notification. During interviews, the facility social worker acknowledged responsibility for issuing the SNF-ABN and admitted that errors in processing led to the notifications not being provided. The Administrator also confirmed that the residents should have received the SNF-ABN as required by federal guidelines.
Inaccurate MDS Coding for Resident Behaviors
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident with dementia. During the 7-day lookback period, progress notes documented that the resident exhibited behaviors such as spitting, urinating on the floor, and refusing care, including declining a nursing assessment and covering his head with a sheet. Despite these documented behaviors, the resident's admission MDS assessment was only coded for verbal behaviors directed toward others for 1-3 days, with no coding for other behavioral symptoms or rejection of care. Staff interviews confirmed that the MDS should have included rejection of care and other behaviors, and the omission was acknowledged as a coding error.
Expired Medications and Vaccines Not Removed from Storage and Carts
Penalty
Summary
Surveyors found that the facility failed to properly remove expired medications and vaccines from medication carts and storage areas. Specifically, three multi-dose insulin injector pens that were past the manufacturer's recommended 28-day use period were found in two medication carts. Additionally, an opened bottle of docusate sodium liquid with an expiration date that had already passed was found in one medication cart. During interviews, nursing staff acknowledged that these items should have been removed according to policy and manufacturer instructions. Further, an opened vial of Pneumococcal vaccine with an expired date and no documented open date was discovered in the medication storage room refrigerator. The interim DON was unable to determine when the vial had been opened and confirmed that both she and the nursing staff were responsible for regularly checking for and removing expired medications and vaccines. The Administrator also confirmed that nursing staff were responsible for dating and discarding insulin pens after 28 days and for removing expired medications from carts and storage areas.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of stroke and aphasia, who was severely cognitively impaired and dependent on staff for all activities of daily living, did not have their call light device within reach. During an observation, the call light string was found placed on top of a light fixture above the resident's head, making it inaccessible. The resident was observed attempting to communicate discomfort and was visibly tearful, indicating pain. When interviewed, the resident confirmed they could use the call light if it was within reach and affirmed experiencing pain at that time. Staff interviews revealed that the nurse was unaware of why the call light string was out of reach and acknowledged the resident's need for a more accessible call light device. The interim DON confirmed that the call light was supposed to be within the resident's reach at all times. The deficiency was based on the failure to ensure the resident's call light device was accessible, thereby not reasonably accommodating the resident's needs and preferences for requesting assistance.
Failure to Maintain Safe and Homelike Resident Room Environment
Penalty
Summary
A resident was moved into a room that had pre-existing damage, including torn sheetrock on the walls, a damaged dresser with a broken drawer track, and a bathroom cabinet with doors that would not latch and a sunken, dirty pressboard bottom. The resident reported that staff were aware of the wall damage at the time of her move-in, and maintenance logs confirmed work orders for wall and baseboard repairs, as well as bathroom fixture repairs, but these issues remained unaddressed for an extended period. Observations confirmed the ongoing presence of these deficiencies, with the resident's dresser drawer being unstable and at risk of falling, and the bathroom cabinet being unusable and containing debris. Interviews with the resident and staff revealed that the resident had previously dropped the dresser drawer on her foot, resulting in bruising and an x-ray, and that staff were aware of the visible damage in the room. The maintenance assistant stated he was not aware of the needed repairs until recently, and the maintenance director explained that repairs had not been completed due to ongoing remodeling in other parts of the facility. The maintenance director also stated that the bathroom cabinet was not usable and that the dresser had suffered water damage from a previously running toilet. The facility's interim DON and administrator acknowledged that the repairs had been delayed for several months, with the administrator stating that six months was too long to wait for such repairs. The resident continued to use the attached bathroom daily despite the cabinet's condition. The facility failed to provide timely maintenance services to ensure a safe, clean, and homelike environment for the resident, as required.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures for enhanced barrier precautions, as observed in the actions of Nurse #5. Resident #6, who was readmitted with a Stage 4 pressure ulcer and a tracheostomy tube, did not have an enhanced barrier precaution sign or personal protective equipment (PPE) available at her door. During an observation, Nurse #5 and two other staff members were found not wearing gowns while providing wound care to Resident #6. Nurse #5 admitted to not wearing a gown due to the absence of the sign, which was removed during a deep cleaning and not replaced. The Director of Nursing confirmed that the sign and PPE should have been present, and staff were trained to wear gowns for such care. Similarly, Resident #8, who also had a Stage 4 pressure ulcer, had an enhanced barrier precaution sign on her door, but no gowns or gloves were available nearby. Nurse #5 was observed performing wound care without donning a gown, despite the sign's instructions. After completing the care, Nurse #5 acknowledged her failure to wear a gown, and another nurse reminded her of the requirement. The Director of Nursing confirmed that Nurse #5 should have worn a gown while providing wound care for Resident #8.
Resident Dignity Violation in Dementia Unit
Penalty
Summary
The facility failed to treat a resident with dignity, as evidenced by an incident involving a resident with Alzheimer's disease residing in a locked dementia unit. The resident was severely cognitively impaired and had no recorded moods or behaviors. A Medication Aide witnessed a Nurse Aide forcibly grabbing the resident by the shirt and pushing her into a chair, causing the chair to hit the wall. The resident expressed a desire to report the incident, to which the Nurse Aide dismissively responded. The Medication Aide reported the incident to the nurse immediately. The facility's Administrator was informed of the incident and conducted an interview with the Nurse Aide involved. The Nurse Aide admitted to forcibly placing the resident in the chair, justifying her actions by claiming the resident was going to disturb other residents. However, the Administrator noted that the resident typically walked around the unit without bothering others, indicating that the Nurse Aide's actions were unnecessary and disrespectful.
Deficiency in Pressure Ulcer Care Documentation and Management
Penalty
Summary
The facility failed to accurately document and manage the pressure ulcer care for a resident, leading to a deficiency in care. The resident, who had multiple complex medical conditions including type 2 diabetes mellitus, severe quadriparesis, and pressure sores, was admitted to the facility with existing wounds. However, the initial skin assessment conducted by Nurse #2 was incomplete, lacking measurements and descriptions of the wounds. The care plan required weekly assessments and specific treatments, but these were not consistently documented or administered as ordered. The facility's Director of Nursing (DON) and Nurse #2 observed the resident's wounds upon admission, noting necrotic tissue and redness, but failed to initiate treatment orders for the right buttock wound. The treatment administration record (TAR) was missing entries for the sacral wound care on specific dates, and interviews with the nursing staff revealed a lack of recall and communication regarding the completion of wound care treatments. The facility's wound care consultant later assessed the wounds, finding significant necrotic tissue and deterioration, which required surgical debridement and a revised treatment plan. The deficiency was further compounded by the absence of documentation for wound care treatments on several occasions, as noted in the TAR and confirmed by interviews with the nursing staff. The DON acknowledged the rapid deterioration of the sacral wound and the failure to complete treatment orders. The facility administrator admitted that it was not best practice to omit treatments and documentation, highlighting a systemic issue in the facility's wound care management.
Failure to Maintain Required RN Coverage and Proper DON Assignment
Penalty
Summary
The facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, and did not designate a Director of Nursing (DON) who worked on a full-time basis. Additionally, the DON served as a charge nurse despite the facility having an average daily census greater than 60 residents. This deficiency was observed for 23 out of 39 days reviewed for staffing. The review of nursing staff schedules and timecards revealed multiple instances where the facility did not meet the required RN coverage, including specific dates where no RN was on duty or the RN worked less than the required hours. The DON's time punches also showed that she did not consistently work full-time hours in her role and was often assigned to the medication cart, which conflicted with her DON responsibilities due to the high census of the facility. Interviews with the Scheduler, DON, and Administrator confirmed the lack of RN coverage and the challenges faced in hiring additional RNs. The Scheduler and Administrator were aware of the requirement but struggled to meet it due to staffing limitations. The DON admitted to being unaware of the specific requirement for RN coverage and explained that she often had to fill in on the medication cart due to staff shortages. The Administrator acknowledged the difficulty in covering RN hours and stated that the facility did not have any agency staff or waivers in place to address the issue. The Administrator also mentioned that the DON was picking up shifts after completing her DON responsibilities, which was not compliant with the regulations given the facility's census. The facility's failure to meet the RN coverage requirements and the improper assignment of the DON as a charge nurse led to the identified deficiency.
Leadership and Staffing Deficiencies
Penalty
Summary
The facility failed to provide effective leadership and oversight, resulting in multiple deficiencies. The Director of Nursing (DON) did not ensure sufficient staffing to administer medications in a timely manner, leading to a resident remaining in bed due to dizziness from not receiving morning medications on time. Additionally, the facility did not have a Registered Nurse (RN) working for at least eight consecutive hours daily, and the DON was not working full-time as required. The DON also served as a charge nurse despite the facility's census being over 60 residents. Furthermore, the facility failed to monitor the expiration of nursing licenses and nurse aide certifications, affecting several staff members. Performance evaluations for nurse aides were not completed annually, and the required 12 hours of annual training for nurse aides were not provided or monitored effectively. The Administrator acknowledged the staffing challenges, citing a corporate decision to not use agency nursing staff and difficulties in recruiting nurses due to the facility's location. The DON had limited training and support since her employment, and the facility could not locate her competency worksheets. The Administrator, with a nursing background, had to assist with resident care and Minimum Data Set (MDS) assessments. She indicated a need for a staff development position to reduce the workload on herself and the DON. Despite increasing the nursing pay scale, the facility continued to struggle with staffing issues.
Failure to Document Post-Dialysis Care
Penalty
Summary
The facility failed to obtain post-dialysis vital signs, record post-dialysis weights, and maintain ongoing communication with the dialysis facility for a resident requiring dialysis care. Resident #58, who was admitted with renal insufficiency and dependence on renal dialysis, had physician orders to record post-dialysis weight and vitals upon return every Tuesday, Thursday, and Saturday. However, the facility did not consistently document these vital signs and weights, as evidenced by missing entries on multiple dates in February and March 2024. Additionally, the dialysis communication forms were often incomplete or missing, and there was no follow-up with the dialysis clinic to obtain the necessary information. Interviews with Resident #58 and staff members revealed that the assigned nurses did not always take the resident's vital signs or ask about his weight upon his return from dialysis. Nurse #1 admitted to not being aware of the resident's return on specific dates and did not follow up with the dialysis clinic when communication forms were incomplete. The Unit Manager and Director of Nursing (DON) confirmed that the assigned nurse was responsible for entering the resident's vital signs and post-dialysis weight and for contacting the dialysis clinic if the information was missing. However, this protocol was not consistently followed. The Director of Nursing and the Administrator acknowledged that the staff should have been following the physician's orders by documenting vital signs and post-dialysis weights. The DON was unaware that the staff had not documented these vital signs or weights and was unsure why this had not been done. The Administrator reiterated that the nursing staff should be adhering to the physician's orders, highlighting a significant lapse in the facility's adherence to proper dialysis care protocols.
Failure to Monitor Nurse Aide Certifications
Penalty
Summary
The facility failed to monitor the North Carolina (NC) Nurse Aide (NA) Registry to ensure that five nurse aides employed at the facility maintained an active Nurse Aide I certification. This deficiency was identified through observation, record review, and staff interviews. Specifically, NA #6 was observed passing medications to a resident despite having an expired NA I certification. The review of NA #6's employment record and daily nursing assignment schedules confirmed that NA #6 had been working as a medication aide on multiple dates after the expiration of their certification. NA #6 stated that they were unaware of the expiration and believed the past Director of Nursing (DON) had submitted the renewal information. The Administrator confirmed that the DON was responsible for monitoring certifications, but due to frequent changes in the DON position, this responsibility had been neglected, leading to the oversight of NA #6's expired certification. The DON admitted to being unaware of the need to track certification expirations until recently. Further investigation revealed that four other nurse aides (NA #9, NA #4, NA #1, and NA #8) also had expired NA I certifications. An audit conducted by the facility confirmed that these nurse aides had worked multiple shifts with expired certifications. The DON, who had recently assumed the role, stated that she was not informed about the responsibility of monitoring certification expirations and was unaware of the expired certifications until the audit was conducted. The Administrator reiterated that the DON was responsible for this task, as outlined in the job description, but acknowledged that the limited orientation time might have contributed to the oversight. The facility's failure to monitor and ensure active certifications for its nurse aides resulted in multiple staff members working without the required credentials. This lapse in oversight was attributed to the frequent turnover in the DON position and the lack of clear communication regarding the responsibility for tracking certification expirations. The facility conducted an immediate audit to identify expired certifications and took steps to remove the affected nurse aides from their assignments until their certifications were renewed and verified as active on the NC Nurse Aide Registry.
Failure to Complete Annual Performance Reviews for Nursing Assistants
Penalty
Summary
The facility failed to complete a performance review every 12 months for 4 of 5 nursing assistants (NAs) reviewed. NA #4, NA #7, NA #6, and NA #5 did not have evidence of performance reviews in their personnel files since their respective dates of hire. This deficiency was identified through staff interviews and record reviews conducted by surveyors. The Director of Nursing (DON) admitted to being unaware of the requirement for annual performance reviews until recently and attributed the oversight to high turnover in the DON position. The Administrator confirmed the absence of performance evaluations in the personnel files and acknowledged that the responsibilities for completing and tracking these evaluations fell to the DON due to the lack of a Staff Development Coordinator. NA #4 and NA #7, both hired on 10/1/20, did not have performance reviews documented in their files. Attempts to interview these NAs were unsuccessful. The DON stated that she had not provided individual training to these NAs based on performance evaluations due to her unawareness of the requirement and the turnover in her position. The Administrator reiterated that the DON was responsible for these evaluations and that the high turnover had led to the oversight. NA #6, hired on 9/7/22, and NA #5, hired on 10/4/22, also did not have performance reviews documented for the past twelve months. Both NAs confirmed in interviews that they had not undergone performance evaluations during their employment. The DON again cited her recent awareness of the requirement and the turnover in her position as reasons for the lack of evaluations. The Administrator confirmed the absence of evaluations in their files and acknowledged the oversight due to the high turnover in the DON position.
Failure to Provide Smooth Pureed Food Consistency
Penalty
Summary
The facility failed to provide a pureed food item with a smooth consistency, which had the potential to affect 9 residents with diet orders for a pureed diet texture. During a lunch meal tray line observation, pureed egg noodles were found to have a lumpy consistency smaller than pea-sized. Cook #1, who was responsible for recording the internal temperature of the food items, intended to serve the lumpy pureed egg noodles without further blending. The District Manager intervened and instructed Cook #1 to further blend the egg noodles to achieve a smooth consistency. Cook #1 admitted that she did not inspect the pureed egg noodles before placing them on the tray line because she was not the one who prepared them. The Dietary Manager confirmed that the pureed egg noodles were prepared by Dietary Aide #1, who had been re-hired two weeks prior and had received training upon rehire. The Dietary Manager also stated that Cook #1 should have inspected the pureed food before placing it on the tray line. The Speech Therapist, who began working at the facility in January 2023, stated that she had not seen pureed foods that caused concern or questioned the consistency. However, she indicated that lumpy pureed foods could be a choking hazard and lead to aspiration pneumonia. The Administrator confirmed that the kitchen staff should have further blended the pureed egg noodles immediately and that they should not have been placed on the tray line with a lumpy consistency. The facility followed the National Dysphagia Diet (NDD) guidelines, which required all pureed foods to have a pudding-like consistency, lump-free, and requiring little to no chewing.
Failure to Ensure Active Nursing Licenses
Penalty
Summary
The facility failed to ensure that Nurse #3 maintained a current and active professional nursing license with the North Carolina Board of Nursing (NCBON). Nurse #3's license expired on a specified date, and despite this, she continued to work at the facility on multiple occasions. Observations confirmed that Nurse #3 was actively providing resident care and conducting medication passes even after her license had expired. The facility's nursing licensure audit and the NCBON registry both indicated the lapse in licensure, yet Nurse #3 remained on duty without a valid license for an extended period. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for monitoring nursing license expirations. The Accounts Payable Personnel stated that she only verified licensure at the time of hiring and was not responsible for tracking expiration dates. The new Director of Nursing (DON) was unaware of her responsibility to monitor license expirations and had not been informed of this duty. The Administrator discovered the expired license during a licensure audit and acknowledged that the new DON might not have had the necessary information to track license expirations. The facility had not reported Nurse #3 to the NCBON for working without a license at the time of the interview.
Repeated Deficiencies in Quality Assurance and Resident Care
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeated deficiencies. These deficiencies were observed in areas such as Resident Rights, Environment, Treatment and Services for Pressure Sores, Supervision to Prevent Accidents, Medication Storage, and Complete/Accurate Medical Records. Specific incidents included staff failing to communicate respectfully with residents, unclean bathrooms, improper wound care, inadequate supervision to prevent resident altercations, unsecured medication carts, and inaccurate medical records documentation. These issues were identified during recertification and complaint investigation surveys conducted on various dates, indicating a pattern of the facility's inability to sustain an effective QAA Program. For instance, the facility was cited for failing to ensure residents were spoken to in a dignified manner, with one resident being scolded by a staff member. Bathrooms in several rooms were found to have fecal matter or black/brown matter on various surfaces. Wound care was not performed per physician's orders, and an alternating pressure air mattress was not set correctly based on a resident's weight. Additionally, a severely cognitively impaired resident hit another resident in the face after previously exhibiting aggressive behavior. Medication carts were left unsecured, and medical records were found to be incomplete or inaccurate, particularly concerning wound treatments. These repeated deficiencies highlight the facility's ongoing failure to maintain and monitor effective quality assurance measures.
Failure to Ensure Required Annual Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that at least 12 hours of annual training, including dementia care and areas of weakness identified in performance reviews, were completed for four nursing assistants. Specifically, the records for Nursing Assistants #4, #7, #6, and #5 did not show evidence of training for areas of weakness as determined in their performance reviews. Additionally, Nursing Assistant #5 did not complete the required dementia training, as evidenced by the absence of their signature on the attendance roster for the dementia in-service training conducted in January 2024. Interviews with the Director of Nursing (DON) and the Administrator revealed that the high turnover in the DON position contributed to the failure to complete performance reviews and provide individualized training. The DON acknowledged conducting general in-service training for dementia and abuse but did not address specific areas of weakness for each nursing assistant. The Administrator confirmed that no annual training logs were maintained, and the duration of the in-service training sessions was not documented, making it impossible to verify if the required 12 hours of training were met. The absence of a Staff Development Coordinator further compounded the issue, as the DON was responsible for overseeing staff training.
Medication Cart Keys Left Unsecured
Penalty
Summary
The facility failed to secure the keys for a medication cart when a Medication Aide left the keys in a resident's room. Specifically, Medication Aide #7 was observed locking the skilled-hall medication cart and positioning it outside Resident #211's door before walking away. Shortly after, Resident #211 was found holding the keys, which had been left in her room by the Medication Aide. The keys included those for the skilled-hall medication cart, which should have been kept in the Medication Aide's possession at all times. Upon returning to the room, the Medication Aide retrieved the keys from Resident #211 and acknowledged that the keys should not have been left behind. The Director of Nursing confirmed that the keys to the medication cart should always remain with the Medication Aide and that leaving them in a resident's room was not acceptable practice. This incident was observed and confirmed through staff interviews, highlighting a lapse in the facility's protocol for securing medication cart keys.
Inaccurate Documentation of Pressure Ulcer Treatment
Penalty
Summary
The facility failed to complete an accurate medical record related to the treatment of pressure ulcers for one resident. Resident #19 was admitted to the facility and had physician orders to cleanse the right heel with wound cleaner, apply collagen particles, calcium silver alginate, and a foam heel dressing, and secure the dressing with kerlix every other day. However, a review of the Treatment Administration Record (TAR) indicated that Nurse #3 recorded providing treatment on a specific date, but an observation revealed that the old dressing was dated two days prior with another staff member's initials, indicating the treatment was not performed as documented. The Director of Nursing confirmed that Nurse #3 had falsified documentation by recording that the wound care was performed when it was not. Attempts to interview Nurse #3 were unsuccessful. The Administrator also confirmed that the documentation should accurately reflect the treatments provided. This discrepancy in documentation was identified during a survey, highlighting a failure in maintaining accurate medical records for Resident #19's pressure ulcer treatment.
Failure to Maintain Accurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to display accurate daily nursing staffing information and maintain the daily nurse staff posting on file for 39 out of 39 days reviewed from February 2024 and March 2024. The review of the nursing staff posting revealed that the number of unlicensed and licensed staff and actual hours worked during the evening and night shifts, as well as the facility census, were not documented for multiple days. Additionally, the facility was unable to provide staffing sheets for several specific days within the reviewed period. Interviews with front desk staff indicated a lack of clarity and consistency in the process of completing the daily nursing staff sheet. Front Desk Staff #1 stated that she filled out the daily nursing staff sheet for the shifts she worked but was unsure who completed the sheet for the night shift. Front Desk Staff #2 mentioned that she had not completed or reviewed the daily nursing staff sheet during her shift. The Administrator confirmed that the front desk staff were responsible for filling out and posting the daily nursing staff sheet, which should have been completed for each shift and posted in a visible location at the front entrance of the building.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe for three residents. Resident #29's quarterly MDS assessment was completed late, as indicated by the assessment signed on 9/11/23. The MDS Nurse acknowledged awareness of the timeline requirements but could not explain the delay. The Administrator confirmed the missed deadline during a spot check and admitted it should not have been missed. Similarly, Resident #16's quarterly MDS assessment was completed late, signed on 1/8/24. The MDS Nurse again acknowledged the timeline requirements but could not provide a reason for the delay. The Administrator identified the late assessments during a spot check and confirmed the missed deadline. Additionally, Resident #75's quarterly MDS assessment, with an Assessment Reference Date (ARD) of 8/14/23, was completed late on 8/29/23. The MDS Nurse admitted the assessment should have been completed sooner and could not explain the delay. The Administrator reiterated that MDS assessments should be completed within 14 days of the ARD date.
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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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