The Foley Center At Chestnut Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Blowing Rock, North Carolina.
- Location
- 621 Chestnut Ridge Parkway, Blowing Rock, North Carolina 28605
- CMS Provider Number
- 345045
- Inspections on file
- 15
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at The Foley Center At Chestnut Ridge during CMS and state inspections, most recent first.
Surveyors found that staff failed to label and date leftover food and did not discard expired items in a nourishment room refrigerator. An unopened egg salad and an opened orange juice were both past their use by dates, and a container of soup lacked a resident name and was not discarded after the appropriate time. Both dietary and nursing staff were expected to label and remove expired food, but expired and unlabeled items were still present.
An opened tube of antifungal cream and a tube of zinc oxide cream were found left unattended on a window sill in a resident's room. The resident, who had not been assessed for self-administration, reported the medications were not his and had been there since he moved in. A medication aide noticed the medications but was unsure about storage requirements, and the supervising nurse was unaware of the situation. Facility leadership confirmed that all medications should be kept secured in the medication cart.
A resident with heart disease experienced respiratory distress and low oxygen saturation levels, but the facility failed to notify a medical provider. Despite repeated reports to the DON, the resident's condition was not reassessed, and no vital signs were documented. The resident was later taken to the hospital by their representative, diagnosed with Influenza A and acute hypoxemic respiratory failure, and subsequently died.
A resident in an LTC facility experienced an acute change in condition with low oxygen saturation levels, but the staff failed to notify a medical provider or take appropriate action. Despite continuous reports of breathing issues, the resident remained in the facility until removed by a representative and taken to the hospital, where they were diagnosed with severe respiratory conditions and later passed away.
A resident with heart disease exhibited symptoms of cough, congestion, and decreased appetite. Despite requests for a chest x-ray, the facility did not perform one, and the resident's condition worsened with low oxygen saturation levels. The facility failed to adequately assess or respond to the resident's acute change in condition, leading to their removal by a representative to a hospital, where they were diagnosed with Influenza A and later died from acute hypoxemic respiratory failure.
A resident with a knee replacement experienced severe pain due to an expired oxycodone order and inadequate pain management. Despite the resident's distress, the on-call provider refused to issue a new order, leaving the resident in pain throughout the night. The facility's failure to address the resident's pain needs promptly led to a deficiency in care.
A resident newly diagnosed with psychosis did not receive a required PASARR review due to communication failures within the facility. The Nurse Practitioner diagnosed the resident with psychosis, but the Social Worker, responsible for initiating PASARR reviews, was not informed. The Acting DON noted that the process for reporting new diagnoses was not followed, leading to the oversight.
The facility failed to document a necessary diagnosis for a resident's indwelling urinary catheter and did not prevent another resident's urinary catheter bag from touching the floor, increasing infection risk. Medical staff confirmed the lack of a valid reason for the catheter, leading to its removal, while observations showed repeated failures to maintain hygiene standards for catheter bags.
The facility failed to provide adequate respiratory care for two residents requiring oxygen therapy. A resident with heart failure had no cautionary oxygen signage posted, indicating a fire hazard. Another resident's oxygen concentrator was observed with a filter caked with dust, despite orders for weekly cleaning. Staff interviews revealed confusion about responsibilities for maintaining oxygen equipment.
The facility failed to label and date open food items and discard expired items in the kitchen's refrigerators. Surveyors found undated and expired food, including milk, cheese, and butter, during inspections. Interviews with the Dietary Manager and Administrator revealed expectations for staff to label and date food and remove expired items, but these practices were not consistently followed.
The facility failed to follow its policies on abuse and misappropriation of property. A cognitively impaired resident was involved in a potential abuse incident with a nurse aide, who was not immediately removed from duty. Additionally, the facility did not thoroughly investigate fraudulent charges on another resident's debit card, failing to interview all relevant staff and residents. The investigation lacked documentation and clarity on the outcome.
A medication error rate of 40% was observed in an LTC facility when an agency nurse nearly administered the wrong medications to a resident due to a failure in verifying the resident's identity. The nurse, new to the facility, did not follow the 'five rights' of medication administration, leading to a mix-up that was only averted by the resident's intervention.
A resident's code status was inaccurately documented in their medical record, with conflicting DNR and MOST forms. Despite the resident's wish to be a full code, the facility's records showed discrepancies. Interviews with staff revealed a lack of oversight in completing and verifying these forms, leading to the error.
A resident with a history of falls and moderate cognitive impairment did not have a prescribed rubbery sheet placed in their wheelchair to prevent sliding, as required by their care plan. Despite being documented in the care plan and Kardex, nurse aides were unaware of this intervention, leading to its omission during a transfer. The nurse supervisor and interim DON confirmed the intervention was discussed and expected to be implemented.
An agency nurse in an LTC facility mistakenly attempted to administer medications intended for one resident to another, due to a failure to verify the resident's identity. The error was caught when the resident questioned the nurse, preventing the administration of potentially harmful medications.
A facility failed to maintain accurate medical records when a NP did not document a resident's encounter in the EHR after assessing them for cough and congestion. The NP prescribed treatments but forgot to complete and sign the progress note. The Interim DON and Administrator confirmed that documentation should accompany every medical provider's assessment.
A facility failed to follow its infection control policies, as observed in two incidents. An agency nurse did not perform hand hygiene between glove changes during wound care for a resident with a stage III pressure ulcer. Additionally, two staff members did not wear the required PPE while checking a resident's brief for incontinence, despite EBP signage indicating the need for gowns and gloves. Misunderstandings about policy requirements and a lack of auditing contributed to these deficiencies.
A facility failed to maintain a resident's dignity and respect when a nurse aide was observed with her hand raised to a cognitively impaired resident's face during an interaction. The incident was witnessed by another nurse aide who heard shouting and saw the aide standing face to face with the resident, suggesting potential physical contact. The resident, who was moderately cognitively impaired, had no recollection of the event. The facility's investigation was incomplete as the involved aide did not provide a statement.
A resident with type 2 diabetes did not receive a scheduled insulin dose due to the medication being unavailable. The nurse on duty was informed of the shortage and contacted the emergency pharmacy, but the insulin was delivered late, resulting in a delayed administration. The night shift nurse administered the insulin but did not document it. Interviews revealed unclear procedures for reordering medications and emergency backup supplies.
Failure to Properly Label and Discard Expired Food in Nourishment Room Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to properly label and date leftover food items and did not discard expired food in one of the nourishment room refrigerators used for resident food storage. Specifically, an unopened container of egg salad was found with a use by date that had already passed, an opened container of orange juice was present without a resident name and past its use by date, and an opened container of soup was labeled with a date but lacked the resident's name and had not been discarded after the appropriate time frame. The Certified Dietary Manager (CDM) confirmed that these items should have been labeled with the resident's name, the date received or made, and a use by date, and should have been discarded once expired. Interviews with staff revealed that both dietary and nursing staff were expected to participate in labeling and discarding expired food items. The CDM stated that dietary staff restocked the refrigerators daily and were responsible for removing expired items, while nurses or Nurse Aides (NAs) were typically responsible for labeling food brought in for residents. The Administrator also indicated that dietary staff were responsible for checking expiration dates and discarding out-of-date food, and that food brought in for residents should be labeled and discarded according to the use by date. Despite these expectations, expired and unlabeled food was found in the nourishment room refrigerator.
Unsecured Topical Medications Left Unattended in Resident Room
Penalty
Summary
Surveyors observed that an opened tube of Miconazole nitrate cream and an opened tube of Zinc oxide cream were left unattended on the window sill in a resident's room. The resident, who had intact cognition and had not been assessed for self-administration of medication, stated that the medications had been present since moving into the room and denied ownership or use of the creams. The medications were not secured in a locked compartment as required. Staff interviews revealed that a medication aide had noticed the medications in the room for several days but was unsure if they needed to be secured. The nurse overseeing the aide was new to the facility and unaware of the unattended medications. Both the Assistant Director of Nursing and the Administrator confirmed that medications should be kept in the medication cart and that the facility should remain free of unattended medications. The Medical Director also stated that all medications should be securely stored.
Failure to Notify Medical Provider of Resident's Respiratory Distress
Penalty
Summary
The facility failed to notify a medical provider when a resident, who was noted to have difficulty breathing and low oxygen saturation levels, was in distress. The resident, who had been readmitted to the facility with a diagnosis of heart disease, was observed by a Medication Aide to have an oxygen saturation in the high 70's/low 80's, which is significantly below the normal range of 92 to 100%. Despite the resident's condition and repeated reports to the Director of Nursing, no medical provider was notified, and the resident's condition continued to deteriorate throughout the day. The resident's Medical Orders for Scope of Treatment indicated a full code status, meaning all medical interventions were to be pursued, including intubation and mechanical ventilation if necessary. However, the facility staff did not follow these directives. The Medication Aide, who was responsible for monitoring the resident, reported the situation to the Director of Nursing but did not contact a medical provider directly, assuming the Director would take appropriate action. The resident's condition was not reassessed by a nurse, and no vital signs were documented in the Medication Administration Record. The resident's representative eventually removed the resident from the facility and took them to the emergency department, where the resident was diagnosed with Influenza A, influenzal bronchitis, and later acute hypoxemic respiratory failure. The resident was admitted to the hospital, where their condition worsened, leading to their death. The facility's failure to notify a medical provider and take appropriate action in response to the resident's acute change in condition was identified as a deficiency.
Removal Plan
- The Director of Nursing met with all direct care nurses to initiate an assessment of 100% of current residents to ensure the provider was notified of any acute change in condition.
- Corrective action was completed for 2 of 79 residents identified as having a change in condition when the provider was notified of the change in condition and orders for the change in condition were carried out by the direct care staff.
- The Administrator audited all residents transferred to the hospital in the last 30 days to ensure provider notification was completed for any acute change in condition.
- The Director of Nursing began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN) and certified nursing assistants on the need to notify the provider for any acute change in condition.
- The DON will ensure that all licensed nurses, RNs, LPNs, and CNAs who do not complete the in-service training will not be allowed to work until the training is completed.
- This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants.
Neglect in Responding to Resident's Medical Emergency
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect during a medical emergency. A resident, identified as Resident #278, experienced an acute change in condition, with oxygen saturation levels dropping to the high 70s/low 80s, which is significantly below the normal range of 92 to 100%. Despite these alarming signs, the facility staff, including the Director of Nursing (DON) and Medication Aide (MA) #1, did not effectively respond to the resident's medical emergency. The DON advised MA #1 to place the resident on oxygen and monitor the levels, but no further action was taken to escalate the situation or notify a medical provider. Throughout the day, MA #1 continued to report the resident's breathing issues and concerns to the DON, but the resident remained in the facility until the Resident Representative (RR) removed them at 4:47 pm. Upon arrival at the Emergency Department, the resident was diagnosed with Influenza A, influenzal bronchitis, and an elevated white blood cell count, indicating an infection. The resident was treated with intravenous fluids, steroids, and a breathing treatment but was later diagnosed with acute hypoxemic respiratory failure, leading to their admission to hospice care and eventual death. The facility's deficient practice was identified for failing to complete and document thorough assessments for the resident's acute change in condition and not responding effectively to the medical emergency. The staff did not notify a medical provider when the resident's condition worsened, which could be considered neglect. Interviews with staff, including MA #1, the Social Worker (SW), and the Interim DON, revealed a lack of understanding and action regarding the severity of the resident's condition, contributing to the neglectful care provided.
Removal Plan
- Administrator and the Director of Nursing conducted in service for all full-time, part-time and as needed staff including agency on the abuse/neglect policy for reporting, identifying, and preventing abuse and neglect.
- All staff (full-time, part-time, and PRN staff, administration, housekeeping, dietary, nursing, therapy and maintenance) were in-serviced on identifying/reporting abuse/neglect immediately using our abuse policy and procedure.
- Any staff that was not educated will not be allowed to work until education is completed by Administration or department heads.
- The Director of Nursing began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN), Medication Aides and certified nursing assistants (full time, part time, and prn including agency) on the need to notify the provider for any acute change in condition.
- The Interdisciplinary Team (Administrator, Director of Nursing, Nurse Managers, Minimum Data Set Coordinators, Unit Manager, Support nurse, Therapy, Health Information Management, Dietary Manager, Medical Director, Pharmacist), were notified of the allegation of neglect related to facilities failure in following and implementing policy related to abuse/neglect, identifying neglect and addressing change of condition in resident and were involved in the removal plan.
- The Administrator and Director of Nurses will ensure that any staff member (full time, part time, and prn including agency) who do not complete the in-service training will not be allowed to work until the training is completed.
- This in-service was incorporated into the new employee facility and agency orientation for all staff (full time, part time, and prn including agency) by the Director of Nurses.
- Administrator will be responsible for ensuring the removal plan is implemented.
Failure to Respond to Resident's Acute Change in Condition
Penalty
Summary
The facility failed to complete and document ongoing thorough assessments for an acute change in condition and did not respond effectively to a medical emergency involving a resident. The resident, who was readmitted with a diagnosis of heart disease, began exhibiting symptoms such as a cough, congestion, and decreased appetite. Despite the resident's representative requesting a chest x-ray, the nurse practitioner did not order one, instead prescribing medication for congestion and breathing treatments. The resident's condition worsened, with oxygen saturation levels dropping significantly, yet the facility did not adequately assess or respond to these changes. Throughout the day, the medication aide reported the resident's breathing difficulties and low oxygen saturation levels to the Director of Nursing (DON), but no effective action was taken. The resident's condition continued to deteriorate, and the representative eventually removed the resident from the facility and took them to the emergency department. At the hospital, the resident was diagnosed with Influenza A, influenzal bronchitis, and later acute hypoxemic respiratory failure, leading to their death. The facility's failure to perform thorough assessments and respond to the resident's acute change in condition resulted in a serious deficiency. The lack of documentation and communication among staff members, as well as the failure to notify medical providers of the resident's worsening condition, contributed to the inadequate response to the medical emergency. This deficiency was identified for one of the three residents reviewed for a change in condition.
Removal Plan
- The Director of Nursing met with all direct care nurses to initiate an assessment of 100% of current residents for any acute change in condition.
- The audit identified residents with an acute change in condition and corrective actions were completed, including notification of the provider, transfer to ER, and X-ray.
- The Director of Nursing began in-servicing all licensed nurses, Registered Nurses, Licensed Practical Nurses, and certified nursing assistants on assessment of any acute change in condition, how to respond to change in condition, when to activate Emergency Medical Services, and the importance of shift to shift report for continuity of care.
- The DON will ensure that all licensed nurses, RNs, LPNs, and CNAs who do not complete the in-service training will not be allowed to work until the training is completed.
- The in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants.
Inadequate Pain Management for Post-Surgical Resident
Penalty
Summary
The facility failed to adequately manage the pain of a resident who had undergone a left artificial knee joint replacement. The resident, who was cognitively intact, had an expired order for oxycodone and was left with only acetaminophen for pain management. On a particular night, the resident was observed by Nurse #10 to be in severe pain, screaming, and crying, yet no new order for stronger pain medication was obtained despite the nurse's attempt to contact the on-call provider. The on-call provider refused to issue a one-time order for oxycodone, instructing that the regular facility provider should address the pain management the following day. As a result, the resident continued to experience significant pain throughout the night, with a pain level documented as 10 out of 10. The nurse administered acetaminophen, but it was insufficient to alleviate the resident's pain. Interviews with staff, including the Nurse Practitioner and the Interim Director of Nursing, revealed that the on-call provider's refusal to prescribe pain medication was atypical. The resident's representative confirmed that the resident had reported experiencing severe pain due to the lack of appropriate pain medication orders. Eventually, a new order for oxycodone was written by the facility provider, but the delay in addressing the resident's pain needs constituted a deficiency in care.
Failure to Request PASARR Review for New Psychosis Diagnosis
Penalty
Summary
The facility failed to request a Pre-admission Screening and Resident Review (PASARR) for a resident who was newly diagnosed with psychosis. The resident, who was admitted with diagnoses including depression and anxiety disorder, was receiving antipsychotic and antidepressant medications. A pharmacy review requested a clarification diagnosis for the use of an antipsychotic, which was addressed by the facility's Nurse Practitioner, who diagnosed the resident with psychosis. However, the Social Worker, responsible for requesting PASARR reviews, was not informed of this new diagnosis and therefore did not initiate a PASARR review. Interviews with facility staff revealed a lack of communication and understanding of the process for informing relevant staff of new diagnoses. The Nurse Practitioner was unaware of the procedure for notifying the Social Worker about diagnoses requiring a PASARR review. The Acting Director of Nursing indicated that the process involved completing a form and sending it to medical records, but in this case, the Director of Nursing uploaded the form herself and did not report the new diagnosis to medical records. Consequently, the Social Worker was not notified, and a PASARR review was not requested for the resident.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to have a documented diagnosis for the use of an indwelling urinary catheter for Resident #18. Resident #18 was admitted to the facility with no urinary diagnosis, yet had an indwelling urinary catheter in place. The physician's orders indicated the catheter was to be changed every 21 days, but there was no supporting diagnosis in the resident's Electronic Health Record (EHR). Interviews with the medical staff, including the Medical Director and Nurse Practitioner, confirmed that there was no valid reason for the catheter, leading to its removal. Additionally, the facility failed to prevent urinary catheter bags from touching the floor, increasing the risk of infection for Resident #48. Resident #48, who had a diagnosis of benign prostatic hyperplasia and severe hydronephrosis, was observed with his urinary drainage bag resting on the floor on multiple occasions. Despite staff being present, the issue was not addressed until later observations. Interviews with nurse aides confirmed that urinary drainage bags should not be in contact with the floor, yet this standard was not maintained. These deficiencies highlight a lack of adherence to proper catheter care protocols, including ensuring a valid medical diagnosis for catheter use and maintaining hygiene standards to prevent infections. The facility's failure to document a necessary diagnosis and to keep catheter bags off the floor represents a significant oversight in resident care.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents requiring oxygen therapy. Resident #15, who was admitted with heart failure and severe cognitive impairment, required supplemental oxygen. However, there was no cautionary oxygen signage posted on or near her door, indicating a fire hazard due to oxygen use. This oversight was confirmed through multiple observations and staff interviews, revealing a lack of awareness and adherence to the facility's protocol for posting such signs upon admission or room transfer. Resident #37, diagnosed with hypertensive heart disease and congestive heart failure, was observed using an oxygen concentrator with a filter caked with white dust. Despite a physician's order to clean the filter weekly, the medication administration record indicated that the cleaning was marked as completed, although the dust buildup persisted. Interviews with various staff members, including nurses and the Maintenance Director, highlighted confusion and miscommunication regarding the responsibility for maintaining the cleanliness of the oxygen concentrators, leading to the deficiency.
Failure to Label and Discard Expired Food Items
Penalty
Summary
The facility failed to properly label and date open food items and discard items that were beyond their expiration date in the kitchen's refrigeration units. During an initial tour, surveyors observed an open gallon of whole milk with a sell-by date that had passed, located in a reach-in refrigerator. Additionally, an open and undated package of American cheese slices and a block of butter, also open and undated, were found in another reach-in refrigerator. The butter was inadequately wrapped, exposing portions to the air. A follow-up visit revealed an open and undated bag of shredded mozzarella cheese in the walk-in refrigerator, with a use-by date that had also passed. Interviews with the Dietary Manager and the Administrator revealed expectations for the dietary staff to label and date all opened food items before storage and to remove any expired or undated items during routine checks. The Dietary Manager reported conducting checks twice a week, while the Administrator expected the dietary staff to adhere to these protocols. Despite these expectations, the observations indicated a failure to consistently implement these practices, leading to the presence of expired and undated food items in the facility's refrigerators.
Failure to Follow Abuse and Misappropriation Policies
Penalty
Summary
The facility failed to adhere to its abuse, neglect, and exploitation policies when it did not immediately remove a nurse aide following an allegation of potential abuse involving a resident. The incident involved a cognitively impaired resident with Alzheimer's disease and dementia, who was reportedly in an altercation with a nurse aide. Another nurse aide witnessed the incident and reported it to a nurse, but the accused nurse aide was allowed to continue working her shift. The facility's policy required immediate suspension of any staff member accused of potential abuse, but this was not followed, and the timeline of reporting the incident was unclear. Additionally, the facility did not conduct a thorough investigation into an allegation of misappropriation of resident property. A resident's friend reported fraudulent charges on the resident's debit card, which were made while the resident was hospitalized. The facility's investigation did not include interviews with all relevant staff or residents, and the investigation report did not indicate whether the allegation was substantiated. The facility's response included advising residents not to bring valuables to the facility, but the investigation lacked comprehensive interviews and documentation. The administrator and social worker were involved in the investigation but did not fully explore all potential leads or interview all necessary parties. The interim Director of Nursing was tasked with interviewing and educating staff but did not document these actions. The administrator relied on corporate guidance and did not interview all staff who had contact with the resident before the fraudulent charges. The investigation was reported to the state agency and local authorities, but the facility's internal investigation was incomplete and lacked clarity on the outcome.
Medication Error Rate Exceeds 5% Due to Identity Verification Failure
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 40% error rate during a medication pass observation. This incident involved a resident who was almost administered the wrong medications due to a mix-up by an agency nurse. The nurse prepared medications intended for another resident and attempted to administer them to the wrong resident. The error was identified when the resident questioned the nurse about the medications and her identity, leading to the realization that the wrong medications were about to be given. The nurse, who was new to the facility, did not verify the resident's identity before attempting to administer the medications, which is a critical step in the medication administration process. The Interim Director of Nursing confirmed that the nurse should have verified the 'five rights' of medication administration, which include the right resident, right medication, right dose, right route, and right time. The nurse acknowledged the mistake and stated that she intended to verify the resident's identity but was interrupted by the resident's intervention.
Inaccurate Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's code status election was accurately reflected throughout their medical record. Resident #57, who was cognitively intact and admitted with a diagnosis of adult failure to thrive, had conflicting documentation regarding their code status. The advanced directives book at the nurse's station contained both a Do Not Resuscitate (DNR) form and a Medical Orders for Scope of Treatment (MOST) form indicating a desire for full code and full scope of treatment, both signed by the MD. Additionally, a physician's order indicated the resident wanted CPR with limited interventions, while the resident expressed a desire to be a full code with a full scope of treatment during an interview. Interviews with various staff members, including the Nurse Supervisor, Medical Records Coordinator, Admission Coordinator, Nurse Practitioner, Social Worker, and Interim Director of Nursing, revealed a lack of clarity and oversight in the process of completing and verifying the MOST and DNR forms. The Nurse Supervisor and Medical Records Coordinator acknowledged the discrepancy and the need for the advanced directives to match the resident's wishes. The Admission Coordinator and Nurse Practitioner described the process of completing these forms during admission, but the forms were not accurately completed or verified, leading to the error. The Interim Director of Nursing confirmed the error and the resident's wish to be a full code.
Failure to Implement Fall Prevention Intervention
Penalty
Summary
The facility failed to implement a care plan intervention for a resident who was at risk of falls due to a cerebral vascular accident and dementia. The resident, who had a history of falls and required moderate assistance with transfers, was supposed to have a rubbery flexible sheet placed in his wheelchair to prevent sliding. This intervention was documented in the resident's care plan and Kardex, following a fall incident where the resident slid to the floor while transferring from the wheelchair to the bed. Despite the care plan and Kardex instructions, the rubbery sheet was not placed in the resident's wheelchair, as observed during a transfer by two nurse aides. The aides, who were familiar with the resident's history of falls, were unaware of the requirement for the rubbery sheet. Interviews with the nurse supervisor and interim Director of Nursing confirmed that the intervention was discussed and expected to be implemented, yet it was not carried out, leading to the deficiency.
Medication Administration Error Involving Two Residents
Penalty
Summary
The facility failed to ensure the correct administration of medications, resulting in a significant medication error involving two residents. Nurse #5, an agency nurse, prepared medications intended for Resident #50, which included aspirin, apixaban, Lisinopril, tramadol, and quetiapine. However, Nurse #5 mistakenly attempted to administer these medications to Resident #286. This error was identified when Resident #286 questioned the nurse about the medications and corrected the nurse on her identity, preventing the administration of the wrong medications. Resident #286, who was admitted with conditions such as Chronic Obstructive Pulmonary Disease, hypertension, depression, anxiety, and a history of blood clots, was at risk of receiving apixaban, a blood thinner, which could have led to adverse effects like unexpected bleeding. The nurse admitted to not verifying the resident's identity and medication details before attempting administration, which is a breach of the facility's protocol for medication administration. Interviews with the Interim DON, NP, and MD confirmed the importance of verifying the right resident and medication to prevent such errors.
Failure to Document Medical Provider Encounter
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was seen by a Nurse Practitioner (NP) for symptoms of cough, congestion, and decreased appetite. The resident's representative requested a chest x-ray and for the resident to be seen by a medical provider. Although the NP assessed the resident and decided against a chest x-ray, opting instead to prescribe Guaifenesin and Duo-neb treatments, she neglected to complete and sign a progress note documenting the encounter in the resident's Electronic Health Record (EHR). Interviews with the NP, Interim Director of Nursing (DON), and the Administrator revealed that the NP acknowledged forgetting to finish and sign the note, which resulted in the absence of documentation in the EHR. The Interim DON and Administrator both confirmed that a signed progress note should accompany every medical provider's assessment of a resident. The Administrator was unaware of the NP's failure to document the encounter until it was brought to attention during the survey.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to its hand hygiene policy during wound care for a resident with a stage III pressure ulcer. Nurse #7, an agency nurse, did not perform hand hygiene when changing gloves during the wound care process. Specifically, after removing a soiled dressing and before donning a new pair of gloves, the nurse did not wash or sanitize her hands. This lapse in protocol was acknowledged by the nurse, who stated she was unaware of the requirement to wash hands between glove changes and after handling soiled dressings. The nurse supervisor confirmed the expectation for hand hygiene during such procedures, but the interim Director of Nursing was unaware of any audits being conducted to ensure compliance. Additionally, the facility did not implement its Enhanced Barrier Precautions (EBP) policy correctly. Two staff members, Nurse #6 and a nurse aide, failed to don the required personal protective equipment (PPE) of gowns and gloves while checking a resident's brief for incontinence. Despite EBP signage indicating the need for PPE due to the resident's condition, the staff did not comply, mistakenly believing the precautions were only necessary for wound care or that the signage was outdated. Interviews with the staff and supervisors revealed a misunderstanding of the EBP requirements and the necessity to follow posted precautions regardless of the resident's current status. The interim Director of Nursing and other supervisory staff expressed expectations for adherence to infection control policies, including hand hygiene and EBP. However, the lack of consistent auditing and clear communication regarding the policies contributed to the observed deficiencies. The facility's failure to implement these infection control measures was noted during the survey, highlighting gaps in staff training and policy enforcement.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect when a nurse aide was observed with her hand raised to a cognitively impaired resident's face during an interaction in the resident's room. The incident involved a resident who was moderately cognitively impaired and had no recollection of the event. The altercation occurred when another nurse aide heard shouting from the resident's room and witnessed the nurse aide standing face to face with the resident, with her hand raised in a manner that suggested she might cover the resident's mouth or strike her. However, the witness did not observe any physical contact. The facility's investigation into the incident revealed that the nurse aide involved did not provide a written statement, and attempts to contact her were unsuccessful. The administrator, who served as the facility's abuse coordinator, confirmed the incident and stated that the nurse aide was terminated. The administrator emphasized the expectation for staff to treat residents with respect and dignity, even in challenging situations. The report highlights a deficiency in maintaining the resident's right to a dignified existence and self-determination.
Failure to Provide Timely Insulin Administration
Penalty
Summary
The facility failed to ensure the availability of necessary medications for a resident with type 2 diabetes, leading to a missed dose of insulin. The resident was prescribed Humulin N Kwikpen to be administered twice daily, with specific instructions to hold the dose if blood sugar levels were below 150 mg/dL. On a particular day, the resident's blood sugar was recorded at 200 mg/dL, but the insulin was not administered at the scheduled time because it was not available. The nurse on duty was informed by a medication aide that the insulin was out of stock and not available in the emergency backup supply. The nurse attempted to address the issue by contacting the on-call medical provider and the emergency pharmacy to order more insulin. However, the insulin was not delivered until later that night, resulting in a delay in administration. The night shift nurse received the insulin delivery and administered the dose but failed to document the administration. Interviews with the nursing staff and the Interim Director of Nursing revealed a lack of clarity on the procedures for reordering medications and the availability of emergency backup supplies, contributing to the deficiency.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
