The Greens At Gastonia
Inspection history, citations, penalties and survey trends for this long-term care facility in Gastonia, North Carolina.
- Location
- 969 Cox Road, Gastonia, North Carolina 28054
- CMS Provider Number
- 345169
- Inspections on file
- 23
- Latest survey
- June 4, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Greens At Gastonia during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and hemiparesis was allowed to smoke unsupervised after an assessment determined she could do so safely, despite no improvement in her condition. While unsupervised, she caught her hair on fire, resulting in burns. Later, the same resident exited the building in her wheelchair without staff knowledge and was found in the parking lot heading toward a main road, stating she wanted to smoke. The facility had not identified her as a wander or elopement risk, and no interventions were in place to prevent her from leaving unsupervised.
A resident who was cognitively intact entrusted a hospitality aide with a debit card to purchase cigarettes, but the aide used the card without authorization for personal purchases and cash withdrawals totaling over $600. The unauthorized transactions were discovered when the resident's card was declined, and the aide later admitted to the misuse. Facility staff confirmed the resident did not authorize these charges, and there was no reimbursement plan in place at the time of the investigation.
A resident with chronic conditions was readmitted with a new order for PRN Tramadol 50 mg, but the prescription was not sent to the pharmacy, resulting in the continued administration of a discontinued 75 mg dose by multiple nurses over several weeks. Staff interviews revealed confusion about procedures for sending new narcotic prescriptions and returning discontinued medications, and the pharmacy confirmed they never received the new order.
A resident with severe cognitive impairment and high ADL needs was left without a functioning call light due to tampering, leaving her unable to call staff for assistance and feeling helpless. Staff and family discovered the unplugged call light with a temperature probe inserted, but could not determine who was responsible or how long the issue persisted.
A resident assessed as clinically unsafe to self-administer medications was found with both a prescribed and a non-prescribed inhaler in their room, which staff were unaware of. The resident reported using both inhalers, despite no physician order allowing self-administration or storage of these medications in the room. Staff interviews confirmed that medications should not have been accessible to the resident under these circumstances.
A dependent resident with severe cognitive impairment and multiple medical conditions was found without a working call light after it was discovered unplugged and tampered with, preventing the resident from calling for assistance. Staff were unable to determine how long the call light had been nonfunctional or who was responsible for the tampering, resulting in the resident being left without a means to request help.
Two residents had discrepancies between their documented code status in care plans and their current DNR orders, with care plans listing them as full code despite signed DNR forms and physician orders indicating otherwise. Staff interviews revealed confusion and lack of clarity regarding responsibility for updating advance directives, with both Social Services and MDS staff unsure of their roles, leading to outdated and inconsistent documentation.
Two residents with multiple medical conditions had their Care Area Assessments (CAAs) incompletely documented, with the MDS Coordinator failing to provide required analysis for most of the triggered care areas in their admission MDS assessments. This resulted in missing information on the nature, causes, and contributing factors for several important care areas, as confirmed by staff interviews.
Surveyors found that three residents' MDS assessments were inaccurately coded: one resident's nightly CPAP use was not documented, another was incorrectly marked as receiving antibiotics despite not receiving any during the assessment period, and a third with a PASRR level II determination was not properly coded due to staff unfamiliarity with PASRR expiration. These errors were confirmed through record review and staff interviews.
A resident with schizoaffective disorder remained in the facility after their initial 30-day PASRR level II expired, but no updated PASRR level II was obtained. The Social Services Director, responsible for monitoring PASRRs, acknowledged that the need for a new screening was overlooked.
A resident with multiple chronic conditions did not receive scheduled doses of pregabalin as ordered, despite staff documenting administration on the MAR, and was also given incorrect doses of tramadol HCL due to staff administering the available 75mg tablets instead of the prescribed 50mg. Staff interviews and record reviews confirmed these medication administration and documentation errors.
A resident with chronic pain did not receive multiple scheduled doses of long-acting morphine due to the medication not being available at the facility. Nursing staff did not consistently reorder the medication in advance, resulting in missed doses and reliance on PRN pain medication instead. The resident, pharmacy consultant, and medical director all confirmed the medication was not available as ordered, and facility leadership was unaware of the issue until after the fact.
Two residents were found with prescription and over-the-counter medicated creams and treatments at their bedsides without physician orders or assessments for self-administration. Staff, including nurses and medication aides, were unaware of the presence or use of these medications, and there was no documentation supporting resident possession or self-administration. Facility leadership confirmed that medications should not be accessible to residents without proper authorization and assessment.
Staff documented the administration of a controlled medication for a resident on the MAR, but failed to record it on the controlled medication declining sheets and did not actually administer the medication. Interviews with nursing staff and a medication aide confirmed the medication was not given, despite being signed for, resulting in incomplete and inaccurate medical records.
A unit manager did not perform hand hygiene after removing gloves and before donning new gloves while providing suprapubic catheter care to a resident, contrary to facility policy. The lapse was observed during care of a resident with a reddened catheter site, and the staff member later acknowledged the oversight.
The facility failed to complete and document weekly skin assessments for a resident with stage IV and stage III pressure ulcers, despite physician orders. Multiple instances of missing documentation were found, and attempts to interview responsible nurses were largely unsuccessful. The interim DON and MD were unaware of the issue.
A resident with multiple diagnoses, including dysphagia and a gastrostomy tube, was fed by a nurse aide who was unaware of the resident's NPO status. The error was discovered by a nurse administering medications, and the resident was sent to the hospital for evaluation. Staff interviews revealed that the aide did not check the meal ticket and was unaware of the resident's diet order.
A resident who had all her teeth extracted remained on a regular diet, causing difficulty in eating. The facility staff, including the RD, DM, and nursing staff, were unaware of the need for a diet change, leading to the resident frequently requesting soft foods and her family having to provide alternative food.
The facility failed to follow hand hygiene protocols during wound care and gastrostomy tube site care for a resident. Both the Treatment Nurse and Unit Manager did not sanitize their hands after removing gloves and before donning new gloves, despite knowing the correct procedures.
The facility failed to maintain accurate TAR for skin assessments for a resident. The TAR showed incomplete documentation and missing diagram sheets for specified dates, with the nurse unable to recall why the forms were not completed. The interim DON expected proper documentation, but attempts to contact the previous DON were unsuccessful.
Failure to Supervise Cognitively Impaired Smoker Leads to Burns and Unsupervised Exit
Penalty
Summary
A deficiency occurred when a facility failed to provide effective supervision and accident prevention for a resident with severe cognitive impairment, hemiparesis, and a history of smoking. The resident had previously been assessed as requiring supervision while smoking due to limited range of motion, weak grasp, and unclear speech, but a subsequent assessment determined the resident could smoke unsupervised. This change was made despite no improvements in the resident's cognition or functional abilities. As a result, the resident was allowed to smoke unsupervised in the designated area. While smoking unsupervised, the resident caught her hair on fire, resulting in singed hair, a blistered eyelid, and mild burns to her hand and behind her ear. The incident was observed by staff after the fact, and the resident required topical treatment for her injuries. The assessment following the incident determined the resident was unable to safely light or hold smoking materials and could not call for emergency assistance, leading to a change back to supervised smoking. Additionally, the resident exited the facility unsupervised in her wheelchair, traveling through the parking lot toward a main road without staff knowledge. She was found by staff after a visitor alerted them, and she stated she was attempting to go smoke. The resident did not have smoking materials in her possession and denied trying to leave the facility, indicating she was seeking staff attention to be taken to smoke. The facility had not identified her as a wander or elopement risk, and there were no interventions in place to prevent her from leaving the building unsupervised.
Removal Plan
- The facility initiated a therapy referral for positioning while in wheelchair for Resident #3.
- Therapy followed resident with plan of treatment.
- The Responsible Person was notified of the incident, follow up treatment plan, and change in supervision with smoking with resident's consent.
- Resident's smoking assessment was re-evaluated by charge nurse and resident was notified that she was now a supervised smoker; resident verbalized understanding and agreement.
- Staff notified of change in supervision with smoking and residents' apparatus by the Director of Nursing.
- Director of Nursing updated smoking binder that is in nurse's stations, front office, and therapy department.
- The facility ordered resident #3 a smoking adaptive apparatus to hold her cigarette.
- Being a supervised smoker, staff will light Resident #3's cigarettes.
- Resident's care plan/kardex updated to reflect that her hair is pulled back per resident acceptance.
- Smoking apron available per resident's acceptance.
- Facility will honor resident's rights and preferences while providing supervision to promote safety.
- The Unit Manager assessed resident for wandering tendencies and determined resident did not present as a risk; resident was provided with a cigarette in designated smoking area.
- Residents' preference for smoking times to be honored per request with staff supervision.
- Facility made aware that resident did not prefer the smoking apparatus and discontinued the apparatus; resident can safely hold a cigarette with supervision.
- Skin assessments were completed on all residents who smoke to ensure no burns identified from smoking; assessments completed by licensed nurses.
- The Director of Nursing and licensed nurses re-assessed all residents who wish to smoke for need of supervision and/or adaptive equipment; no additional residents were noted.
- The Director of Nursing and licensed nurses reviewed care plans and Kardex's for all supervised and unsupervised smokers to ensure up to date and accurate with no additional concerns noted.
- The charge nurse completed a resident headcount to ensure that all residents were accounted for.
Failure to Protect Resident from Misappropriation of Property
Penalty
Summary
A resident who was cognitively intact and had been admitted to the facility entrusted a hospitality aide with his debit card to purchase cigarettes, a practice that had occurred regularly for several months. On one occasion, the aide used the resident's debit card without authorization to make multiple purchases at various stores and to withdraw cash from an ATM, resulting in approximately $628.75 in unauthorized transactions. The resident was unaware of these additional charges and only discovered the missing funds when attempting to make a payment on his account, at which point the card was declined. Upon investigation, it was revealed that the hospitality aide admitted to using the resident's debit card for personal purchases and cash withdrawal without the resident's permission. The incident was reported to law enforcement, and the aide was subsequently terminated. The resident expressed sadness and disappointment, stating that he had trusted the aide due to her previous kindness and care. Interviews with facility staff, including the former business office manager and former administrator, confirmed that the resident did not authorize the additional transactions and that there was no plan in place to reimburse the resident for the stolen funds at the time of their departure from the facility. The resident had not been reimbursed for the stolen money and did not understand the delay in repayment. The facility failed to protect the resident from misappropriation of property, as required by regulation.
Failure to Provide Correct Dosage of PRN Pain Medication Due to Pharmacy Communication Breakdown
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including congestive heart failure and diabetes with neuropathy, was readmitted from the hospital with a new physician order for as-needed Tramadol HCL 50 mg for pain. Despite the new order being entered into the electronic medical record, the prescription for the new dosage was not sent to the pharmacy, resulting in the pharmacy not dispensing the correct medication. As a result, the facility continued to have the discontinued 75 mg dose available in the medication cart, and the resident received the incorrect dosage on multiple occasions over two months. Multiple nursing staff, including agency nurses, administered the discontinued 75 mg dose instead of the newly ordered 50 mg dose, as documented on the controlled medication declining sheet and confirmed in staff interviews. Several nurses were unaware of the need to send a new prescription to the pharmacy when a narcotic dosage changed, and some had not received education on returning discontinued narcotics. The medication cart was observed to contain only the 75 mg blister packs, and staff relied on what was available in the cart, assuming it matched the current order. Interviews with the pharmacist, medical director, and facility leadership confirmed that the pharmacy had not received a prescription for the new dose and that the expectation was for discontinued medications to be returned and new prescriptions to be sent for dose changes. The failure to communicate the new order to the pharmacy and to remove the discontinued medication from the cart led to the resident receiving the wrong dose of pain medication on several occasions.
Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, who required substantial to maximal assistance for all activities of daily living except eating, was found to have a non-functioning call light. The resident was unable to call staff for assistance due to the call light being unplugged and a temperature probe inserted into the plug, preventing it from alarming. This issue was discovered by the resident's family member during a visit, who observed the unplugged call light and reported the incident to facility administration. The resident expressed feelings of helplessness due to being unable to call for assistance when needed. Staff interviews confirmed that the call light was not working when checked during morning rounds, and a nurse aide provided a replacement call light from an adjacent empty bed after noticing the issue. Multiple staff members, including nurse aides and a unit manager, acknowledged the tampering of the call light but were unable to determine when or by whom it had been done. The facility's expectation, as stated by the Director of Nursing and Administrator, was that all residents should have functioning call lights to request assistance.
Failure to Prevent Unsafe Self-Administration of Medication
Penalty
Summary
A resident with chronic obstructive pulmonary disease (COPD) and acute respiratory failure was assessed by the interdisciplinary team and determined to be clinically unsafe to self-administer medications. Despite this assessment, the resident was found to have both a Symbicort inhaler and an albuterol inhaler stored in the drawer of his bedside table. The resident reported that some nursing staff were aware of the Symbicort inhaler being kept in his room, but none of the staff were aware of the albuterol inhaler. The resident also stated he had used both inhalers while in the facility, although he could not recall the specific dates of use. Review of the resident's physician orders confirmed that only the Symbicort inhaler was prescribed, with no order for albuterol or for any medications to be kept in the resident's room for self-administration. Nursing staff interviewed were unaware of the presence of the inhalers and stated that medications should not be kept in a resident's room unless the resident was assessed as safe to self-medicate and had a physician's order. Facility leadership confirmed that medications should be removed if found in the room of a resident not approved for self-administration.
Failure to Ensure Functioning Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a dependent resident with severe cognitive impairment and multiple medical conditions, including diabetes, hypertension, and dementia, was found without a functioning call light. The resident required substantial assistance with activities of daily living and was always incontinent of bowel and bladder. On the day of the incident, a family member discovered the call light unplugged, with a temperature probe cover placed in the plug to prevent it from alarming, rendering the resident unable to call for assistance. Staff interviews confirmed that the call light had been tampered with and was not operational when discovered. The nurse aide assigned to the resident noticed the call light was unplugged during morning rounds and, believing maintenance was working on it, provided a call light from an adjacent empty bed after confirming it worked. However, it was not clear how long the original call light had been nonfunctional prior to discovery. Other staff members recalled the resident was generally able to use her call light, but on this occasion, the tampering prevented its use. The issue was reported by the family member to the facility's former Administrator, who initiated a grievance. Despite efforts, the facility was unable to determine who was responsible for tampering with the call light. Interviews with staff and management confirmed the expectation that all residents should have access to functioning call lights, but this expectation was not met in this instance, resulting in the resident being unable to summon assistance as needed.
Failure to Maintain Accurate Advance Directives in Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date advance directives in the medical records for two residents. For one resident, the care plan indicated a full code status, while a physician's order and a signed DNR form in the advance directive binder reflected a Do Not Resuscitate (DNR) status. Staff interviews revealed confusion regarding the resident's current code status, with the nurse relying on the care plan, which was outdated, and the Social Services Director unaware of the change due to being on leave. The responsibility for updating the care plan was unclear among staff, with the Social Worker, MDS Coordinator, and Unit Manager each providing different accounts of who should update the documentation. For another resident, the care plan also indicated a full code status, despite a recent physician's order and signed DNR form indicating a change to DNR. The Social Services Director acknowledged that the code status must have changed after a hospital stay and was not updated in the care plan. The Social Services Assistant, who attended the care plan meeting where the change was discussed, did not update the care plan and was unsure of her responsibilities, as she was still in training. The Administrator confirmed that both Social Workers and the MDS Coordinator were responsible for updating care plans to reflect changes in advance directives.
Incomplete Care Area Assessments for Two Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) comprehensively for two residents upon admission. For one resident with diagnoses including heart failure, diabetes mellitus, and atrial fibrillation, the admission Minimum Data Set (MDS) assessment triggered seven care areas, but analysis of findings was only provided for nutritional status. The remaining six triggered areas—communication, functional abilities, urinary incontinence and indwelling catheter, falls, dehydration/fluid maintenance, and pressure ulcer/injury—lacked documentation describing the nature of the problems, root causes, contributing factors, risk factors, and reasons for care planning. Similarly, another resident with non-Alzheimer's dementia, anxiety disorder, and depression had nine care areas triggered, but only the nutritional status area was analyzed, leaving eight areas without comprehensive assessment. Interviews with the MDS Coordinator confirmed that the required analyses for the triggered care areas were not completed before submission of the MDS assessments for both residents. The MDS Coordinator acknowledged responsibility for the oversight and could not explain how the error occurred. The DON and Administrator both stated their expectations that all CAAs be individualized and completed comprehensively prior to submission, which was not done in these cases.
Inaccurate MDS Coding for Respiratory Care, Antibiotic Use, and PASRR Status
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for three residents in the areas of respiratory care, antibiotic use, and PASRR status. For one resident with a diagnosis of sleep apnea and a physician order for nightly CPAP use, the MDS assessment did not reflect the use of a CPAP device, despite documentation in the Medication Administration Record (MAR) and confirmation from nursing staff that the device was applied nightly. The MDS nurse responsible for coding acknowledged that the information was missed during the assessment process. Another resident was incorrectly coded as receiving antibiotics on the MDS assessment, even though the MAR showed no antibiotics were administered during the assessment period following the resident's return from the hospital. The MDS coordinator confirmed the error after reviewing the records. Additionally, a third resident with schizoaffective disorder and a PASRR level II determination was not coded appropriately on the admission MDS. The MDS nurse responsible was unfamiliar with the expiration of the PASRR level II and mistakenly coded it as a level I, resulting in inaccurate documentation.
Failure to Obtain Updated PASRR Level II for Resident with Expired Screening
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level II was obtained for a resident with schizoaffective disorder after the initial 30-day PASRR level II expired. Record review showed that the resident was admitted with a 30-day PASRR level II, which expired, but no subsequent level II PASRR was completed while the resident remained in the facility. Interviews with the Social Services Director and the Administrator confirmed that the responsibility for monitoring and obtaining PASRR level II screenings was assigned to the Social Services Director, who acknowledged that the need for a new PASRR was overlooked after the initial one expired.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by the physician for one resident. The resident, who had diagnoses including chronic diastolic congestive heart failure, Type 2 diabetes mellitus with diabetic polyneuropathy, and intervertebral disc degeneration, was cognitively intact and had physician orders for pregabalin 200mg twice daily for neuropathy and tramadol HCL 50mg every six hours as needed for pain. Review of medication administration records and controlled medication declining sheets revealed multiple instances where pregabalin was not administered as scheduled, despite being documented as given on the Medication Administration Record (MAR). Staff interviews confirmed that the medication was not actually administered on those occasions, and the Director of Nursing (DON) and other staff acknowledged that discrepancies between the MAR and controlled medication sheets, along with correct narcotic counts, indicated the medication had not been given. Additionally, the resident received incorrect doses of tramadol HCL on several occasions. Although the physician's order specified 50mg, the controlled medication declining sheets and staff interviews confirmed that 75mg doses were administered multiple times. Several nurses and medication aides stated that they administered the 75mg dose because that was what was available in the blister pack, and they did not verify the correct dose against the physician's order. The DON confirmed that the blister packs contained 75mg tablets, not the ordered 50mg dose. Both the Medical Director and the facility Administrator stated that they expected medications to be administered as ordered and for documentation to be accurate and honest. The Medical Director specifically noted that missing doses of pregabalin could cause increased pain or discomfort for the resident. The deficiency was identified through review of records, interviews with staff, and direct confirmation of medication administration errors and documentation inaccuracies.
Failure to Prevent Significant Medication Error Due to Unavailable Scheduled Pain Medication
Penalty
Summary
A significant medication error occurred when a resident with chronic pancreatitis, severe chronic kidney disease, and chronic pain did not receive seven scheduled doses of a long-acting pain medication (MS Contin ER 30 mg) as ordered by the physician. The medication was prescribed to be administered three times daily for pain management. The missed doses were due to the medication not being available at the facility on multiple occasions across March and April, as documented in the Medication Administration Record and nursing notes. Nursing staff and medication aides reported that the medication was not available to administer at the scheduled times, and in several instances, the pharmacy had not yet delivered the medication. Staff interviews revealed that the process for reordering medications was not consistently followed, with some staff not contacting the pharmacy or physician promptly when the medication supply was low or depleted. Instead, staff often relied on administering the resident's as-needed (PRN) pain medication in place of the scheduled long-acting medication, which was not equivalent in duration or frequency. The resident was aware of the missed doses and expressed confusion and concern about the facility's inability to maintain an adequate supply of his prescribed pain medication, especially given his ongoing need for pain control. The pharmacy consultant and medical director both confirmed that medications should be reordered before the last dose is given, and the medical director considered the missed doses a significant medication error. The DON and administrator were not aware of the missed doses until after the fact and acknowledged that medications should be available as ordered.
Failure to Secure and Monitor Resident Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and labeling of drugs and biologicals for two residents who had medicated creams and over-the-counter treatments at their bedsides. One resident with dementia, gout, and peripheral vascular disease was observed with a lidded pump container of prescription topical medicated cream for foot pain on his bedside table. The resident stated he brought the cream from home and applied it as needed, but there was no physician order for the medication, and staff were unaware of its presence. The resident was not assessed as able to self-administer medications, and the cream had an expired date. Multiple staff members, including a medication aide and a nurse, reported not noticing the cream in the resident's room during their medication administration duties. Another resident, who was cognitively intact but required extensive assistance with activities of daily living, was found with several over-the-counter medicated products on her bedside tray, including rubbing alcohol, medicated gels, cortisone cream, vapor rub, and oral pain relief gel. The resident reported using these products for various ailments and stated she obtained them from family and friends. There was no documentation of a physician order or an assessment for self-administration of medications or treatments in her medical record. Staff members, including nurses and medication aides, were unaware that the resident possessed or self-administered these products and had not paid close attention to the items on her bedside tray. Interviews with the Medical Director, Director of Nursing, and Administrator confirmed that residents should not have medications or treatments in their possession or self-administer without a physician order and proper assessment. The staff's lack of awareness and failure to observe and remove unauthorized medications from residents' rooms contributed to the deficiency in ensuring drugs and biologicals were properly labeled and securely stored according to professional standards.
Failure to Accurately Document and Administer Controlled Medication
Penalty
Summary
Staff failed to maintain a complete and accurate medical record for a resident prescribed pregabalin, a controlled substance, for neuropathy and pain. On multiple occasions, the Medication Administration Record (MAR) indicated that the medication was administered, with signatures from various nurses and a medication aide. However, corresponding entries were missing from the controlled medication declining sheets, and staff interviews confirmed that the medication was not actually given on those dates, despite being signed as administered on the MAR. The controlled medication count was also correct, further indicating that the doses were not dispensed. Interviews with the involved staff, including nurses and a medication aide, revealed that they did not administer the medication even though they had signed for it on the MAR. The Director of Nursing and Medical Director both stated that accurate and honest documentation is expected on both the MAR and the narcotic record. The administrator also confirmed the expectation that medications are administered as ordered and documented accurately. The failure to document and administer the medication as ordered resulted in incomplete and inaccurate medical records for the resident.
Failure to Perform Hand Hygiene Between Glove Changes During Catheter Care
Penalty
Summary
Unit Manager #2 failed to follow the facility's Handwashing/Hand Hygiene policy while providing suprapubic catheter care to Resident #83. During the procedure, after cleaning the catheter site and removing her gloves, Unit Manager #2 did not perform hand hygiene before donning a new pair of gloves to apply a dressing. This action was observed directly by surveyors, and the facility's policy specifically requires hand hygiene after glove removal and before donning clean gloves for aseptic tasks. Resident #83 had a suprapubic catheter with a slightly reddened area at the insertion site, which was being cleaned and dressed by Unit Manager #2. The failure to perform hand hygiene occurred after the initial cleaning and before the application of a new dressing. Both the Infection Preventionist and the Director of Nursing confirmed in interviews that the expected procedure was not followed, and Unit Manager #2 acknowledged the oversight during her interview.
Failure to Document Weekly Skin Assessments for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to complete and document weekly skin assessments as ordered by the physician for a resident with a known stage IV pressure ulcer to the sacrum and a known stage III pressure ulcer to the right heel. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had physician orders for weekly skin checks every Thursday. However, reviews of the resident's Medication Administration Record (MAR) and electronic medical record (EMR) revealed multiple instances where these assessments were not documented, specifically on 02/18/24, 03/07/24, 03/14/24, 04/04/24, and 04/19/24. Attempts to interview the nurses responsible for these shifts were largely unsuccessful, with some nurses unable to recall why the assessments were not completed and documented. The interim Director of Nursing (DON) and the oncoming DON confirmed that their expectation was for weekly skin assessments to be completed and documented in the EMR. The interim DON was unsure if the system failed to flag the assessments or if the nurses omitted them. The Medical Director (MD) was also unaware that the weekly skin assessments were not being completed as ordered. Despite efforts to promote wound healing through nutritional supplements and therapy, the lack of documented skin assessments indicated a failure to follow physician orders and ensure proper monitoring of the resident's condition.
Resident Fed Despite NPO Order
Penalty
Summary
The facility failed to prevent a resident from being fed despite having a diet order of nothing by mouth (NPO) with continuous enteral tube feeding. Resident #3, who was admitted with multiple diagnoses including cerebrovascular accident, hemiplegia, aphasia, dysphagia, and gastrostomy tube for feedings, was fed by a nurse aide who was unaware of the resident's NPO status. The resident received two spoonsful of grits, one spoonful of eggs, and approximately two ounces of orange juice before the error was discovered by a nurse administering morning medications. The nurse aide, who was assigned to Resident #3 for the first time, did not check the name on the meal ticket and was unaware of the resident's NPO status. The error was identified when Nurse #4 entered the room to provide medications and found the aide feeding the resident. The tray, which belonged to another resident, was subsequently removed by the Medical Records/Central Supply representative during her rounds. Despite the incident, the resident did not exhibit any immediate adverse effects and was sent to the hospital for evaluation at the request of the family. Interviews with staff revealed that the facility had protocols in place to prevent such incidents, including documentation in the care tracker and regular rounds by administrative staff. However, the nurse aide's lack of awareness and failure to check the meal ticket led to the resident being fed. The incident was reported to the interim Director of Nursing, and the facility conducted education sessions with staff to reinforce the importance of adhering to diet orders and checking meal tickets before feeding residents.
Failure to Provide Appropriate Diet for Resident with Dental Extractions
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of a resident who had all her teeth extracted. Despite the dental extraction report and the resident's expressed difficulty in adjusting to her new diet, the resident remained on a regular diet. The Registered Dietitian (RD) and Dietary Manager (DM) were unaware of the need for a diet change, and the nursing staff did not communicate the necessary dietary adjustments. The resident's family member observed the resident struggling to eat a fried pork chop and had to provide alternative food from home. The resident frequently requested soft foods like pudding and applesauce, indicating her difficulty with the regular diet. Interviews with staff revealed a lack of communication and documentation regarding the resident's dietary needs after her teeth were extracted. The previous RD was unaware of the diet change, and the current RD, who started after the resident's discharge, confirmed that no dietary documentation was found about the teeth removal. The DM and nursing staff also did not receive or act on any information about the necessary diet change. The interim Director of Nursing (DON) stated that her expectation would have been to assess the resident's tolerance to the regular diet and follow recommendations, but this did not occur. Attempts to contact the previous DON were unsuccessful.
Failure to Follow Hand Hygiene Protocol During Wound and Gastrostomy Tube Care
Penalty
Summary
The facility failed to implement their Infection Control Policy for hand hygiene/handwashing during wound care and gastrostomy tube site care for Resident #3. The Treatment Nurse did not sanitize her hands after removing gloves and before donning new gloves while providing wound care to Resident #3's right heel and sacral wound. Despite knowing the proper procedure, the Treatment Nurse admitted to forgetting to sanitize her hands at the appropriate times. The Infection Preventionist and the interim Director of Nursing confirmed that the Treatment Nurse was aware of the correct hand hygiene protocol but did not follow it during the observed care session. Similarly, Unit Manager #1 did not sanitize her hands after doffing gloves and before donning new gloves while providing gastrostomy tube site care for Resident #3. Unit Manager #1 also acknowledged that she knew the correct procedure but forgot to perform hand hygiene as required. The Infection Preventionist and the interim Director of Nursing confirmed that Unit Manager #1 was knowledgeable about the proper hand hygiene practices but failed to adhere to them during the observed care session.
Failure to Maintain Accurate Skin Assessment Records
Penalty
Summary
The facility failed to maintain an accurate Treatment Assessment Record (TAR) for skin assessments for one resident. Resident #2, who was cognitively intact and required assistance with various activities, had a physician's order for weekly skin assessments to be completed every Wednesday on the day shift. However, the TAR for February 2024 showed that the skin assessment on 2/7/24 was completed, but the nurse who initialed/signed the TAR could not be identified. Additionally, Nurse #3 signed off on the skin assessments for 2/14/24 and 2/21/24, but there were no corresponding documentation diagram sheets for these dates, indicating a lack of record for potential skin concerns discovered during the assessments. During interviews, Nurse #3 confirmed working with Resident #2 on the specified dates and usually completing the documentation diagram forms during the assessments but could not recall why the forms were not completed on those days. The interim Director of Nursing (DON) stated that her expectation was for skin assessment documentation to be completed and documented in the medical record. Attempts to contact the previous DON were unsuccessful, leaving the issue unresolved at the time of the report.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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