The Greens At Hickory
Inspection history, citations, penalties and survey trends for this long-term care facility in Hickory, North Carolina.
- Location
- 3031 Tate Boulevard Se, Hickory, North Carolina 28602
- CMS Provider Number
- 345232
- Inspections on file
- 20
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Greens At Hickory during CMS and state inspections, most recent first.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents experienced medication administration errors during observed passes. For a resident with diabetes, an insulin pen was used without performing the manufacturer-required priming step before delivering a 20-unit Tresiba dose. In a separate case, a resident ordered to receive one spray of fluticasone furoate in each nostril once daily was instead given two sprays in each nostril. These observed deviations from the physician orders and product instructions resulted in a calculated medication error rate above 5%.
Two residents received medications prescribed for other residents when agency nurses failed to verify the correct recipient during medication passes. In one case, a cognitively intact resident with multiple chronic conditions was given his roommate’s bedtime medications, including metformin, carvedilol, trazodone, melatonin, senna, and tizanidine, after the nurse pulled the wrong MAR and did not follow the five rights of medication administration. In the second case, a cognitively intact resident with ESRD, CAD, HTN, DMII, and COPD was given acetaminophen and buspirone ordered for another resident at a time when he had no scheduled meds, with the error identified only after a family member questioned the unexpected dosing and staff confirmed the wrong-resident administration through MAR review.
A resident with severe cognitive impairment, malnutrition, and feeding difficulty, who required partial/moderate staff assistance with eating, was observed being fed lunch while seated in a wheelchair in a hallway across from the nurse’s station. A Speech Therapist stood beside the resident and provided bites of food throughout the meal, despite empty chairs being available nearby. The ST later stated she did not see any chairs and that the resident was in the hallway due to a flu/COVID-19 outbreak, although the resident normally ate in the dining room. The DON and Administrator both reported they expected staff to be seated and to feed residents in a respectful manner, and the reasonable person concept was applied to determine that hallway feeding while standing over the resident failed to ensure a dignified dining experience.
A resident with dementia, diabetes, COPD, and bilateral hand contractures had orders and care plan interventions for weekly head-to-toe skin assessments, use of bilateral palm guards, and monitoring of skin and contracture-related complications. Despite this, nursing and MDS staff did not remove hand splints or palm guards during assessments and documented that nails were trimmed and no new skin issues were present, while surveyors later observed long fingernails and a reddened area on the right palm matching the middle fingernail, which had previously pressed into the contracted hand. The resident reported disliking long nails because they dug into his skin, and staff acknowledged foul odor and moist exudate in the right hand but had not identified or reported the reddened area or notified the wound nurse, resulting in the skin issue remaining unassessed and untreated.
The facility failed to ensure meals were palatable, attractive, and served at appetizing temperatures, as multiple cognitively intact residents reported undercooked or overcooked items, excess liquid on plates, bland or poorly seasoned food, and meals that were often cool or cold by the time they arrived, especially to rooms at the end of hallways. A grievance had been filed about liquids from vegetables saturating other foods, and residents described burnt toast, runny mashed potatoes, and trays that looked unappetizing. Test trays showed that, although food left the kitchen above required holding temperatures, by the time trays reached the halls the items were only warm, lacked visible steam, included mushy or pale components, and had liquids bleeding between foods, confirming concerns about both temperature control and food quality.
A resident received another resident's medications in error, and although a Change in Condition form was completed by the DON with vital signs, allergies, and notification details, neither the nurse who made the error nor the supervising nurse documented which specific medications were administered. As a result, the medical record lacked any entry identifying the medications given in error, leaving the record incomplete and inaccurate regarding the medication incident.
The facility failed to obtain and document informed consent, including discussion of risks and benefits, before initiating and escalating the psychotropic medication divalproex sodium for three severely cognitively impaired residents with dementia and related psychiatric diagnoses. A psychiatric NP recommended divalproex for behaviors such as aggression, agitation, hallucinations, and evening agitation, and physicians ordered progressive dose increases that were administered as recorded on the MAR. However, the medical records for each resident contained no evidence that a representative had been informed in advance of the risks versus benefits or had consented, and both the unit manager and DON acknowledged in interviews that psychotropic consents were their responsibility and had been overlooked, despite the administrator’s stated expectation that such consents be obtained prior to starting or changing psychotropic medications.
The facility failed to maintain accurate and consistent advance directive documentation for two residents. For one cognitively intact resident, a physician’s DNR order and a DNR form in the advance directive binder were not reflected in the care plan, which continued to list the resident as full code with interventions for full resuscitation. For another resident with severe cognitive impairment, physician orders, the care plan, and the EMR banner all showed DNR status, but the DNR form was missing from the advanced directives notebook used by staff for rapid code-status verification, reportedly due to the form not returning after a hospital transfer and not being replaced or detected during routine checks.
A resident with newly documented diagnoses of PTSD and major depressive disorder, along with recent suicidal ideations and ongoing psychiatric treatment with an antidepressant, did not have a Level II PASRR evaluation requested or documented. Although the resident’s care plan and psychiatric notes reflected active serious mental health conditions and targeted interventions, the SW did not initiate a Level II PASRR because no new behaviors were observed, and the facility was unable to produce any evidence that a Level II PASRR request had ever been submitted.
Surveyors found that the facility did not follow physician and RD orders for double portions/double protein portions for two residents. One resident with hypothyroidism and prior unintentional weight loss had an order and care plan for a regular diet with double portions, but during an observed lunch received only a standard serving of chicken despite a tray card specifying double portions; the resident reported rarely receiving the ordered double portions, and dietary staff confirmed the plate did not meet the double-protein standard. Another resident with diabetes, adult failure to thrive, multiple comorbidities, and end-of-life skin failure had an order for a mechanical soft diet with double protein portions, yet an observed chicken salad sandwich was plated as a thin, standard sandwich rather than with the required double meat, which the RD and Dietary Manager later confirmed did not meet the ordered double protein portion.
Surveyors found that wheelchairs and geri chairs used by three residents were repeatedly observed over several days with dried white and yellow-brown substances on armrests, frames, and padding, as well as hair or string-like debris wrapped around wheels, without improvement. The Environmental Services Director stated that such equipment was cleaned monthly and as needed, with the last cleaning having occurred weeks earlier, and noted that housekeeping had not been notified by nursing staff that these specific chairs required additional cleaning. The Administrator reported he expected equipment to be kept clean and for nursing staff to alert housekeeping when more frequent cleaning was necessary.
Expired medications and IV fluids were found in three medication storage rooms of a facility. The ADON and Unit Manager, responsible for checking for expired items, failed to identify numerous expired syringes of Heparin and bags of Normal Saline. The DON confirmed that the facility did not follow its medication storage process.
The facility failed to accurately code MDS assessments for two residents, leading to deficiencies in opioid medication and bowel continence documentation. One resident was not coded for opioid use despite receiving medication, and another was inaccurately coded for bowel continence despite documented incontinence. Errors were attributed to mis-clicks by MDS nurses, as confirmed by interviews with nursing staff.
A resident with COPD was found to be receiving oxygen at 4 liters per minute instead of the prescribed 2 liters. Observations revealed that nursing staff failed to check the oxygen concentrator settings as required. The resident, with moderately impaired cognition, was unaware of the correct setting and unable to adjust it. The DON acknowledged the oversight and the need for more frequent monitoring.
A facility did not follow a pharmacy recommendation to monitor side effects and behaviors for a resident on antipsychotic medication. Despite being aware of the recommendation, the DON acknowledged it was overlooked, and the Consultant Pharmacist's follow-up was delayed due to a hurricane.
A resident with schizophrenia was prescribed risperidone, but the facility failed to monitor for side effects and behaviors as recommended by the Consultant Pharmacist. Despite the pharmacist's suggestion in August, the MARs lacked monitoring instructions from July to November. Staff interviews revealed that the responsibility for adding these instructions was not fulfilled, with the DON and a nurse acknowledging the oversight.
Two nurse aides failed to follow infection control protocols during incontinence care for a resident with a stage IV sacral wound. One aide did not sanitize her hands after removing soiled gloves, while the other improperly handled soiled linen by throwing it on the floor. Both aides had recently received training on infection control.
Medication Administration Errors Result in Exceeded Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 28 medication administration opportunities, resulting in a 7.14% error rate. For one resident with diabetes mellitus, a physician order dated 12/06/25 directed administration of 20 units of Tresiba insulin via prefilled pen injector once daily subcutaneously. Manufacturer instructions for the Tresiba pen specified that the pen must be primed with 2 units before each dose by dialing to 2 units, holding the pen with the needle up, tapping gently, and pressing the button until the counter returned to 0 and a drop of insulin appeared. During an observation on 01/22/26, Nurse #5 removed the Tresiba pen from the medication cart, dialed the dose directly to 20 units, and administered the insulin without priming the pen as required by the manufacturer’s instructions. In a subsequent interview, the nurse stated she followed the five rights of medication administration and acknowledged she knew the pen should have been primed and believed she had primed it before giving the dose. In a separate incident, another resident had a physician order dated 01/13/26 for fluticasone furoate nasal spray, one spray in both nostrils once daily for sinus/allergies. On 01/22/26, during observed medication administration, Nurse #7 prepared and administered the nasal spray and was seen giving two sprays in each nostril instead of the ordered one spray in each nostril. In a later interview, the nurse recounted administering two sprays in each nostril, then reviewed the order, which specified one spray in each nostril, and stated she should have read the order more carefully. These two observed deviations from physician orders and manufacturer instructions during medication administration contributed to the facility’s medication error rate exceeding the 5% threshold.
Medication Administration Errors Involving Wrong-Resident Dosing
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered according to physician orders, resulting in residents receiving medications prescribed for other residents. In the first incident, a cognitively intact resident with diagnoses including diabetes mellitus, hypertension, constipation, restless leg syndrome, hallucinations, and major depressive disorder was given his roommate’s medications during a bedtime medication pass. The medications administered in error included melatonin, sennosides, tizanidine, trazodone, carvedilol, and metformin, all of which were ordered for the roommate. The error occurred when the nurse assigned to both residents’ section pulled the roommate’s medications and mistakenly administered them to the wrong resident. The circumstances leading to this first error included the nurse’s failure to follow basic medication administration protocols. The DON later explained that the agency nurse did not check the five rights of medication administration before giving the medications. The resident was his own responsible party and was informed of the error, and the on-call provider was notified. The Medical Director later stated that the roommate was not on anything that could harm the resident and that the resident was prescribed some of the same medications he received in error. However, the deficiency centers on the nurse’s incorrect selection and administration of medications intended for another resident during the medication pass. In the second incident, another cognitively intact resident with diagnoses including end stage renal disease on dialysis, coronary artery disease, hypertension, diabetes mellitus type II, and COPD received medications that were not prescribed for him during a 2:00 PM medication pass. This resident had no medications ordered at that time, but was given acetaminophen 325 mg (three tablets) and buspirone 7.5 mg (one tablet), which were ordered for a different resident with spastic hemiplegia following stroke, diabetes mellitus type II, and chronic pain syndrome. The error was discovered when the resident’s family member questioned the administration of medications at a time the resident did not usually receive them. Review of the MARs by facility staff confirmed that the agency nurse had administered another resident’s scheduled 2:00 PM medications to this resident, constituting a second medication administration error arising from failure to ensure that medications were given only to the residents for whom they were prescribed.
Failure to Provide Dignified Dining Assistance in Hallway
Penalty
Summary
The deficiency involves the facility’s failure to provide a dignified dining experience for a dependent resident when a Speech Therapist (ST) assisted with a meal while standing in a hallway. The resident, admitted with diagnoses including malnutrition and feeding difficulty, had a significant change MDS showing severe cognitive impairment and a need for partial/moderate staff assistance with eating. During a continuous observation of a lunch meal, the resident was seated in a wheelchair in the hall directly across from the nurse’s station with his meal tray on an overbed table. The ST stood on the resident’s right side and provided bites of food while three empty chairs were observed behind the nurse’s station. In a subsequent interview, the ST confirmed she fed the resident in the hallway and remained standing the entire time, stating she did not see any available chairs and that the resident usually ate in the dining room but was in the hallway that day due to a flu/COVID-19 outbreak. The DON stated she expected staff to be seated when feeding residents and believed feeding in the hallway was safer than in resident rooms because more staff were available if an emergency occurred. The Administrator stated he expected residents to be fed in a respectful manner and for staff to be seated when feeding residents. The reasonable person concept was applied, as individuals might feel a lack of dignity when assisted with eating in a hallway and when staff stand over them.
Failure to Identify and Treat Hand Skin Breakdown Related to Overgrown Nails and Contractures
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough skin assessments and obtain appropriate treatment orders for a reddened area on a resident’s right palm caused by an overgrown fingernail in the setting of bilateral hand contractures. The resident had diagnoses including COPD, diabetes mellitus, bilateral hand contractures, and dementia, and was severely cognitively impaired, requiring total assistance with all ADLs except eating. Physician orders included a weekly head-to-toe skin assessment on a specific shift and an order for bilateral palm guards with instructions to check skin integrity prior to application. The care plan identified the resident as having an ADL self-care performance deficit and an alteration in musculoskeletal status related to bilateral hand contractures, with interventions that included adaptive equipment, bilateral hand splints, good hygiene, skin monitoring, and notification of the provider for complications. Despite these orders and care plan interventions, multiple assessments and observations failed to identify and address a reddened area on the resident’s right palm caused by his middle fingernail pressing into his palm. A weekly skin assessment documented that the resident’s fingernails were cleaned and trimmed and that there were no new skin abnormalities, even though later observations showed long fingernails extending approximately 1/4 inch beyond the fingertips and an indentation in the right palm matching the middle fingernail. The reddened area on the palm measured approximately 0.2 cm by 0.2 cm by 0.1 cm and appeared to have been open at one time but was no longer open, remaining red in color. Staff, including the MDS coordinator and nurses, reported that they did not remove the resident’s splints or palm guards during assessments and were not aware of any skin issues on his hands. Over several days, surveyor observations documented that the resident’s fingernails remained long, that the middle finger continued to press into the palm, and that there was a malodor and moist exudate previously noted in the right hand by staff. The resident himself stated that he wanted his fingernails trimmed because he did not like them long as they dug into the skin of his hand, and he reported that no one had discussed cutting his fingernails with him. Nurse aides and nursing staff acknowledged noticing foul odor and moist exudate in the right hand at times and cleaning and drying the area, but they had not identified or reported the reddened area caused by the fingernail until it was pointed out during observations. The wound nurse was never notified of any skin issue on the resident’s right hand, and unit management and therapy staff were unaware of the reddened area until the time of the surveyor’s observations and interviews, demonstrating that the ordered and care-planned skin monitoring and assessment processes were not effectively carried out for this resident. Facility leadership, including the DON and Administrator, stated that nurses should have been checking the resident’s hands and palms daily and during weekly skin assessments, removing palm guards to thoroughly observe the skin, and recognizing and reporting new skin issues for treatment and further evaluation. However, the documented assessments and staff interviews show that these actions did not occur, resulting in the reddened area on the resident’s right palm from his middle fingernail pressing into his skin going unrecognized and untreated over time.
Failure to Provide Palatable, Proper-Temperature Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable, attractive meals at safe and appetizing temperatures for multiple cognitively intact residents. One resident had previously filed a grievance about excess liquid saturating meal plates, specifically noting that liquid from vegetables was running into other foods. In subsequent interviews, this resident reported ongoing concerns that food was often undercooked, greasy or watery, toast was burnt, and mashed potatoes were extremely runny, and stated that the quality and presentation of meal trays had not improved despite voicing these concerns. Two additional cognitively intact residents also reported dissatisfaction with the quality and temperature of their meals. One resident stated that meal trays were often cold and lacked good flavor or texture. Another resident described the food quality and temperature as unsatisfactory, saying the trays looked like vomit and that most days the meals arrived cold to his room, which was located at the end of a hall. During a Resident Council group interview, several residents reported issues with food, including lack of seasoning and over- or undercooking of various items. Direct observations of two test trays further demonstrated problems with palatability, appearance, and temperature. Although foods on the service line were initially above 135°F, by the time the test trays were plated, transported, and observed, there was no visible steam, and most items were only warm, not hot. One tray’s yams were mushy and bland, and the other tray’s chicken tenders appeared pale with soft, mushy breading; liquid from the cabbage bled into the chicken and rice, affecting presentation. Residents who received similar meals on that day rated them poorly, describing them as cool, not very appetizing, and with poor appearance. The Dietary Manager acknowledged that the test tray meals were not warm and that delayed tray delivery on the halls, especially to rooms at the end of hallways, could contribute to the temperature issues.
Failure to Document Medications Given in Error in Resident Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who received another resident's medications in error. The resident was admitted on an unspecified date and experienced a medication variation on the night of 11/06/25, when the assigned nurse administered medications intended for a different resident. A Change in Condition form completed by the DON on 11/06/25 documented that a medication variation had occurred, included the resident's vital signs, allergies to penicillin and tuberculin solution, and noted there were no changes in the resident's mental, physical, or behavioral status. The form also documented that the resident, who was his own responsible party, and the on-call physician service were notified, and that the physician ordered monitoring for changes. Despite this, the medical record contained no documentation specifying which medications were given in error. The Change in Condition form did not list the medications administered by mistake, and there was no other documentation in the record identifying them. Supervisor #9 reported that the nurse who made the error had informed her that she had given the resident another resident's medications, but stated she did not document the medications because she believed the responsibility lay with the nurse who made the error. The DON confirmed that neither the nurse nor the supervisor documented the specific medications given in error and acknowledged that this information should have been entered into the medical record at the time of the incident and included on the Change in Condition form.
Failure to Obtain Informed Consent for Psychotropic Medication Initiation
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent, including discussion of risks and benefits, prior to initiating the psychotropic medication divalproex sodium for three residents reviewed for unnecessary medications. For each of these residents, divalproex sodium was ordered and administered as a psychotropic/anticonvulsant and mood-stabilizing medication without evidence in the medical record that the resident or their representative had been informed in advance of the risks versus benefits or had consented to the treatment. The Medication Administration Records confirmed that the medication was given as ordered over extended periods. One resident was admitted with diagnoses including unspecified dementia, psychotic mood disturbance, anxiety, and depression, and was identified on the MDS as severely cognitively impaired and receiving antianxiety, antidepressant, and antipsychotic medications. A psychiatric NP note documented increased aggressive behavior, hoarding, and visual hallucinations, with a recommendation to start divalproex sodium. Physician orders show a series of dose escalations from 125 mg twice daily to 500 mg twice daily over time for dementia and psychotic mood disorder, yet the medical record contained no documentation that the resident’s representative was informed of the risks and benefits or provided consent before initiation. The unit manager and DON both acknowledged that consent for this psychotropic medication had been overlooked. A second resident, admitted with unspecified dementia, Alzheimer’s disease, bipolar disorder, and delusional disorder, was also severely cognitively impaired per MDS and was receiving antidepressant, anticonvulsant, and antipsychotic medications. A psychiatric NP note described increased irritability, anger, and agitation, and recommended starting divalproex sodium 125 mg daily, which was subsequently titrated up to 500 mg twice daily according to physician orders. The MAR showed the medication was administered as ordered, but there was no documentation that the resident’s representative had been informed in advance of the risks versus benefits or had consented. The unit manager and DON stated that obtaining consent for this psychotropic medication was their responsibility and that it had been overlooked. A third resident, admitted with unspecified dementia, major depressive disorder, hallucinations, and anxiety disorder, had a psychiatric NP note describing increased evening agitation, cursing, and yelling at staff and peers, with a plan to start divalproex sodium 250 mg twice daily for disturbed mood and anxiety. Physician orders documented dose increases up to 500 mg twice daily for dementia and anxiety, and the MAR confirmed ongoing administration. The resident was identified as severely cognitively impaired on the MDS and was receiving antidepressant, anticonvulsant, and antipsychotic medications. The medical record lacked any documentation that the resident’s representative was informed in advance of the risks versus benefits of divalproex sodium or had provided consent. In interviews, the unit manager and DON again stated that consents for this psychotropic medication were not obtained and were overlooked, while the administrator stated he expected informed consents, including discussion of risks and benefits, to be obtained prior to starting or changing psychotropic medications.
Inconsistent Advance Directive Documentation and Missing DNR Forms
Penalty
Summary
The facility failed to maintain accurate and consistent documentation of advance directives across the medical record and related reference tools for two residents. For one cognitively intact resident, the care plan initiated on 04/18/25 documented a full code status with interventions to call 911 and initiate all life-sustaining measures if the resident’s heart or breathing stopped. However, the medical record contained a physician’s order dated 01/12/26 for Do Not Resuscitate (DNR), and a DNR form dated the same day was present in the advance directive binder at the nurse’s station. The MDS Coordinator stated it was the MDS nurse’s responsibility to update care plans when new orders were written and acknowledged that the resident’s care plan should have been revised on 01/13/26 after review of new orders, but this was missed. For another resident with severe cognitive impairment, the physician’s orders and care plan documented a DNR status, and the EMR banner also indicated DNR. The facility maintained an advanced directives notebook at the nurse’s station for quick reference in emergencies, but this resident’s DNR form was not present in the notebook. A nurse reported that in an emergency she would check both the EMR and the notebook, and if no DNR form was in the notebook, she would determine the resident to be full code. The unit manager and DON explained that DNR forms were to be completed on admission, kept in the notebook, and sent with the resident to the hospital, with the receiving nurse responsible for verifying the form’s return and the unit manager responsible for weekly checks. They indicated the resident’s DNR form likely did not return from a recent hospital transfer and had not been replaced or identified as missing, resulting in the absence of the DNR form in the notebook despite an active DNR order.
Failure to Request Level II PASRR After New Serious Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to request a Level II Preadmission Screening and Resident Review (PASRR) evaluation after a resident was given new diagnoses of serious mental health disorders. The resident had a Level I PASRR completed prior to or at admission, and the annual MDS later indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. However, the resident’s cumulative diagnoses list showed active diagnoses of Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder, recurrent severe without psychotic features, both added after admission. The resident’s care plan documented a possible history of an unknown traumatic event or experience, signs and symptoms of PTSD, and recent suicidal ideations, with interventions focused on meaningful activities, reducing known trauma triggers, and using techniques such as art to reminisce on positive memories. A psychiatric progress note documented ongoing treatment for major depressive disorder and PTSD, with the resident prescribed citalopram and instructions to continue monitoring for symptoms. Despite these documented serious mental health diagnoses and ongoing psychiatric treatment, review of the medical record revealed no Level II PASRR evaluation, and the facility could not provide documentation that a request for such an evaluation had been submitted. In an interview, the social worker stated that when the PTSD diagnosis was added, she reviewed the record, saw no new behaviors, and therefore did not request a Level II PASRR screen, and she could not find any record of a Level II PASRR request. The administrator stated that his expectation was that a Level II PASRR be requested when indicated by a new psychiatric diagnosis.
Failure to Provide Ordered Double Protein Portions for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and RD diet orders for double portions or double protein portions for two residents. One resident was admitted with hypothyroidism and a history of unintentional weight loss and had a physician order for a regular diet with double portions for weight management. The RD documented that the resident had a good appetite, usually ate 75–100% of meals, and that adding double portions to all meals helped stabilize the resident’s weight. The care plan directed staff to provide the diet as ordered and monitor intake, and the MDS showed the resident was cognitively intact and had no recent weight gain or loss. During a lunch observation, the resident’s meal ticket indicated a regular diet with double portions, but the tray contained only two chicken tenders, one serving of mashed potatoes, one serving of cabbage, and one dinner roll. The resident reported he was supposed to receive double portions and stated he had only received double portions approximately twice since admission, adding that he could eat four chicken tenders. The Dietary District Manager confirmed that double portions meant two servings of protein and that the resident should have received four chicken tenders. The Dietary Manager and Dietary Aide #1 both acknowledged that, given the physician order for double portions, the resident should have received four chicken tenders and that the aide, who was responsible for checking tray accuracy, had overlooked the missing double portion. A second resident, admitted with diabetes and adult failure to thrive, had a nutrition care plan noting nutritional risk related to multiple comorbidities, abnormal nutrition-related labs, and the need for a texture-modified diet. Interventions included RD evaluation and serving the diet as ordered. The MDS showed moderate cognitive impairment, dependence on staff for eating, a mechanically altered diet, and nutrition/hydration interventions for skin problems. The RD progress note documented a current order for a mechanical soft diet with double protein portions and end-of-life skin failure at multiple sites, and the physician’s order specified a mechanical soft diet with double protein portions. Observation of this resident’s lunch tray showed a chicken salad sandwich, potato salad, chopped broccoli salad, and mandarin oranges; the sandwich appeared uniformly thin with bread edges touching, indicating it did not contain a double protein portion. The RD later stated that double protein meant double meat in sandwiches, and the Dietary Manager explained that double protein portions should be plated using a #8 scoop so that the meat would be visibly thicker and prevent the bread from fully meeting, confirming that the observed sandwich did not meet the ordered double protein portion.
Failure to Maintain Clean and Sanitary Wheelchairs and Geri Chairs
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain sanitary wheelchairs and geriatric chairs for multiple residents. For one resident, repeated observations over several days showed a wheelchair with a dried yellow-brown substance on both armrests, the frame, and all four wheels, with no change in condition between observations. For a second resident, a geriatric chair was observed on multiple occasions with dried white and yellow substances on both armrests, a dried yellow-brown substance on the headrest padding to the left of the resident’s head, and visible strands of hair or string-like debris wrapped around parts of all four wheels, again with no improvement noted over several days. A third resident’s geriatric chair was observed on several different days with a dried white substance on both armrests and visible strands of hair or string-like debris wrapped around parts of all four wheels, with the condition persisting across all observations. In a joint interview, the Environmental Services Director reported that wheelchairs and geriatric chairs were cleaned once a month and as needed by housekeeping staff, and that the last cleaning occurred on 12/11/25. The Environmental Services Director also stated that housekeeping staff had not been notified by nursing staff that these specific chairs needed additional cleaning. The Administrator stated he expected wheelchairs and geriatric chairs to be clean and expected nursing staff to notify housekeeping if more frequent cleaning was needed.
Expired Medications Found in Facility's Storage Rooms
Penalty
Summary
The facility failed to remove expired medications and intravenous fluids from three of its four medication storage rooms, specifically the East, North, and Memory Care units. During observations, numerous expired syringes of Heparin and bags of Normal Saline were found, with expiration dates ranging from February 2022 to September 2024. The Assistant Director of Nursing (ADON) and the Unit Manager were responsible for ensuring that expired medications were not present, with the ADON claiming to have recently audited the medication carts and storage rooms. However, the ADON admitted to never checking the drawers where the expired Heparin was stored. Interviews with the ADON and the Director of Nursing (DON) revealed a lack of adherence to the facility's medication storage process. The ADON stated that she checked medication carts for expired medications and supplies but was uncertain about the thoroughness of her checks in the medication storage rooms. The DON confirmed that the ADON should have been checking for expired medications and supplies at least weekly, indicating a failure in following the established procedures for medication storage and management.
Inaccurate MDS Coding for Opioid Use and Bowel Continence
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of opioid medication and bowel continence. Resident #65, who was admitted with chronic pain, was not coded as taking opioid medications in her quarterly MDS assessment, despite receiving hydrocodone-acetaminophen twice daily during the assessment lookback period. Interviews with the MDS Nurse and Director of Nursing confirmed that the opioid medication should have been accurately coded, but a mis-click was identified as the cause of the error. Similarly, Resident #67, admitted with a fracture of the left femur, was inaccurately coded as 'not rated' for bowel continence in his significant change in status MDS assessment. However, records showed he had 10 bowel movements and was incontinent during the lookback period. The MDS Nurse acknowledged the mistake, attributing it to a mis-click, and the Director of Nursing confirmed that the resident's bowel continence should have been correctly coded. Both cases highlight the facility's failure to ensure accurate MDS assessments, as expected by the Administrator.
Failure to Deliver Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to ensure that supplemental oxygen was delivered at the physician-prescribed rate for a resident with coronary artery disease, heart failure, and chronic obstructive pulmonary disease (COPD). The resident was supposed to receive oxygen at 2 liters per minute, as per the physician's order. However, observations on two consecutive days revealed that the oxygen concentrator was set to deliver 4 liters per minute. The resident, who had moderately impaired cognition and required substantial assistance, was unaware of the correct oxygen setting and could not reach the concentrator to adjust it. Interviews with nursing staff revealed lapses in monitoring the oxygen concentrator settings. Nurse #1, responsible for the resident during the day shifts, admitted to not checking the setting on one of the days. Unit Manager #1 also failed to verify the correct setting, focusing only on the tubing and bag changes. The Director of Nursing acknowledged that nurses were responsible for checking the settings every shift but learned that the resident might have been adjusting the concentrator using a Reacher. The facility had not identified this as a problem or included it in the care plan for more frequent monitoring.
Failure to Implement Pharmacy Recommendations for Antipsychotic Monitoring
Penalty
Summary
The facility failed to implement a pharmacy recommendation for a resident receiving antipsychotic medication. The resident, who was admitted with a diagnosis of schizophrenia, was prescribed risperidone at varying dosages over several months. A pharmacy report dated August 16, 2024, recommended adding side effect and behavior monitoring to the resident's medication regimen. However, reviews of the Medication Administration Records from July to November 2024 showed no such monitoring instructions were added. Interviews with the Consultant Pharmacist, Director of Nursing (DON), and the Administrator revealed that the recommendation was acknowledged but not acted upon. The Consultant Pharmacist expected the facility to implement the monitoring before her next review, but her follow-up was delayed due to a hurricane. The DON admitted awareness of the recommendation but stated it was overlooked despite having sufficient time to address it. The Administrator expressed an expectation for staff to follow pharmacy recommendations when provided.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to monitor side effects and behaviors for an antipsychotic medication prescribed to a resident diagnosed with schizophrenia. The resident was admitted with intact cognition and was receiving risperidone, an antipsychotic medication, with dosage adjustments over several months. Despite a pharmacy report suggesting the addition of monitoring instructions for side effects and behaviors, the Medication Administration Records (MAR) from July to November did not include these directions. Interviews with staff revealed that the responsibility for adding monitoring instructions to the MARs was not fulfilled. Nurse #1, who was the resident's full-time nurse, acknowledged the absence of monitoring instructions and admitted it was her oversight. The Consultant Pharmacist had notified the facility of the need for monitoring instructions in August, but due to scheduling disruptions, a follow-up review was delayed. The Director of Nursing was aware of the pharmacist's request but admitted it was overlooked. The Administrator expected staff to address pharmacy recommendations, but this was not done in this case.
Infection Control Deficiencies During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control program as evidenced by the actions of two nurse aides during incontinence care for a resident with a stage IV sacral wound. Nurse Aide #1 did not adhere to the facility's hand hygiene policy by failing to sanitize her hands after removing soiled gloves multiple times during the care process. Despite the presence of a hand sanitizer dispenser in the resident's room, the aide neglected to use it, citing nervousness due to being observed. This lapse in hand hygiene occurred after contact with the resident's soiled dressing and before applying lotion to the resident's back. Additionally, Nurse Aide #2 mishandled soiled linen by throwing it on the floor after removing it from the resident's bed, contrary to the facility's policy that requires soiled linen to be placed directly into a designated container. The Unit Manager, who was present during the care, acknowledged witnessing the improper handling of the linen but did not intervene in time to correct the action. Both aides had recently attended a skills fair that included education on infection control, yet these deficiencies were observed during their care of the resident.
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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