The Greens At Pinehurst Rehabilitation & Living Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Pinehurst, North Carolina.
- Location
- 205 Rattlesnake Trail, Pinehurst, North Carolina 28374
- CMS Provider Number
- 345177
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Greens At Pinehurst Rehabilitation & Living Ce during CMS and state inspections, most recent first.
The facility failed to accurately code MDS assessments for medications for two residents. One resident with bladder dysfunction and urinary retention was coded on a quarterly MDS as receiving an antibiotic during a seven-day assessment period, even though the MAR showed no antibiotic administration during that time, which the MDS coordinator later confirmed as an error. Another resident with dementia, psychotic disturbance, and PTSD was ordered Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR showed it was given; however, the MDS nurse coded this as an antianxiety medication on the MDS, later acknowledging that Hydroxyzine is an antihistamine and that the antianxiety classification on the assessment was incorrect.
A resident with major depressive disorder, generalized anxiety disorder, and PTSD was admitted with a short‑term Level II PASRR approval that had a defined expiration date. The admission MDS showed the resident had not been evaluated and determined to have a serious mental illness, intellectual disability, or related condition under a current Level II PASRR. Facility records contained no evidence that staff submitted a referral to obtain a new Level II PASRR evaluation before the prior approval expired. In interviews, the SW acknowledged that the Level II PASRR had expired without renewal due to an oversight, and the Administrator stated that PASRR evaluations were expected to be monitored and updated before expiration.
A resident with hypertension and constipation had physician orders for Metoprolol and MiraLax via G-tube twice daily, scheduled for administration at 9:00 AM. On one occasion, an agency nurse fell behind on the morning med pass and did not administer these medications until around noon, outside the facility’s one-hour before/after scheduled time requirement. The nurse did not request assistance despite prior instructions for agency staff to do so if they were falling behind. The DON and Medical Director confirmed that medications were required to be given within the established one-hour window and that this expectation was not met, although the resident showed no clinical ill effects.
A resident with dysphagia, gastrostomy status, and aphasia following a stroke was receiving continuous enteral feeding and scheduled water flushes via G-tube. A nurse administered medications through the G-tube using a syringe she had noticed was discolored, then rinsed it with water, separated the syringe and plunger, and stored them in a plastic bag without allowing them to air dry. Later observation found the syringe tip and lower barrel coated with thick, crusted yellow material and the storage bag containing water droplets with pooling. The DON stated the syringe should have been washed, allowed to dry before storage in a dry bag, and that a stained syringe should have been discarded and replaced. This practice had the potential to cause bacterial growth and contamination.
Surveyors found that the ADON failed to follow infection control policies for hand hygiene and glove use while performing wound care on two residents under enhanced barrier precautions for wounds and, for one resident, an indwelling urinary catheter. The ADON did not perform hand hygiene before donning gloves, did not change gloves or perform hand hygiene between removing soiled dressings and applying clean dressings, and placed soiled dressings and used gauze on clean barriers next to unused supplies. She also exited a room wearing a gown, retrieved supplies from the hallway, reentered without hand hygiene, and continued wound care without appropriate glove changes, contrary to facility policies requiring hand hygiene at specified points and proper handling of soiled and clean items.
The facility failed to ensure residents and their representatives were routinely invited to participate in care planning. A cognitively intact resident and the resident’s representative were not included in multiple care plan meetings, and the resident reported never being invited or informed about such meetings despite wishing to participate. Another resident with dementia and multiple comorbidities had a representative who received only one invitation to a care plan conference and was unaware that regular care plan reviews should occur. The SW reported she had only been organizing 72‑hour post‑admission or concern‑driven meetings, was unaware she was responsible for scheduling routine quarterly and annual care plan conferences based on the MDS calendar, and confirmed these had not been completed for all residents. The administrator acknowledged learning that required quarterly and annual care plan meetings and invitations for residents and representatives had not been carried out as expected.
A dependent resident with a contracted hand and reduced mobility, care planned as needing assistance with personal hygiene and documented on MDS as dependent for personal hygiene, did not receive appropriate fingernail care. Over multiple observations, the resident’s fingernails remained long, jagged, and soiled, despite the resident’s stated preference for short nails and reports that long nails caused discomfort by stabbing into the contracted hand. Bath and skin review documentation addressed only toenails, and weekly skin assessments lacked fingernail documentation. The assigned NA acknowledged not providing or offering nail care during a bed bath, and nursing staff interviews confirmed that nail care oversight during weekly skin assessments and routine hygiene was not carried out for this resident.
A resident with intractable epilepsy and moderately impaired cognition had physician orders and a care plan directing scheduled anti-seizure medications via G-tube to be given at specific morning times. On one morning, an agency nurse fell behind on medication administration and did not give the resident’s 8:00 AM and 9:00 AM anti-seizure doses until shortly after noon, 3–4 hours late and outside the facility’s one-hour before/after policy window, and did not request assistance despite prior instruction that agency staff should do so if behind. Review of the MAR, interviews with the nurse, DON, and Medical Director, and the resident’s record confirmed the delay and that the medications were not administered as ordered, although the resident showed no documented clinical ill effects.
The facility failed to accurately post and maintain daily nurse staffing information, with multiple days where the posted counts of NAs, an RN, and LPNs did not match the actual staffing schedule, including miscounts and misclassification of an RN as an LPN. The Scheduler acknowledged not updating postings when staff called out, did not show, or when coverage staff arrived. On at least one observed day, the daily staffing sheet in the reception area was not current, displaying an outdated date instead of the day’s staffing, while the Scheduler and DON each believed the other had ensured proper posting, and leadership later suggested the sheet may have been removed and not replaced.
The facility failed to date leftover food items in the dry goods storage area and walk-in cooler, as observed during a survey. Issues included undated corn flakes, brown sugar, sliced cheese, sliced ham, and cooked mixed vegetables. Staff interviews revealed a lack of adherence to proper food storage protocols, with the new Dietary Manager acknowledging responsibility for ensuring correct dating and storage.
The facility failed to accurately code MDS assessments for falls for three residents. One resident with vascular dementia had a fall with a minor injury that was not recorded. Another resident with a history of stroke and repeated falls had multiple falls, but only one was recorded. A third resident with dementia had two falls without injuries, which were not reflected in the assessments. The MDS Coordinator confirmed these were oversights.
Expired Latanoprost eye drops were found in a medication cart during an observation at an LTC facility. Nurse #1 confirmed the medications were expired and removed them. The DON stated that nurses are responsible for checking expiration dates, but there was no set schedule for unit managers to do so. The facility Pharmacist visits bi-monthly to check carts but did not recall which carts were reviewed last.
The facility did not ensure that NAs received their required annual Dementia training, affecting four NAs who had not been trained since June 2023. The DON and Administrator acknowledged the oversight, which was attributed to the SDC's medical leave. The DON confirmed the training should be completed yearly, and the Administrator expected it to be done annually.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for medications for two residents. For one resident with bladder dysfunction and urinary retention, review of the Medication Administration Record (MAR) for a specified seven-day period showed that no antibiotic medications were administered. However, the quarterly MDS assessment for that same assessment period was coded to indicate the resident had received an antibiotic. Upon review of the MDS and MAR, the MDS Coordinator confirmed that the antibiotic entry on the MDS was incorrect and that the resident had not received an antibiotic during the assessment window. For another resident with dementia with psychotic disturbance and PTSD, physician orders directed administration of Hydroxyzine 12.5 mg twice daily for anxiety, and the MAR confirmed the medication was given as ordered throughout the month reviewed. The quarterly MDS assessment, completed by an MDS nurse, documented that the resident was receiving medications from the antianxiety drug classification and included indications for antianxiety use. During interview, the MDS nurse stated the resident was not ordered any medications classified as antianxiety drugs and acknowledged she had coded the resident as receiving antianxiety medications based on the Hydroxyzine order, being unsure of its drug class. After reviewing medication information, she confirmed Hydroxyzine is classified as an antihistamine and acknowledged that coding it as an antianxiety medication on the MDS was an error.
Failure to Renew Expired Level II PASRR Authorization
Penalty
Summary
The facility failed to obtain a new Level II Preadmission Screening and Resident Review (PASRR) evaluation after the expiration of a short‑term approval for nursing home placement for one resident. The resident was admitted with diagnoses including major depressive disorder, generalized anxiety disorder, and post‑traumatic stress disorder, and the admission MDS indicated the resident had not been evaluated by a Level II PASRR and determined to have a serious mental illness, intellectual disability, or related condition. Record review showed the resident was admitted with a Level II PASRR for short‑term admission that had a specific issuance and expiration date, but there was no documentation that the facility submitted a referral for another Level II PASRR evaluation to extend approval beyond the expiration date. In interviews, the Social Worker confirmed that the resident’s Level II PASRR for short‑term admission had expired and acknowledged that she had not submitted a request for another Level II PASRR evaluation, describing the lapse as an oversight that had fallen through the cracks and stating that a new evaluation should have been requested before the temporary one expired. The Administrator stated that she expected PASRR evaluations to be monitored and kept up to date and acknowledged that a review for this resident should have been requested before the expiration date.
Late Administration of Scheduled Medications Outside Required Time Frame
Penalty
Summary
The deficiency involves the facility’s failure to administer scheduled medications as ordered by the physician and within the facility’s required time frame for one resident. The resident was admitted with diagnoses including hypertension and constipation and had active physician orders for Metoprolol Tartrate 25 mg via G-tube twice daily for hypertension, with parameters to hold for heart rate less than 65 or systolic blood pressure less than 100, and MiraLax 17 gm/scoop via G-tube twice daily for constipation. The March 2026 MAR showed both Metoprolol and MiraLax were scheduled for 9:00 AM but were not administered until 12:07 PM on a specific date, outside the facility’s accepted window of one hour before or one hour after the scheduled time. During interview, the nurse who administered the medications stated he was an agency nurse working intermittently at the facility and reported that he fell behind on morning medication administration and did not give the resident’s morning medications until noon. He acknowledged that he did not request assistance to ensure medications were given on time. The DON stated that medications were required to be administered on time, that agency staff had been instructed to request assistance if they fell behind, and that medications should be given within one hour before or after the scheduled time. The Medical Director confirmed that the resident experienced no ill effects and that vital signs remained within normal limits, and he acknowledged the facility’s requirement that medications be administered within the one-hour window and his expectation that staff follow this policy.
Improper Cleaning and Storage of G-Tube Syringe
Penalty
Summary
The deficiency involves the facility’s failure to properly clean and dry a G-tube syringe before storage for a resident receiving enteral nutrition and medications. The resident had diagnoses including unspecified dysphagia, gastrostomy status, and aphasia following a stroke, and received more than half of her total calories from enteral feedings. Active orders included continuous tube feeding at 72 ml/hr over 20 hours with water flushes every 4 hours. Review of the MAR showed that a nurse administered medications via the G-tube in the morning. Later that morning, surveyors observed the resident’s G-tube flush syringe stored in a plastic bag hanging from the feeding pump pole, labeled as changed at midnight. The syringe was separated from the plunger, but the elongated tip and lower third of the barrel contained thick, crusted yellow material, and the storage bag contained water droplets with pooling at the bottom. During interview, the nurse who had administered the medications acknowledged that she had observed the syringe was discolored when she used it earlier. She stated that some medications could stain syringes and reported that she rinsed the syringe with water after use but had no supplies to scrub it. She explained that she separated the syringe and plunger and placed them into the storage bag after rinsing, and she was not aware that the syringe and plunger should be allowed to air dry before being placed into a clean, dry bag. The DON later stated that the syringe should have been washed, the plunger removed to allow drying before storage in a dry bag to prevent bacterial growth, and that the stained syringe should have been discarded and replaced, with G-tube syringes routinely replaced on night shift. The report states that this deficient practice had the potential to cause bacterial growth and contamination.
Failure to Follow Hand Hygiene and Glove Protocols During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene and glove use during wound care. The facility’s policy required alcohol-based hand rub as the preferred method of hand hygiene when hands are not visibly soiled, and specified hand hygiene before donning gloves, before handling clean or soiled dressings, after handling used dressings or contaminated equipment, and after removing gloves. The enhanced barrier precautions protocol required staff to wear gloves and a gown for high-contact resident activities such as wound care and to perform hand hygiene before and after leaving the resident’s room. During wound care for a resident on enhanced barrier precautions for wounds and an indwelling urinary catheter, the Assistant Director of Nursing (ADON) donned a gown and gloves before entering the room and placed a clean towel as a barrier on the bedside table, then placed clean supplies on it. She removed a soiled dressing from the resident’s right foot and placed it on the clean barrier next to unused supplies, did not remove gloves or perform hand hygiene before cleaning the wound, and then opened and applied collagen and a bordered dressing without changing gloves or performing hand hygiene. She then removed a soiled sacral dressing, placed it on the bedside barrier, cleaned the sacral wound, and again opened and applied collagen and a bordered dressing without changing gloves or performing hand hygiene between handling soiled items and clean supplies. In a separate observation of wound care for another resident on enhanced barrier precautions for a wound, the ADON donned a gown and gloves without performing hand hygiene before entering the room. She placed a clean towel and clean wound care supplies on the bedside table, repositioned the resident, removed a soiled sacral dressing and left it on the bed, then cleaned the wound and placed used gauze on the towel next to clean supplies. Without removing gloves or performing hand hygiene, she opened collagen with silver, applied it to the wound, and applied a silicone-bordered dressing. She removed her gloves without performing hand hygiene, exited the room wearing the gown, retrieved tape from the wound cart in the hallway, reentered the room without hand hygiene, and donned clean gloves. She then removed a soiled dressing from the resident’s right foot, left it on the bed, and wrapped the foot with a dry dressing without changing gloves or performing hand hygiene between soiled and clean tasks. After completing wound care, she discarded used dressings and the towel, removed her gown and gloves, and washed her hands. These observations showed failure to follow the facility’s infection control policies for hand hygiene, glove changes, and handling of soiled dressings and clean supplies during wound care under enhanced barrier precautions.
Failure to Involve Residents and Representatives in Routine Care Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and/or their representatives with the opportunity to participate in the care planning process as required. For one cognitively intact resident, the 5‑day MDS showed intact cognition, yet review of the electronic health record revealed that neither the resident nor the resident representative were listed as attendees at multiple care plan meetings. In an interview, this resident reported never being invited to a care plan meeting since admission, was unaware that such meetings were held, and stated he would have liked to attend with his daughter to be actively involved in his care plan. The social worker acknowledged that she had not sent invitations to this resident for care planning meetings and confirmed that quarterly or annual care plan meetings with residents and/or representatives had not been completed. For another resident with dementia with psychotic disturbance, PTSD, abnormal weight loss, failure to thrive, and anemia, MDS assessments documented severe cognitive impairment. Records showed that the resident’s representative received only one written invitation to a care plan conference, which occurred in November and was documented as including the representative. The representative confirmed being notified and invited only once and was unaware that routine care plan conferences should have occurred. The social worker stated she had only been sending invitations and holding care meetings for 72‑hour post‑admission residents or when concerns were expressed, and that she was unaware she should have been inviting all residents and/or representatives on a routine basis based on the MDS calendar. She confirmed that quarterly and annual care plan meetings for all residents and/or representatives had not been completed because she did not know it was her responsibility. The administrator stated she had been made aware that annual and quarterly care plan meetings had not been completed for all residents and that residents and/or representatives were not invited to attend care planning meetings, despite her expectation that plans of care be reviewed quarterly and as needed with them.
Failure to Provide Required Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to provide adequate fingernail care for a dependent resident who required assistance with activities of daily living, including personal hygiene. The resident was admitted with a contracture of the left hand and reduced mobility and had a care plan indicating an ADL self-care performance deficit, with dependence on staff for personal hygiene. A significant change MDS documented the resident as cognitively intact, without rejection of care, and dependent on others for personal hygiene. Bath skin review sheets for multiple dates documented only toenail condition, with no reference to fingernails. During observations on two consecutive days, the resident’s fingernails on both hands were noted to be jagged or broken, extended more than 1/4 inch past the fingertips, and had a brown substance underneath the free edge of the nails. The left hand fingers were curled inward due to contracture, though no wounds were observed in the palm when the resident uncurled the fingers using the right hand. In interviews, the resident stated a preference for short fingernails, especially on the contracted left hand, explaining that long nails often stabbed into the palm and caused discomfort. The resident reported that NAs sometimes cleaned under her nails but no one had offered to cut them, and later confirmed that although she received a bath, her fingernails were not cleaned. The NA assigned on one of the observation days acknowledged typically checking nails during baths but admitted she did not provide or offer nail care during the resident’s bed bath that morning and did not provide a reason. Nurse #1 stated that it was the assigned nurse’s responsibility to ensure nail care was provided and that nurses were supposed to complete a nail review during weekly skin assessments, but was unsure when the resident was due for such an assessment. Review of the weekly skin assessments showed no documentation regarding the resident’s fingernails on the last recorded assessment, and the DON stated she expected NAs to provide nail care on bath days and had designated an NA to complete weekly nail inspections, but was unsure how this resident’s nail care had been missed.
Late Administration of Anti-Seizure Medications by Agency Nurse
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when scheduled anti-seizure medications were not administered as ordered. Resident #12, admitted with intractable epilepsy without status epilepticus and with moderately impaired cognition, had active physician orders for Lacosamide 150 mg twice daily via G-tube, Levetiracetam 1000 mg every morning and at bedtime via G-tube, and Phenytoin Sodium Extended 100 mg twice daily via G-tube. The resident’s care plan included an intervention to give anti-seizure medications as ordered by the physician. The March 2026 MAR showed that Phenytoin Sodium Extended 200 mg was scheduled for 8:00 AM, Lacosamide 150 mg for 9:00 AM and 5:00 PM, and Levetiracetam 1000 mg for 9:00 AM and 9:00 PM. On 3/16/26, Nurse #2, an agency nurse who worked intermittently at the facility, did not administer the resident’s scheduled 8:00 AM and 9:00 AM anti-seizure medications until 12:07 PM, resulting in the medications being given 3 to 4 hours late and outside the facility’s acceptable one-hour before/after administration window. In an interview, Nurse #2 stated he fell behind on morning medication administration and did not request assistance to ensure medications were given on time. The DON stated that seizure medications were required to be administered on time, that agency staff had been instructed to request help if they fell behind, and that she was unaware the medications had been given outside the acceptable timeframe. The Medical Director confirmed the late administration of the anti-seizure medications and noted that, although the resident did not appear to have suffered ill effects and vital signs remained within normal limits with no documented seizure activity, the delay could have increased the resident’s risk for seizure activity.
Failure to Accurately Post and Maintain Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information and to ensure that the posted information matched the actual staffing schedule. Record review of 30 days of postings compared to the staffing schedules showed discrepancies on 7 days, including incorrect counts of NAs on various shifts and an incorrect count and classification of an RN and LPNs on one day. The Scheduler confirmed that she did not update the posted staffing sheet when staff called out, were no-shows, or when replacement staff came in, and she acknowledged miscounting an RN as an LPN on one shift. The Administrator stated that the daily posted nurse staffing sheet and the nursing schedule should match the number of staff who actually worked each shift. The facility also failed to ensure that the daily staffing sheet was posted on at least one observed day. During the initial tour and a later observation on the same day, the staffing posting in the reception area was dated several days earlier, indicating that the current day’s staffing information was not displayed. The Scheduler stated that she or the DON were responsible for posting the daily staffing sheets on weekdays and believed the DON had posted the sheet that morning. The DON reported that she had posted the sheet early that morning and suggested it might have been removed for review and not replaced. The Administrator reported being told by the DON that the sheet had been posted and suggested it was possible someone removed it and failed to return it to the display area.
Improper Food Storage and Dating in Facility
Penalty
Summary
The facility failed to properly date leftover food items stored in the dry goods storage area and the walk-in cooler, as observed during a survey. Specific issues included an open and undated bag of corn flakes, an undated bag of leftover brown sugar stored in an unsealed plastic bag, an undated leftover package of sliced cheese, an undated leftover package of sliced ham, and a stainless-steel container with cooked mixed vegetables that had not been dated. These observations were made during a survey conducted on December 2, 2024. Interviews with staff revealed a lack of adherence to proper food storage protocols. The Dietary Manager, who was new to the position, acknowledged her responsibility for ensuring food items were dated and stored correctly. Another staff member indicated awareness that refrigerated leftovers should be used within three days and dry goods should be sealed, labeled with an open date, and used within seven days. The Dietary Aide confirmed that food items should be sealed, dated, and checked daily for expiration. The Administrator also acknowledged the importance of sanitary and safe food practices and noted the Dietary Manager's newness to the role.
Inaccurate MDS Coding for Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the area of falls. Resident #63, who was admitted with vascular dementia, experienced a fall with a minor injury on 9/20/24, which was not recorded in the annual MDS assessment dated 11/9/24. The MDS Coordinator confirmed the oversight during an interview. Similarly, Resident #64, with a history of stroke and repeated falls, had multiple falls between 7/5/24 and 8/7/24, but the quarterly MDS assessment dated 9/15/24 only recorded one fall with minor injury. The MDS Coordinator acknowledged the error, stating it was an oversight. Resident #3, diagnosed with dementia, had falls on 7/24/24 and 8/5/24, both without injuries. However, these incidents were not reflected in the quarterly MDS assessments dated 7/31/24 and 9/15/24, respectively. The MDS Coordinator confirmed the omissions during an interview, attributing them to oversight. The facility's Administrator expressed that it was his expectation for MDS assessments to be coded accurately in the area of falls.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to discard expired medications in one of the two medication carts reviewed for storage and labeling. During an observation of the Masters Hall medication cart, it was found that there were three opened bottles of Latanoprost eye drops, all of which were past the manufacturer's recommended discard date of six weeks after opening. Nurse #1 confirmed the medications were expired and removed them from the cart. She admitted to not checking the medication cart for expired medications on the day of the observation. The Director of Nursing stated that all nurses were responsible for checking the dates on multi-use medications before administration to ensure they were not expired. However, there was no set schedule for unit managers to check the medication carts for expired medications. The facility Pharmacist, who visits every other month, also checks the medication carts for expired medications but did not recall which carts were reviewed during the last visit in October. The Pharmacist confirmed the manufacturer's recommendation for discarding Latanoprost eye drops six weeks after opening.
Failure to Provide Annual Dementia Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) received their required annual Dementia training. This deficiency was identified for four NAs, who had not received Dementia training since June 2023. The NAs in question had been employed at the facility for varying lengths of time, with hire dates ranging from December 1999 to December 2022. During interviews, both the Director of Nursing (DON) and the Administrator acknowledged the oversight, attributing it to the absence of the Staff Development Coordinator (SDC) due to medical leave since October 2024. The DON confirmed that the Dementia training should be completed yearly, and the Administrator stated it was his expectation that the NAs receive this training annually.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
