The Laurels Of Pender
Inspection history, citations, penalties and survey trends for this long-term care facility in Burgaw, North Carolina.
- Location
- 311 S Campbell Street, Burgaw, North Carolina 28425
- CMS Provider Number
- 345298
- Inspections on file
- 19
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at The Laurels Of Pender during CMS and state inspections, most recent first.
Surveyors found multiple opened insulin pens and an insulin vial on several medication carts without documented opened dates, despite manufacturer instructions requiring discard after a set number of days once opened. A medication aide on one hall reported that staff were responsible for checking carts for expired medications but stated she did not check insulin dates because she could not administer insulin, while the unit manager confirmed nurses were expected to date insulin pens when opened and identified from pharmacy labels when the pens were received. On another cart, a nurse acknowledged that all nurses were responsible for ensuring insulin products were dated when opened and that the undated Tresiba pen, Lispro vial, and Insulin Glargine pen should have been labeled so staff would know their use-by timeframe. On a skilled care cart, another medication aide similarly stated that all staff should check for expired medications but did not check insulin dates, and the overseeing unit manager admitted she should have verified that all opened insulin pens were dated. The DON stated her expectation that nurses date all insulin pens and vials upon opening so staff can determine if they remain appropriate for use.
Surveyors found that staff failed to properly label, date, and discard opened and expired food items in the kitchen freezers, dry goods storage, and nourishment rooms. Opened bread products in the freezers and dry storage lacked opened and expiration dates, and an opened nectar-consistency nutritional supplement in a nourishment room had no date despite manufacturer instructions for use within a limited time. Disposable food containers labeled with a resident’s name were either missing dates or not discarded within the facility’s stated three-day limit for outside food. The Dietary Manager and Administrator acknowledged expectations that nursing staff label outside food and dietary staff monitor and discard expired items, but these practices were not consistently followed.
A resident admitted with bipolar disorder, dementia, and anxiety was started on multiple psychotropic medications, including an antipsychotic, an anticonvulsant/mood stabilizer, and an antidepressant, which were administered as ordered. The admission MDS showed the resident was cognitively intact and receiving these medications, but review of the electronic record found no completed psychotropic consent form and no documentation that risks versus benefits of the medications had been reviewed with the resident or a representative. The unit manager, NP, and DON all confirmed that the psychotropic consent form should have been completed by the admitting nurse at admission, with a discussion of risks versus benefits prior to medication administration, but this did not occur or was not documented.
A resident with ESRD and a right upper arm A/V fistula, documented by the hospital and facility staff as positive for bruit and thrill but not yet mature, was admitted and later readmitted with a right chest permacath for dialysis. Although the care plan referenced protecting and monitoring the fistula, physician orders and the MAR addressed only the permacath, with no orders to assess the A/V fistula for bruit, thrill, or signs of infection, and no formal restrictions on blood pressures or lab draws in that arm. Multiple nurses, the unit manager, wound nurse, NP, and DON acknowledged the presence of the fistula and indicated that “batch orders” for fistula care should have been initiated on admission, but these orders were never entered, resulting in the fistula not being formally assessed or managed per provider orders.
A resident with orthostatic hypotension was prescribed midodrine with specific blood pressure hold parameters, yet nursing staff and medication aides repeatedly documented administering the drug when systolic blood pressure readings exceeded the ordered threshold. During two consecutive monthly medication regimen reviews, the Consultant Pharmacist reviewed the MARs but documented no new irregularities and did not address these administrations outside the ordered parameters. In interviews, the pharmacist acknowledged that his review process should have identified medications given outside ordered parameters and admitted missing these irregularities, while the DON confirmed that identifying such issues was an expected part of the monthly review.
A resident with hypotension had an order for midodrine 2.5 mg BID with instructions to hold the dose if SBP exceeded 120 mm/Hg or DBP exceeded 80 mm/Hg, but the MAR repeatedly showed the drug as administered despite recorded SBP values above the ordered parameter. Multiple nurses and a medication aide later stated they had either held the medication or not given it, yet documented it as administered on the electronic MAR. The DON reported that medications were expected to be documented accurately and that held medications should be recorded as held with the reason, and confirmed that documentation for this resident’s midodrine was inaccurate.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy when two nurse aides provided incontinence care to a resident with a tracheostomy, gastrostomy tube, and Stage IV sacral pressure ulcer while wearing gloves but not gowns, despite EBP signage and PPE supplies at the room and prior infection control training. The Infection Control Preventionist and DON confirmed that gowns should have been used for this high-contact care under EBP. In addition, the facility did not follow its Tuberculosis Control Plan for a newly admitted resident: although Step 1 of the two-step tuberculin skin test (TST) was completed with a negative result, Step 2 was not administered within the required 1–3 week window and was delayed for several months after an initial documented refusal, without timely re-offer, contrary to facility policy and acknowledged guidelines.
A resident admitted after surgical repair of a left femur fracture had hospital orders for Aquacel dressing and a subsequent physician order for weekly cleansing and silicone foam with silver dressing to the left thigh incision, with a care plan directing wound treatments as ordered and monitoring for infection. Despite these orders, no wound care was documented for nearly two weeks, and the Treatment Administration Record showed one missed treatment without explanation in the progress notes. An RN reported the resident refused care once and never received wound care from her, while the Wound Nurse acknowledged not completing or documenting wound care attempts after reported refusals. A nurse aide stated the resident would often accept care if re-approached. When wound care was finally performed, the original hospital dressing remained in place, and only then was the incision assessed and redressed, contrary to the ordered schedule.
A nursing assistant misappropriated funds from a resident by using the resident's bank account information to create a Cash App account and transferring money to herself and family members. The resident, who had multiple chronic health conditions and was assessed as cognitively intact, denied ever giving permission for these transactions. The misappropriation was discovered by a family member and confirmed through facility investigation and law enforcement, with the nursing assistant ultimately admitting to accepting money in violation of facility policy.
Failure to Date Opened Insulin Pens and Vials on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multi-dose insulin pens and an insulin vial were dated when opened, as required to comply with manufacturer instructions for safe use. During observation of the 400-hall medication cart with a medication aide, surveyors found opened Humalog and Lantus prefilled insulin pens without an opened date, despite manufacturer directions to discard them 28 days after opening. The medication aide stated that nurses and medication aides were responsible for checking medication carts for expired medications but explained that, as a medication aide, she could not administer insulin and did not check dates on insulin products. The unit manager for that hall stated that nurses should be checking the carts to ensure there were no expired medications and that all insulin pens were dated once opened, and she identified from the pharmacy labels that the Lantus and Humalog pens had been received on 01/12/26 and had been used without being dated when opened. On the 100-hall long-term care medication cart, observed with a nurse, surveyors found an opened Tresiba prefilled insulin pen, an opened Lispro insulin vial, and an opened Insulin Glargine prefilled insulin pen, all without opened dates, even though manufacturer instructions required discarding Tresiba 56 days after opening and the Lispro vial and Insulin Glargine pen 28 days after opening. The nurse stated that all nurses were responsible for checking their medication carts for expired medications and ensuring insulin pens and vials were dated when opened, and acknowledged that these insulin products should have had an opened date so staff would know when they should be used by. On the 100-hall skilled care medication cart, observed with another medication aide, an opened Lantus prefilled insulin pen was found without an opened date, despite manufacturer instructions to discard after 28 days once opened. This medication aide stated that all nurses and medication aides were responsible for checking medication carts for expired medications but, as a medication aide who could not administer insulin, she did not check opened dates on insulin pens. The overseeing unit manager stated she should have checked the cart at the start of the shift to ensure all insulin pens were dated once opened. The DON reported that her expectation was that once an insulin pen or vial was opened, nurses should place an opened date on it so they could determine if the medication was still good for use according to manufacturer instructions.
Failure to Label, Date, and Discard Opened and Expired Food Items
Penalty
Summary
Surveyors identified a deficiency related to food storage and labeling practices in the facility’s kitchen, freezers, dry goods storage, and nourishment rooms. During an initial kitchen tour with the Dietary Manager, surveyors observed multiple opened food items in the front kitchen freezer and an outside freestanding freezer, including bread sticks, biscuits, and garlic bread, that lacked any opened dates or expiration dates. In the dry goods storage room, an opened package of hamburger buns and an opened loaf of bread that were no longer in their original packaging were also found without opened dates or expiration dates. The Dietary Manager acknowledged that all opened foods in the freezer and dry goods storage should be labeled with the date opened and the expiration date. Further observations in the nourishment rooms revealed additional labeling and dating failures. In the 400-hall nourishment room, surveyors found an opened container of nectar-consistency nutritional supplement with no opened date or expiration date, despite the manufacturer’s label stating it should be consumed within four days of opening. A disposable food container labeled with a resident’s name but without a date received or expiration date was also present. In the 100-hall nourishment room, a disposable food container with a resident’s name was dated but not discarded after the facility’s stated three-day limit for outside food. The Dietary Manager stated there should not be any expired food in the nourishment rooms, that nursing staff were responsible for labeling outside food with the resident name and date received, and that dietary staff were responsible for monitoring expiration dates and discarding expired food and supplements. The Administrator stated he expected staff to check for expired food and to label and date food stored in the kitchen and nourishment rooms.
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 administration for one resident. Resident #98 was admitted with diagnoses including bipolar disorder, dementia, and anxiety, and had physician orders dated 01/07/26 for multiple psychotropic medications: Amitriptyline 25 mg, two tablets in the evening for bipolar disorder; Depakote Sodium ER 500 mg, three tablets in the evening for dementia; and Seroquel 300 mg, one tablet in the evening for dementia. The Medication Administration Record from 01/07/26 through 01/15/26 showed that these medications were administered as ordered during this period. The admission MDS assessment documented that the resident was cognitively intact and received antipsychotic, anticonvulsant, and antidepressant medications during the assessment period. Record review revealed no documentation that Resident #98 or a resident representative had consented to, or had been informed in advance of, the risks versus benefits of receiving Seroquel and Amitriptyline. Unit Manager #2 explained that the admission packet includes a checklist, with item #6 being the psychotropic medication consent form that should be reviewed and signed and is located in the electronic record; upon review of the electronic record, she confirmed there was no documentation of this consent or of a risks-versus-benefits discussion. The Nurse Practitioner stated that the psychotropic consent form should have been completed upon admission and that it was important for the nurse to inform the resident of the risks versus benefits of each psychotropic medication prior to administration. The DON similarly reported that the psychotropic consent form should have been completed by the admitting nurse at admission, with risks versus benefits discussed for each ordered psychotropic medication before the medications were given.
Failure to Obtain and Implement Orders for Assessment of Maturing A/V Fistula in Dialysis Resident
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement provider orders to assess and manage a maturing right upper extremity arteriovenous (A/V) fistula for a resident with end stage renal disease who was dependent on dialysis. Hospital records dated 12/08/25 documented that the resident had an A/V fistula placed in October 2025 in anticipation of dialysis, which was positive for bruit and thrill but not yet mature, and that a permacath was placed during that hospitalization. On admission and readmission to the facility in December 2025 and January 2026, the resident’s diagnoses included end stage renal disease with dependence on renal dialysis, and the Minimum Data Set reflected that the resident was receiving dialysis services. The care plan dated 12/17/25 identified risk for complications related to dialysis and included interventions such as not drawing blood or taking blood pressure in the arm with the fistula, observing for signs of infection, palpating for thrill, and listening for bruit, with instructions to report abnormalities to the physician. Despite these care plan interventions, the physician orders written on 12/18/25 and again on 01/11/26 addressed only the permacath, specifying dialysis days and monitoring the catheter site for bleeding, infection, and intact caps, with no orders to assess or protect the right arm A/V fistula. Nursing documentation, including skilled care notes and skin assessments, repeatedly acknowledged the presence of the right upper arm A/V fistula and described it as positive for bruit and thrill or as a dialysis access, while also noting the right chest permacath. The Medication Administration Records for December 2025 and January 2026 showed that staff were documenting assessments of the permacath site but contained no orders or documentation for assessment of the A/V fistula site. Interviews with staff confirmed that no orders were initiated for the A/V fistula on either admission. One nurse stated she assessed the A/V fistula and found a positive bruit and thrill but did not enter any orders, explaining that unit managers usually entered “batch orders” for A/V fistulas, which would include assessing bruit and thrill, monitoring for infection, and restricting blood pressures and lab draws in the affected arm. The unit manager, wound treatment nurse, nurse practitioner, and DON each acknowledged awareness of the A/V fistula’s presence, with some staff mistakenly believing it was an old, non-functioning access and others stating that admitting nurses should have initiated batch orders for the maturing fistula. The DON and unit manager confirmed that orders to assess the A/V fistula site were not entered on either admission, despite expectations that such orders should have been in place.
Consultant Pharmacist Failed to Identify Midodrine Dosing Outside Ordered Parameters
Penalty
Summary
A deficiency occurred when the Consultant Pharmacist failed to identify and report a medication irregularity during two consecutive monthly medication regimen reviews for one resident receiving midodrine for orthostatic hypotension. The resident had an order for midodrine 2.5 mg twice daily with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120 mm/Hg or the diastolic blood pressure exceeded 80 mm/Hg. Review of the November medication administration record (MAR) showed multiple instances where midodrine was documented as administered despite SBP readings above the ordered parameter, including blood pressures of 124/53, 124/68, 129/54, and 129/56 mm/Hg. The Consultant Pharmacist’s November medication regimen review, dated 11/18/25, documented that there were no new irregularities and did not address these administrations outside the ordered parameters. In December, the MAR again showed repeated administrations of midodrine when the resident’s SBP exceeded the ordered hold parameter, with documented blood pressures such as 122/67, 121/66, 132/60, 121/60, 121/67, 122/61, 124/62, 128/61, 131/72, 139/74, 124/69, and 134/68 mm/Hg at the time the medication was signed as given by various nurses and medication aides. The Consultant Pharmacist’s December medication regimen review, dated 12/18/25, again stated there were no new irregularities and did not address the ongoing administration of midodrine outside the specified parameters. In a subsequent interview, the Consultant Pharmacist acknowledged that his monthly review process included checking current and prior MARs for medications given outside ordered parameters, stated that such doses should have been documented as held when outside parameters, and admitted that he should have addressed these irregularities but missed them due to human error. The DON confirmed that the Consultant Pharmacist was expected to identify such issues during the monthly reviews.
Inaccurate MAR Documentation for Parameter-Dependent Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate documentation on the Medication Administration Record (MAR) for a resident receiving midodrine for hypotension. The physician’s order dated 11/6/25 directed that midodrine 2.5 mg be given twice daily and held if the systolic blood pressure (SBP) was over 120 mm/Hg or the diastolic blood pressure was over 80 mm/Hg. The MAR for November, December, and January reflected this order, yet multiple entries showed blood pressure readings above the ordered SBP parameter with the medication still documented as administered. Specific examples included blood pressures of 124/53, 129/54, 132/60, 122/61, 124/62, 134/68, 126/66, and 127/70 mm/Hg, all recorded with midodrine signed out as given. During interviews, the nursing staff and medication aide involved acknowledged that their documentation on the electronic MAR was incorrect. One nurse stated that on 11/15/25 she documented that she administered midodrine when she had not. Another nurse reported that when the resident’s blood pressure was outside the ordered parameters, he held the medication but erroneously documented it as administered on several dates. The medication aide similarly stated that she documented in error that she administered midodrine on two January administrations. The DON stated that her expectation was that medications be administered and documented accurately, and that when a medication is held it should be documented as held with the reason, and acknowledged that the resident’s midodrine was not documented accurately, emphasizing the importance of accurate documentation for evaluation of the resident’s medical condition.
Failure to Follow Enhanced Barrier Precautions and TB Screening Protocols
Penalty
Summary
Surveyors identified that the facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care of a resident with complex medical needs. The resident had a tracheostomy, a gastrostomy tube, and a Stage IV sacral pressure ulcer, and an EBP sign was posted on the room door with a PPE supply bag containing gloves and gowns. During an observation, two nurse aides provided incontinence care to this resident while wearing gloves but did not don gowns, despite the EBP requirements for targeted gown and glove use during high-contact resident care activities. Both aides reported they did not know they were required to wear gowns when providing care to this resident and expressed confusion about PPE use and the purpose of EBP, even though they stated they had received infection control training. The Infection Control Preventionist Nurse confirmed that staff had received infection control training on EBP and were required to complete monthly infection control in-services through an online platform. She stated that the two nurse aides should have worn gowns along with gloves when providing direct care to the resident on EBP. The DON also stated that staff received infection control training and were expected to follow infection control guidelines and wear PPE when providing direct care to residents on EBP. These statements confirmed that the observed care did not comply with the facility’s written EBP policy and expectations for PPE use. Surveyors also found that the facility failed to follow its Tuberculosis (TB) Control Plan for a newly admitted resident. The policy required all first-time residents to receive a two-step tuberculin skin test (TST) on admission, with Step 2 administered 1–3 weeks after Step 1 if the initial reaction was less than 10 mm. The resident received Step 1 with a negative result of 0.1 mm, but Step 2 was not administered within the required 1–3 week timeframe and instead was given several months later. The Infection Control Preventionist Nurse reported that the Medication Administration Record showed the resident refused Step 2 on one date, but acknowledged that staff should have re-offered the test within the required timeframe and that this did not occur. The resident, who was cognitively intact, did not recall refusing the test and stated she would have agreed to complete Step 2 if it had been offered again. The Nurse Practitioner and DON both indicated that the two-step TST guidelines called for Step 2 to be given within 1–3 weeks after Step 1, confirming that the facility did not follow its TB screening policy for this resident.
Failure to Follow Physician Orders for Post-Surgical Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide timely wound care to a resident with a left femur fracture surgically repaired prior to admission. The hospital discharge summary ordered Aquacel dressing to remain in place on the left surgical wound for seven days and then be replaced with new Aquacel. Upon admission, the Wound Nurse entered a physician’s order to cleanse the left lateral thigh wound with wound cleanser, apply a protective barrier to the peri-wound, and cover with a silicone foam with silver dressing every seven days and as needed. The resident’s care plan identified risk for complications from the left thigh surgical wound, with goals for healing without infection and interventions to observe for signs of infection, report abnormalities to the physician, and provide wound treatments as ordered. The MDS admission assessment documented that the resident had moderately impaired cognition, occasional rejection of care, and a surgical wound, but no wound care. From admission through mid-month, there was no documented evidence that wound care was provided to the resident’s left femur surgical wound. The TAR showed that on one date Nurse #6 coded wound care as not performed and directed to see progress notes, but the progress notes contained no explanation for the missed treatment and no documentation of any wound care from admission through that date. In interviews, Nurse #6 stated the resident refused wound care on that date and that she reported the refusal to the Wound Nurse, and also stated she never provided wound care to the resident at any time. The Wound Nurse confirmed that wound care had not been completed because of a reported refusal and that she did not document her own attempt when the resident refused on another day. A nurse aide reported that the resident sometimes refused care but would usually accept it with redirection or re-approach. When wound care was finally observed nearly two weeks after admission, the original hospital dressing dated several days before admission was still in place, and the Wound Nurse then removed it and applied a new silicone foam dressing. The DON and Medical Director both stated that wound care should have been provided according to the physician’s order and sooner than 13 days after admission.
Misappropriation of Resident Funds by Nursing Assistant
Penalty
Summary
A nursing assistant (NA) used a resident's bank account information without permission to create a Cash App account in the resident's name and transferred funds to herself and her family members over several months. The resident, who had multiple chronic medical conditions including chronic respiratory failure, diabetes, heart failure, and hemiplegia, was assessed as cognitively intact on the Minimum Data Set. The misappropriation was discovered when a family member noticed unusual transactions on the resident's bank statement and brought it to the attention of the facility's Business Office Manager (BOM). The transactions, which totaled over $8,000, were linked to the NA through matching names on the Cash App transactions and the NA's personnel file and social media accounts. Upon being confronted, the NA initially denied involvement but later admitted to accepting money from the resident, claiming it was given as gifts or with permission. However, the resident consistently denied ever giving the NA permission to use her bank information or debit card, and stated she was unaware of Cash App until the incident was explained to her. Interviews with law enforcement, the BOM, the former Director of Nursing (DON), and the resident's family corroborated that the NA had accessed the resident's financial information without authorization and used it for personal expenses, including bills and purchases unrelated to the resident's care. The facility's investigation revealed that the NA had violated the facility's policy prohibiting staff from accepting gratuities or gifts from residents. The incident was reported to local law enforcement, Adult Protective Services, and the state regulatory agency. The NA was terminated following the investigation. The resident experienced emotional distress as a result of the theft, expressing anger and hurt over the loss of her money. The case was also investigated by the North Carolina Nursing Assistant Registry, which confirmed the misappropriation of funds.
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.
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