The Oaks-brevard
Inspection history, citations, penalties and survey trends for this long-term care facility in Brevard, North Carolina.
- Location
- 300 Morris Road, Brevard, North Carolina 28712
- CMS Provider Number
- 345462
- Inspections on file
- 19
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Oaks-brevard during CMS and state inspections, most recent first.
Surveyors found that the facility repeatedly failed to obtain and document informed consent before initiating psychotropic medications for several residents with dementia, mood disorders, psychosis, and anxiety. Multiple residents with severe cognitive impairment were receiving antipsychotics, antidepressants, antianxiety agents, and mood stabilizers such as olanzapine, haloperidol, quetiapine, lorazepam, trazodone, duloxetine, venlafaxine, lamotrigine, mirtazapine, and fluoxetine without any record that they or their representatives had been informed of the risks and benefits or had consented. Interviews with the Administrator, DON, ADON, MDS nurse, and SW showed that responsibility for obtaining psychotropic consents was shared between the MDS nurse and SW, but they were not consistently notified of new or changed orders, were unclear that consents were required for all psychotropics (not just antipsychotics), and acknowledged that frequent staff turnover and process gaps led to consents "slipping through the cracks."
A cognitively intact resident with an existing DNR order informed the facility of this status at admission, and both the physician orders and EMR documented the resident as DNR. However, the DNR form was not present in the advance directives notebook at the nurse’s station, one of the two locations designated by the facility for such documentation. Nursing staff reported they rely on either the advance directives notebook or the EMR to determine code status, and the Interim DON and Administrator acknowledged that the notebook and EMR were expected to match, but in this case they did not.
Surveyors found that the facility did not consistently provide required Medicare beneficiary notices when Part A skilled coverage ended for two residents. One resident was discharged home on the last covered day without receiving a Notice of Medicare Non-Coverage (NOMNC), and there was no documentation that the notice had been issued. Another resident received and signed a NOMNC and remained in the facility after skilled coverage ended, but did not receive a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN). The MDS Coordinator, who is responsible for issuing these notices based on information from therapy and consultation with the provider, reported that the first notice was overlooked while she was on vacation and that she forgot to issue the SNF ABN for the second resident. The Administrator confirmed the expectations for timely issuance of NOMNCs and SNF ABNs and that these expectations were not met in these cases.
Surveyors found that the facility did not request a PASRR Level II evaluation after a resident with a prior Level I status was later diagnosed with major depressive disorder and PTSD and was receiving antidepressant therapy, despite PASRR guidance requiring further screening when new mental illness diagnoses or treatment changes occur. In addition, for another resident with severe cognitive impairment, multiple serious mental illness diagnoses, and a documented PASRR Level II determination specifying specialized services such as psychological testing and psychiatric evaluation, the facility’s comprehensive care plan did not address or incorporate these Level II PASRR recommendations, which staff acknowledged as an oversight.
The facility failed to have a qualified professional directing the activities program, as both the Activity Director and Life Enrichment Specialist lacked formal training and certification. The AD, who transitioned from a nursing assistant role, relied on online resources and previous calendars without formal guidance. The Life Enrichment Specialist also lacked formal training, having only received informal instruction from the AD. The former Administrator was aware of the issue but did not ensure training, while the current Administrator has begun addressing the deficiency.
The facility failed to address and communicate resolutions to concerns raised by residents during Resident Council meetings over 12 months. Meeting minutes lacked documentation of old business, and residents repeatedly voiced issues related to dietary services, staff behavior, and facility maintenance without receiving feedback or resolution. The Activity Director, responsible for recording minutes, admitted to not having formal training, and there was no formal process for documenting or resolving grievances raised during meetings.
The facility failed to provide scheduled group activities during evenings and weekends, leading to resident dissatisfaction and feelings of boredom and loneliness. The Activities Director worked weekdays only, leaving nursing staff to assist with activities during evenings and weekends, but they were unable to provide sufficient support. Residents expressed the importance of having activities to look forward to, and staff confirmed the absence of scheduled activities during these times.
A resident reported her dentures missing shortly after admission, but the facility failed to follow its grievance policy. Despite notifying staff, the resident did not receive follow-up, and the grievance was not logged or resolved within the required timeframe. The Social Worker admitted to forgetting to complete the grievance report, and the Administrator confirmed the grievance process was not followed, resulting in the resident being discharged without her dentures.
The facility did not follow pharmacy recommendations for securing narcotics in the West Hall Medication Storage Room. The narcotic lock box, containing Lorazepam, was found removable from a locked refrigerator. Staff interviews revealed awareness of the issue, which had been identified in a previous pharmacy report, but no resolution had been implemented.
A resident with a history of migraines did not receive her prescribed PRN migraine nasal spray, Stadol, during her stay at the facility due to a failure in the medication reconciliation process. The NP and ADON did not ensure the medication was entered into the MAR, and the double-check system was not effectively implemented. The resident informed staff of her need for the medication, but it was not addressed, and the facility's records lacked a verified discharge summary.
The facility failed to store narcotics in a permanently affixed compartment in a medication room. The narcotic lock box, containing Lorazepam, was found removable inside a locked refrigerator. The ADON believed the medications were secure due to the locked room and refrigerator. The Consultant Pharmacist and DON acknowledged the issue, which had been noted in a previous pharmacy report, but no resolution had been implemented.
A resident reported being held down by staff and denied bathroom access, but the facility failed to follow its abuse policy. The incident was not immediately reported to APS, and the investigation lacked thorough documentation, including interviews with involved parties. The DON delayed responding, and the accused staff were not immediately suspended, resulting in a deficiency in handling the reported abuse.
A facility failed to properly manage a controlled medication, Acetaminophen-Codeine, for a resident who was discharged. An audit revealed 13 tablets were unaccounted for, and the medication card was missing. Interviews with nursing staff showed inconsistencies in handling the narcotic card, and the facility could not provide the controlled substance card count sheet. The DHS suspected the medication card might have been accidentally discarded, and the missing tablets were never recovered.
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 for multiple residents. For one resident with generalized anxiety disorder and severe cognitive impairment, the record showed an active PRN lorazepam order with no documentation that the responsible party was informed in advance of the risks and benefits or that consent was obtained. Another resident with major depressive disorder, anxiety disorder, borderline personality disorder, hallucinations, and unspecified psychosis, who had intact cognition and no documented behaviors, was receiving risperidone, duloxetine, and lamotrigine without any record that she or her guardian had been informed of the risks and benefits or had consented to these treatments. A third resident with schizophrenia, anxiety disorder, bipolar disorder, and schizoaffective disorder, with moderate cognitive impairment and no behavioral symptoms, was receiving trazodone, venlafaxine, quetiapine, and haloperidol, again with no documentation that the responsible party had been informed in advance or had consented. Another resident with Alzheimer’s disease, major depressive disorder, anxiety disorder, and insomnia, who was severely cognitively impaired and wandering, was receiving mirtazapine, fluoxetine, lamotrigine, and lorazepam on a routine basis. The electronic medical record contained no documentation that the responsible party had been informed in advance of the risks and benefits of these medications or had consented. A resident with dementia, major depressive disorder, and hallucinations was receiving daily olanzapine for hallucinations, with MDS documentation of severe cognitive impairment and daily antipsychotic use, but there was no record that the responsible party had been informed of the risks and benefits or had consented. Another resident with unspecified dementia, generalized anxiety disorder, major depressive disorder, and cognitive communication deficit, who was severely cognitively impaired and receiving antidepressant, antipsychotic, and anticonvulsant medications routinely, was administered olanzapine, lamotrigine, and trazodone without documentation that the representative had been informed in advance of the risks versus benefits or had consented. Interviews with facility staff revealed systemic process issues contributing to the lack of psychotropic consents. The Administrator stated that the Social Worker (SW) and MDS Coordinator were responsible for obtaining psychotropic medication consents but acknowledged that no consent forms could be found for the identified residents and was unsure where the breakdown occurred. The MDS Coordinator and SW both confirmed they shared responsibility for obtaining consents when new psychotropic medications were ordered or existing orders were changed, but reported they were not always informed of new orders or changes, and that providers sometimes added or changed psychiatric medications without notifying them. The Assistant DON/Interim DON and DON stated they believed consents were required for antipsychotics but were not aware of the need for consents for all psychotropic medications, and both cited frequent position changes and acknowledged that obtaining psychotropic consents had “slipped through the cracks.” Psychiatric Nurse Practitioners documented ongoing psychotropic regimens and stability for some residents, including notes that one resident was stable on olanzapine with no indication for gradual dose reduction, and another was stable on olanzapine, lamotrigine, and trazodone with no medication changes needed. However, despite these ongoing psychotropic treatments and routine administration documented on the MARs, the facility’s records lacked corresponding informed consent documentation for each of the psychotropic medications identified in the survey. Staff interviews consistently confirmed the absence of psychotropic consent forms for the affected residents and an inability to explain precisely where in the process the failure to obtain and document consent had occurred.
Failure to Maintain Consistent DNR Documentation in Designated Locations
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s advance directive documentation in both locations designated by facility policy. A cognitively intact resident, admitted with an existing Do Not Resuscitate (DNR) status, reported that he had informed the facility of his DNR upon admission and understood it to mean that staff would not perform CPR if needed. The resident’s physician orders contained an advanced directive order for DNR, and the electronic medical record (EMR) displayed a DNR status in the advance directive banner at the top of the resident’s EMR page. However, when surveyors reviewed the advance directive notebook kept at the nurse’s station, there was no DNR form on file for this resident, despite the EMR and physician orders indicating DNR status. A nurse stated that she would look either in the advance directives notebook or in the EMR to determine a resident’s code status. The Interim DON confirmed she was responsible for ensuring the notebook matched the EMR and for obtaining provider signatures on DNR forms, and acknowledged that the resident’s DNR form was missing from the notebook. The Administrator also stated that code status information in the advance directives binder and EMR should match and that staff were expected to check either source for code status.
Failure to Provide Required Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide required Medicare beneficiary notices related to the end of Medicare Part A skilled coverage for two residents. For one resident, whose Medicare Part A skilled services ended on 10/31/25 and who discharged home the same day, review of the medical record and the facility’s Beneficiary Notice worksheet showed no evidence that a Notice of Medicare Non-Coverage (NOMNC) was reviewed with or provided to the resident or the responsible party. The MDS Coordinator, who is responsible for issuing NOMNCs and SNF ABNs, stated that therapy staff notify her when skilled coverage is scheduled to end and she then consults with the provider to determine if any additional skilled needs exist before issuing the appropriate notice. She reported that when this resident discharged home, the social worker and financial counselor were covering her duties while she was on vacation and the NOMNC issuance was overlooked. The Administrator confirmed that the MDS Coordinator is expected to issue a NOMNC at least two days before skilled services end and that there was no documentation that this occurred for this resident. For another resident, a NOMNC was discussed with and signed by the resident, indicating that Medicare Part A coverage for skilled services would end on 11/15/25, and the resident remained in the facility after skilled coverage ended. However, review of the medical record revealed no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was reviewed with or provided to this resident. The MDS Coordinator again stated she is responsible for issuing both NOMNCs and SNF ABNs and explained her usual process of being informed by therapy when skilled coverage is ending and then determining if any other skilled needs exist before issuing the applicable notices. She acknowledged that she simply forgot to provide a SNF ABN to this resident when the NOMNC was issued. The Administrator stated that the MDS Coordinator is responsible for issuing a SNF ABN when a resident remains in the facility and/or appeals the NOMNC and that he would have expected this resident to receive a SNF ABN when Medicare Part A skilled services ended.
Failure to Request PASRR Level II Evaluation and Integrate Level II Recommendations Into Care Planning
Penalty
Summary
The facility failed to comply with PASRR requirements for residents with serious mental illness. For one resident with an existing Level I PASRR determination, subsequent psychiatric progress notes documented new diagnoses of chronic, stable major depressive disorder and PTSD, along with treatment with sertraline and ongoing monitoring. The resident’s MDS assessments reflected active diagnoses of anxiety disorder, depression, and PTSD, as well as use of antianxiety and antidepressant medications and moderate cognitive impairment. Despite the PASRR Determination Notification specifying that no further screening was required unless a significant change occurred suggesting a mental illness diagnosis or change in treatment needs, the facility did not submit a request for a Level II PASRR evaluation after these new mental illness diagnoses were identified. The social worker, who was responsible for submitting Level II requests, stated she was not always notified of new mental illness diagnoses and acknowledged that no Level II request was submitted for this resident following the new diagnoses. For another resident with a documented Level II PASRR determination, the facility failed to incorporate the PASRR recommendations into the resident’s care plan. This resident had cumulative diagnoses including major depressive disorder, anxiety disorder, borderline personality disorder, hallucinations, and unspecified psychosis, with MDS findings of severe cognitive impairment, delusions, and frequent behavioral symptoms. A Level II PASRR Determination Notification indicated that nursing placement was appropriate and specified specialized services of psychological testing and psychiatric evaluation. However, review of the comprehensive care plan showed no care plan addressing the Level II PASRR specialized services determination. The MDS Coordinator, who was responsible for developing care plans, confirmed the resident had a Level II PASRR and that a care plan should have been developed, but it was not, which was described as an oversight.
Lack of Qualified Activities Program Leadership
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as neither the Activity Director (AD) nor the Life Enrichment Specialist had received formal activities training or certification. The AD, who had previously worked as a nursing assistant and then as a Life Enrichment Specialist, assumed the AD position in December 2023 without any formal training or certification. She relied on online resources and previous activity calendars to guide her work but expressed a desire for formal training to improve the activities program for residents. Similarly, the Life Enrichment Specialist, who also transitioned from a nursing assistant role, had only received informal training from the AD and had not completed any state training courses or obtained certification. Interviews with the former and current Administrators revealed a lack of oversight and follow-through regarding the training and certification of the AD and Life Enrichment Specialist. The former Administrator acknowledged awareness of the lack of formal training and certification but could not recall why it was not pursued. The current Administrator, who began employment in October 2024, was recently made aware of the issue and had initiated discussions with the regional office to arrange formal training and certification for both staff members. The deficiency had the potential to affect all residents at the facility, as the activities program was not being directed by qualified professionals.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to effectively address and communicate resolutions to concerns raised by residents during Resident Council meetings over a period of 12 out of 14 months. The Resident Council meeting minutes consistently lacked documentation of old business, and there was no indication that previous concerns were read, approved, revised, or resolved. Residents repeatedly voiced issues related to dietary services, staff behavior, and facility maintenance, yet there was no evidence of follow-up or resolution communicated back to the residents. Interviews with residents revealed a shared sentiment that their concerns were not being adequately addressed by the facility staff. Residents expressed frustration over the lack of feedback and resolution to their issues, with some concerns persisting over several months. The Resident Council President acknowledged that while some issues might take time to resolve, the residents would appreciate communication regarding the efforts being made to address their concerns. The Activity Director, responsible for recording the minutes of the Resident Council meetings, admitted to not having received formal training on how to document or address the concerns raised during these meetings. The Director of Nursing and the Social Worker also confirmed that there was no formal process in place for documenting or resolving grievances raised during Resident Council meetings. The previous Administrator did not ensure that the concerns were documented or resolved, leading to a lack of accountability and communication with the residents.
Lack of Evening and Weekend Activities
Penalty
Summary
The facility failed to provide scheduled group activities during evenings and weekends, which was important to the residents. The December 2024 activity calendar showed that activities were only scheduled on weekdays, with no evening or weekend activities except for a church service every other Sunday. The Activities Director, who worked Monday through Friday, was responsible for all activities and relied on nursing staff to assist residents during evenings and weekends. However, the nursing staff was not able to provide sufficient support for activities during these times. Residents expressed dissatisfaction with the lack of scheduled activities during evenings and weekends, leading to feelings of boredom, loneliness, and depression. Resident #4, #44, #51, and #56, all cognitively intact, reported during a resident council meeting that they had no scheduled activities during these times, except for the occasional church service. They emphasized the importance of having activities to look forward to and the negative impact of their absence on their mental well-being. Interviews with facility staff, including a nurse and a nursing assistant, confirmed the absence of scheduled group activities during evenings and weekends. They noted that residents were left to find their own activities, such as watching television or doing puzzles, due to insufficient staffing to assist with activities. The Administrator acknowledged the issue and mentioned the facility's ongoing efforts to hire an activity assistant for evenings and weekends, as well as potential schedule adjustments for the Activities Director.
Failure to Implement Grievance Policy for Missing Dentures
Penalty
Summary
The facility failed to implement its grievance policies and procedures when a resident reported her dentures missing. The resident, who was cognitively intact and admitted for aftercare following joint replacement surgery, informed staff that her dentures had been missing since the day after her admission. Despite notifying multiple staff members, the resident did not receive follow-up regarding the resolution of her grievance. The facility's grievance policy requires grievances to be resolved within three business days, but there was no record of a grievance being filed or resolved within this timeframe. The Social Worker (SW) acknowledged awareness of the missing dentures and stated that the facility investigated missing items. However, the SW admitted to forgetting to complete the grievance report until it was requested. The Director of Nursing (DON) and Activities Director (AD) searched for the dentures, including checking the trash and dumpster, but were unable to locate them. The SW stated that the facility was not liable to replace the dentures as they could not verify how they were lost, and there was no documentation of follow-up with the resident regarding the grievance. The Administrator confirmed awareness of the missing dentures and stated that a grievance report should have been started immediately. However, the grievance was not logged, and the Administrator had not reviewed or signed the grievance report. The Administrator and SW both indicated that the grievance process was not followed as per the facility's policy, resulting in the resident being discharged without her dentures and without a resolution to her grievance.
Failure to Securely Affix Narcotic Lock Box in Medication Storage Room
Penalty
Summary
The facility failed to adhere to pharmacy recommendations for the secure storage of narcotics in one of the medication rooms reviewed. During an observation of the West Hall Medication Storage Room, it was found that the narcotic lock box, which contained four unopened vials of Lorazepam, was inside a locked refrigerator but was not permanently affixed, making it removable. This issue was previously identified in the Consultant Pharmacy report dated November 26, 2024, which noted that controls in the refrigerator were under double lock and key but were in the process of being secured in a non-removable lock box. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Consultant Pharmacist, the Director of Nursing (DON), and the Administrator, revealed awareness of the issue. The ADON believed the medications were appropriately secured due to the locked room and refrigerator. The Consultant Pharmacist confirmed the need for the narcotic box to be permanently affixed, as noted in the November report. The DON acknowledged the issue had persisted since her hiring in April 2021, and the Administrator admitted ongoing discussions about securing the narcotic box without reaching a resolution.
Failure to Administer PRN Migraine Medication
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was admitted with a discharge order for a PRN migraine nasal spray, Stadol, which was not entered into the facility's medication administration record (MAR). The resident, who was cognitively intact and had a history of migraines, did not receive the prescribed medication during her stay at the facility. Despite informing multiple nursing staff and discussing the issue with the doctor, the resident's need for the migraine medication was not addressed. The Nurse Practitioner (NP) and Assistant Director of Nursing (ADON) were involved in the medication reconciliation process but failed to ensure the Stadol order was entered into the system. The NP recalled that the ADON had contacted her for medication reconciliation, and she had not ordered any medications to be stopped. However, the ADON admitted to having trouble entering the order into the computer system and forgot to return to it, likely due to interruptions. The double-check system, which involves another nurse verifying the entered medications, was not effectively implemented, as the ADON was unsure who had performed the second check. The facility's Consulting Pharmacist and Medical Director confirmed that the medication reconciliation process was not completed correctly, as there was no verified discharge summary in the resident's electronic medical record. The Medical Director, who was unaware of the omission, noted that the Stadol order was not continued as intended. The Director of Nursing (DON) and the facility Administrator were also unaware of the missing medication order and the lack of a verified discharge summary in the resident's record.
Narcotic Storage Deficiency in Medication Room
Penalty
Summary
The facility failed to store narcotics in a locked, permanently affixed compartment in one of the medication rooms reviewed. During an observation of the West Hall Medication Storage Room, it was found that the narcotic lock box was inside a locked refrigerator but was not permanently affixed, making it removable. This lock box contained four unopened vials of Lorazepam, a Schedule IV antianxiety medication. The Assistant Director of Nursing (ADON) believed that the medications were appropriately secured since both the medication storage room and the refrigerator were locked. The Consultant Pharmacist confirmed that the narcotic box should be permanently affixed to the refrigerator and noted that this issue had been identified in the November 2024 pharmacy report. The Director of Nursing (DON) acknowledged that the narcotic box had not been permanently affixed since her hiring in April 2021 and was aware of the requirement for it to be secured. The Administrator also acknowledged awareness of the issue and mentioned ongoing discussions about how to affix the narcotic box, but no resolution had been reached.
Failure to Implement Abuse Policy and Conduct Thorough Investigation
Penalty
Summary
The facility failed to implement its abuse policy and procedure in the case of a resident who reported being held down by staff and denied access to the bathroom. The facility's policies required immediate reporting of any allegations of abuse to the administrator and notification of Adult Protective Services (APS), neither of which occurred in this instance. The initial allegation report was marked as an abuse investigation, but APS was not notified, and the investigation lacked thorough documentation, including interviews and statements from involved parties. The resident, who was hard of hearing, reported that three staff members held his arms down and yelled at him not to ring the call light. Despite the report, there was no interview or statement from the resident included in the investigation, nor were there statements from the accused staff members or other relevant personnel. The Director of Nursing (DON) was informed of the incident but did not immediately respond, as the situation was deemed non-urgent. The DON later interviewed the resident, but the description of events changed, and the accused staff members were not immediately suspended. Interviews with staff revealed inconsistencies in the handling of the incident. The Activity Director (AD) and a nursing assistant reported the incident to the DON, but neither was interviewed or asked to provide a written statement. The DON and the former administrator conducted interviews with the accused staff, leading to suspensions, but the investigation was not completed promptly, and APS was not notified. The facility's failure to follow its abuse policy and conduct a timely and thorough investigation resulted in a deficiency in handling the reported abuse incident.
Controlled Medication Mismanagement
Penalty
Summary
The facility failed to maintain effective systems for the identification, storage, and return of a controlled medication, specifically Acetaminophen-Codeine, for a resident who was discharged. The resident had an order for this opioid medication to be administered as needed for severe pain. Upon discharge, the facility did not ensure the remaining medication was properly accounted for and returned to the pharmacy. An audit conducted by the Assistant Director of Health Services (ADHS) revealed that 13 tablets of the medication were unaccounted for, and the medication card was missing. Interviews with nursing staff who worked on the relevant medication cart indicated a lack of clarity and consistency in handling the narcotic card. Some nurses recalled seeing the card, while others did not, and there was no specific recollection of dates or times. The facility was unable to provide the controlled substance card count sheet for the period in question, further complicating the situation. The responsible party for the resident confirmed that the medication was not sent home with the resident, and a prescription was provided upon discharge. The Director of Health Services (DHS) and the ADHS conducted a thorough investigation, including interviews and a review of the medication carts. The DHS suspected that the medication card might have been accidentally discarded during the collection of discontinued medications. Despite efforts to locate the missing tablets, they were never recovered. The facility acknowledged the deficiency and recognized the need for a revised medication handling process to prevent future occurrences.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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