The Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Winston-salem, North Carolina.
- Location
- 901 Bethesda Road, Winston-salem, North Carolina 27103
- CMS Provider Number
- 345284
- Inspections on file
- 19
- Latest survey
- August 22, 2025
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at The Oaks during CMS and state inspections, most recent first.
Dietary staff did not monitor or document the chemical sanitization level of the low temperature dish machine, resulting in the machine operating below the required chlorine level. The dietary manager and aides were unaware of the need to test the sanitizer level, and the issue was only discovered after a malfunction was observed and repaired. This failure could have affected all residents receiving food service.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Debris including straws, cup lids, empty chip bags, and milk cartons was found behind all dumpsters, with staff interviews revealing confusion over which department was responsible for cleaning the area. The lack of clear assignment led to debris being left behind after garbage collection.
The facility submitted inaccurate RN staffing data to CMS because agency RNs did not consistently clock in, leading to missing hours in the PBJ report. Although daily schedules showed an RN was present, the lack of proper timecard documentation resulted in incomplete reporting of RN coverage.
The facility closed its dining room for nine days after a single staff member tested positive for COVID-19, restricting several cognitively intact residents who preferred to eat in the dining room. Despite the facility's policy lacking clear outbreak definitions or dining instructions, and public health officials confirming that group dining should not have been suspended for one case, the dining room remained closed, leading to resident dissatisfaction and a failure to support resident choice.
Resident council meetings were consistently held in open, non-private areas such as the dining room and adjacent lounge, resulting in frequent disruptions and lack of privacy due to staff and visitor traffic. Residents expressed frustration over the inability to meet privately, and facility leadership was unaware of the requirement for a private meeting space.
Two residents admitted with complex medical needs did not have baseline care plans developed within 48 hours of admission. Although admission assessments were completed, staff reported that baseline care plans were typically finalized within 72 hours, resulting in a delay in formally addressing the residents' immediate care needs.
A resident with lymphedema and other chronic conditions did not receive physician-ordered compression wraps to both legs as documented in the TAR. The resident was found without the wraps during an observation, despite staff documentation indicating they had been applied. The nurse whose initials appeared on the record denied performing the task and was unaware of the proper procedure, resulting in a failure to meet professional standards of care.
A resident did not receive the specialized rehabilitative services required for their care, as the facility failed to provide or arrange for these necessary interventions according to the resident's care plan.
Two residents who shared rooms did not have privacy curtains, resulting in a lack of privacy when needed. Both residents, who were cognitively intact, reported the absence of curtains for an extended period and had requested them without resolution. Facility staff, including housekeeping and the Administrator, were unaware of the missing curtains despite daily checks being expected.
A resident with lymphedema had a physician's order for daily compression wraps, but nursing documentation falsely indicated the wraps were applied when they were not. Observation confirmed the wraps were not present, and the nurse whose initials appeared on the record stated she did not perform the task or know how her initials were entered. Facility leadership confirmed that documentation should accurately reflect care provided.
The facility failed to address grievances raised during Resident Council Meetings over several months, concerning untimely water cup refills and unavailable snacks. Despite documentation of these issues, no follow-up actions were demonstrated. Interviews with two cognitively intact residents confirmed the ongoing nature of these unresolved grievances. The Activities Director outlined the grievance reporting process, but the DON admitted to not addressing the concerns, and the Administrator acknowledged the lack of follow-up.
A resident in a LTC facility did not receive requested dentures due to a lapse in transitioning dental care services. The resident, who was cognitively impaired and on a mechanically altered diet, had requested new dentures, which were approved by Medicaid. However, the facility terminated their contract with the dental provider before the dentures could be made. The social worker failed to contact the resident or their responsible party to transition to a new dental provider, resulting in the resident not receiving the necessary dental care.
A resident, who was cognitively intact, was not invited to participate in care plan meetings since August 2022, despite expressing a desire to be included. The facility's social worker and office manager confirmed the oversight, with the latter assuming the resident preferred to consult with a friend. The administrator acknowledged that residents should be invited to their care plan meetings.
A resident with urinary bladder cancer and a urostomy had their tubing unsecured, contrary to the physician's order. The care plan required the tubing to be anchored with a leg band, but during care, it was observed unsecured. Staff interviews revealed a lack of awareness and responsibility for securing the tubing, with both a nurse aide and a nurse failing to ensure the tubing was properly anchored.
A resident with Vascular Dementia and Hemiparesis fell during incontinent care when a nurse aide attempted to reposition her alone, contrary to her care plan requiring two-person assistance. The bed was in a high position, contributing to the fall, which resulted in a hematoma on the resident's forehead. Medical evaluations showed no fractures or intracranial hemorrhage.
Failure to Monitor Chemical Sanitization in Dish Machine
Penalty
Summary
Dietary staff failed to demonstrate competency in monitoring the chemical sanitization level of the low temperature dish machine, as required by facility policy and manufacturer guidelines. The dish machine was observed to have a chlorine level of 0 ppm, below the minimum requirement of 50 ppm. The dietary manager confirmed that staff were only recording rinse/wash temperatures and not the chemical sanitization level. Interviews revealed that neither the dietary manager nor dietary aides had previously measured or documented the chemical sanitization level for the dish machine, and the dietary manager was unaware of the minimum required level. Further review showed that the dish machine had a malfunctioning nozzle, which was only identified and repaired after the deficiency was observed. Staff interviews indicated a lack of training and awareness regarding the need to test and document the chemical sanitization level each shift. The failure to monitor and document the chemical sanitization process could have affected all 111 residents served by the dietary department.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Improper Disposal of Garbage and Refuse Behind Dumpsters
Penalty
Summary
Debris such as straws, cup lids, empty chip bags, and empty milk cartons was observed behind all three dumpsters during an inspection. Staff interviews revealed confusion regarding responsibility for cleaning the dumpster area, with the Maintenance Director, Dietary Manager, and Administrator each providing differing accounts of which department was assigned to this task. The Maintenance Director stated he typically picked up debris in the parking lot but believed the dietary department was responsible for the dumpster area, while the Dietary Manager indicated that maintenance was responsible. The Administrator clarified that the dietary department was responsible, but maintenance and housekeeping were currently handling the area. The debris was left behind the dumpsters after garbage collection, and there was no clear assignment or consistent practice for ensuring the area was cleaned daily.
Inaccurate RN Staffing Data Submitted Due to Agency Nurses Not Clocking In
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system for one of three reviewed quarters, specifically regarding Registered Nurse (RN) hours. The PBJ report for the specified quarter showed no RN hours recorded on four dates, while daily staff schedules indicated that an RN was onsite for at least eight hours on those days. Nursing staff time detail reports, however, did not reflect the presence of an RN, aligning with the PBJ data. Interviews with the Scheduling Coordinator revealed that agency RNs sometimes did not clock in upon arrival, resulting in their hours not being captured in the facility's timecard system or the PBJ submission. The Administrator confirmed unawareness of this issue and acknowledged that all staff, including agency nurses, are required to document their time in the system.
Failure to Honor Resident Dining Preferences During COVID-19 Response
Penalty
Summary
The facility failed to honor residents' preferences for dining location by closing the dining room for nine days following a single employee testing positive for COVID-19. This action affected at least three cognitively intact residents who regularly ate in the dining room and expressed unhappiness and distress over the closure. The facility's COVID-19 Response Program policy, last revised in August 2025, did not define 'outbreak' or provide instructions regarding dining activities during an outbreak, only requiring notification of the health department for suspected or confirmed cases. Despite this, the Administrator and DON reported that they closed the dining room based on what they believed were instructions from the county health department, although no documentation or confirmation of such guidance was found. Interviews with county health officials revealed that an outbreak is defined as two or more cases within a 14-day period, and that the facility was only under surveillance with one positive case, not requiring cessation of group dining. The Communicable Disease Nurse and Public Health Nursing Supervisor both stated that they would not have advised the facility to suspend group dining with only one positive case. The facility's actions were not supported by their own policy or by public health guidance, resulting in the residents' right to choice and self-determination being restricted without appropriate justification.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to honor residents' rights to organize and participate in resident council meetings in a private setting. Over a six-month period, all resident council meetings were held in the dining area or a lounge adjacent to the dining room, both of which lacked privacy due to being open spaces without walls or doors. Residents reported frequent disruptions from staff and visitors, as the lounge was directly next to the entrance hallway and dining room, allowing conversations to be overheard and meetings to be interrupted. Resident council members expressed frustration about the lack of privacy and the inability to conduct meetings without interference. The activity director confirmed that there was no dedicated activity room or private area available for these meetings and acknowledged that disruptions occurred when staff and visitors were unaware of the meetings. The administrator was unaware of the requirement for private meeting spaces and had not received complaints from residents regarding this issue.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete baseline care plans addressing the immediate needs of two residents within 48 hours of their admission. One resident was admitted with diagnoses including diabetes, heart failure, and end stage chronic kidney disease, and required dialysis, antidepressant, and diuretic medications. Despite the completion of the nursing admission assessment, there was no evidence that a baseline care plan was developed within the required timeframe. Staff interviews revealed that baseline care plans were typically completed within 72 hours, often during the interdisciplinary care conference, and sometimes delayed over weekends. Another resident was admitted with multiple sclerosis, polyneuropathy, depression, and pressure ulcers, requiring antidepressant medications, physical therapy, and daily wound care. Similarly, the nursing admission assessment was completed, but no baseline care plan was documented within 48 hours of admission. Staff interviews confirmed that the practice was to complete baseline care plans within 72 hours, not the required 48 hours, and that immediate care needs were not formally addressed in a timely manner for these residents.
Failure to Apply Compression Wraps as Ordered and Inaccurate Documentation
Penalty
Summary
A deficiency occurred when nursing staff failed to apply compression wraps to a resident's legs as ordered by the physician for the management of lymphedema. The resident, who had diagnoses including congestive heart failure, morbid obesity, and lymphedema, had a physician's order for bilateral leg compression wraps to be applied every morning and removed every evening. On the day in question, the Treatment Administration Record (TAR) indicated that the wraps were applied at 8:00 AM by a nurse. However, during an interview and observation at 10:00 AM, the resident was found without compression wraps and expressed concern about the omission, stating that staff had previously applied and removed the wraps as ordered. Further investigation revealed that the nurse whose initials appeared on the TAR for the application of the wraps denied applying them and was unsure how her initials were recorded. She also lacked knowledge about the frequency and timing of the wrap application and removal. The Director of Nursing confirmed that physician-ordered tasks should be carried out by nursing staff. The failure to apply the compression wraps as ordered and the inaccurate documentation on the TAR constituted a failure to meet professional standards of quality care.
Failure to Provide Required Specialized Rehabilitative Services
Penalty
Summary
A resident did not receive specialized rehabilitative services as required for their care. The facility failed to provide or obtain these services, which were necessary to meet the resident's assessed needs. This inaction resulted in the resident not receiving the appropriate rehabilitative interventions as indicated in their care plan.
Failure to Provide Privacy Curtains for Shared Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains for two residents who shared rooms, resulting in a lack of privacy when needed. Both residents were cognitively intact and reported not having privacy curtains for an extended period. Observations confirmed that neither resident had a privacy curtain in place, and their beds were positioned closest to the door, offering no privacy when the door was open. One resident stated he had not had a privacy curtain in a while and could not recall the reason, while the other reported never having a privacy curtain since admission and had requested one from staff without success. Interviews with facility staff revealed that the Director of Housekeeping was unaware of the missing curtains and stated that housekeeping was responsible for checking and maintaining privacy curtains daily. The Administrator also was not aware of the missing curtains and confirmed that it was housekeeping's responsibility to ensure each resident had a privacy curtain and that they were clean and in place. Daily checks for privacy curtains and their cleanliness were expected but not carried out effectively, leading to the deficiency.
Inaccurate Documentation of Compression Wrap Application
Penalty
Summary
The facility failed to ensure accurate and truthful documentation regarding the application of compression wraps for a resident with a physician's order for daily application and removal of the wraps to both legs for lymphedema. Review of the Treatment Administration Record (TAR) showed that nursing staff documented the application of compression wraps at 8:00 AM. However, during an interview and observation at 10:00 AM, the resident stated she did not have compression wraps on, and it was confirmed by direct observation that no wraps were present on either leg. Further investigation revealed that the nurse whose initials appeared on the TAR as having applied the wraps at 8:00 AM stated she did not actually perform the task and was unaware of how her initials were recorded for that time. The nurse also indicated she did not know the frequency or timing for the application or removal of the wraps. Both the DON and the Administrator confirmed that the expectation is for staff to accurately document only the tasks they have personally completed, and that initials on the TAR should reflect the individual who performed the task.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to address grievances raised during Resident Council Meetings over a three-month period. Concerns were consistently noted in the meeting minutes for February, March, and April 2024, regarding the untimely filling of water cups and the unavailability of snacks for residents. Despite these issues being documented, the facility did not demonstrate any response or follow-up actions to resolve the grievances. The Resident Council Follow-Up forms attached to the meeting minutes did not show any facility response to the concerns raised. Interviews with residents and staff further highlighted the lack of action taken by the facility. Two residents, both cognitively intact, confirmed during a July 2024 meeting that the issues had been ongoing and unresolved. The Activities Director explained the process of reporting grievances to the appropriate department heads, but the Director of Nursing admitted to not addressing the concerns. The Administrator also acknowledged that grievances should have been addressed and followed up with the residents, indicating a breakdown in the facility's grievance resolution process.
Failure to Provide Dentures to Resident
Penalty
Summary
The facility failed to assist a resident in obtaining dentures, which was necessary for their dietary needs and overall well-being. The resident, who was cognitively impaired and had a diagnosis of hemiplegia, was admitted with a mechanically altered diet due to weight fluctuations secondary to hemodialysis. The resident had previously requested new dentures from the facility dentist, as noted in the dental provider's documentation, but had not received them. The upper dentures had been approved by Medicaid, but the facility terminated their contract with the dental provider before the dentures could be made. The transition to a new dental provider was not effectively managed, as the facility's social worker did not reach out to the resident or their responsible party to offer dental services. Despite receiving new consent forms from the new dental provider, the social worker admitted to not contacting the resident due to being busy. Consequently, the resident's request for dentures was not fulfilled, and the responsible party was not informed about the status of the dentures. The facility administrator acknowledged that dental services should be provided in a timely manner, indicating a lapse in the facility's process for transitioning dental care services.
Failure to Invite Resident to Care Plan Meetings
Penalty
Summary
The facility failed to invite a resident to participate in the care planning process, which is a requirement for person-centered care. The resident, who was cognitively intact, expressed during an interview that he had not been invited to attend a care plan meeting for a long time and desired to be included. The facility's social worker confirmed that the resident had not attended a care plan meeting since August 2022 and could not verify if he had been invited to any meetings after that date. The office manager admitted to not inviting the resident to his care plan meetings, assuming he preferred to consult with a friend, and acknowledged the oversight in not sending invitations to both the resident and his friend. The facility administrator confirmed that residents should be invited to their care plan meetings.
Failure to Secure Urostomy Tubing
Penalty
Summary
The facility failed to secure the urostomy tubing for a resident as per the physician's order. The resident, who was admitted with urinary bladder cancer and urine retention, required extensive assistance with activities of daily living and had a urostomy. The care plan specified that the catheter tubing should be anchored using a leg band to prevent excess tension. However, during an observation of incontinent care, the urostomy tubing was found unsecured, and no anchoring device was present on the resident's legs. Interviews with the staff revealed a lack of awareness and responsibility regarding the securing of the urostomy tubing. The nurse aide was unaware of the unsecured tubing at the start of her shift and believed it was the nurses' responsibility to apply the anchors. Similarly, the nurse on duty did not check the tubing status at the beginning of her shift and was unaware of the absence of the stabilization device. The Director of Nursing confirmed that it was expected for the nursing staff to secure the urinary catheter tubing to prevent injury and maintain urine flow.
Failure to Provide Safe Incontinent Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide incontinent care in a safe manner, resulting in a fall for Resident #29. Resident #29, who was admitted with diagnoses of Vascular Dementia and Hemiparesis affecting the right side of her body, required two-person assistance for bed mobility. During an incident, a nurse aide attempted to reposition Resident #29 alone, which led to the resident rolling off the bed and falling to the floor. At the time of the fall, the bed was in a high position, which contributed to the severity of the incident. The incident report indicated that during morning care, Resident #29 was turned onto her left side by a single nurse aide, who then attempted to adjust the under pad. This action caused the resident to roll off the bed. The fall resulted in a hematoma on the resident's left forehead, although subsequent medical evaluations, including a CT scan and x-rays, showed no fractures or intracranial hemorrhage. The resident was returned to the facility the same day after being sent out for evaluation. Interviews with staff revealed that the nurse aide involved in the incident did not seek assistance from another staff member, despite being available. The nurse practitioner and another nurse assessed the resident immediately after the fall. The facility's care plan for Resident #29 clearly indicated the need for two-person assistance for bed mobility, which was not followed during the incident, leading to the deficiency.
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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