Tsali Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherokee, North Carolina.
- Location
- 267 Tsali Care Way, Cherokee, North Carolina 28719
- CMS Provider Number
- 345475
- Inspections on file
- 26
- Latest survey
- August 1, 2025
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Tsali Care Center during CMS and state inspections, most recent first.
Two residents were not provided with dignified care, as one was brought out to visit family with uncombed hair, twisted clothing, and improperly worn socks, while another was left with visible chin hairs after a shower, despite facility policy requiring grooming and shaving to be offered. Staff failed to ensure proper grooming and respectful treatment, resulting in a deficiency related to residents' rights to dignity and self-determination.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in ADL performance was clinically unavoidable, as required by regulations.
A resident with a recent lower limb amputation and diabetes was being transferred from a facility van when, due to an unsecured wheelchair cushion, the individual slid out of the chair and landed on the surgical stump. The cushion, meant to prevent skin breakdown, was not properly buckled, which allowed it to slide out with the resident. The incident resulted in significant pain and required ambulance transport and hospital treatment for wound dehiscence. Staff interviews and documentation confirmed the cushion was not secured at the time of the incident.
A resident was denied visitation with his wife after she was suspected of carrying a parasite, despite no evidence of infestation being found by staff or pest control. The wife was banned from the building and property, and the resident was not allowed to meet her outside or receive food she brought. Staff interviews confirmed the ban was enforced based on unsubstantiated concerns, and the facility's own policies regarding visitation rights were not followed.
A resident with a traumatic amputation and diabetes was given a 48-hour discharge notice, followed by a 30-day notice, both lacking required information about the appeals process. The facility's actions did not comply with policy or regulatory requirements for discharge notices.
A resident with a traumatic amputation and Type 1 Diabetes Mellitus, along with the resident's representative, did not receive required notifications of care plan meetings. The Social Service Director relied on an automated system that failed to send notifications, and neither the resident nor the representative received notice or copies of care plans prior to a recent meeting. Facility policy required such notifications and documentation, but these steps were not followed.
A resident with multiple chronic conditions and existing pressure ulcers did not receive daily wound care and dressing changes as ordered by a physician. Despite updated orders from a consulting podiatrist for daily dressing changes, nursing staff continued to provide care only three times a week for about one week. The oversight was discovered after the resident's wounds worsened and concerns were raised by the resident's spouse and outside providers.
A resident with multiple chronic conditions and a known allergy to contrast dye did not receive three ordered doses of prednisone prior to an angiogram because the medication order was not transcribed onto the MAR. The omission was discovered after the resident’s wife inquired, and staff confirmed the medication had not been administered as required by facility policy.
A nurse failed to properly disinfect a blood glucose monitor after use on a resident with diabetes, wiping the device for only five seconds instead of the required one-minute wet time as specified by facility policy and the disinfectant instructions. The device was then returned to the insulin cart without adequate disinfection.
The facility failed to serve hot meals to residents eating breakfast in their rooms, affecting all 55 residents. Complaints were documented over several months, with residents expressing dissatisfaction with cold food. A test tray evaluation confirmed that breakfast items were served at temperatures below what is considered hot. The Administrator expected staff to assist in serving hot food, but this was not achieved.
A facility failed to ensure coordinated care and communication for a resident requiring dialysis. The resident was taken to a dialysis center without a scheduled appointment, resulting in no available chair. There was a lack of communication regarding the resident's condition, weight monitoring, and nutritional status. The facility did not document pre and post dialysis weights, and there was no assessment by the Registered Dietitian. Staff interviews revealed a lack of communication with the dialysis center, and the facility's policy for coordination and communication was not followed.
A resident with multiple diagnoses, including neuropathy, did not receive prescribed pain medications, leading to unmanaged pain rated as eight out of ten. Despite the resident's complaints, staff failed to assess and address the pain adequately, with incomplete pain assessments and lack of communication. The facility's policy on pain management documentation and reporting was not followed.
The facility failed to issue Notice of Medicare Non-Coverage (NOMNC) forms to 12 residents who no longer qualified for Medicare Part A. The [NAME] Specialist, unaware of her responsibility, did not send any NOMNC notices. The Administrator confirmed the oversight, acknowledging that the facility's policy requiring NOMNC delivery at least two days before service termination was not followed.
The facility's assessment failed to involve direct care staff or residents, lacked a detailed staffing plan for each unit and shift, and did not address resources for grandfathered smoking residents. Additionally, staff competencies and training requirements were not clearly documented.
The facility failed to maintain a functioning wash temperature gauge on the dish machine, affecting all residents. Observations showed the gauge consistently registered below the required 150 F, and staff had not used temperature strips for accurate readings. Maintenance was unaware of the issue until the survey, despite previous repairs in January. The facility's policy required daily checks, which were not effectively conducted.
The facility did not address resident grievances about cold food, as documented in Resident Council Meeting Minutes. Despite regular complaints from residents about late and cold food trays, particularly for meals delivered to rooms, no effective follow-up or resolution was communicated. The Activity Director forwarded these concerns to the Administrator and Dietary Manager, but residents reported no changes or feedback, leading to ongoing dissatisfaction.
The facility failed to ensure that residents were given the opportunity to formulate advance directives. A resident with a heart attack diagnosis had no Living Will on file despite indicating its formulation. Two residents with severe cognitive impairment had no documentation of advance directives or opportunities to formulate them. Another resident, who was cognitively intact, also lacked advance directives. Staff interviews revealed inadequate follow-up and oversight in the admission process regarding advance directives.
A facility reported a medication error rate of 16.13%, exceeding the acceptable 5% threshold. Errors included improper administration of insulin by an LPN and RN, who failed to prime insulin pens, and incorrect application of eye ointment and drops by a medication aide. The DON confirmed these errors, highlighting deviations from prescribed methods.
A resident with severe cognitive impairment and infections was left undressed in bed and during transfer to a shower chair, wearing only a pull-up diaper. The resident expressed a desire to be dressed, but staff did not assist, leaving him undressed after an incontinence episode before breakfast. The DON confirmed that residents should be dressed after such episodes, highlighting a failure to uphold the resident's right to dignity.
A resident did not receive a quarterly financial statement as required by facility policy. Despite being cognitively intact and his own responsible party, the resident confirmed not receiving the statement, and facility records lacked documentation of its delivery. The [NAME] Specialist was unable to verify the delivery, and the Administrator expected compliance with the policy, but no evidence was found in the records.
A facility failed to provide a safe and clean environment for a resident, as a worn and soiled mattress and an unclean slipper pan were found in the resident's room. The DON acknowledged that the CNAs should have reported the mattress's condition and ensured its replacement, and that the slipper pan should have been discarded and replaced.
A facility failed to notify a resident and their representative of the reasons for hospital transfers on two occasions. The resident, with severe cognitive impairment, was transferred due to a suspected stroke and a complicated UTI. Required documentation was not maintained, and interviews with staff confirmed the absence of necessary transfer notices in the resident's medical record.
A resident with severe cognitive impairment was transferred to the hospital due to a suspected stroke, but the facility failed to provide written notification of its bed hold policy. The facility's procedure mandates that a copy of the bed hold policy be sent with the resident, but this was not done, as confirmed by the Administrator.
A facility failed to submit a referral for a Level 2 PASSAR evaluation for a resident with an expired Level 2 PASSAR. The resident, admitted with major depressive disorder, anxiety disorder, PTSD, and type 2 diabetes, was receiving orthopedic aftercare. The Social Worker confirmed the oversight, unaware that Level 2 approvals could be short-term and expire.
The facility failed to update care plans for two residents after falls and changes in condition. One resident with severe cognitive impairment and a history of falls did not have their care plan revised after multiple falls. Another resident, admitted with acute pyelonephritis and MRSA, experienced a fall and a decline in function, yet their care plan did not reflect the need for two-person assistance during transfers. The facility's policy on safe lifting was not followed, contributing to the deficiencies.
A resident with severe cognitive impairment and recent fall history reported right arm pain and immobility, which CNAs failed to report to the LPN. The OT noticed the issue and sought further evaluation. Training records showed incomplete documentation for one CNA, indicating a deficiency in communication and training protocols.
The facility failed to provide medications as ordered for two residents, with one missing Duloxetine for anxiety and another missing Xifaxan for liver disease due to pharmacy delays. The DON was unaware of these issues and expected staff to reorder medications timely. Additionally, a MA did not document the dispensing of controlled medications as per policy, which required immediate entry on the inventory sheet.
The facility failed to properly label and date medications, including insulin pens and an inhaler, as required by manufacturer guidelines. An LPN incorrectly labeled a LISPRO Insulin Pen with a 60-day discard date instead of the correct 28 days, and a LANTUS Insulin Pen was found without any dates. Additionally, an ADVAIR DISKUS inhaler was not dated upon opening. The DON confirmed the expectation for accurate dating and discard documentation.
The facility failed to implement Enhanced Barrier Precautions for a resident with pressure ulcers, lacking necessary signage and PPE. Additionally, an LPN did not disinfect a glucometer according to the manufacturer's instructions, using a wipe with an incorrect contact time. The ICP and DON confirmed these deficiencies, highlighting lapses in infection control practices.
A resident with dementia and muscle weakness experienced multiple falls due to a malfunctioning tennis ball slider device on their walker, resulting in serious injuries. The facility failed to conduct a thorough investigation or adhere to its fall management policy, leading to repeated incidents. Staff interviews revealed inadequate documentation and follow-up on equipment condition, contributing to the deficiency.
The facility failed to provide sufficient nurse staffing, particularly during the night shift, leading to delays in resident care. Observations and interviews revealed that the facility did not meet its planned CNA staffing ratio, resulting in residents waiting for assistance and missing scheduled showers. Staff reported being overwhelmed, with one CNA per hall being insufficient to meet resident needs. The facility's staffing issues were worsened by the elimination of agency staff and challenges in covering shifts due to callouts.
The facility failed to maintain resident dignity during medication administration and meal times. A CNA discussed personal matters and funeral arrangements in front of residents while assisting with meals, and called out to residents from across the room to prompt them to eat. An RN administered an insulin injection to a resident without providing privacy, exposing the resident's abdomen in a public area.
The facility failed to ensure proper infection control practices, including hand hygiene and cleaning of glucometers. Staff did not wash or sanitize their hands between resident contacts or assist residents with hand hygiene before and after meals. Additionally, glucometers were not cleaned before and after use, contrary to facility policy. The residents involved had severe cognitive impairments and were dependent on staff for personal hygiene.
Failure to Provide Dignified Care and Proper Grooming
Penalty
Summary
Two residents were not treated in a manner that promoted their dignity and quality of life. One resident, who was cognitively impaired and dependent on staff for activities of daily living, was observed by his representative to have been brought out of his room with uncombed hair, twisted clothing, and socks put on incorrectly. The representative also reported that the certified nurse aides assigned to assist the resident displayed unprofessional behavior, such as rolling their eyes and making dismissive comments during the transfer process. Documentation confirmed that a grievance was filed regarding this incident, and the facility's own records indicated that the resident was not properly groomed or dressed when brought out to visit with family. Another resident, who was cognitively intact and required staff assistance with bathing and grooming, was found to have visible, unshaven chin hairs of varying lengths after a documented shower. The resident stated that she was supposed to be shaved on shower days but was neither shaved nor asked if she wanted to be shaved during her most recent shower. A certified medication aide confirmed that residents should be offered shaving with each shower and acknowledged that the resident's appearance was not consistent with this expectation. Both incidents were in direct violation of the facility's policy, which requires that all residents be treated with respect and dignity, and that care be provided in a manner that maintains or enhances their quality of life. The failure to ensure proper grooming and respectful treatment during care activities led to a deficiency in upholding residents' rights to dignity and self-determination.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Secure Wheelchair Cushion Leads to Resident Fall During Van Transfer
Penalty
Summary
A deficiency occurred when a resident with a recent below-knee amputation and a history of Type 1 Diabetes Mellitus was not safely transferred from a facility van. The resident, who was cognitively intact, returned from a medical appointment and was being assisted by a staff van driver. During the transfer, as the wheelchair was being maneuvered down the ramp, the resident leaned forward and slid out of the wheelchair, landing on his recently operated stump. The cushion, which was intended to prevent skin breakdown, was not properly secured to the wheelchair and slid out with the resident. Multiple staff interviews confirmed that the cushion's securing strap was not buckled, allowing it to move from its position due to the smooth surfaces of both the cushion and the wheelchair seat. The incident resulted in the resident experiencing significant pain and requiring ambulance transport to the hospital, where he was diagnosed with a fall from the wheelchair and dehiscence of the surgical wound on his stump. Facility documentation and staff interviews consistently indicated that the failure to properly secure the wheelchair cushion directly contributed to the resident's fall during the transfer process.
Failure to Honor Resident Visitation Rights Due to Unsubstantiated Infestation Concerns
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of his choosing, specifically restricting a cognitively intact resident from seeing his wife. The resident's wife was banned from entering the facility after reporting that she had been bitten or stung by something in the resident's room, which led the administrator to suspect she might have a parasite. The administrator required her to obtain medical clearance before returning. Despite no evidence of bugs or infestation being found by staff, pest control, or housekeeping, the ban remained in place for approximately two weeks. During this period, the resident's wife was not allowed to visit inside or outside the facility, and staff prevented the resident from meeting her outside or receiving food she brought. Staff interviews confirmed that the ban was enforced due to concerns about a possible infestation, but no actual infestation was identified. The resident and his wife both reported that she was threatened with arrest for trespassing if she did not leave the property when attempting to deliver food. Staff, including CNAs, LPNs, and the Social Service Director, acknowledged awareness of the ban and confirmed that no bugs were found on the resident, his wife, or in the room. The Social Service Director and DON stated that the resident should have been allowed to visit with his wife outside, but this did not occur. The facility's pest control company confirmed that no additional services were requested and that bed bugs would not die out without treatment. The facility's own resident handbook states that visitation rights will be honored unless they infringe on the rights of others, but there was no evidence that this was the case.
Failure to Provide Proper Discharge Notice and Required Information
Penalty
Summary
A cognitively intact resident with a history of complete traumatic amputation to the left lower leg and Type 1 Diabetes Mellitus was admitted to the facility and continued to receive services, including physical therapy. On one occasion, the resident was issued a 48-hour discharge notice by the Assistant Administrator without an explanation or inclusion of information regarding the appeals process. Later the same day, a 30-day discharge notice was provided, also lacking the required information about the appeals process. Both notices instructed the resident to remove all personal belongings and vacate the room by the specified dates. Interviews with the resident and the Assistant Administrator confirmed that the discharge notices did not contain all the information required by regulation, specifically omitting details about the appeals process. Review of facility policy and the resident's contract agreement indicated that a 30-day notice is required except in emergencies, and that all applicable federal and state regulations must be followed. The facility failed to provide the resident with a proper discharge notice containing the necessary information and appropriate notice period as required.
Failure to Notify Resident and Representative of Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and the resident's representative received notification of care plan meetings, as required by facility policy. The resident, who was cognitively intact and admitted with a complete traumatic amputation to the left lower leg and Type 1 Diabetes Mellitus, reported not receiving any notice of care plan meetings prior to March 2025. The resident's wife also stated she had never received notice of a care plan meeting, despite specifically requesting to be invited at the time of admission. Both the resident and his wife confirmed they were not notified of any care plan meetings before March, nor did they receive copies of any prior care plans. Interviews with facility staff revealed that the Social Service Director (SSD) was responsible for setting up care plan meetings and notifying residents and their representatives. The SSD indicated that the automated notification system through the electronic medical record (ClinNEX in Point Click Care) had not been functioning, resulting in the lack of notification for the resident and his wife. The Assistant Administrator and Director of Nursing confirmed that it was expected for care plan meetings to be set up by personal phone call, mail, or hand delivery if the resident was their own representative. Review of facility policy confirmed the requirement to notify residents and their families or responsible parties of care plan meetings and to maintain records of such notifications.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease, did not receive wound care and dressing changes as ordered by the physician. The resident was admitted with existing pressure ulcers and deep tissue injuries, and the wound care orders were updated several times by consulting specialists, including instructions for daily dressing changes. Despite these orders, the facility continued to provide wound care only on Monday, Wednesday, and Friday for approximately one week, rather than daily as required by the most recent physician orders. The failure to update and implement the correct wound care orders was identified through a review of the Treatment Administration Record (TAR), interviews with nursing staff, and communication with the resident's spouse and outside providers. The wound care nurse was responsible for transcribing new orders to the TAR but did not update the frequency of dressing changes after receiving new instructions from the podiatrist. This oversight was confirmed by both the wound care nurse and the Director of Nursing, who acknowledged that the orders were not correctly changed and implemented for about one week. During this period, the resident's wounds were noted to be worsening, with increased size and depth, as documented by the consulting podiatrist. The resident's spouse raised concerns about the lack of daily dressing changes, which prompted further investigation and ultimately led to the discovery of the error. The facility's policy required that provider orders be reviewed and followed prior to providing wound care, but this was not done in this instance, resulting in the resident not receiving the prescribed daily wound care.
Failure to Administer Ordered Pre-Procedural Medication for Allergy Prevention
Penalty
Summary
A resident with a history of heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease, and known allergies to iodine and contrast dye, was scheduled for an angiogram. Pre-procedure instructions required the resident to receive three doses of prednisone to prevent an allergic reaction due to the known allergy. The instructions were communicated to nursing staff, and the orders were to be transcribed onto the Medication Administration Record (MAR). However, the order for the three doses of prednisone was not transcribed onto the MAR, and there was no documentation that the resident received any of the required doses prior to the procedure. The omission was discovered when the resident’s wife inquired about the medication, and staff confirmed that no order for prednisone was present in the system. As a result, the resident did not receive the prescribed pre-procedure medication as required by the facility’s policy for safe and timely medication administration.
Improper Disinfection of Glucometer After Use
Penalty
Summary
A deficiency occurred when a registered nurse failed to properly disinfect a blood glucose monitor after use on a resident with Type 2 Diabetes Mellitus who was moderately cognitively impaired. During observation, the nurse was seen wiping the glucometer with an Oxivir TB wipe for only five seconds before placing it back in the insulin cart, despite stating that the required wet/contact time for disinfection was one minute. The nurse confirmed that the glucometer was not cleaned and disinfected for the full required time. The facility's policy and the disinfectant manufacturer's instructions both specify that reusable items, such as glucometers, must be cleaned and disinfected between residents with a one-minute wet time and allowed to air dry.
Facility Fails to Serve Hot Meals to Residents
Penalty
Summary
The facility failed to ensure that food and beverages were served at an appetizing temperature for residents who ate breakfast in their rooms, potentially affecting all 55 residents. An anonymous complaint and Resident Council Meeting Minutes from February to July 2024 revealed ongoing concerns about food trays being delivered late and cold. Specific complaints were documented in the meeting minutes, with residents expressing dissatisfaction with the temperature of their meals, particularly breakfast. During a confidential interview, a resident confirmed that breakfast was consistently cold and unappetizing, with no reheating offered. On October 17, 2024, a test tray evaluation was conducted following complaints of cold food. Observations began at 9:00 a.m., and a calibrated thermometer was used to measure food temperatures. The test tray revealed that waffles, scrambled eggs, sausage patty, and spiced apples were all served at temperatures below what is considered hot, with readings ranging from 68 to 90 degrees Fahrenheit. CNA #1 confirmed that the food items did not taste hot, and no residents requested reheating. During an interview, the Administrator stated that all staff should assist with passing trays and expected residents to receive hot food.
Failure in Coordinated Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure coordinated care and communication for a resident requiring dialysis services. Resident A, who was admitted with multiple diagnoses including End Stage Renal Disease, was taken to a dialysis center without a scheduled appointment, resulting in no available chair for treatment. There was a lack of communication between the facility and the dialysis center regarding the resident's condition, weight monitoring, nutritional status, and changes in status. The facility did not have new orders for dialysis upon the resident's admission, and there was no documentation of communication with the dialysis center to schedule treatments. The medical record review revealed that the facility did not document pre and post dialysis weights for Resident A, nor was there an assessment by the Registered Dietitian. The Director of Nursing admitted that the facility relied on the dialysis center to notify them of weight changes and was unaware of the process for nutritional assessments. The Certified Dietary Manager stated that nutritional assessments should occur within 48 hours of admission, but the facility did not monitor dialysis weights. Additionally, there was no documentation of monitoring the resident's AV fistula, and the facility continued to monitor a PD catheter that was no longer in use. Interviews with staff indicated a lack of communication and coordination with the dialysis center. The facility previously used a daily communication sheet, which was discontinued at the dialysis center's request, and no alternative communication method was implemented. The facility's policy required coordination and communication with the dialysis center, including monitoring weight changes and nutritional care, but these were not followed, leading to inadequate care for Resident A.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to manage pain effectively for a resident, identified as Resident #159, who was admitted with multiple diagnoses including hemiplegia, anxiety disorder, and neuropathy. The resident's care plan included interventions for pain management, such as administering medications as ordered and monitoring their effectiveness. However, the facility did not administer prescribed pain medications, including Tylenol and Hydro/apap, as needed for pain relief. The medication administration record (MAR) and narcotic sheet indicated that the resident did not receive any of the prescribed pain medications, and there was no documentation of refusals or administration. The resident reported experiencing significant pain, rated as eight out of ten, and stated that he had not received any pain relief. Despite the resident's complaints, the staff, including LPNs and medication aides, failed to assess and address the resident's pain adequately. The resident's pain assessments were incomplete, and there was a lack of communication and documentation regarding the resident's pain and the effectiveness of pain management interventions. The resident expressed a preference for Hydrocodone, but the facility did not provide education or document the refusal of alternative pain management options such as the Lidocaine patch. Interviews with staff revealed a lack of coordination and communication regarding the resident's pain management. The Director of Nursing (DON) acknowledged that the resident's pain was a concern and confirmed that the resident did not receive the prescribed Hydro/apap during the ordered timeframe. The Medical Director (MD) noted that the resident was experiencing post-stroke pain and was on Gabapentin for neuropathic pain. The MD intended to explore other pain management options after reviewing the resident's medical record. The facility's policy required documentation and reporting of pain assessments and interventions, which were not adequately followed in this case.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) form to 12 residents who no longer qualified for Medicare Part A, despite having days remaining. This deficiency was identified through interviews and a review of facility documents and policies. The [NAME] Specialist, who began working at the facility on 08/05/24, admitted to not sending any NOMNC notices and was unaware of her responsibility to do so. The Administrator confirmed that the [NAME] Specialist was responsible for sending out these notices and was unaware that they were not being sent. The facility's policy requires that the NOMNC be delivered at least two calendar days before Medicare-covered services end, but this was not adhered to for the 12 residents involved.
Inadequate Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment, which is essential for determining the necessary resources to care for residents effectively during both routine operations and emergencies. The assessment, revised and updated in 2024, was completed by the Administrator, the Director of Nursing, the Medical Director, and a Governing Board Member, but did not involve direct care staff or solicit input from residents, their representatives, or family members. This lack of involvement from key stakeholders could lead to an incomplete understanding of the facility's needs. Additionally, the staffing plan outlined in the assessment was inadequate as it did not specify staffing needs for each unit, shift, or weekends, nor did it consider changes in the resident population. The facility also failed to address the resources required for residents who were grandfathered for smoking. Furthermore, the assessment did not clearly state staff competencies and required training, as the documentation for annual education, orientation checklists, and competency checklists was incomplete or missing. The Administrator admitted to being unaware of the updated requirements for the Facility Assessment and acknowledged the need to plan for grandfathered smoking residents and streamline staff training.
Dish Machine Temperature Gauge Malfunction
Penalty
Summary
The facility failed to ensure the dish machine in the dietary department had a functioning wash temperature gauge, affecting all 56 residents. During an observation and interview, it was noted that the wash cycle gauge on the dish machine consistently registered below the required minimum temperature of 150 degrees Fahrenheit, with readings of 146 F and 144 F. The Assistant Dietary Manager (ADM) confirmed that the machine's instructions required a minimum wash temperature of 150 F and acknowledged that the wash temperature never reached this minimum. The ADM also stated that maintenance had previously serviced the machine for not reaching the required temperature. Further investigation revealed that maintenance had not been informed of the issue until the day of the observation. The ADM admitted that staff had not been using temperature strips to verify the wash temperature and had been relying on the faulty gauge for documentation. A review of the dish machine temperature logs from February to August 2024 showed that the wash temperature only met the minimum requirement on a few occasions. Additionally, a work order from January 2024 indicated previous issues with the machine's temperature, which were addressed by replacing parts and verifying the temperature. The facility's policy required daily maintenance checks of the temperature gauges, which were not effectively carried out, leading to the deficiency.
Failure to Address Resident Grievances on Cold Food
Penalty
Summary
The facility failed to address grievances voiced by residents regarding cold food, as documented in the Resident Council Meeting Minutes from February 2024 through July 2024. The minutes revealed consistent complaints about food trays being delivered late and cold. Despite these concerns being raised regularly, there was no evidence of effective follow-up or resolution. The Activity Director, responsible for documenting and forwarding these concerns, indicated that the minutes were sent to the Administrator and the relevant Department Head, such as the Dietary Manager, but no feedback or corrective action was communicated back to the residents. During a group interview conducted in August 2024, six alert and oriented residents confirmed that meals were frequently cold, particularly breakfast and lunch. They expressed frustration that despite raising these issues in meetings, no changes were made, and they were not informed of any plans to address the problem. The residents noted that the issue was specific to meals delivered to rooms, not those served in the dining room. The lack of response and action from the facility staff contributed to the ongoing dissatisfaction among the residents regarding the quality of their meals.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide residents with the opportunity to formulate advance directives, as evidenced by the cases of four residents. Resident #33, who was cognitively intact, had signed a form indicating the formulation of a Living Will and Do Not Resuscitate order, but no Living Will was found in the records. Resident #31, with severe cognitive impairment, had no advance directives or documentation indicating an opportunity to formulate them. Similarly, Resident #112, also with severe cognitive impairment, had a form with only initials and no indication of advance directives, and no documentation of an opportunity to formulate them. Resident #9, who was cognitively intact and his own responsible party, also had no advance directives or documentation of an opportunity to formulate them. Interviews with facility staff revealed a lack of follow-up and oversight in ensuring that advance directive documentation was completed and that residents were provided the opportunity to formulate them. The Social Worker indicated that the Admission Coordinator was responsible for handling advance directives during the admission process. However, the Admission Coordinator admitted to not following up to ensure all documents were obtained and completed, resulting in the deficiency noted in the report.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 16.13% due to five medication errors out of 31 opportunities. On one occasion, an LPN administered 12 units of LISPRO Insulin to a resident without priming the insulin pen, which is necessary to ensure the full dose is delivered. The LPN admitted to not being aware of the need to prime the pen. Similarly, an RN administered 22 units of FIASP Insulin to another resident without priming the pen, acknowledging awareness of the requirement and the potential for the resident not receiving the full dose. Additionally, a medication aide incorrectly administered Erythromycin Eye Ointment and Refresh Eye drops to a resident. The aide applied a drop of ointment instead of a ribbon along the lower eyelid and failed to administer the Refresh eye drops to the right eye, while administering two drops instead of one to the left eye. The DON confirmed the errors, noting the correct method for administering the ointment and the eye drops as per the physician's orders.
Failure to Ensure Resident Dignity by Dressing After Incontinence
Penalty
Summary
The facility failed to uphold the resident's right to a dignified existence by not ensuring that a resident was dressed appropriately. Resident #112, who had severe cognitive impairment and was diagnosed with acute pyelonephritis and MRSA infection, was observed in bed with only a cover pulled up to his chin and wearing only a pull-up diaper. The resident expressed a desire to be dressed, stating that his clothes were dirty, but he had clean shirts available in his closet. Despite this, staff did not assist him in getting dressed. Further observations revealed that Certified Nurse Aides (CNAs) #3 and #4 transferred the resident to a shower chair while he was still undressed, wearing only an incontinence brief. CNA #3 admitted to leaving the resident undressed after an episode of incontinence before breakfast, as she planned to take him to the shower afterward. The Director of Nursing confirmed that the expectation was for residents to be dressed after such episodes and not left undressed for meals. This failure to dress the resident after an incontinence episode and before breakfast was a violation of the facility's Resident Rights, which emphasize the right to a dignified existence and reasonable accommodation of needs and preferences.
Failure to Provide Quarterly Financial Statement to Resident
Penalty
Summary
The facility failed to provide a quarterly statement of personal funds to a resident, identified as Resident #9, who was cognitively intact and his own responsible party. The resident was readmitted to the facility and had not requested or appointed another representative to receive his personal fund statements. During interviews, Resident #9 confirmed that he did not receive the quarterly statement dated June 30, 2024, and expressed a desire to know the balance in his account. The facility's policy required that resident fund statements be sent out quarterly, but there was no documentation in the medical or financial records to confirm that the statement was delivered to Resident #9. The [NAME] Specialist #1, who had been in her role for two weeks, was unable to verify whether the quarterly statement was provided to Resident #9. She only had a sticky note indicating that the statement was hand-delivered, but it lacked a delivery date or the name of the person who delivered it. The Administrator expected that quarterly statements be provided to residents or their representatives, but the facility's records did not reflect compliance with this expectation. An email from the Social Worker to the Administrator suggested that the resident received the trust statement, but this was not corroborated by the records available at the time of the survey.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as evidenced by a worn and soiled mattress and an unclean slipper pan. During an observation, a resident's mattress was found to have a large, discolored, and dirty area, indicating significant wear and lack of cleanliness. Additionally, a slipper pan in the resident's bathroom contained brown residue and was improperly stored on top of a package of briefs. The Director of Nursing acknowledged that the Certified Nursing Assistants should have reported the condition of the mattress and ensured it was replaced, and that the slipper pan should have been discarded and replaced.
Failure to Notify Resident of Hospital Transfer Reasons
Penalty
Summary
The facility failed to provide timely notification to a resident, their representative, and the ombudsman regarding the reasons for the resident's transfer to the hospital. This deficiency was identified for one resident who was transferred to the hospital on two separate occasions. The resident, who had severe cognitive impairment, was initially transferred due to symptoms indicative of a stroke and later for a complicated urinary tract infection. In both instances, there was no documentation in the resident's medical record indicating that written notice of the reasons for the hospital transfers was provided to the resident or their representative. Interviews with facility staff, including the Medical Records clerk, Administrator, and Director of Nursing, revealed that the necessary transfer documentation was not maintained in the resident's electronic medical record. The facility's procedures and policies required that a Nursing Home Notice of Transfer/Discharge form be completed and included in the resident's medical record, but this was not done. The forms available did not have a section to specify reasons for hospital transfers, and no copies of the required notices were found for the resident's hospitalizations.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a resident with written notification of its bed hold policy during a transfer to the hospital. This deficiency was identified for one resident out of a sample of three. The resident, who had severe cognitive impairment, was initially admitted to the facility with acute pyelonephritis and MRSA infection. On a particular day, the resident exhibited symptoms of a suspected stroke, prompting immediate medical intervention and transfer to the hospital via airlift. Upon review of the resident's electronic medical record, it was found that there was no documentation indicating that the resident or their representative received a written notice of the facility's bed hold policy at the time of transfer. The facility's procedure for hospital transfers explicitly requires that a copy of the bed hold policy be sent with the resident. During an interview, the Administrator confirmed that this protocol was not followed in the case of the resident's transfer.
Failure to Submit Referral for Level 2 PASSAR Evaluation
Penalty
Summary
The facility failed to submit a referral for a Level 2 PASSAR (Pre-Admission Screening and Resident Review) evaluation for a resident with an expired Level 2 PASSAR. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, post-traumatic stress disorder, and type 2 diabetes mellitus, and was receiving orthopedic aftercare following a surgical amputation. The resident's Level 2 PASSAR was initially approved for short-term admission and had expired. There was no evidence in the medical record that the facility had submitted a referral for another Level 2 evaluation to extend approval beyond the expiration date. During an interview, the Social Worker confirmed that the resident's Level 2 PASSAR had expired and admitted she had not submitted a request for another evaluation. She was unaware that Level 2 approvals could be short-term and have expiration dates.
Failure to Update Care Plans After Falls and Changes in Condition
Penalty
Summary
The facility failed to revise the care plan for two residents after significant events, leading to deficiencies in their care. Resident #51, who had severe cognitive impairment and a history of falls, experienced multiple falls while in the facility. Despite being identified as high risk for falls, the care plan was not updated to address the falls on two specific occasions, nor were new interventions implemented to prevent further incidents. The MDS Coordinator confirmed that the care plan was not revised following these falls. Resident #112, who was admitted with acute pyelonephritis and MRSA infection, also experienced a fall that was not adequately addressed in the care plan. After a significant change in condition, including a fall that resulted in a decline in function and mobility, the care plan still indicated that the resident required assistance from only one person for transfers. However, observations showed that two CNAs were needed to transfer the resident safely, indicating a discrepancy between the care plan and the resident's actual needs. The MDS Coordinator acknowledged that the care plan was not updated to reflect the resident's fluctuating abilities and the need for additional assistance. The facility's policy on safe lifting and moving of residents was not adhered to, as evidenced by the manual lifting of Resident #112 without the use of mechanical aids or proper techniques. The policy requires ongoing assessment and documentation of residents' transfer needs, which was not done in these cases. This failure to update care plans and follow established policies contributed to the deficiencies identified by the surveyors.
Failure to Report Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) were competent in reporting changes in a resident's condition, specifically for Resident #112. This resident, who had severe cognitive impairment and was dependent on assistance for transfers, reported right arm and shoulder pain and an inability to move the arm. Despite these complaints being observed by CNAs #3 and #4, the change in condition was not reported to the Licensed Practical Nurse (LPN) #1. The resident had a history of a recent fall, which was not initially linked to the current symptoms by the CNAs. The Occupational Therapist (OT) #2, upon noticing the resident's condition, sought out the Director of Rehab and the nurse to report the issue and inquire about an x-ray. LPN #1 confirmed that no report of the resident's condition had been made to her prior to the OT's intervention. The facility's training records showed that CNA #4 had received orientation training, but there was no documentation for CNA #3's training or competencies. This lack of documentation and failure to report the resident's condition highlights a deficiency in the facility's training and communication protocols.
Medication Availability and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure the availability of medications as ordered for two residents. Resident #14 did not receive Duloxetine for anxiety on three consecutive evenings due to a delay in pharmacy delivery. Similarly, Resident #9 missed doses of Xifaxan for liver disease on five occasions due to unavailability from the pharmacy. The Director of Nursing (DON) was unaware of these supply issues and noted that the facility received pharmacy deliveries twice daily. The DON expected staff to reorder medications when supplies were low and to inform her of any difficulties in obtaining medications. The Medical Director expressed concern about Resident #14 missing Duloxetine due to anxiety but noted that missing Xifaxan for Resident #9 was not a significant error. Additionally, the facility failed to follow its policy for documenting the dispensing of controlled medications. During a medication pass observation, a Medication Aide (MA) did not sign off the declining inventory sheet after dispensing Clonazepam and Oxycodone to Resident #14. The MA acknowledged the oversight, and the DON emphasized the importance of completing the inventory sheet immediately after dispensing controlled medications to ensure accurate counts. The facility's policy required staff to document the date, time, amount administered, and signature on the inventory sheet immediately after administering controlled medications.
Medication Labeling and Dating Deficiency
Penalty
Summary
The facility failed to ensure proper labeling and dating of medications, specifically insulin pens and an inhaler, as observed during a survey. On August 19, 2024, an LPN was seen opening a new LISPRO Insulin Pen for a resident and incorrectly labeling the 'Do Not Use After' date as 60 days post-opening, contrary to the manufacturer's guidelines of 28 days. The LPN later acknowledged the mistake and corrected the date. Additionally, an opened LANTUS Insulin Pen for another resident was found on the medication cart without any date of opening or discard date. Further observations on August 21, 2024, revealed an opened ADVAIR DISKUS for a different resident that was not dated when opened. A medication aide confirmed that the inhaler should have been dated upon opening, as it must be discarded 30 days after being opened. The Director of Nursing confirmed the expectation for staff to date medications when opened and to accurately document discard dates. The manufacturer's prescribing information for the medications in question was reviewed, confirming the correct storage and discard guidelines.
Infection Control Deficiencies in EBP and Glucometer Disinfection
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident admitted with pressure ulcers. The resident, who had been admitted with one stage 2 and one stage 3 pressure ulcer, as well as unstageable pressure ulcers, did not have EBP signage or personal protective equipment at the room entry. The Infection Control Preventionist (ICP) confirmed that the resident had not been on EBP since admission and there was no documentation from the previous facility regarding the status of the pressure ulcers. The facility's policy required gowns and gloves for certain residents during high-contact care activities, such as wound care, but this was not followed for the resident in question. Additionally, the facility did not ensure that a single-resident use glucometer was cleaned and disinfected according to the manufacturer's instructions. An LPN used a sanitizing wipe with a one-minute contact time instead of the required three-minute contact time as per the instructions on the CAVI brand wipes. The LPN was unaware of the correct contact time and used the wrong wipes, which was confirmed by the Director of Nursing. The competency checklist for the LPN indicated the use of one-minute contact time wipes, but did not specify the brand, leading to the oversight.
Failure to Investigate Falls Leads to Resident Injuries
Penalty
Summary
The facility failed to conduct a thorough investigation into the falls experienced by a resident, leading to significant injuries. The resident, who had a history of dementia, muscle weakness, and anxiety disorder, suffered multiple falls resulting in a right femoral neck fracture, a type 4 fracture of the sacrum, and rib fractures. The initial fall occurred when the resident was found on the floor without shoes, and a tennis ball slider device had come off the walker. The facility did not complete the necessary Fall Questionnaire, which was supposed to initiate the investigation process. Subsequent to the first incident, another fall occurred when a CNA witnessed the resident fall and hit her head, again due to the tennis ball slider device coming off the walker. Despite the recurrence of the issue with the walker, the facility did not conduct a comprehensive root cause analysis to address the malfunctioning equipment. The facility's policy on fall risk reduction and management was not followed, as it required an investigation to determine the causes of falls and to modify interventions accordingly. Interviews with staff revealed that the tennis ball slider devices were not consistently checked or documented for wear and tear, and the same faulty device was reattached to the resident's walker after the first fall. The lack of documentation and follow-up on the equipment's condition contributed to the repeated falls and injuries sustained by the resident. The facility's failure to adhere to its fall management policy and to properly investigate and address the root causes of the falls resulted in a deficiency in providing a safe environment for the resident.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nurse staffing to meet the needs and preferences of residents, particularly during the night shift. Observations and interviews revealed that the facility did not meet its planned Certified Nursing Assistant (CNA) staffing ratio of 1:13 on several occasions, with ratios reaching as high as 1:23 on certain nights. This staffing shortage led to delays in resident care, such as a resident waiting 30 minutes for assistance to use the toilet and another resident missing scheduled showers due to staff being too busy. Residents and staff reported that the insufficient staffing levels affected the quality of care provided. For instance, a resident who preferred showers during the night shift was unable to receive them as planned, and another resident was not assisted out of bed in time for lunch or activities, causing distress. Staff interviews confirmed that the workload was overwhelming, with one CNA per hall being insufficient to meet the needs of residents requiring frequent care, such as turning, repositioning, and two-person assistance. The facility's staffing issues were exacerbated by the elimination of agency staff and challenges in covering shifts due to callouts. The facility's assessment and staffing plan did not accurately reflect the needs of the residents, leading to inadequate nurse and CNA coverage on multiple occasions. The administration acknowledged the staffing deficiencies and the need to revise the facility assessment to ensure adequate staffing levels.
Failure to Maintain Resident Dignity During Medication Administration and Meal Times
Penalty
Summary
The facility failed to maintain the dignity of residents during medication administration and meal times. Specifically, a CNA assisted a resident with lunch while discussing funeral arrangements for another resident and personal matters with other staff members, in the presence of multiple residents. Additionally, the CNA called out to residents from across the room to prompt them to eat, rather than providing face-to-face encouragement. This behavior was observed with several residents who had severe cognitive impairments, including Alzheimer's and non-traumatic brain dysfunction. Furthermore, during a medication administration, an RN instructed a resident to lift her shirt and simultaneously pulled down the top of her pants to administer an insulin injection, exposing the resident's abdomen in a public area. This action was performed without providing privacy, resulting in the resident's exposure to other residents and staff members present in the dining room. Interviews with the staff confirmed these actions and acknowledged that they should have provided more privacy and respect to the residents during these activities.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, specifically in the areas of hand hygiene and cleaning of glucometers. Observations revealed that staff did not wash or sanitize their hands between direct contact with multiple residents, nor did they assist residents with hand hygiene before and after meals. For instance, a CNA did not wash or sanitize her hands between feeding one resident and repositioning another. Additionally, an RN did not wash or sanitize her hands after removing gloves and before handling another resident's glass. These actions were contrary to the facility's Handwashing and Hand Hygiene policy, which mandates hand hygiene before and after direct contact with residents, before applying and after removing gloves, and when assisting residents with meals. Furthermore, the facility failed to ensure that glucometers were cleaned and disinfected before and after each use. An RN was observed performing blood glucose tests on two residents without cleaning their respective glucometers. The RN admitted to not cleaning the devices and acknowledged the importance of doing so. The Infection Control Preventionist confirmed that staff were expected to follow the policy for cleaning glucometers and assisting residents with hand hygiene, but these protocols were not adhered to during the observations. The residents involved had severe cognitive impairments and were dependent on staff for personal hygiene, making adherence to these protocols crucial for their care.
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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