University Place Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 9200 Glenwater Drive, Charlotte, North Carolina 28262
- CMS Provider Number
- 345142
- Inspections on file
- 27
- Latest survey
- August 27, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at University Place Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a seizure disorder did not receive their prescribed Cenobamate medication for 14 days, leading to a mild seizure. The medication was not available on the cart, and nurses on the second shift were unaware of its absence, failing to notify the pharmacy. This oversight was due to a lack of adherence to the 6 rights of medication administration.
A resident with a seizure disorder did not receive the prescribed doses of Cenobamate due to a failure in requesting the medication from the pharmacy. Despite this, two nurses documented the administration of the medication on the MAR, unaware that it was unavailable on the medication cart. The discrepancy was discovered during an investigation initiated by the ADON and Administrator.
A medication handling error occurred when a nurse failed to properly dispose of a plastic bag used to crush medications, leading to a resident mistakenly sprinkling the contents on his breakfast. The resident, who was cognitively intact, realized the bitter taste and spit it out, avoiding ingestion. The bag was intended for another resident with severe cognitive impairment. The nurse claimed the bag was empty, and staff interviews revealed a lack of awareness and communication about the incident.
A resident with a mechanical soft diet order due to dysphagia and other conditions repeatedly received crispy bacon, which was not ground as required. Despite the resident's complaints and the staff's awareness of his dietary needs, the tray card was never corrected, leading to the resident receiving inappropriate meals. Interviews with staff revealed a lack of communication and documentation regarding the resident's dietary preferences and education on the risks of eating crispy bacon.
A resident with a regular diet and mechanical soft texture preference did not receive scrambled eggs for breakfast as documented on his tray card. Despite attending Food Committee Meetings, his preference was not consistently honored, particularly when cheese eggs or an omelet were served. Staff interviews revealed awareness of his preference, but an oversight led to the resident receiving a cheese omelet instead, which he did not prefer.
A resident with severe cognitive impairment and a history of falls was transferred by a single nurse aide without the required mechanical lift, contrary to the care plan. The aide, an agency staff member, was not properly informed about the resident's transfer needs, leading to a deficiency in accident prevention and supervision.
The facility failed to assess two residents for the ability to self-administer medications. One resident was found with medications left on their overbed table, and another had a bottle of antacid chewable tablets. Both incidents were against the facility's policy, and neither resident had been assessed for self-administration.
The facility failed to provide adequate nail care for two dependent residents, resulting in long, dirty fingernails. Despite being scheduled for regular showers and requiring substantial assistance for personal hygiene, staff inconsistencies and a lack of monitoring led to the deficiency.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in PASRR levels and restraint usage. Errors were attributed to human oversight and staff changes, with the Administrator and DON acknowledging the need for corrections.
The facility failed to properly label and store insulin pens, with observations revealing missing open dates, expired insulin, and improper storage. Nurses were unaware of their responsibilities, and the DON confirmed the expected procedures were not followed.
The facility failed to remove expired food items and unlabeled personal items from a resident's nourishment room. An 8 oz. fat-free milk with an expired best-by date and three unlabeled lunch bags were found in the memory care unit nourishment room. Staff had been educated not to store personal items in the nourishment room and to discard expired items, but these practices were not followed.
The facility's QAA committee failed to maintain procedures and monitor interventions, leading to repeat deficiencies in MDS coding, food sanitation, and infection control. Inaccurate MDS assessments were found for several residents, and expired and unlabeled food items were discovered in nourishment rooms. Additionally, staff did not follow proper hand hygiene and infection control practices during wound care and incontinence care.
The facility failed to complete PASRR Level II for three residents with mental health diagnoses, including delusional disorder, severe dementia with psychotic disturbance, dementia with mood disturbance disorder, and major depressive disorder. The Social Worker and Administrator acknowledged the oversight and confirmed that the assessments should have been completed in a timely manner.
Failure to Administer Seizure Medication Leads to Resident Seizure
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when they did not administer a daily dose of Cenobamate, a seizure medication, from September 5 through September 18. This lapse in medication administration led to the resident experiencing a mild seizure on September 18, characterized by eyes rolling back and upper body twitching lasting approximately two minutes. The resident had been admitted with a diagnosis of seizure disorder and had persistent breakthrough seizures, necessitating a specific medication regimen. The resident's medication orders included a gradual increase in Cenobamate dosage, which was not followed due to the medication not being available on the medication cart. Nurses on the second shift, who were responsible for administering the medication, were unaware that Cenobamate was missing and assumed it had been given. They did not identify the absence of the medication, nor did they notify the pharmacy to request the required doses. This oversight was compounded by a lack of adherence to the 6 rights of medication administration, which include verifying the right resident, drug, dosage, route, time, and documentation. Interviews with nursing staff revealed a misunderstanding of responsibilities regarding medication availability and administration. The facility's investigation determined that the error occurred because the increased doses of Cenobamate were never requested from the pharmacy. The resident's seizure on September 18 prompted a review of the medication administration process, revealing that the medication had not been administered as ordered, leading to the significant medication error.
Failure to Document Seizure Medication Administration
Penalty
Summary
The facility failed to accurately document the administration of a seizure medication, Cenobamate, for a resident diagnosed with a seizure disorder. The resident was supposed to receive Cenobamate 50 mg daily at bedtime from September 5 to September 18, followed by an increased dose of 100 mg starting September 19. However, a review of the Medication Administration Record (MAR) indicated that the medication was documented as given during this period, despite the controlled substance count sheet showing the last pill was administered on September 4. This discrepancy was discovered when the Assistant Director of Nursing (ADON) was informed by a nurse that the medication was not available on the cart, prompting an investigation. Interviews with the involved nurses revealed that they were unaware of the medication's unavailability and had mistakenly documented its administration on the MAR. The ADON and the Administrator confirmed that the medication was not requested from the pharmacy when the dose was increased, leading to the medication not being available for administration. The nurses involved were unable to explain why they documented the administration of a medication that was not present, highlighting a failure in maintaining accurate medical records and safeguarding resident-identifiable information.
Medication Handling Error Involving Two Residents
Penalty
Summary
The facility failed to properly dispose of a plastic bag used to crush medications, which led to a medication error involving two residents. Resident #23, who was cognitively intact and frequently reported severe pain, mistakenly believed the crushed medication in the bag was powdered sugar and sprinkled it on his breakfast. Upon tasting the bitter substance, he realized it was not sugar and spit it out, avoiding ingestion. The plastic bag had another resident's name on it, indicating it was intended for Resident #24, who was severely cognitively impaired and had no signs of pain. Nurse #1, who was responsible for administering medications, had crushed acetaminophen tablets for Resident #24 and placed the used plastic bag in her pocket instead of disposing of it properly. While assisting with breakfast tray distribution, the bag accidentally fell onto Resident #23's tray. Nurse #1 later realized the bag was missing and found it in Resident #23's room. Despite the incident, Nurse #1 claimed the bag was empty and had already administered the medication to the correct resident. Interviews with staff, including the DON, Unit Manager, and former Social Worker, revealed a lack of awareness and communication regarding the incident. The DON was informed by Nurse #1 that the bag was empty, and no further action was taken. The Unit Manager and former Social Worker were not fully aware of the details or the handling of the situation. The Physician Assistant confirmed that an extra dose of acetaminophen would not have caused harm to Resident #23, but the incident highlighted a lapse in medication handling procedures.
Failure to Provide Appropriate Diet for Resident with Mechanical Soft Texture Order
Penalty
Summary
The facility failed to provide food in a form that met the individual needs of a resident with a physician order for a regular diet with mechanical soft texture. The resident, who had diagnoses including dysphagia, dementia, and a cognitive communication deficit, was observed not eating his breakfast because it included crispy bacon, which was not ground as required by his diet order. Despite the resident's repeated complaints about receiving bacon that he could not eat due to his swallowing difficulties, the issue persisted, and his tray card incorrectly recorded a preference for crispy bacon. The resident expressed that he had been receiving bacon inappropriately for years, despite his diet order for ground meat. He stated that he could not eat the bacon because it was too hard and large, causing him to cough. The resident also mentioned that he had never requested crispy bacon and preferred to avoid pork. Staff interviews revealed that although some staff members were aware of the resident's dietary needs, the tray card was never corrected, and the resident continued to receive inappropriate meals. Interviews with various staff members, including a nurse aide, unit manager, speech therapist, certified foodservice manager, registered dietitian, and the administrator, highlighted a lack of communication and documentation regarding the resident's dietary needs and preferences. The speech therapist and registered dietitian confirmed that the resident should have been educated on the risks of eating crispy bacon, but there was no documentation of such education. The facility's failure to provide the resident with the appropriate diet as ordered by his physician resulted in the deficiency noted in the report.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide a resident with scrambled eggs for breakfast according to his preference, as documented on his tray card. This deficiency was identified for a resident who had a physician order for a regular diet with mechanical soft texture and was at risk for nutritional decline due to a history of weight loss and varying appetite. Despite attending weekly Food Committee Meetings, the resident expressed that his preference for scrambled eggs was not consistently honored, particularly when the menu included cheese eggs or an omelet. On the day of observation, the resident received a cheese omelet instead of scrambled eggs, which he did not prefer, leading to him not finishing his meal. Interviews with staff revealed that the resident's preference for scrambled eggs was known, but not always provided. A nurse aide familiar with the resident's preferences stated that she would return his tray to the kitchen if it did not meet his dietary needs, but she did not set up his tray on the day in question. The Unit Manager, who was not familiar with the resident's care needs, did not notice the discrepancy. The Certified Foodservice Manager, who had been in the position for three weeks, acknowledged the oversight. The Registered Dietitian, who often assisted on the tray line, was unaware of the resident's unmet preference as it had not been discussed in meetings or reported by staff.
Failure to Safely Assist Resident During Transfer
Penalty
Summary
The facility failed to safely assist a resident during a transfer, resulting in a deficiency related to accident hazards and supervision. Resident #1, who was severely cognitively impaired and required extensive assistance with transfers, was transferred by a single nurse aide without the use of a mechanical lift, as specified in the resident's care plan. The nurse aide, who was an agency staff member and unfamiliar with the resident, assumed the resident was a one-person assist due to a lack of proper orientation and education on the resident's care needs. Observations revealed that the nurse aide transferred the resident from the bed to a wheelchair without any visible incident, but without following the care guide that required a mechanical lift. Interviews with facility staff, including the unit manager, nurse, director of nursing, and administrator, confirmed that the nurse aide was not properly informed about the resident's transfer requirements. The staff acknowledged that the resident had a history of falls and should have been transferred using a mechanical lift, as documented in the care guide and care plan.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to assess residents for the ability to self-administer medications for two residents. Resident #2, who was cognitively intact, had physician orders for Gabapentin and Hydrocodone-Acetaminophen but no orders to self-medicate. An observation revealed that medications were left on Resident #2's overbed table, and the resident admitted to not taking them immediately. The Director of Nursing confirmed that no residents were allowed to self-medicate, and Nurse #1 admitted to leaving the medications, thinking the resident had taken them. The Administrator reiterated that residents were not allowed to self-administer medications without an assessment. Resident #3, also cognitively intact, was found with a bottle of antacid chewable tablets on her overbed table. Multiple observations confirmed the presence of the tablets, and the resident admitted to taking some. Nurse #2 and the Director of Nursing both confirmed that residents were not allowed to self-administer medications and that Resident #3 had not been assessed for this ability. The Administrator confirmed that the antacid tablets were removed and stored securely. Both incidents highlight the facility's failure to assess residents for self-administration of medications and to ensure that medications were not left at residents' bedsides. This lack of assessment and improper handling of medications led to residents having unauthorized access to their medications, which is against the facility's policy and procedures.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents who were dependent on staff for activities of daily living. Resident #4, who was admitted with diagnoses including hemiplegia and muscle weakness, was observed to have long, dirty fingernails despite being scheduled for regular showers. The resident's care plan indicated a need for maximal assistance with personal hygiene, yet staff interviews revealed inconsistencies in performing nail care. The resident's representative had previously raised concerns about the resident's nail hygiene, but the issue persisted. Observations confirmed that the resident had long, dirty fingernails with a brown substance underneath, and staff members admitted to not noticing or addressing the issue adequately. Resident #5, admitted with vascular dementia and requiring substantial assistance for personal hygiene, also had long, dirty fingernails. Despite being scheduled for regular showers, there was no documentation of nail care in the resident's records. Observations confirmed that the resident had long, dirty fingernails with a brown substance underneath. Staff interviews revealed that some nurse aides were uncomfortable with cutting nails and would report the issue to a nurse instead. However, there was no clear protocol or monitoring system in place to ensure that nail care was consistently performed. Interviews with the Staff Development Coordinator, Unit Manager, Director of Nursing, and Administrator highlighted a lack of clarity and consistency in the facility's nail care procedures. While staff were trained to perform nail care, there was no system in place to audit or monitor its completion. The Director of Nursing and Administrator were unaware of the specific deficiencies in nail care for Residents #4 and #5, indicating a gap in oversight and communication within the facility.
Inaccurate MDS Coding for PASRR and Restraints
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for several residents, leading to discrepancies in their Preadmission Screening and Resident Review (PASRR) levels and restraint usage. Resident #41, who had diagnoses including hemiplegia, hemiparesis, anxiety, and psychosis, was not coded as having a level II PASRR on his MDS despite a determination letter indicating otherwise. The MDS Coordinator, who started in October 2023, was unaware of this requirement, and both the Administrator and Director of Nursing (DON) confirmed the oversight was due to human error. Similarly, Resident #102, diagnosed with dementia, was not coded as having a level II PASRR on her MDS, despite a determination letter from May 2021. The MDS Coordinator attributed this to an oversight by the previous coordinator. Both the Administrator and DON were unaware of this discrepancy and acknowledged it as an error that needed correction. Resident #84, with diagnoses of dementia, schizophrenia, and anxiety, was also not correctly coded for a level II PASRR on the MDS, despite having a PASRR identification number in the medical record. The MDS Coordinator initially misunderstood the PASRR status, leading to the incorrect coding. Additionally, Resident #110 was incorrectly coded for the use of a limb restraint on the quarterly MDS assessment, despite no evidence of restraint use in the care plans or previous MDS assessments. The current MDS Coordinators confirmed that the resident did not use a limb restraint and attributed the error to a previous coordinator. The Administrator emphasized the expectation for accurate MDS assessments and the need for entries to be checked before final submission.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to properly label and store insulin pens in accordance with professional principles. During an observation of the Garden City medication cart, an opened Glargine insulin pen and an opened Novolin insulin pen were found without open dates. Additionally, an opened insulin pen with an open date of 12/08/2023 was found, which had passed its 28-day expiration date. Nurse #6 was unaware of the missing dates and the expired insulin pen, believing that the 3rd shift nursing staff were responsible for checking the medication carts for expired medications. Similarly, an observation of the Arboretum Cart revealed two unopened insulin pens stored in the medication cart instead of the refrigerator, and a Glargine insulin pen with an illegible open date. Nurse #7 did not realize the insulin pens lacked open dates, were not refrigerated, and had an illegible open date. The Director of Nursing confirmed that all insulin pens should be labeled with a 28-day expiration date when opened, stored in the refrigerator until use, and checked regularly by all nurses to ensure no expired medications are available for use.
Expired and Unlabeled Food Items Found in Nourishment Room
Penalty
Summary
The facility failed to remove expired food items and unlabeled personal items from a resident's nourishment room. During an observation and interview with a Nurse Aide (NA), an 8 oz. fat-free milk with an expired best-by date and three unlabeled lunch bags were found in the memory care unit nourishment room. The NA indicated that nursing staff stored their personal items in the nourishment room due to the break room being located on the other side of the facility. The NA also mentioned that nursing staff had been educated not to store personal items in the nourishment room and to discard expired items. The Dietary Manager (DM) confirmed that dietary aides check nourishment rooms daily but could not recall if they had been checked over the weekend. The Director of Nursing (DON) stated that nursing staff were educated not to store personal belongings in the nourishment rooms and were responsible for discarding expired items. The Administrator expected staff to check nourishment rooms daily and discard any expired or unlabeled items, and confirmed that it was inappropriate for nursing staff to store personal items in the nourishment room refrigerator.
Repeat Deficiencies in MDS Coding, Food Sanitation, and Infection Control
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following multiple surveys, resulting in repeat deficiencies. Specifically, the facility failed to accurately code the Minimum Data Set (MDS) assessment for several residents, including those reviewed for Preadmission Screening and Resident Review (PASRR) and restraints. Additionally, the facility did not accurately code the MDS assessment related to tobacco use for residents reviewed for smoking. These inaccuracies were identified during the recertification and complaint investigation surveys. The facility also failed to maintain sanitary conditions in food storage areas, as expired and unlabeled food items were found in multiple nourishment rooms and the walk-in cooler. Furthermore, the facility did not ensure proper hand hygiene and infection control practices during wound care and incontinence care for several residents. Staff members were observed not following hand hygiene protocols, such as not sanitizing hands and changing gloves between tasks, which compromised infection control measures. These deficiencies were noted during both the focused infection control survey and the recertification and complaint investigation surveys.
Failure to Complete PASRR Level II for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for residents with mental health diagnoses upon admission and for residents with new mental health diagnoses. Specifically, three residents were affected: Resident #141, who was diagnosed with delusional disorder and severe dementia with psychotic disturbance upon admission; Resident #31, who was diagnosed with dementia with mood disturbance disorder after admission; and Resident #49, who was diagnosed with major depressive disorder after admission. In each case, the required PASRR Level II was not completed, despite the diagnoses indicating it was necessary. Interviews with the Social Worker (SW) and the Administrator revealed that the SW was responsible for completing PASRR assessments upon admission, changes in condition, or new diagnoses. The SW admitted that Resident #141's PASRR Level II was overlooked, and she was not made aware of the new diagnoses for Residents #31 and #49. The Administrator confirmed that PASRR Level II should have been completed in a timely manner for all three residents based on their mental health diagnoses, but this was not done, leading to the deficiency noted in the report.
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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