Vero Health & Rehab Of Sylva
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylva, North Carolina.
- Location
- 417 Cloverdale Road, Sylva, North Carolina 28779
- CMS Provider Number
- 345302
- Inspections on file
- 29
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Vero Health & Rehab Of Sylva during CMS and state inspections, most recent first.
The facility submitted inaccurate PBJ staffing data to CMS, showing missing RN and licensed nurse coverage for multiple days, despite schedules and time clock reports confirming adequate coverage. The inaccuracy resulted from a transition between payroll systems and lack of data review prior to submission.
Two residents with moderate cognitive impairment and no upper extremity limitations were unable to reach the pull cords for their bedside lights, despite expressing a desire to use them. Observations showed the cords were positioned out of reach, and staff interviews confirmed the issue had not been addressed for both residents.
A resident's code status was inconsistently documented, with the care plan listing full code while the EHR, physician's order, and code status binder indicated DNR. Staff interviews revealed the Social Worker did not update the care plan due to not receiving the signed advance directive paperwork, resulting in conflicting information about the resident's wishes.
A resident was not offered, administered, or properly documented for the pneumococcal vaccine as required by facility policy. The resident, who was cognitively intact, reported not being offered the vaccine, and staff interviews confirmed there was no documentation of consent, administration, or refusal in the records. The DON and Corporate Nurse Consultant were unable to provide evidence that the vaccine process had been followed.
A resident's COVID-19 vaccination status was not determined or documented, with no evidence of informed consent, administration, or refusal found in the medical record. The resident, who was cognitively intact, reported not being offered the vaccine since admission and was unsure of his current status. Facility staff, including the DON and Corporate Nurse Consultant, were unable to locate any documentation regarding the resident's COVID-19 vaccine status.
A review of records and staff interviews revealed that the facility did not have a valid surety bond in place to cover the total balance of personal funds deposited by 55 residents in the trust fund account. The bond had expired, and key staff were unaware of its status until the survey.
Survey results were stored in a binder located in a first-floor lobby, placed about five feet high, making it inaccessible to residents whose rooms were on a secured second floor. Residents reported not knowing the binder's location and stated they would need staff assistance to access it, with one wheelchair user unable to reach it independently. Facility staff confirmed the binder was not accessible to residents without help.
A resident with a history of obstructing ureteral stones and UTIs was not followed up with a urologist as required after hospital discharge. The facility failed to schedule the necessary appointment, leading to multiple UTIs and antibiotic resistance. Communication and coordination issues among staff contributed to the deficiency.
The facility failed to provide adequate portable oxygen tanks, confining residents to their rooms for several days, and did not maintain dignity during meal assistance for a resident. Residents with respiratory conditions were unable to leave their rooms due to a reported shortage of portable oxygen tanks, leading to feelings of depression and boredom. Additionally, a resident requiring assistance with eating was fed by a staff member standing over her, which was identified as a dignity issue.
The facility failed to maintain a safe and sanitary environment, with mold observed at a nursing station, repeated flooding due to poor drainage, and unclean kitchen vents. Additionally, a resident's bed footboard and another resident's wheelchair armrests were in disrepair, with staff failing to report or address these issues in a timely manner.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. A nurse did not wear a gown while caring for a resident with a feeding tube, and a nursing assistant did not change gloves or perform hand hygiene after catheter care. Additionally, a resident was not assisted with hand hygiene before meals, despite being dependent on staff for such care.
The facility's kitchen failed to maintain food safety and hygiene standards, with wet and dirty dishware, spoiled produce, and moldy bread observed. Staff interviews revealed a lack of routine checks for spoilage and cleanliness, with no specific staff assigned to these tasks. The Dietary Manager and Administrator acknowledged these oversights.
The facility did not involve two cognitively intact residents in their care planning process. Both residents had not attended care plan meetings since March, despite revisions to their care plans in May and June. The Social Worker cited staffing changes and a state survey as reasons for the delays.
A non-ambulatory resident with osteoarthritis was unable to access a light switch behind her bed due to a broken cord, requiring reliance on staff for assistance. Despite regular care from nursing staff and maintenance walkthroughs, the issue was not identified or reported, highlighting a lapse in communication and attention to resident needs.
A resident, assessed as a safe smoker, requested a fourth smoking session after dinner, which aligns with the facility's policy allowing up to four sessions daily. Despite the resident's cognitive intactness and clear communication of his preference, the facility only provides three sessions, citing staff availability issues. This failure to accommodate the resident's choice led to a deficiency.
A facility failed to report a neglect incident to the State Agency involving a resident who did not receive incontinence care from a Nurse Aide (NA). The NA had expressed discomfort in caring for the resident and requested reassignment, which was communicated to a nurse who agreed to provide care. The Administrator was unaware of the neglect until receiving the CMS-2567 and did not file an initial report, believing the issue was thoroughly investigated.
A facility failed to complete a PASRR application for a resident with new psychiatric diagnoses, including delusional disorder and dementia with behavioral disturbances. The resident was admitted with an outdated Level I PASRR, and despite being prescribed medications for these conditions, a new application was not completed. Interviews revealed that staff were unaware of the need for a new PASRR application, leading to the oversight.
A resident with severe cognitive impairment and physical limitations did not receive proper nail care or meal assistance. Observations showed the resident eating with unclean hands and struggling to open meal items without adequate staff support. Despite care plans requiring regular nail checks and meal assistance, staff failed to provide consistent help, leading to unhygienic conditions and inadequate meal support.
A resident with hemiplegia and a muscle contracture did not have a prescribed hand splint applied due to a lack of communication and documentation after discharge from occupational therapy. The splint, necessary for contracture management, was not transitioned to nursing staff, and the order was missing from the MAR and TAR.
A resident with hemiplegia and hemiparesis was unsafely transferred from bed to wheelchair using a mechanical lift without locking the wheels, causing instability. The nurse involved was inexperienced with the lift, leading to the oversight. The Rehabilitation Manager and DON confirmed the importance of locking the wheels for stability.
A resident with respiratory failure and severe cognitive impairment was observed using supplemental oxygen without a physician's order. Despite the resident's need for oxygen due to breathing issues, no order was found in the records. Interviews with the DON, a Nurse Practitioner, and the Administrator confirmed the oversight.
A travel nurse at an LTC facility, unfamiliar with the facility's mechanical lift, failed to lock the lift's wheels during a resident transfer, leading to an unstable and unsafe situation. The nurse had not received proper training, as the COTA responsible for lift training did not keep up with agency staff. The DON acknowledged the need for a more comprehensive orientation checklist to include lift training for all staff.
A resident with severely impaired cognition and diagnoses including Diabetes Mellitus and hypertension was not assessed for eligibility or offered the pneumococcal vaccine. The resident's vaccination status was not up to date, and the reason was coded as not offered. Interviews with the Infection Preventionist and DON revealed awareness of the oversight, with the DON citing insufficient time to complete a vaccine audit. The Administrator also acknowledged the oversight.
The facility failed to provide quarterly statements for residents' personal funds accounts, affecting several residents who were cognitively intact. The Business Office Manager did not issue statements unless requested, due to a misunderstanding of regulatory requirements. The facility's Administrator was unaware of this issue, which arose after the transition to an electronic fund management system.
The facility failed to notify a medical provider of a resident's significant condition changes, leading to the resident's death. Additionally, the facility did not inform a resident's Guardian after a positive THC test. Staff miscommunication and failure to follow protocols were evident.
A resident experiencing a medical emergency was neglected when staff failed to activate emergency medical services after administering Naloxone for a suspected drug overdose. The resident later died. Additionally, the resident did not receive necessary incontinence care, leading to a fall and severe injuries. The facility also failed to notify a medical provider of significant changes in the resident's condition and did not ensure nursing staff were trained in emergency response.
A resident with a complex medical history exhibited symptoms of a drug overdose, including being non-responsive with constricted pupils and impaired respirations. Despite administering Narcan, the staff failed to call 911 as required by the physician's order, leading to the resident's death. Interviews revealed a lack of familiarity with the facility's Narcan policy and inadequate training.
The facility failed to enforce their smoking policy, leading to a resident vaping while on oxygen, and did not prevent a cognitively impaired resident from exiting the facility unsupervised. Additionally, a resident was exposed to an illegal substance, resulting in altered mental status and impaired mobility.
The facility failed to ensure nursing staff were trained and competent in responding to medical emergencies, leading to the death of a resident who showed signs of opioid overdose. The involved nurses did not notify a medical provider or initiate emergency procedures, and the lack of proper orientation and training for agency nurses contributed to the mishandling of the situation.
A resident missed three doses of lorazepam due to the facility's failure to obtain the medication from the pharmacy. The resident experienced significant anxiety symptoms, and staff were unaware they could request an electronic prescription for immediate pickup from a local pharmacy.
A resident with an anxiety disorder missed three scheduled doses of lorazepam due to a failure in medication administration, leading to severe anxiety symptoms. Despite staff efforts to obtain the medication, it was not available, causing significant distress for the resident.
The facility failed to report suspicious white powder and a pill splitter found in a resident's room to law enforcement after a suspected overdose and did not notify APS after another resident alleged abuse. The facility's investigation was incomplete, and key evidence was lost.
The facility failed to ensure that the Medical Director (MD) was aware of the Narcan policy, which had the potential to affect all residents with active orders for the medication. The MD, who started in February 2024, admitted to being unfamiliar with the policy, and the Administrator confirmed that the MD had only been notified of the updated policy after issues were identified during the survey.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in visitation rights, safe environment, notification of changes, quality of care, accident hazards, pharmacy services, and significant medication errors. Issues included restricted visitation, failure to notify medical providers of significant changes, unsupervised resident exits, exposure to illegal substances, and missed medication doses.
A facility restricted a resident's right to receive visitors by denying access to a former social worker who had continued to visit the resident after terminating her employment. The resident, who had severe cognitive impairment and required extensive assistance, became visibly upset when informed of the restriction. The administrator made this decision without consulting the resident or their family, citing concerns about setting a precedent for other former employees.
The facility failed to maintain clean and sanitary conditions in multiple resident rooms and bathrooms, with issues including stained floors, dirty privacy curtains, and baseboards in disrepair. Housekeeping and maintenance staff cited staffing shortages as a reason for incomplete cleaning and maintenance tasks.
Inaccurate PBJ Staffing Data Submission Due to Payroll System Transition
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) for one reviewed federal fiscal quarter. Specifically, the PBJ report indicated there were no Registered Nurse (RN) hours reported for several dates and the entire month of March, as well as a lack of 24-hour licensed nursing coverage for multiple days. However, review of daily staff schedules and time clock reports showed that an RN was onsite for at least 8 hours each day and licensed nursing coverage was present 24 hours a day during the period in question. For one date, the Director of Nursing (DON), a salaried employee, was onsite but did not appear in the time clock records due to not clocking in or out. The Human Resources (HR) Director, responsible for PBJ submissions, confirmed that the data for the quarter was submitted without a thorough review for accuracy, citing a transition between two payroll systems as a contributing factor. The HR Director prioritized timely submission over data verification due to the payroll system change. The Corporate Nurse Consultant also confirmed that RN coverage was consistently provided, and attributed the inaccurate PBJ data to the payroll system transition, which resulted in missing or incorrect staffing information being reported to CMS.
Failure to Ensure Pull Cords for Bedside Lights Were Within Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not ensuring that the pull cords for the lights above their beds were within reach. Both residents had moderate cognitive impairment but no impairment of their upper extremities, and each expressed a desire to use the pull cord to control their lights. Observations revealed that the beds were positioned so that the pull cords hung against the wall and were not accessible to the residents while in bed. One resident stated she wanted to use the pull cord but could not reach it and was unsure when she last used it, while the other also reported being unable to reach her pull cord despite wanting to use it. Interviews with facility staff indicated that maintenance issues were tracked through a computer system, which the Maintenance Director reviewed daily. The Maintenance Director acknowledged that the pull cord for one resident was not within reach and was unaware of the issue for the other resident. The Corporate Nurse Consultant agreed that the pull cords should be accessible to residents who are able and wish to use them. The deficiency was identified through observations, record reviews, and interviews with residents and staff.
Failure to Ensure Consistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected throughout the medical record. Although the resident's advance directive care plan indicated a full code status, other documentation in the electronic health record (EHR), a physician's order, and the code status binder at the nurses' station all indicated a Do Not Resuscitate (DNR) status. The discrepancy was identified during a review of the resident's records and confirmed through staff interviews. Staff interviews revealed that the Social Worker (SW) and MDS Nurse were responsible for updating the advance directive care plan when a resident's code status changed. The SW acknowledged that the care plan was not updated to reflect the DNR status because the signed advance directives paperwork was not returned to her after being completed by the family. The Director of Nursing (DON) confirmed that the care plan should match the code status in the EHR and code status binder, and that the SW was responsible for updating the care plan when changes occurred.
Failure to Offer, Administer, or Document Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer, administer, or document the pneumococcal vaccine for one resident who was reviewed for immunizations. According to the facility's policy, residents are to be assessed for eligibility and offered the pneumococcal vaccine series within 30 days of admission unless medically contraindicated or previously vaccinated. The resident in question was admitted to the facility and was found to be cognitively intact. The Minimum Data Set indicated the vaccine was offered and declined, but there was no signed consent, administration record, or documentation of refusal in the resident's electronic health record. Interviews with the resident revealed that he had not been offered the pneumococcal vaccine since admission. The DON, who also served as the Infection Preventionist, was unable to confirm whether the vaccine had been offered or administered and could not locate any documentation in the paper or electronic records. The Corporate Nurse Consultant also confirmed there was no documentation available and acknowledged that there were areas for improvement in the immunization process, but no new process had been initiated at the time of the survey.
Failure to Determine and Document Resident COVID-19 Vaccination Status
Penalty
Summary
The facility failed to determine and document the COVID-19 vaccination status of a resident who was admitted and assessed as cognitively intact. Upon review of the resident's electronic health record, there was no signed informed consent, record of administration, or documentation of refusal for the COVID-19 vaccine. Additionally, there was no evidence in the medical record of any past COVID-19 vaccinations administered to the resident. The resident reported that he typically kept his immunizations up to date and had received prior COVID-19 vaccines, but stated he had not been offered the vaccine since admission and was unsure if he was up to date. Interviews with facility staff, including the DON and the Corporate Nurse Consultant, revealed that neither could locate documentation regarding the resident's COVID-19 vaccine status in any records. The DON, who also served as the Infection Preventionist, was new to the facility and unable to confirm if the resident had received or been offered the vaccine. The Corporate Nurse Consultant acknowledged there was no reason for the lack of documentation and recognized areas for improvement in the immunization process, but no new process had been initiated at the time of the survey.
Failure to Maintain Valid Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a valid surety bond to secure the personal funds of all residents deposited in the resident trust fund account. Record review showed that the total balance in the Resident Trust Fund Account was $63,647.25 for 55 residents. The Surety Bond Continuation Certificate provided indicated that the bond, which was for $90,000, had expired and was no longer in effect. Staff interviews revealed that the Business Office Manager was unaware of the bond's expiration and deferred responsibility to the corporate office, while the Corporate Nurse Consultant was also unaware that the bond had expired until it was brought to their attention during the survey. The Administrator was not available for interview during the survey.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to make survey results easily accessible to residents, as required. Observations over three days revealed that the survey results were kept in a binder placed in a wall file pocket in the first-floor lobby, approximately five feet high. All resident rooms were located on the second floor, which was only accessible by a secured elevator. The stairwell door on the second floor was also locked and required a code, further limiting resident access to the first floor and the survey results binder. During a Resident Council Meeting, all five residents present stated they did not know where the survey results binder was located. After being informed, they indicated that accessing the binder would require staff assistance to unlock the elevator and accompany them to the lobby. One resident using a wheelchair noted she would not be able to reach the binder independently due to its height. Interviews with the Social Services Director and the Corporate Nurse Consultant confirmed that the only survey results binder was in the first-floor lobby and was not accessible to residents without staff help.
Failure to Follow Up with Urologist Leads to Multiple UTIs
Penalty
Summary
The facility failed to follow up with a urologist for a resident who was hospitalized for obstructing ureteral stones, hydronephrosis, UTI, pyelonephritis, and sepsis. After being discharged from the hospital with a stent and a urinary catheter, the resident was supposed to have a follow-up appointment with a urologist the following week. However, the appointment was not scheduled, and the order for the follow-up was mistakenly discontinued by the Director of Nursing, who assumed it was an old order without verifying if the appointment had been completed. The resident experienced multiple UTIs and urinary pain while waiting for the urology follow-up, which was repeatedly rescheduled due to transportation issues and prioritization of other residents' appointments. The facility's Transportation Aide and Receptionist were responsible for scheduling appointments, but there was a lack of communication and oversight to ensure the resident's urgent medical needs were prioritized. The resident's condition was further complicated by antibiotic resistance, and the facility's failure to secure timely urology follow-up contributed to ongoing health issues. Interviews with facility staff, including the DON, Unit Managers, and medical providers, revealed a breakdown in communication and coordination regarding the resident's care plan and follow-up appointments. The facility's appointment scheduling process lacked a clear system for tracking and prioritizing urgent medical appointments, leading to delays in necessary medical evaluations and treatments for the resident. This deficiency affected the resident's health and increased the risk of further complications.
Oxygen Supply and Dignity Issues in Resident Care
Penalty
Summary
The facility failed to treat residents in a dignified manner by not providing adequate portable oxygen tanks, resulting in residents being confined to their rooms for several days. Resident #51, who has chronic respiratory failure and COPD, was unable to leave her room due to the lack of portable oxygen tanks, which made her feel depressed and anxious. Similarly, Resident #77, with acute and chronic respiratory failure and pulmonary fibrosis, and Resident #8, with COPD, were also confined to their rooms due to the shortage of portable oxygen tanks. These residents expressed feelings of boredom and upset due to their inability to perform daily activities. The issue arose when the facility reportedly ran out of portable oxygen tanks for a period of three days, as noted by Nurse #3, who confirmed the absence of tanks upon checking the storage room. Despite the central supply staff and the Director of Nursing stating that the facility did not completely run out of tanks, the residents' accounts and Nurse #3's observations indicate otherwise. The central supply staff maintained that deliveries were consistent, and the facility had a system in place to order more tanks if needed, yet the residents experienced a disruption in their daily routines due to the lack of portable oxygen. Additionally, the facility failed to maintain dignity during meal assistance for Resident #34, who required substantial assistance with eating due to cognitive impairment and physical limitations. NA #3 was observed standing over Resident #34 while feeding her, despite the availability of chairs in the dining room. This practice was identified as a dignity issue by both Nurse #3 and the Director of Nursing, who emphasized the importance of being at eye level with residents during feeding to ensure a respectful and effective dining experience.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several deficiencies observed during the survey. At nursing station #1, a dark black substance, suspected to be mold, was found on the wall and ceiling, with a moist drip line extending down the wall. The Maintenance Director, who had been in his role for over three months, acknowledged the presence of the substance and identified it as mold due to the moisture and residue left on his fingers. Despite the Maintenance Director's awareness, the issue had not been addressed until after the surveyor's observation. The facility also failed to manage outside water drainage, resulting in flooding in one of the hallways, the dining room, and two resident rooms. The Maintenance Director admitted that the dining room had flooded multiple times due to an issue with the drain outside the building, which had not been resolved despite previous attempts. The flooding was exacerbated by rain, and the Maintenance Director suggested that the gravel and plastic outside the building needed to be removed and the ground graded to prevent further flooding. Additionally, the facility did not maintain the kitchen air vents in a sanitary condition, with three out of six vents over the food preparation area covered in a black substance. The Dietary Manager was aware of the issue since the last health department inspection in October 2023, but the vents had not been cleaned or replaced. Furthermore, the facility failed to repair a resident's bed footboard and another resident's wheelchair armrests, both of which had been in disrepair for an extended period. Staff members were either unaware of the issues or had not communicated them effectively to the Maintenance Director, resulting in prolonged neglect of necessary repairs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and implement an infection control policy, specifically regarding Enhanced Barrier Precautions (EBP). Nurse #4 was observed providing care to a resident with a feeding tube without wearing a gown, which is required under EBP. The nurse acknowledged awareness of EBP but did not follow the protocol, and the Director of Nursing (DON) and Infection Preventionist admitted that the protocols had not been implemented due to a lack of staff training. Additionally, a nursing assistant (NA) failed to change gloves and perform hand hygiene after providing urinary catheter care and before handling clean bedding for another resident, which was against the facility's urinary catheter care policy. The facility also did not adhere to its hand hygiene policy for a resident who was dependent on staff for hand hygiene before meals. The resident was observed eating with unclean hands and long fingernails, which had a dark substance underneath. The assigned NA admitted to not assisting the resident with hand hygiene before meals, as it was not a practice previously done at the facility. Both the DON and the Administrator acknowledged that staff should have assisted the resident with hand hygiene and checked nail cleanliness before meals.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in the kitchen, as observed during a survey. Ready-for-use metal pans and cooking pots were found to be stacked while still wet, and some were dirty. Specifically, 4 out of 7 small square metal pans, 2 out of 5 large rectangle metal pans, 3 out of 3 deep small rectangle metal pans, and 2 out of 3 deep small square metal pans were wet-nested. Additionally, 2 out of 3 large deep cook pots, 3 out of 5 large rectangle metal pans, and 3 out of 3 small deep rectangle metal pans were dirty. The cold food storage contained spoiled cucumbers with white fuzzy growth, and a plastic storage container was improperly dated. In the dry storage area, 2 out of 6 loaves of bread had visible mold growth and were not dated. Interviews with staff revealed a lack of routine checks for spoilage and cleanliness. The Dietary Manager acknowledged that pots and pans should have been air-dried and checked for cleanliness before storage. She also stated that produce and cold storage items should be checked daily for spoilage and expiration, but no specific staff member was assigned to this task. The bread was supposed to be dated when removed from the delivery box, but this was missed. The Administrator confirmed that the kitchen should have been checking for expired and spoiled food, and ensuring that pots and pans were clean and dry before being put away.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to involve residents and/or their representatives in the development and implementation of their person-centered care plans for two residents. Resident #27, who was cognitively intact, had not been invited to a care plan meeting since March 14, 2024, despite her care plan being revised in May 2024. The Social Worker, responsible for scheduling these meetings, acknowledged that care plan meetings were delayed due to a previous staff member's departure and a state survey in May 2024, which led to rescheduling. Similarly, Resident #37, also cognitively intact, had not participated in a care plan meeting since March 26, 2024, although his care plan was revised in June 2024. The Social Worker confirmed that Resident #37's care plan meeting was overdue due to the same staffing and scheduling issues. The Administrator noted that a state survey in May 2024 contributed to the rescheduling of care plan meetings, further delaying the process.
Inaccessible Light Switch for Non-Ambulatory Resident
Penalty
Summary
The facility failed to accommodate the needs of a dependent resident, identified as Resident #60, by not ensuring accessibility to a light switch located behind her bed. Resident #60, who was admitted to the facility and moved to her current room in August 2023, was found to have intact cognition but was non-ambulatory due to osteoarthritis and impairment in both lower extremities. During an observation, it was noted that the light switch cord was broken and inaccessible from her bed, requiring her to rely on nursing staff to control the light fixture, which she found inconvenient. Despite the issue persisting since her room change, Resident #60 had not reported the problem to the staff. Interviews with nursing staff, including a nurse aide and a nurse who frequently cared for Resident #60, revealed that they were unaware of the broken switch cord and its inaccessibility. The Maintenance Director also acknowledged the oversight, despite conducting regular walkthroughs to identify repair needs, and depended on staff to report such issues. The Director of Nursing and the Administrator both expressed expectations for staff to be attentive to residents' living environments and report repair needs promptly, highlighting a lapse in communication and attention to resident needs within the facility.
Facility Fails to Accommodate Resident's Smoking Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating a request for a fourth smoking session, despite the resident being assessed as a safe smoker. The facility's smoking policy allows for up to four smoking times daily, but currently only three are scheduled. Resident #83, who is cognitively intact and uses a wheelchair, expressed a desire for an additional smoking session after dinner, aligning with his preference to smoke after each meal. This request was communicated during a resident council meeting, but the facility has not implemented the additional session. Interviews with staff, including the Activity Aide and the Director of Nursing, revealed awareness of the resident's request for a fourth smoking session. However, the facility has not made arrangements to accommodate this request, citing uncertainty about staff availability for supervision after dinner. The Administrator acknowledged the policy allows for four sessions but stated that the facility has not committed to providing them. This inaction led to the deficiency, as the facility did not fully support the resident's choice as outlined in their policy.
Failure to Report Neglect to State Agency
Penalty
Summary
The facility failed to submit an Initial Allegation Report to the State Agency for a resident reviewed for neglect. The facility's policy, dated 2017, requires that all reports of resident abuse, neglect, and injuries of unknown source be promptly and thoroughly investigated by facility management. Additionally, the policy mandates that the facility Administrator or designee promptly notify relevant persons or agencies, including law enforcement, of any suspected or substantiated incidents of mistreatment, neglect, or abuse. During a complaint investigation survey, the facility was cited for neglect when a Nurse Aide (NA) failed to provide incontinence care to a resident. The Administrator was not made aware of the neglect while surveyors were onsite and only learned of the issue upon receiving the CMS-2567. The NA had expressed discomfort in caring for the resident and requested reassignment, which was communicated to a nurse who agreed to provide personal care for the resident. Despite this, the Administrator did not file an initial report to the State Agency, believing the issue had been thoroughly investigated and unaware of the neglect. The Administrator was officially notified of the neglect when informed of immediate jeopardy during the survey.
Failure to Complete PASRR Application for Resident with New Psychiatric Diagnosis
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with a new psychiatric diagnosis. Resident #41 was admitted with a Level I PASRR dated nearly three years prior to his admission. Upon admission, the resident had diagnoses including delusional disorder, dementia with behavioral disturbances, and psychosis not due to a substance or known physiological condition. Despite being prescribed medications for these conditions, a new PASRR application was not completed to determine if a Level II PASRR referral was necessary. Interviews with facility staff revealed a lack of awareness and action regarding the need for a new PASRR application. The Social Worker, who was new to the facility, indicated that the previous Social Worker handled PASRR applications, and a new application had not been completed for Resident #41. The Administrative Assistant was unaware that the Level I PASRR was outdated and did not request a new application from the hospital. The Administrator acknowledged the need for a new PASRR application for new psychiatric diagnoses but was unaware of the resident's new diagnosis, leading to the oversight.
Failure to Provide Adequate Nail Care and Meal Assistance
Penalty
Summary
The facility failed to provide adequate nail care and meal assistance to a resident with severe cognitive impairment and physical limitations. The resident, who was admitted with diagnoses including dementia and stroke sequelae, required substantial assistance with eating and personal hygiene. Observations revealed that the resident was eating with his hands, which were noted to have long fingernails with a dark substance underneath, indicating a lack of proper nail care. Despite the care plan specifying that nails should be checked and cleaned regularly, this was not done, leading to unhygienic conditions. During a dining observation, the resident was seen struggling to open a milkshake carton and ice cream cup, and was not provided with the necessary assistance by the staff present. The resident attempted to eat using his hands, despite having silverware available, and was only intermittently cued by staff to use a spoon. The staff, including a nurse aide and a hospitality aide, failed to consistently assist the resident with meal setup or provide the necessary feeding assistance, as outlined in the care plan. Interviews with staff, including the nurse aide, nurse, occupational therapy assistant, Director of Nursing, and Administrator, confirmed the oversight in providing meal assistance and nail care. The staff acknowledged that the resident's nails should have been checked and cleaned regularly, especially since the resident ate with his hands. Additionally, the staff admitted that they should have provided more consistent meal assistance and cueing to ensure the resident used utensils properly, as he required supervision and encouragement to do so.
Failure to Apply Hand Splint for Contracture Management
Penalty
Summary
The facility failed to apply a hand splint to a resident, identified as Resident #43, for the management of a contracture. Resident #43 was readmitted to the facility with diagnoses including hemiplegia and hemiparesis following a stroke, affecting the right dominant side, and a muscle contracture. The care plan for Resident #43, last reviewed on 5/30/24, included an intervention for wearing a right hand-based splint for 4-6 hours daily to manage and prevent contracture. However, the order for the splint was not present on the resident's July 2024 medication administration record (MAR) or treatment administration record (TAR). Observations conducted on multiple occasions revealed that Resident #43 did not have the splint applied, and it was not visible in his room. Interviews with staff, including an Occupational Therapy Assistant (OTA) and nurses, indicated a lack of awareness and communication regarding the management of the splint after Resident #43 was discharged from occupational therapy services on 7/3/24. The OTA stated that the splint was kept in the therapy closet and was applied by therapy staff, but there was no documentation or communication to nursing staff about the need to continue applying the splint after discharge from therapy. Further interviews with the Nurse Practitioner and Director of Nursing confirmed that the splint should have been applied daily to prevent further contracture. However, the management of the splint was not transitioned to nursing, and nursing staff were not educated on its application. The Director of Nursing and the facility Administrator acknowledged that the splint was necessary for contracture management, but the order was not reflected in the MAR or TAR, leading to the deficiency.
Unsafe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a total mechanical lift, as observed during a transfer from bed to wheelchair. The incident involved a resident with hemiplegia and hemiparesis following a stroke, who required extensive assistance with activities of daily living and was dependent on a total mechanical lift for transfers. During the transfer, Nurse #1 and Nurse Aide #1 did not lock the wheels of the lift, resulting in an unstable transfer as the lift moved while the resident was being lowered into the wheelchair. Nurse #1, who had never assisted with a total mechanical lift before, mistakenly believed the wheels were locked. The Rehabilitation Manager and the Director of Nursing both confirmed that the wheels should be locked to ensure stability and prevent the lift from rolling during transfers. This oversight in procedure had the potential to cause injury to the resident during the transfer process.
Failure to Obtain Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen for a resident with respiratory failure. The resident, who was admitted with a diagnosis of respiratory failure and had severe cognitive impairment, was observed wearing oxygen at 2 liters per minute on multiple occasions. Despite the resident's need for oxygen due to breathing problems, a review of the physician's orders revealed no order for oxygen. Interviews with the Director of Nursing and the Nurse Practitioner confirmed that the resident should have had an order for oxygen, and the Administrator acknowledged the oversight.
Inadequate Training on Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that staff was adequately trained in using a total mechanical lift, leading to a deficiency in the care provided to a resident. During an observation, a nurse and a nurse aide attempted to transfer a resident from bed to wheelchair using a mechanical lift. The nurse, who was a travel nurse and worked as a weekend supervisor, was unfamiliar with the facility's lift and had not received training on its use. The nurse did not lock the wheels of the lift, causing it to be unstable during the transfer, which could have compromised the resident's safety. The Certified Occupational Therapist Assistant (COTA) responsible for providing lift training admitted to not keeping up with agency staff training and had not trained the nurse in question. The Director of Nursing acknowledged the oversight and recognized the need for a more comprehensive orientation checklist that includes lift training for all staff, including agency personnel. The lack of proper training and oversight led to the unsafe transfer of the resident, highlighting a gap in the facility's training procedures.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to assess and offer the pneumococcal vaccine to a resident, identified as Resident #5, who was admitted with diagnoses including Diabetes Mellitus and hypertension. The resident's admission Minimum Data Set indicated severely impaired cognition and noted that the pneumococcal vaccination was not up to date, with the reason being that it was not offered. Interviews with the Infection Preventionist and the Director of Nursing (DON) revealed awareness of the oversight, with the DON stating that they had been employed for only a few weeks and had not yet completed a resident vaccine audit. The previous Infection Preventionist or DON had not offered or provided the vaccine to the resident. The Administrator acknowledged the oversight in not offering or administering the pneumococcal vaccine to Resident #5.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly statements for residents' personal funds accounts, affecting four residents who were reviewed. Each of these residents, identified as cognitively intact, reported not receiving statements about their personal funds balance. Interviews with the residents and their family members confirmed the absence of these statements, which are essential for residents to manage their finances effectively. The Business Office Manager (BOM) revealed that statements were not issued unless specifically requested by the residents. This practice was based on the BOM's understanding that there was no state-regulated requirement to provide regular statements. The BOM mentioned that the facility's Resident Fund Management Service (RFMS) had transitioned to an electronic system about a year ago, and since then, statements were only sent upon request, not quarterly as expected. The facility's Administrator was unaware of the issue until it was brought to her attention during the survey. The lack of awareness and the BOM's misunderstanding of the requirements led to the deficiency, as residents were not receiving the necessary information to manage their personal funds effectively. This oversight highlights a gap in communication and understanding of regulatory expectations within the facility's financial management practices.
Failure to Notify Medical Provider and Guardian
Penalty
Summary
The facility failed to notify a medical provider of significant changes in a resident's condition. Resident #8 was observed to be unresponsive to painful stimuli, had low oxygen saturation levels, and pupil constriction. Nurse #14 suspected a drug overdose and administered two doses of Narcan without notifying a medical provider. Although Resident #8 temporarily responded to the Narcan, he was later found with no heart rate or respiratory rate and was pronounced dead. The Medical Director confirmed that the resident should have been sent to the hospital and that the facility's policy for Narcan administration was not followed. Additionally, the facility failed to notify the Guardian of Resident #6 after the resident tested positive for THC. Resident #6 was found with slurred speech and impaired movements, and a urine drug screening confirmed the presence of THC. Nurse #2 did not notify the Guardian immediately, assuming that the Director of Nursing or Unit Manager would do so. The Guardian was not informed of the drug screening results in a timely manner, which was against the facility's expectations. Interviews with staff revealed a lack of communication and adherence to protocols. Nurse #14 and Nurse #20 both assumed the other had notified the medical provider regarding Resident #8's condition. Similarly, Nurse #2 and Unit Manager #2 assumed the other had notified Resident #6's Guardian. The Director of Nursing and the Medical Director both confirmed that the facility's policies were not followed, leading to significant lapses in care and communication.
Removal Plan
- Re-education to licensed nursing staff, including agency nurses on ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders by the Director of Nursing Services/Assistant Director of Nursing (designee). Licensed nursing staff that are not available will not be scheduled until the education has been completed.
- Facility wide audit completed by Nurse Consultant to determine if for any resident who received Narcan, the medical provider has been notified. The audit identified 3 residents who have a diagnosis of opioid dependence, one resident has scheduled pain management, and two residents have prn pain management per physician order.
- The actions the facility will take to ensure the nurses notify the medical provider of administration of Narcan by the DNS reviewing the 24-hour report on a daily basis for appropriate notification documentation in the Electronic Medical Record (EMR). Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the Director of Nursing Services and/or the Assistant Director of Nursing Services, Unit Managers, and Supervisors.
- If the Director of Nursing Services is unavailable the Assistant Director of Nursing will assume this responsibility of reviewing the 24-hour report.
- Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose prior to working their first shift by the DNS/Assistant Director of Nursing (designee).
Neglect and Failure to Provide Emergency Care
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when they did not provide appropriate care and services during a medical emergency. Resident #8 was found unresponsive with low oxygen saturation and constricted pupils, indicating a possible drug overdose. Nurse #14 administered two doses of Naloxone but did not activate emergency medical services. Later that day, Resident #8 was found without a heart rate or respiratory rate and was pronounced dead. Additionally, the facility neglected to provide incontinence care to Resident #8, who was cognitively intact but experiencing mental status changes, including hallucinations and confusion. Despite requiring increased assistance with toileting, Resident #8 was left unattended and fell while attempting to go to the bathroom, resulting in a left hip fracture and a laceration that required surgical repair. The facility also failed to notify a medical provider of significant changes in Resident #8's condition and did not ensure that nursing staff were trained and competent in responding to medical emergencies. This lack of proper care and communication contributed to the resident's deteriorating condition and eventual death.
Removal Plan
- The licensed nursing staff who neglected to activate emergency response were Nurse #14 and Nurse #20.
- The facility has filed a report of the neglect to the health care personnel registry.
- Education on the facility policy for Abuse and Neglect Prevention was presented to all facility staff by the Administrator, Director of Nursing and Assistant Director of Nursing. This educational in-service included the policy and implementation of procedures to prevent abuse and neglect.
- Included in this education was a review of staff training expectations on preventing, identifying, reporting abuse and neglect.
- The facility has filed a report of the neglect to the licensing agency.
- The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders.
- The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers.
- Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee).
- The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy.
Failure to Initiate Emergency Medical Services for Drug Overdose
Penalty
Summary
The facility failed to initiate emergency medical services for a resident who exhibited symptoms of a drug overdose. The resident was found slumped over, non-responsive, with constricted pupils and impaired respirations. Despite these critical signs, the staff did not call 911 as required by the physician's order for Narcan administration. The resident was later pronounced dead, and this deficiency affected one of the three residents reviewed for quality of care. The resident had a complex medical history, including chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, congestive heart failure (CHF), obstructive sleep apnea, anxiety disorder, and panic disorder. The resident's care plan included monitoring for respiratory depression and administering oxygen and pain medications as ordered. However, there was no mention of opioid or Narcan use in the care plans. On the day of the incident, the resident received multiple medications, including opioids and sedatives, which likely contributed to the overdose. Interviews with the staff revealed a lack of familiarity with the facility's policy for Narcan administration and the necessity to call 911. The nurse who administered Narcan did not call emergency services, believing that the resident's Do Not Resuscitate (DNR) status precluded further action. This misunderstanding was compounded by the fact that the nurse had not received training on Narcan administration. The facility's failure to activate emergency medical services as required by the physician's order directly contributed to the resident's death.
Removal Plan
- The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders.
- Licensed nursing staff that are not available will not be scheduled until the education has been completed.
- The DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response.
- Feedback will be provided by the DNS to the licensed nurse addressing any challenges or barriers in the use of Narcan and/or the activation of the emergency response.
- Re-education was provided to licensed nursing staff about the activation of the emergency response when Narcan is administered.
- Agency licensed nurses working at the facility will receive education on activating emergency response when administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee).
- The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders.
- The DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers.
- Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee).
- The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system, which is denoted in the revised Narcan Administration Policy.
Failure to Enforce Smoking Policy and Prevent Elopement
Penalty
Summary
The facility failed to enforce their smoking policy and monitor a resident with a history of non-compliance with the smoking policy. Resident #8, who was on oxygen, was found to have a vape pen in his possession on multiple occasions and was observed vaping while on oxygen. This placed both Resident #8 and his roommate at increased risk for fire and combustion. Despite repeated infractions, the facility did not revoke Resident #8's smoking privileges or issue a discharge notice, and staff were unable to determine how Resident #8 was obtaining the vape pens and cigarettes. The facility's smoking policy was not effectively enforced, and staff were unable to adequately supervise residents while smoking or vaping. The facility also failed to prevent a resident with moderate cognitive impairment and a history of wandering and exit-seeking behaviors from exiting the facility unsupervised. Resident #1 was found outside the facility in freezing temperatures, wearing inadequate clothing, and holding multiple pieces of mail. Staff disarmed the emergency exit door alarm without initiating the facility's elopement protocol, conducting a full resident head count, or thoroughly searching the area. This failure placed Resident #1 at high risk for serious injury from falls and hypothermia. Additionally, the facility failed to protect a resident from exposure to an illegal substance. Resident #6 experienced altered mental status, impaired physical mobility, and slurred speech after being exposed to tetrahydrocannabinol (THC). The drug screening test confirmed the presence of THC in Resident #6's system. These deficient practices affected multiple residents and posed a high likelihood of serious injury to all residents involved.
Removal Plan
- The list of resident smokers, including those who vape, was updated by social services. This updated smoking list included the current residents who also vape. The intent of this list is to provide a tool for the staff assigned to supervise the smokers to be able to be a check and balance for any changes.
- An audit was completed by the Nurse Consultant to ensure that the smokers' smoking assessments were completed. The audit denoted that 23 smoking assessments required updating. Assessments, which included the safe use of oxygen, were completed.
- The Administrator sent out to families/guardians a letter/text message via Cliniconex/Point Click Care (PCC) regarding the purchase of cigarettes, lighting materials, and vapes. Families/guardians are to give smoking items to the nurse or activities so they can be secured.
- The smoking policy was revised to include that if a resident who is on oxygen and there is suspicion of not complying with the smoking policy and refuses a room search, the facility (Administrator and/or DNS) will notify the police or fire safety of the unsafe situation.
- The staff were educated on the revised smoking policy which included that residents cannot have cigarettes, lighting material, and vape pens on their person, or in their rooms. Education was provided by the Director of Nursing/Assistant Director of Nursing/Unit Managers/Supervisors. All staff including contract staff, have been educated as to the policy expectations for following steps for ensuring enforcement of this policy. This information was provided by the Administrator and the Director of Nursing. The Administrator educated the Director of Human Resources of the updated policy and procedures addressing staff's conduct if and when they engage in any personal smoking procedures. This includes the disciplinary procedures that will occur in the event these policy expectations aren't followed. Staff smoking policy expectations was added to the employee onboarding checklist to document that this policy has been reviewed and understood.
- Residents who smoke and utilize oxygen were educated on removal of oxygen prior to going outside to smoke or vape by the Director of Nursing/Assistant Director of Nursing/Unit Managers/Supervisors. Reminders will be given upon each designated smoking time to all smoking and vaping residents by the assigned staff members providing supervision.
- Education was provided to the smokers by social service on the smoking policy and the policy and procedures of failure to abide by safety requirements.
Failure to Ensure Nursing Staff Competency in Medical Emergencies
Penalty
Summary
The facility failed to ensure that nursing staff were trained and competent in responding to medical emergencies, activating emergency procedures with emergency medical services (EMS), and notifying medical providers. This deficiency was observed in the case of a resident who was unresponsive to painful stimuli, had low oxygen saturation levels, and pupil constriction, indicative of a possible opioid overdose. Despite these critical signs, the nursing staff did not notify a medical provider or initiate emergency procedures with 911, leading to the resident's death. The involved staff members, Nurse #20 and Nurse #14, demonstrated a lack of competency in handling the emergency situation, including the administration of Narcan and the subsequent steps required for emergency response and medical provider notification. Nurse #20, who was an agency nurse on her first day at the facility, did not receive proper orientation or training on emergency procedures, including the administration of Narcan. She relied on Nurse #14, who also lacked training and familiarity with the facility's policies. Nurse #20 did not know that EMS should be notified when Narcan is administered and was not aware of how to contact the on-call provider. Nurse #14, who was the weekend supervisor, also did not follow through with the necessary emergency response steps, mistakenly believing that the resident's DNR status precluded further action. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that agency nurses typically did not receive a shift orientation before working on the floor. The facility's failure to provide adequate training and orientation to its nursing staff, particularly agency nurses, directly contributed to the mishandling of the medical emergency involving the resident. This lack of preparedness and competency among the nursing staff resulted in a critical delay in emergency response, ultimately leading to the resident's death.
Removal Plan
- An audit was completed by the Nurse Consultant on the number of residents who are prescribed opioid medication, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids.
- The Director of Nursing/Assistant Director of Nursing (designee) has re-educated the licensed nursing staff on medical emergencies and emergency activation response per physician orders.
- The actions the Director of Nursing/ Assistant Director of Nursing (designee) will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers, which can require re-education if needed.
- Agency licensed nurses working at the facility will receive education on medical emergencies and activation of the emergency response by the DNS/Assistant Director of Nursing (designee).
- Licensed nursing staff, including agency staff that are not available will not be scheduled until the education has been completed. The Director of Nursing/Assistant Director of Nursing (designee) will provide education on medical emergencies, medical provider notification, and activation of emergency response for the nursing staff unavailable before they start the shift.
- The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy.
- The facility will initiate Mock Medical Emergencies Drills on each shift weekly x 4 weeks, and then ongoing monthly upon completion of the licensed nursing education. The DNS and/or the ADNS will critique the drill denoting areas in need of improvement.
Failure to Administer Antianxiety Medication
Penalty
Summary
The facility failed to obtain an antianxiety medication from the pharmacy, resulting in a resident missing three doses of lorazepam. This deficiency affected a resident who was admitted with an anxiety disorder and had physician orders for lorazepam to be administered three times a day. On the day in question, the resident did not receive any doses of lorazepam, leading to significant anxiety symptoms including panic, sweating, crying, and shaking. The resident repeatedly requested the medication and sought assistance from family members to calm down. Nurse #17, who was assigned to care for the resident, was informed that the resident was out of lorazepam and attempted to contact the pharmacy to obtain the medication. Despite notifying the ADON and DON, the medication did not arrive before the end of her shift. The ADON and DON were new to their roles and were unaware that they could request an electronic prescription to be sent to a local pharmacy for immediate pickup. Instead, they waited for the scheduled nightly delivery from the facility pharmacy, which did not arrive in time. Interviews with the resident's mother, the Medical Director, and the Pharmacist confirmed the failure to obtain the medication in a timely manner. The Pharmacist had no record of a stat request for the medication on the day in question. The Administrator acknowledged the difficulty in getting the prescription refilled and confirmed that the resident missed three scheduled doses of lorazepam, which contributed to the resident's increased anxiety.
Failure to Administer Scheduled Lorazepam Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors by not administering three scheduled doses of lorazepam, an antianxiety medication. Resident #7, who was admitted with an anxiety disorder, had a physician's order for lorazepam one milligram (mg) three times a day. On the day in question, the resident did not receive the scheduled doses at 8:00 AM, 2:00 PM, and 9:00 PM, as indicated in the Medication Administration Record (MAR). This resulted in the resident experiencing severe anxiety symptoms, including panic, sweating, crying, and shaking, and repeatedly asking for assistance from family members to calm down. Nurse #17, who was assigned to care for Resident #7 on the day of the incident, reported that the resident was out of lorazepam and that there was none available in the emergency back-up medication dispenser. Despite notifying the Assistant Director of Nursing (ADON) and Director of Nursing (DON) and contacting the pharmacy, the medication did not arrive before the end of her shift. Throughout the day, Resident #7 exhibited signs of distress and repeatedly requested his medication, which was not available. Interviews with the nursing staff, the resident's mother, and the Medical Director confirmed the medication error. The Medical Director stated that a temporary prescription should have been issued, and the ADON and DON acknowledged that in hindsight, they should have arranged for the medication to be picked up from a local pharmacy. The Administrator confirmed that the resident missed three scheduled doses of lorazepam on the day in question, leading to significant anxiety and distress for Resident #7.
Failure to Report and Investigate Suspected Abuse and Overdose
Penalty
Summary
The facility failed to report suspicious white powder and a pill splitter found in a resident's room to local law enforcement after the resident was suspected of a drug overdose and was given two doses of Naloxone with a positive response. The facility also failed to investigate and preserve potential evidence when they lost the white powder. Staff interviews revealed that the pill splitter and white powder were found and reported to the nursing leadership, but no further action was taken, and the items were lost. The Administrator claimed to be unaware of the incident despite being present at a meeting where it was discussed. Additionally, the facility failed to submit a complete investigation report and notify Adult Protective Services (APS) after another resident alleged abuse from a staff member. The resident reported being fed inappropriately and physically restrained by a nurse aide. The facility's investigation was incomplete, missing key evidence such as a text message from the resident detailing the abuse. The Administrator and other staff members were aware of the allegation but did not ensure that APS was notified. These deficiencies affected two residents, one of whom died after a suspected overdose, and the other who alleged abuse. The facility's policies on abuse investigations and reporting to state agencies were not followed, leading to a lack of proper investigation and notification to the appropriate authorities.
Medical Director Unaware of Narcan Policy
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) was aware of resident care policies related to the administration of Naloxone or Narcan, a medication designed to rapidly reverse opioid overdose in an emergency situation. The MD, who started working at the facility in February 2024, was not familiar with the facility's Narcan policy. This deficiency was identified during a review of the Medical Director/Attending Physician job description and interviews with the MD and the Administrator. The job description included responsibilities such as attending quality assurance meetings, providing guidance to staff, and ensuring compliance with state and federal regulations. However, the MD admitted during an interview that he was unaware of the Narcan policy, which required staff to notify Emergency Medical Services when administering the medication. The Administrator also confirmed that the MD had attended some QA meetings but was not aware of the Narcan policy until it was discussed during the current survey. The deficiency had the potential to affect all residents with active orders for Narcan. The Administrator revealed that the MD had been notified of the updated Narcan policy only after the issues were identified during the survey. This lack of awareness and communication regarding critical resident care policies could have serious implications for the timely and effective administration of emergency medications like Narcan. The facility's failure to ensure that the MD was fully informed about essential care policies highlights a significant gap in the coordination and oversight of medical care within the facility.
Repeated Deficiencies in Quality of Care and Safety
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following multiple recertification and complaint investigation surveys. This resulted in seven repeat deficiencies in areas such as visitation rights, safe and comfortable environment, notification of changes, quality of care, accident hazards, pharmacy services, and significant medication errors. For instance, the facility imposed a restricted visitation schedule that limited indoor and outdoor visitation of family and friends to 30 minutes per visit, affecting a resident's visitation rights. Additionally, the facility failed to notify a medical provider of significant changes in a resident's condition, leading to the resident's death after suspected drug overdose without timely medical intervention. The facility also failed to ensure a safe and comfortable environment. One resident with a history of wandering and exit-seeking behaviors was found outside the facility unsupervised, wearing inappropriate clothing for the cold weather, which posed a high likelihood of serious injury from falls and hypothermia. Another resident was exposed to an illegal substance, resulting in altered mental status and impaired physical mobility. The facility's failure to enforce their smoking policy and monitor a resident with a history of non-compliance led to the resident vaping while on oxygen, increasing the risk of fire and combustion. In terms of pharmacy services and significant medication errors, the facility failed to obtain and administer prescribed medications, leading to missed doses and adverse effects on residents. One resident missed three doses of antianxiety medication, resulting in panic, sweatiness, crying, and shaking. Another resident missed multiple doses of an anticonvulsant medication, and the facility failed to administer a short-acting insulin as ordered by the physician. These repeated deficiencies indicate the facility's inability to sustain an effective QAA program, despite the committee meeting regularly to discuss plans of correction and implement changes.
Facility Restricts Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing by restricting visitation for a resident with severe cognitive impairment. Resident #3, who required extensive assistance for most activities of daily living, expressed a strong preference for having family or a close friend involved in discussions about their care. Despite this, the facility's administrator denied visitation from a former social worker who had continued to visit the resident after terminating her employment. The resident became visibly upset when informed that the social worker would no longer be able to visit, indicating the importance of these visits to the resident's emotional well-being. The administrator left a voicemail for the former social worker, stating that she would no longer be allowed to visit the facility due to her status as a self-terminated employee. The administrator justified this decision by expressing concerns about setting a precedent for other former employees. Despite the resident's clear preference and emotional response, the administrator did not consult with the resident or their family before making this decision. The facility owner chose not to send a formal letter to the former social worker, leaving the situation unresolved and the resident without the desired visits.
Facility Fails to Maintain Clean and Sanitary Conditions
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in multiple resident rooms and bathrooms, as observed by surveyors. Specifically, the shared bathroom floors in several rooms were found with dried yellow and brown stains, and food debris was scattered across the floors of other rooms. Housekeeping staff admitted to being unable to clean all assigned rooms due to staffing shortages, and the Housekeeping Director confirmed that routine cleaning was not always completed as expected. Additionally, privacy curtains in some rooms had large, dried stains that were not addressed despite daily checks by housekeeping staff. The baseboards in certain rooms were also found to be dirty and in disrepair. In one instance, a baseboard had a dried dark brown stain that was not cleaned over several days. The Housekeeping Director acknowledged that baseboards should be cleaned when visibly soiled and during deep cleaning sessions, but staffing shortages had hindered these efforts. Furthermore, the bathroom in one room had a strong odor of urine and visible yellow and brown stains around the base of the toilet, which were not addressed despite daily cleaning protocols. Maintenance issues were also identified, including baseboards pulling away from the walls in some bathrooms. The Maintenance Director stated that random room checks were conducted weekly, and management staff were responsible for reporting any concerns. However, the Maintenance Director was unaware of the specific issues with the baseboards in the identified rooms. The Administrator confirmed that while some environmental issues had been corrected, there were still ongoing projects to address, and she expected resident rooms and bathrooms to be clean and free of odors, with privacy curtains and baseboards in good repair.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
