Village Care Of King
Inspection history, citations, penalties and survey trends for this long-term care facility in King, North Carolina.
- Location
- 440 Ingram Road, King, North Carolina 27021
- CMS Provider Number
- 345381
- Inspections on file
- 19
- Latest survey
- January 8, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Village Care Of King during CMS and state inspections, most recent first.
The facility did not maintain documented evidence of an active QAPI program for all residents during the review period. Although a written QAPI plan described data-driven decision-making, goal setting, and use of quality data, monthly QAPI committee records contained only staff signatures without any documented discussion topics, identified concerns, data tracking, or Performance Improvement Plans (PIPs). The Administrator reported that QAPI meetings occurred monthly and concerns were discussed verbally using a computer-based system, but was unable to produce any records showing identified issues, goals, or ongoing PIPs, and acknowledged that no formal PIPs were in place during the period reviewed.
A resident admitted with major depression, PTSD, anxiety, and insomnia, and documented on the admission MDS as having a serious mental illness while receiving antidepressant medications, did not receive a required Level II PASRR evaluation. The resident had an existing Level I PASRR from a prior setting, but facility records contained no evidence that a Level II evaluation was requested. The SW acknowledged not submitting the request, stating the resident was inadvertently missed in the usual morning-meeting process used to identify new admissions needing PASRR screening, and the Administrator reported being unsure whether Level II PASRR requests had been submitted for this or any resident, despite expecting the SW to do so for residents with serious mental health diagnoses.
The facility failed to develop comprehensive, measurable care plans for two residents with identified behavioral, PTSD, and hospice needs. One resident with major depression, PTSD, anxiety, and insomnia had documented verbal abuse toward staff and refusals of care in nursing notes, yet the care plan addressed only depression, antidepressant use, and rejection of care, omitting specific interventions for verbal behaviors and PTSD. Another resident receiving hospice services after readmission had hospice confirmed on the MDS, but the care plan contained no focus, goals, or interventions related to hospice care. Staff interviews revealed confusion over responsibility for care plan development, with the MDS nurse, social worker, and DON each indicating that any nurse could update care plans and that no single person was designated to create them.
A resident in a LTC facility suffered a severe leg fracture after being manually lifted from a shower chair to a bed by a nursing assistant, despite requiring maximum assistance with a sliding board or mechanical lift. The resident's care plan was missing, and staff inconsistencies in transfer practices contributed to the incident.
A resident experienced severe pain and swelling in her right leg after being manually lifted from a shower chair to a bed, resulting in her leg getting caught and causing a fracture. Despite the resident's complaints to multiple nurses, none notified the physician or conducted a thorough assessment until two days later, when an x-ray revealed the fracture. The facility failed to notify the physician of the resident's change in condition in a timely manner.
A resident in a LTC facility experienced a delay in medical treatment after reporting severe leg pain following a manual transfer by a nursing assistant. Despite multiple complaints, several nurses failed to conduct comprehensive assessments or document the resident's condition over two days. It was only after a thorough assessment by a nurse on the third day that a fracture was discovered, leading to appropriate medical intervention.
Lack of Documented QAPI Activities and Performance Improvement Plans
Penalty
Summary
The facility failed to maintain and produce documented evidence of a comprehensive and ongoing Quality Assurance and Performance Improvement (QAPI) program for calendar year 2025, affecting all 94 residents. Review of the facility’s written QAPI plan showed it described principles such as making resident care decisions based on data, setting performance goals, measuring progress toward those goals, and using collected quality improvement data to guide daily operations. However, when surveyors reviewed the QAPI committee meeting minutes from January through December 2025, the documents only contained signatures of interdisciplinary staff in attendance each month and lacked any documentation of topics discussed, identified concerns, data tracking, or measures taken or planned to address concerns in the form of Performance Improvement Plans (PIPs). During an interview, the Administrator stated that the QAPI committee met monthly and that meetings were conducted in person while using a computer-based documenting system, but formal meeting minutes were not taken and concerns were discussed verbally. The Administrator was unable to provide any documentation from the computer-based system or other sources showing identified concerns, data tracking, goals, or ongoing PIPs for 2025. The Administrator further acknowledged that there were no formal ongoing PIPs in place during the previous calendar year or at the time of the interview, despite the facility’s written QAPI policy outlining the expectation for systematic identification, reporting, investigation, analysis, and prevention of adverse events and the development, implementation, and evaluation of corrective actions.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with serious mental illness. Documentation showed the resident had a Level I PASRR determination dated 10/24/22 with no expiration date and was admitted in April 2025 with diagnoses including major depression, post-traumatic stress disorder (PTSD), and anxiety. The admission MDS assessment documented that the resident had a serious mental illness and/or intellectual disability and was receiving antidepressant medications, with pertinent diagnoses of major depression, insomnia, anxiety, and PTSD. A psychiatric progress note dated 9/29/25 further confirmed ongoing treatment for major depressive disorder, PTSD, and insomnia with duloxetine and trazodone. Record review revealed no evidence that a Level II PASRR evaluation had ever been requested or completed for this resident. The facility was unable to provide documentation that a request for a Level II PASRR evaluation had been submitted. In an interview, the Social Worker stated the resident was admitted with a Level I PASRR and acknowledged she had not submitted a Level II request, explaining that she typically identified new admissions needing PASRR screening through morning meetings and must have inadvertently missed this resident. In a separate interview, the Administrator reported uncertainty about whether Level II PASRR requests had been submitted for this or any resident and stated an expectation that the Social Worker would request a new Level II PASRR evaluation for residents admitted with serious mental health diagnoses, even if they had a prior Level I from another facility.
Failure to Develop Comprehensive Care Plans for Behavioral, PTSD, and Hospice Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing all identified needs for two residents. For one resident admitted with major depression, post-traumatic stress disorder (PTSD), and anxiety, the admission MDS documented these diagnoses and the use of two antidepressants, and a later psychiatric note confirmed major depressive disorder, PTSD, and insomnia with ongoing antidepressant therapy. Nursing progress notes from September 2025 onward documented verbal abuse toward staff and refusals of weights and blood draws. The resident’s comprehensive care plan, initiated in April 2025 and last revised in December 2025, included depression, antidepressant use, and rejection of care, but did not include any focus, goals, or interventions related to the resident’s verbal behaviors or PTSD diagnosis. Staff interviews showed that nurse aides recognized the resident as alert, oriented, and sometimes challenging due to refusals of care, and described strategies such as using two aides and leaving the room to allow the resident to calm down before reattempting care. The MDS nurse reported that the resident was not coded for behaviors on any MDS assessments because the behaviors did not occur daily during the look-back periods and believed the social worker handled mental illness and behavior care plans, while the social worker stated she did not complete any portions of care plans and that nursing staff were responsible. The DON acknowledged awareness of the resident’s behaviors and that the resident should have been care planned for verbal behaviors and PTSD, and also stated there was no single person responsible for creating care plans, with any nurse able to update them. In a second case, another resident was readmitted with hospice services following hospitalization, and hospice services began in November 2025, with a significant change MDS confirming hospice. However, the resident’s care plan, last revised in September 2025, lacked any focus area, goals, or interventions for hospice care. The MDS nurse and DON both indicated that hospice services should have been included in the care plan and described that there was no designated individual responsible for care plans, with any nurse able to update them.
Inadequate Supervision and Unsafe Transfer Practices Lead to Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision and safe care for a resident, leading to an accident that resulted in a severe injury. The resident, who was cognitively intact and dependent on assistance for transfers due to impaired functional limitations, was manually lifted by a nursing assistant from a shower chair to a bed. This action caused the resident's right leg to hit the shower chair and become caught, resulting in severe pain and swelling. An x-ray confirmed an acute distal tibia/fibula fracture. The resident's care plan, which was missing at the time of the incident, indicated that she required maximum assistance with transfers using a sliding board or mechanical lift due to her inability to bear weight. Despite this, the nursing assistant manually lifted the resident without the use of a mechanical lift or additional staff assistance, contrary to the recommended transfer methods. The resident reported severe pain during the transfer, but the nursing assistant continued the transfer without seeking immediate medical assessment. Interviews with staff revealed inconsistencies in the understanding and implementation of the resident's care plan. The nursing assistant involved in the incident claimed that the care plan did not specify the use of a mechanical lift, and that manual lifting was a common practice among staff. The facility's failure to ensure the availability and adherence to an accurate care plan, along with the lack of proper supervision and training for staff, contributed to the resident's injury.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who experienced severe pain and swelling in her right leg after being manually lifted from a shower chair to a bed by a nursing assistant. The incident occurred when the resident's leg got caught between the shower chair and the bed, causing significant pain. Despite the resident's complaints of pain to multiple nurses over the following days, none of the nurses notified the physician or conducted a thorough assessment until two days later when a nurse finally assessed the resident and notified the provider. The resident, who was cognitively intact, reported the incident and her pain to the nursing assistant immediately after the transfer. However, the nursing assistant did not inform the nurse about the specifics of the transfer or the resident's pain. Subsequent nurses who were informed of the resident's pain either did not assess the resident or did not notify the physician, believing there was no need for further action. It was not until a nurse on the third day assessed the resident's leg, found it swollen and discolored, and notified the provider, that an x-ray was ordered, revealing a fracture. The medical director and regional nurse consultant confirmed that the physician was not notified of the resident's complaints of pain until two days after the incident. The facility's administrator stated that all residents should have their needs met and that the physician should be notified of any change in condition. The failure to notify the physician in a timely manner resulted in a delay in diagnosing and treating the resident's fracture.
Failure to Assess Resident's Injury Leads to Delayed Treatment
Penalty
Summary
The facility failed to complete and document ongoing comprehensive assessments for a resident who reported leg pain, which delayed medical treatment and interventions. On October 22, 2024, a resident was manually lifted by a nursing assistant from a shower chair to a bed, causing the resident's right leg to hit the chair and get caught between the chair and the bed, resulting in pain and swelling. Despite the resident's complaints of severe pain, multiple nurses failed to conduct a comprehensive assessment of the resident's condition over the following days. The resident, who was cognitively intact and had a history of conditions including right hand contracture and spinal issues, reported the incident and pain to several staff members. However, the nurses on duty did not perform thorough assessments or document the resident's condition adequately. Nurse #1, who was informed of the pain, did not assess the resident, and Nurse #2, who was aware of the incident, did not report it to the administration or document an assessment. Nurses #3 and #4 also failed to document any assessments despite being notified of the resident's pain. It was not until October 24, 2024, that Nurse #5 assessed the resident and noted swelling and discoloration of the leg, leading to a physician being notified and an x-ray being ordered. The x-ray revealed a fracture, and the resident received new orders for additional pain medication. The facility's Regional Nurse Consultant and Medical Director confirmed that the resident was not assessed on the days following the incident, and the deficiency in care was acknowledged by the facility's administration.
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.
