Warren Hills Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Warrenton, North Carolina.
- Location
- 864 Us Hwy 158 Business West, Warrenton, North Carolina 27589
- CMS Provider Number
- 345240
- Inspections on file
- 17
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Warren Hills Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, pleural effusion, and CHF was started on scheduled ipratropium/albuterol nebulizer treatments for wheezing, but subsequent assessments by the Medical Director and PA repeatedly documented clear lungs, no wheeze, and no respiratory complaints while the medication continued to be administered. Nursing staff, including a support nurse, reported they had not observed ongoing wheezing to justify continued scheduled use, yet the order was never changed to PRN or discontinued. The consultant pharmacist did not recommend adjustment because provider notes indicated continuation of the current regimen, and the PA later stated she intended the bronchodilator to be PRN and was unaware it was still being given routinely. The DON acknowledged the order should have been PRN from the start and that there was no process to systematically review older standing medication orders.
Staff failed to follow hand hygiene and infection control policies during IV therapy and wound care. A nurse prepared medications at a cart, then entered a resident’s room and managed a PICC line and IV antibiotic setup without removing gloves or performing hand hygiene between handling equipment and accessing the line. In separate observations, a wound nurse cleansed two pressure ulcers on one resident and then applied new dressings without changing gloves or performing hand hygiene between wounds or before handling clean dressings, and similarly removed an old dressing from another resident’s pressure ulcer, cleaned the wound, and opened new dressings without an interim glove change or hand hygiene. These actions did not comply with the facility’s IPCP, hand hygiene, and IV therapy policies.
The facility failed to accurately code MDS assessments for three residents. One resident with dementia and multiple pressure ulcers, including a documented stage 4 sacral ulcer, was coded only for a stage 3 ulcer and a DTI, omitting the stage 4 wound. Another resident receiving IV vancomycin via a PICC line for osteomyelitis was coded for IV medication use but not for IV access, despite a care plan addressing PICC-related risks. A third resident with coronary artery disease and cerebral infarction, who was receiving clopidogrel as documented on the MAR, was incorrectly coded as receiving an anticoagulant. The MDS nurse and a support nurse acknowledged these coding errors, and leadership confirmed that the assessments should have been completed accurately.
A resident with severe cognitive impairment and right-sided hemiparesis following a stroke had a care plan and physician order for daily application of a resting hand orthosis, along with ROM exercises and skin checks, to manage contractures. After OT discharge, nursing staff were responsible for splint management, but surveyors repeatedly observed the resident in bed without the splint, which was seen on the bedside table, while the Treatment Administration Record showed it as applied. An RN reported relying on therapy staff to place the splint and documented it as in place without managing its placement or removal, despite facility leadership stating that nursing was responsible for ensuring the splint was applied per the order.
A resident with neuromuscular bladder dysfunction and urinary retention had a physician-ordered indwelling urinary catheter that was observed on multiple occasions without a leg band securement device in place, despite facility staff acknowledging that a leg band was required to prevent dislodgement. During wound care and a later observation, surveyors noted the catheter tubing was unsecured, and the resident reported that staff sometimes forgot to apply the securement device. The IP, a nurse, and a NA each described that nurses were responsible for ensuring the leg band was in place and NAs were expected to notify nurses when it was missing, but this did not occur consistently for this resident.
A resident admitted with pneumonia and cellulitis developed shortness of breath and low O2 saturation, leading an RN to initiate 2 L O2 via nasal cannula and notify the provider, but the oxygen order was never successfully entered into the electronic system. The RN reported difficulty entering the order and did not seek assistance, while the Support Nurse, who stated that the nurse obtaining the order is responsible for entry, did not review the resident’s orders to confirm the oxygen order was present. The DON confirmed the RN’s responsibility to both notify the provider and enter the oxygen order, resulting in the resident receiving ongoing supplemental O2 without a documented physician order.
Surveyors found that two open ophthalmic medications on one medication cart were not dated when opened, contrary to manufacturer instructions and facility practice. An RN observed an open bottle of brimonidine/timolol 0.2/0.5% eye drops and an open bottle of olopatadine 0.2% eye drops on the Hall 100 cart without any open dates, even though both products are to be used or discarded within four weeks of opening. The nurse assigned to the cart stated that medications are supposed to be dated when first opened but she was not present when these were opened and could not explain the omission, and the DON confirmed that nurses are expected to date medications upon opening and verify dates before use.
The facility failed to document advance directive education and opportunities for 13 residents, despite having physician orders for full code or DNR. Interviews revealed that advance directives were supposed to be reviewed during care plan meetings, but documentation was lacking. The Administrator acknowledged the need for proper documentation and reassessment of advance directives.
A resident, who was cognitively intact, was not provided with written or verbal notification of a new roommate. The facility's Social Worker admitted to not following the expected process of notifying residents and their responsible parties about roommate changes. The Director of Nursing and the Administrator confirmed the expectation of providing both verbal and written notifications, which was not met in this instance.
A facility failed to refer a resident with a serious mental illness for a Level II PASRR. The resident, diagnosed with delusional disorder, was not referred for further screening despite a significant change in status. The Social Worker and Admissions Director were unaware of the need for a Level II PASRR upon readmission, and the Administrator acknowledged the oversight as a problem.
Expired medication was found in a medication cart during an observation. An opened bottle of Senna-Plus with an expiration date of October 2024 was discovered. A medication aide acknowledged the oversight, stating that the assigned medication aide or nurse should check for expired medications each shift. The DON and Administrator confirmed that the responsibility for checking and removing expired medications lies with the assigned staff.
The facility failed to notify the Ombudsman of hospital transfers for four residents, as required. Record reviews and staff interviews revealed that the Social Worker was unaware of the obligation to send discharge information to the Ombudsman, and the Administrator was not informed of the oversight. This deficiency highlights a communication gap within the facility regarding notification responsibilities.
Failure to Reassess and Discontinue Unnecessary Scheduled Bronchodilator Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications by not evaluating the continued need for a bronchodilator prescribed for wheezing. A resident with dementia, pleural effusion, and CHF was started on scheduled ipratropium bromide/albuterol nebulizer treatments every four hours after a nurse reported wheezing to the PA, who also ordered a chest x-ray. The chest x-ray later showed no acute findings, and subsequent clinical assessments by the Medical Director and PA over the following months consistently documented that the resident denied chest pain and shortness of breath, had even and unlabored respirations, and had lungs clear to auscultation without wheeze. Despite this, the MAR showed the bronchodilator continued to be administered as ordered, except when refused, through late February. During observation, the resident was noted in bed without wheeze or shortness of breath, with a nebulizer machine at the foot of the bed. The support nurse responsible for the resident stated she was unsure why the bronchodilator was still being given, as she had not observed wheezing and staff had not reported ongoing symptoms to support its use. The consultant pharmacist reported she reviewed the resident’s medications monthly but did not address the bronchodilator with the provider because the PA’s visit notes indicated continuation of the current treatment plan. The PA later stated the medication should have been ordered PRN for occasional wheeze, that she had not observed wheezing or been informed of it, and that she was unaware the medication continued to be administered on a scheduled basis. The DON acknowledged the order should have been written as PRN initially and that nursing staff should have recognized the absence of symptoms and contacted the provider to change or discontinue the order, and also noted there was no process in place to review older standing orders during clinical meetings.
Failure to Follow Hand Hygiene and Infection Control Practices During IV Therapy and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program and Hand Hygiene policy during IV therapy and wound care. Facility policies required staff to perform hand hygiene after contact with non-intact skin, before dressing care or touching wounds, after handling used dressings, after touching equipment near a resident, and to wash hands thoroughly prior to flushing a PICC line. During a continuous observation of medication administration for Resident #28, Nurse #3 donned gloves, prepared medications at the medication cart, and then entered the resident’s room without removing gloves or performing hand hygiene. While still wearing the same gloves used to handle the medication cart and equipment, Nurse #3 hung and primed IV antibiotic tubing, manipulated the IV pump, removed the disinfecting cap from the PICC line, wiped the hub, flushed the PICC line, and connected the IV antibiotic tubing before finally removing gloves and performing hand hygiene after the IV was started. A second component of the deficiency occurred during wound care for Resident #2, who had a stage 4 sacral pressure ulcer with slough and a stage 3 left buttock pressure ulcer. The Wound Treatment Nurse performed initial hand hygiene and donned clean gloves, then cleansed the stage 4 sacral ulcer with wound cleanser and gauze, followed by cleansing the stage 3 left buttock ulcer without changing gloves or performing hand hygiene between the two wounds. The nurse then prepared and applied new wound dressings to both wounds while still wearing the same soiled gloves used for cleansing, and only removed the gloves and performed hand hygiene after all dressings were in place and the treatment was completed. A third observation involved wound care for Resident #22’s left buttock pressure ulcer. The Wound Nurse performed hand hygiene, donned a gown and clean gloves, and removed the old dressing. Without removing gloves or performing hand hygiene after handling the soiled dressing, the nurse proceeded to clean the wound with gauze soaked in wound cleanser and then opened new dressings while still wearing the same gloves. Only after opening the new dressings did the nurse remove gloves and perform hand hygiene, then donned new gloves to place calcium alginate in the wound bed, apply zinc oxide to the wound edges and surrounding area, and cover the wound with a dry dressing. These observed practices did not follow the facility’s infection control and hand hygiene policies requiring glove changes and hand hygiene at key points during wound care and invasive line management.
Inaccurate MDS Coding for Wounds, IV Access, and Medications
Penalty
Summary
The facility failed to ensure accurate completion of MDS assessments for three residents by not correctly coding existing conditions and treatments documented in their records. One resident with dementia and behaviors had a wound provider note identifying a stage 4 pressure ulcer to the sacrum, a stage 3 pressure ulcer to the left buttock, and an unstageable deep tissue injury to the right heel. However, the quarterly MDS assessment coded only one stage 3 pressure ulcer and one unstageable deep tissue injury, omitting the documented stage 4 pressure ulcer. The MDS nurse confirmed that the stage 4 pressure ulcer was present at the time of the assessment and acknowledged she had overlooked it despite having the wound provider documentation available. Another resident admitted with osteomyelitis of the right ankle and foot had a physician order for IV vancomycin via a PICC line and a care plan addressing IV medication via PICC with associated risks. The admission MDS assessment coded IV medication use but did not code IV access, and the MDS nurse later acknowledged that the PICC line should have been coded as IV access and that it was inadvertently overlooked. A third resident with coronary artery disease and a history of cerebral infarction had a standing order and ongoing administration of clopidogrel, an antiplatelet medication, as documented in the MAR. The quarterly MDS assessment for this resident was coded as receiving an anticoagulant, and the nurse being trained on MDS completion confirmed this was an error in coding. In each case, the Administrator stated that the responsible MDS staff should have completed the assessments accurately based on the available information.
Failure to Apply Prescribed Hand Splint for Contracture Management
Penalty
Summary
The deficiency involves the facility’s failure to apply a prescribed resting hand orthosis to a resident’s right hand for contracture management as ordered. The resident was admitted with a history of stroke with right-sided hemiparesis/hemiplegia and had severe cognitive impairment, with documented functional limitations in range of motion on one side of both upper and lower extremities. The care plan, initiated and later reviewed, included interventions such as performing ROM exercises with morning and evening care, applying the resting hand orthosis daily, and completing hand hygiene and skin checks. An OT discharge summary documented that the resident had reached maximum potential, that an order for the orthosis was in place, and that both family and nursing staff had been educated on splinting. A physician’s order directed that the right upper extremity splint be applied daily on day shift with hand hygiene and skin checks to prevent contracture and skin breakdown. On multiple observations over two consecutive days, the resident was seen in bed without the splint in place, while the splint was observed lying on the table in the room. Despite this, the TAR showed that the splint was documented as in place on those days by a nurse. In interview, the nurse stated that therapy staff had been placing the splint and then notifying her, and she would document it as applied, and she believed the splint was to remain in place for 8 hours, but she did not manage its placement or removal. The Rehabilitation Manager clarified that once the resident was discharged from therapy, nursing was responsible for managing the splint per the physician’s order, and that the recommended wear time was up to 4 hours during the day shift. The DON and Administrator both stated that the nurse on duty for those days was responsible for ensuring the splint was applied as ordered.
Failure to Maintain Securement Device for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to secure an indwelling urinary catheter with a leg band securement device for a resident with neuromuscular bladder dysfunction and urinary retention. The resident was admitted with these diagnoses and had a physician’s order for an indwelling urinary catheter. A quarterly MDS documented that the resident was cognitively intact and had an indwelling catheter. During a wound care observation, surveyors noted that the resident did not have a leg band in place to secure the catheter tubing, although there was no tension on the tubing at that time. In an interview immediately afterward, the resident reported that staff sometimes forgot to place the securement device and was unable to recall how long it had been missing, though he denied discomfort or tension on the tubing. On a subsequent observation the next day, the resident was again seen in bed with the catheter tubing not secured, and there was still no tension on the tubing. The Infection Preventionist confirmed that the resident was supposed to have a leg band to prevent the catheter from becoming dislodged and stated that the nurse on the hall was responsible for ensuring the leg band was in place, with nurse aides expected to notify the nurse if it was missing. Nurse #4 stated that nurses were responsible for checking for the leg band and reported not being aware that it was absent. NA #1 acknowledged being informed by the Infection Preventionist that the leg band was missing and stated the resident usually had one, but she had not yet reached him on her care rounds to notify the nurse. NA #1 also stated the resident received his bath on night shift, and attempts to contact the night-shift NA who cared for the resident during the relevant period were unsuccessful. The DON stated that either the nurse or the nurse aide should have ensured the catheter tubing had a securement device in place.
Failure to Obtain and Enter Physician Order for Supplemental Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a physician order for supplemental oxygen for a resident who required respiratory support. The resident was admitted with cellulitis of the right lower leg and pneumonia and was cognitively intact, with the admission MDS indicating no use of supplemental oxygen. On one occasion, the resident complained of shortness of breath and was found to have oxygen saturation levels in the 80s on room air. Nurse #3 applied 2 L of oxygen via nasal cannula, which improved the saturation to 94–96%, and documented that the provider was notified via electronic communication. However, a review of the physician orders showed no order for supplemental oxygen for this resident. Nurse #3 reported that she did obtain an oxygen order from the provider but had difficulty entering it into the system and did not realize it had not been successfully entered. She stated that she usually could “fumble” through entering orders and that Support Nurses normally entered physician orders, so she did not frequently perform this task. She did not notify a Support Nurse or seek assistance when she encountered difficulty entering the oxygen order. The Support Nurse assigned to the resident stated that the nurse who obtained an order was responsible for entering it and acknowledged she did not think to review the resident’s orders to ensure the oxygen order was present. The DON confirmed that Nurse #3 was responsible for notifying the provider and entering any orders for supplemental oxygen and stated that Nurse #3 should have reached out to her or another nurse for help when having difficulty entering the order. At the time of observation, the resident continued to receive 2 L of oxygen via nasal cannula without a corresponding physician order in the record.
Undated Open Ophthalmic Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication labeling and storage on the Hall 100 medication cart, where two ophthalmic medications were found open without documented open dates. During an observation with a nurse, one plastic squeeze bottle of brimonidine/timolol 0.2/0.5% eye drops, used to treat eye conditions such as glaucoma, and one plastic squeeze bottle of olopatadine 0.2% eye drops, an antihistamine for allergic conjunctivitis, were noted to be open with no open date recorded, despite manufacturer instructions that each be used or discarded within four weeks of opening. The nurse present stated that medications were supposed to be dated when initially opened but she had not been present when these bottles were opened and could not explain why they were not dated. The DON confirmed that facility practice required nurses to date medications when opened and to check any open medication for an open date before administering it, but this had not occurred for the two eye drop bottles on the Hall 100 cart.
Failure to Document Advance Directive Education and Opportunities
Penalty
Summary
The facility failed to provide written documentation for advance directive information and the opportunity to formulate an advance directive for 13 out of 22 residents reviewed. This deficiency was identified through record reviews and interviews with residents and staff. The residents involved had varying levels of cognitive impairment, with some being cognitively intact and others having severe or moderate cognitive impairment. Despite holding physician orders for either full code or Do Not Resuscitate (DNR), there was no documentation in their medical records indicating that education regarding the formulation of an advance directive was provided or that an opportunity to formulate one was offered to the residents or their responsible parties. Interviews with the facility's Social Worker and Administrator revealed that advance directives were supposed to be reviewed during care plan meetings and documented in the Care Plan assessment or Social Services assessment upon admission and readmission. The Social Worker mentioned that an advance directive form was filled out to show that the topic was discussed with residents or their families during care planning, and this form was uploaded into the electronic medical record. However, the form lacked documentation of education regarding the formulation of an advance directive or evidence that an opportunity to formulate one was offered. The Administrator acknowledged that the education and discussion of advance directives should have been documented for each resident in the facility. He also stated that residents were expected to be reassessed for advance directives upon readmission and during care plan meetings. The absence of proper documentation and education regarding advance directives for the residents reviewed highlights a significant deficiency in the facility's compliance with residents' rights to make informed decisions about their care.
Failure to Notify Resident of Roommate Change
Penalty
Summary
The facility failed to provide written notification of a roommate change for a resident who was cognitively intact. The resident, who was admitted to the facility on an unspecified date, reported that approximately 2 to 3 weeks prior to the interview, she received a new roommate without any prior written or verbal notification. The resident discovered the new roommate upon returning from an appointment, indicating a lack of communication from the facility regarding the change. The facility's Social Worker (SW) admitted that her usual process involved verbally notifying residents and their responsible parties about roommate changes, but not in writing. However, in this instance, the SW did not notify the resident or their responsible party either verbally or in writing. The Director of Nursing and the facility Administrator confirmed that it was expected for residents and their responsible parties to be notified both verbally and in writing prior to any roommate changes, which did not occur in this case.
Failure to Conduct Level II PASRR for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to refer a resident with a serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR). The resident was admitted and later readmitted to the facility, and on a specified date, was diagnosed with delusional disorder. A Level I PASRR determination letter indicated that no further screening was required unless a significant change in the resident's status occurred. Despite the diagnosis of a serious mental illness, there was no documentation of a Level II PASRR referral for the resident. Interviews with the Social Worker and Admissions Director revealed a lack of awareness and oversight regarding the need for a Level II PASRR screening upon the resident's readmission. The Admissions Director admitted to failing to check the resident's PASRR status upon readmission, acknowledging that the resident met the criteria for a serious mental illness and should have been referred for further screening. The Administrator was also unaware of the oversight, acknowledging it as a problem.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to dispose of expired medications in one of the three medication carts observed for medication storage. During an observation of the 600 Hall medication cart, an opened bottle of Senna-Plus with an expiration date of October 2024 was found. Medication Aide #2 acknowledged that the medication should have been discarded and stated that the medication aide or nurse assigned to the cart was responsible for checking for expired medications each shift. Both the Director of Nursing (DON) and the Administrator confirmed that the responsibility for checking and removing expired medications from the cart lay with the medication aides and nurses assigned to the cart.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding the transfer of four residents to the hospital. This deficiency was identified during a record review and staff interviews. The residents involved were transferred to the hospital on various dates in 2023 and 2024, but there was no documentation indicating that the Ombudsman received the required written notification for these transfers. The residents returned to the facility after their hospitalizations, but the lack of notification persisted. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the Ombudsman. The Social Worker admitted to not sending discharge information to the Ombudsman for residents transferred to the hospital, stating she was unaware of this obligation. The Administrator also acknowledged that he was not aware that the Social Worker had not submitted the necessary discharge reports to the Ombudsman, indicating a gap in communication and understanding of responsibilities within the facility.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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