Wellington Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Knightdale, North Carolina.
- Location
- 1000 Tandal Place, Knightdale, North Carolina 27545
- CMS Provider Number
- 345436
- Inspections on file
- 24
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Wellington Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A Unit Manager did not follow infection control protocols during tracheostomy care for a resident with quadriplegia, failing to change gloves and perform hand hygiene between handling soiled and clean materials. This lapse was observed and confirmed through staff interviews, revealing a lack of awareness of proper procedures to prevent contamination.
A dependent resident with severe physical limitations did not have her call light device consistently placed within reach, despite staff training and care plan requirements. Staff were observed leaving the room without ensuring the call bell was accessible, and the resident reported this occurred frequently, leaving her unable to request assistance as needed. The issue was only corrected when a therapist noticed and repositioned the call bell appropriately.
Surveyors identified that several residents' MDS assessments were inaccurately coded regarding PASARR status, antiplatelet medication administration, and falls. For example, a resident with a Level II PASARR determination was not coded as such, another receiving daily Aspirin was not marked as receiving antiplatelet therapy, and a resident's fall with injury was omitted from the discharge MDS. Staff interviews confirmed these errors were due to oversight and inaccurate documentation.
A resident with bipolar affective disorder was admitted with a PASRR Level II approval limited to a 30-day stay, but the facility failed to recognize and act on the expiration of this approval. The PASRR letter was not scanned into the electronic record, leading to a missed rescreening. The oversight was discovered during an audit, and the resident reported no concerns with care at the time.
The facility did not include required PASRR Level II status in the care plans of two residents and failed to add hospice care services to the care plan of another resident. Staff interviews revealed confusion and lack of clarity regarding responsibility for updating care plans to reflect these critical services.
Three residents' care plans were not properly updated: one resident's code status was incorrectly listed as DNR instead of full code, another resident's care plan did not include a new stage 3 pressure ulcer despite physician orders, and a third resident's care plan continued to reference bed rails after they had been removed due to cognitive changes. Staff interviews revealed confusion about responsibility for updating care plans.
A resident with a physician's order for daily lidocaine patches had the patches applied as directed, but nursing staff failed to consistently remove them according to the schedule. Instead, the resident was allowed to remove the patches herself, and staff did not verify removal, resulting in patches remaining on beyond the prescribed time. Interviews with nursing staff and leadership confirmed that the patches were not removed as ordered.
A resident with a hand contracture had a resting hand splint applied by nursing staff without a physician's order, therapy instructions, or a documented wearing schedule. The splint was present in the resident's room and was applied based on staff assumptions rather than formal guidance, despite the resident not being cleared by therapy to use the splint outside of supervised sessions. The application and removal of the splint were not documented in the medical record or TAR, and the resident was unaware of its intended use.
A resident with Parkinson's disease was found with bilateral quarter length side rails in use without documented assessment, entrapment risk evaluation, informed consent, physician's order, or care plan update. Staff interviews revealed confusion over responsibility for side rail assessments, and neither therapy nor nursing completed the necessary steps prior to installation.
A Business Office Manager failed to perform hand hygiene after moving a urinal and before assisting a resident with their meal, including opening a milk carton and placing a straw, contrary to facility policy. The staff member had received infection control training but did not follow proper procedures during the observed event.
A resident with a seizure disorder did not receive his prescribed Keppra medication after returning from the hospital due to a transcription error. The nurse responsible failed to have another nurse verify the medication orders, resulting in four missed doses and subsequent seizures that required hospitalization.
A resident with cognitive impairment and mobility issues was found with long fingernails, despite care plans requiring regular trimming. Staff interviews revealed that the resident did not refuse care, but the nurse aide failed to notice the nail length. The DON confirmed that nails should be trimmed on shower days or when noticed, but this was not done.
A facility failed to follow infection control protocols during tracheostomy and pressure ulcer care. A Respiratory Therapist did not perform hand hygiene or wear a gown while caring for a resident on enhanced barrier precautions. Additionally, a Treatment Nurse did not perform hand hygiene between glove changes during pressure ulcer care. Both staff members were unaware or forgot the facility's policies, leading to potential infection risks.
A resident with Alzheimer's and blindness was using bolsters to prevent falls, brought in by their responsible party. The facility failed to assess these bolsters as restraints, lacked medical justification, and did not have a physician order. Staff were aware of the bolsters but did not remove them, and there was no consensus on whether they were restraints. The Administrator acknowledged the need for an assessment, leading to a deficiency.
The facility failed to complete significant change MDS assessments for two residents following changes in their hospice care status. One resident was admitted to hospice without the required assessment, and another was discharged from hospice without the assessment being completed within 14 days. Staff interviews confirmed the necessity of these assessments, but they were missed.
A facility failed to accurately code the MDS assessment for a resident regarding antianxiety medication. Despite an indication of medication use, records showed no administration of clonazepam or other antianxiety drugs. The MDS Nurse admitted to an error in coding, and the DON emphasized the need for accurate assessments.
A medication cart was left unattended and unlocked in a hallway between rooms 143-150. The cart was visible from the nurse's station, but no staff were present. Medication Aide returned to the cart and confirmed it was left unlocked. Interviews with the DON and Administrator confirmed the cart should be locked when not in use.
Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
Unit Manager #2 failed to adhere to professional standards of practice and infection prevention protocols during tracheostomy care for a resident with quadriplegia and a tracheostomy. During a continuous observation, the Unit Manager removed soiled split gauze and a soiled inner cannula from the resident's tracheostomy site, disposed of them, and then proceeded to handle clean supplies and perform subsequent tasks without changing gloves and performing hand hygiene between the soiled and clean portions of the procedure. The Unit Manager only removed gloves and performed hand hygiene after completing the entire care process, including handling both soiled and clean items. Interviews with the Unit Manager revealed a lack of awareness regarding the need to change gloves and perform hand hygiene between handling soiled and clean materials during tracheostomy care. The Infection Preventionist and Administrator both confirmed that the expected standard of care would require splitting the procedure into soiled and clean parts, with appropriate glove changes and hand hygiene to prevent the spread of disease-causing organisms to the resident's airway. The failure to follow these protocols was directly observed and confirmed through staff interviews.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure a dependent resident's call light device was consistently placed within reach, as required by the resident's care plan. The resident, who had multiple sclerosis and post-polio syndrome, was dependent on staff for all activities of daily living and could only use the call bell if it was positioned directly under the side of her neck due to limited muscle control. During observations, the call bell was found clipped to the resident's upper right chest, which she stated was not accessible, and later was observed lying on the floor out of reach. The resident reported that staff often left the room without ensuring the call bell was correctly positioned, making her feel helpless. Multiple staff interviews confirmed that both nursing and therapy staff were trained to ensure call bells were within reach before leaving a resident's room, but this was not consistently practiced. On one occasion, a nurse entered the room, performed care tasks, and left without checking the call bell's placement. The assigned nursing assistant also left the resident without the call bell in reach, planning to return shortly but did not immediately do so. The speech therapist ultimately noticed the call bell was out of reach and repositioned it appropriately. Facility leadership, including the unit manager, DON, and administrator, all stated that call bells should always be within reach, regardless of the resident's ability to call out for help.
Inaccurate MDS Coding for PASARR Status, Medication, and Falls
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents in the areas of Pre-admission Screening and Resident Review (PASARR) status, medication administration, and falls. For one resident with a history of cerebral infarction, the MDS assessment did not reflect her current Level II PASARR determination, despite documentation and staff acknowledgment that she had an active Level II PASARR status. Another resident with a history of cerebrovascular accident was not coded as receiving antiplatelet medication on the MDS, even though physician orders and medication administration records confirmed daily administration of Aspirin, an antiplatelet agent. Staff interviews confirmed these coding errors were due to oversight. A third resident, admitted with a progressive neurological condition, was also incorrectly coded on the MDS as not having a Level II PASARR determination, despite documentation to the contrary. Additionally, this resident experienced a fall resulting in a laceration and hospital visit, but the incident was not captured in the discharge MDS assessment. Staff interviews revealed that the fall should have been documented in the MDS, but was missed. In each case, staff and administration acknowledged that the MDS assessments were not coded accurately, as required.
Failure to Timely Rescreen Expired PASRR Level II for Resident with Mental Health Diagnosis
Penalty
Summary
The facility failed to obtain further approval and screening through the Level II Pre-admission Screening and Resident Review (PASRR) evaluation process as required for a resident with a diagnosis of bipolar affective disorder. The resident was admitted with a PASRR Level II Determination Notice that specified nursing facility placement was appropriate for a limited stay of no more than thirty days, with an explicit expiration date. However, the facility did not recognize that the PASRR had expired, and the required rescreening was not completed in a timely manner. The deficiency was identified when the Social Worker discovered the expired PASRR during a periodic audit, noting that the original PASRR letter had not been scanned into the electronic record, which contributed to the oversight. Interviews confirmed that the facility had not been consistently tracking PASRR statuses to ensure they were current, and the lapse was only discovered after the expiration had already occurred. The resident involved reported receiving all needed care and had no concerns at the time of the survey.
Failure to Develop Comprehensive Care Plans for PASRR and Hospice Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all required areas for three residents. For two residents with Level II Pre-admission Screening Resident Review (PASRR) determinations, their care plans did not reflect their PASRR status in a timely manner. One resident's PASRR Level II status was not included in the care plan until several months after admission, despite documentation and staff interviews confirming the requirement. There was confusion among staff regarding responsibility for ensuring PASRR status was included in the care plan, with both the Social Worker and MDS Nurses indicating differing understandings of their roles. Another resident's Level II PASRR determination was not care planned due to the notification letter not being uploaded into the system, which staff acknowledged as the likely cause for the omission. Additionally, a resident who was accepted into hospice care did not have hospice services reflected in their care plan, even though hospice provider notes and the Minimum Data Set indicated the resident was receiving hospice care. Staff interviews confirmed that hospice care should have been included in the care plan, and the MDS Nurse responsible acknowledged the omission. The Director of Nursing and Administrator both stated their expectation that hospice care would be included in the care plan when initiated.
Failure to Revise Care Plans for Code Status, Pressure Ulcer, and Bed Rail Discontinuation
Penalty
Summary
The facility failed to ensure that comprehensive care plans were accurately revised and updated for three residents, as required. For one resident with end stage renal disease on hemodialysis, the care plan incorrectly listed the code status as Do Not Resuscitate (DNR), despite both the physician's order and the advance directive indicating the resident was a full code. Multiple staff interviews revealed confusion regarding responsibility for updating the code status in the care plan, with MDS Nurses, the Social Worker, and the Administrator each providing differing accounts of who should make these updates. Another resident, who was readmitted with a stage 4 pressure ulcer of the sacrum, had a care plan that failed to include a newly developed stage 3 pressure ulcer on the right buttocks, despite a physician's order for wound care to that area. Staff interviews confirmed that the new wound should have been added to the care plan, and that MDS Nurses were responsible for making this update after being informed of new wounds during morning meetings. However, the stage 3 pressure ulcer was not incorporated into the care plan. A third resident, admitted with a history of stroke, had a care plan that continued to reference the use of bed rails even after the rails had been removed due to changes in the resident's cognition and safety needs. Observations and staff interviews confirmed that bed rails were no longer present or in use, and that the decision to remove them had been communicated in a morning meeting attended by the interdisciplinary team, including MDS Nurses. Despite this, the care plan was not updated to reflect the discontinuation of bed rails.
Failure to Remove Topical Pain Patch per Physician's Order
Penalty
Summary
A deficiency occurred when nursing staff failed to remove a topical lidocaine pain patch from a resident in accordance with the physician's order. The resident, who was alert and oriented, had a physician's order for lidocaine 4% patches to be applied to the shoulders and chest once daily and removed per schedule, with no order for self-administration. Observations revealed that the resident had three lidocaine patches on her body, dated from the previous day, and she reported that while the nurse applied the patches in the morning, she removed them herself whenever she chose. Documentation showed that the patches were applied as ordered, but removal was not consistently performed by nursing staff as required. Nurse interviews confirmed that on at least one occasion, a nurse allowed the resident to remove the patches herself and did not verify their removal. Another nurse observed that patches from the previous day were still present when applying new ones but did not notify the unit manager on that day. The unit manager did not recall being notified about the issue, and the DON stated that the nurse should have removed the patches herself according to the physician's order. The NP confirmed that the order specified a removal time for a reason and that the nurse should have followed the order.
Splint Applied Without Physician Order or Schedule
Penalty
Summary
A deficiency occurred when a resident with a right-hand contracture was found to have a resting hand splint applied without a physician's order, therapy instructions, or a documented splint wearing schedule. The resident was moderately cognitively impaired and had functional limitations in both upper and lower extremities. Although the resident had received occupational therapy for two days and was not enrolled in a restorative nursing program, there was no documentation in the medical record or Treatment Administration Record (TAR) regarding the application or removal of a splint. Observations revealed the splint was present in the resident's room on multiple occasions, and interviews with nursing staff indicated that the splint was being applied based on assumptions rather than formal instructions. Nursing staff reported reapplying the splint during their shifts, but acknowledged there was no physician's order or splint schedule, and the application was not documented as a task in the computer system. The resident herself was unaware of the purpose of the splint or when it should be worn. The Therapy Director clarified that the splint had been ordered for use only during supervised therapy sessions, as the resident was not yet able to tolerate it for extended periods. The plan was to provide a physician's order, staff training, and a splint schedule only after the resident could tolerate the splint for more than one hour. Despite this, the splint remained in the resident's room, leading to confusion among nursing staff and resulting in its unsupervised application.
Failure to Complete Required Assessments and Documentation Prior to Side Rail Installation
Penalty
Summary
The facility failed to follow required procedures before installing side rails for a resident diagnosed with Parkinson's disease. The resident was observed on multiple occasions with bilateral quarter length side rails in the raised position, yet there was no documentation of an assessment for side rail use, no evaluation of entrapment risk, no signed informed consent, no physician's order, and no care plan addressing side rail usage. The resident's medical record and care plan did not reflect the presence or use of side rails, and the quarterly MDS assessment indicated the resident did not have side rails as a restraint and was independent with bed mobility. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for side rail assessments. The Unit Manager stated she had never completed a nursing side rail assessment, while the ADON indicated that therapy should evaluate residents first, followed by a nursing assessment, consent, physician's order, and care plan update. However, neither therapy nor nursing staff had completed these steps for the resident in question. The Director of Therapy and Physical Therapist both stated they did not perform side rail assessments, and the Administrator was unable to explain why the required assessments and documentation were not completed for this resident.
Failure to Perform Hand Hygiene After Handling Urinal During Meal Assistance
Penalty
Summary
A deficiency occurred when the Business Office Manager failed to follow the facility's hand hygiene policy while assisting a resident with their meal. The Business Office Manager entered a resident's room to deliver a lunch tray, placing it on the overbed table next to a urinal containing urine. After obtaining the resident's permission, the Business Office Manager moved the urinal to the bedside table without donning gloves or performing hand hygiene. Subsequently, the Business Office Manager assisted the resident by removing the lid from the lunch plate, opening a milk carton, and placing a straw in the milk, all without performing hand hygiene after handling the urinal. Interviews with the Business Office Manager revealed a lack of awareness regarding the infection control implications of touching the urinal and then handling food items. The Infection Preventionist, DON, and Administrator all confirmed that the correct procedure would have involved setting the tray on a clean surface, donning gloves to move the urinal, removing gloves, and performing hand hygiene before assisting with the meal. Documentation showed that the Business Office Manager had received training on infection control and hand hygiene upon hire, but failed to implement these practices during the observed incident.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to administer seizure medication to a resident after he returned from the hospital, resulting in four missed doses of Keppra, an anti-seizure medication. The resident, who had a history of seizures related to a stroke, was admitted to the facility with a physician's order for Keppra 500 mg twice daily. However, upon his return from the hospital, the medication order was not entered into his electronic medical record, leading to missed doses on subsequent days. The resident experienced seizures on the third day after his return, which required readmission to the hospital. The seizures were attributed to the missed doses of Keppra, as the resident was sensitive to low levels of the medication. The oversight occurred because the nurse responsible for entering the medication orders did not have a second nurse verify the orders against the hospital discharge summary, as was the facility's protocol. Interviews with facility staff, including the Unit Manager and the nurse involved, revealed that the error was due to a failure in the transcription process. The nurse admitted to not having another nurse verify the medication orders, which led to the omission of the Keppra order. The facility's Consultant Pharmacist confirmed that the missed doses likely caused the resident's seizure activity.
Removal Plan
- Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.
- Address how the facility will identify other residents having the potential to be affected by the same deficient practice.
- Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.
- Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to maintain proper personal hygiene for a resident who required assistance with activities of daily living. Resident #4, who was moderately cognitively impaired and had diagnoses including muscle weakness and lack of coordination, was observed with long fingernails on two separate occasions. The resident's care plan specified that his nails should be checked and trimmed on bath days and as necessary, yet this was not adhered to. Interviews with staff revealed that the resident did not refuse care, and the nurse aide responsible for his morning care admitted to not noticing the length of the resident's nails. The Director of Nursing confirmed that nails should be trimmed on shower days or when staff noticed they were long. Despite these protocols, the staff failed to notice and address the resident's long nails, leading to the deficiency.
Infection Control Lapses in Tracheostomy and Pressure Ulcer Care
Penalty
Summary
The facility failed to adhere to its hand hygiene policy and enhanced barrier precautions during tracheostomy care for a resident. The Respiratory Therapist (RT) did not perform hand hygiene after touching a potentially contaminated surface and before handling the tracheostomy. Additionally, the RT did not wear a gown while providing care to a resident on enhanced barrier precautions, despite a sign on the door indicating the requirement. The RT was unaware of the facility's policy and mistakenly believed that tracheostomy care was not a sterile procedure. The RT's supervisor confirmed that the RT should have worn a gown and performed hand hygiene as per the facility's policy. In another instance, the facility failed to implement its hand hygiene policy during pressure ulcer care for a resident. The Treatment Nurse did not perform hand hygiene between removing soiled gloves and applying clean gloves while changing a dressing on a resident's pressure ulcer. The nurse admitted to forgetting to perform hand hygiene due to nervousness, although she acknowledged the importance of doing so to prevent infection spread. The Director of Nursing (DON) confirmed that hand hygiene should always be performed after removing soiled gloves and before applying clean ones. These deficiencies highlight lapses in following established infection prevention protocols, specifically regarding hand hygiene and the use of personal protective equipment. The RT and Treatment Nurse both failed to adhere to the facility's policies, which are designed to prevent the spread of infection and protect residents from potential harm.
Failure to Assess Bolsters as Restraints for Resident
Penalty
Summary
The facility failed to identify and assess bolsters as a restraint for a resident with Alzheimer's disease and blindness, who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's responsible party (RP) had brought in bolster pillows to prevent the resident from falling out of bed, as the resident could move around independently. However, there was no medical justification or physician order for the use of these bolsters, and no restraint assessment was completed. Observations revealed the bolsters were placed under the fitted sheet on either side of the resident, and staff were aware of their presence but did not remove them. Interviews with staff, including a nurse, nurse aide, Director of Rehabilitation, MDS Nurse, Director of Nursing, and the Administrator, revealed a lack of consensus on whether the bolsters constituted a restraint. The MDS Nurse indicated that bolsters under the fitted sheet would likely be considered a restraint, while the Director of Nursing and a nurse believed they did not restrict the resident's movement. The Administrator acknowledged the bolsters likely restricted movement, given the resident's condition, and stated the resident should have been assessed for their safe use. The facility's failure to properly assess and document the use of bolsters as a restraint led to this deficiency.
Failure to Complete Significant Change MDS Assessments for Hospice Status Changes
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set (MDS) assessment for two residents following changes in their hospice care status. Resident #76, who had chronic obstructive pulmonary disease, muscle weakness, and Alzheimer's disease, was admitted to hospice care, but the required MDS assessment was not completed. Interviews with the Director of MDS Education and the MDS Nurse confirmed that the assessment was necessary following the hospice election, but it was missed. The Director of Nursing also acknowledged that MDS assessments should be completed according to the Resident Assessment Instrument (RAI) manual's schedule. Similarly, Resident #48, who was initially admitted with hospice services, was discharged from hospice care, but the significant change MDS assessment was not completed within the required 14 days. The MDS Nurse was aware of the discharge but could not explain why the assessment was missed. The Director of Nursing and the Administrator were both unaware that the assessment had not been completed, although they confirmed it should have been done within the specified timeframe.
Inaccurate MDS Coding for Antianxiety Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of medications, specifically for unnecessary medications. The resident, who was admitted with a diagnosis of dementia, was noted to be moderately cognitively impaired and was indicated to be taking antianxiety medication. However, a review of the resident's physician orders and Medication Administration Record (MAR) revealed no documentation of the administration of clonazepam or any other antianxiety medication during the specified period. An interview with the MDS Nurse confirmed that the medication section of the resident's MDS assessment was coded in error, acknowledging it as a mistake. The Director of Nursing also indicated that the MDS assessments should be accurate.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to secure resident medications stored in an unattended medication cart, which was observed between rooms 143-150. During a continuous observation, the medication cart was left unlocked from 8:35 AM to 8:47 AM, with the red dot on the push lock visible, indicating it was not engaged. The cart was parked in the hallway, visible from the nurse's station, but no staff were present. Two Nurse Aides were passing breakfast trays, and no residents were near the cart. Medication Aide #1 returned to the cart at 8:47 AM and opened the top drawer without unlocking it, confirming she had left it unlocked. Interviews with the Medication Aide, the Director of Nursing, and the Administrator confirmed that the cart should be locked when not in use, and the Medication Aide was responsible for it during their shift.
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.
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