Wesley Pines Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Lumberton, North Carolina.
- Location
- 1000 Wesley Pines Road, Lumberton, North Carolina 28358
- CMS Provider Number
- 345180
- Inspections on file
- 19
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Wesley Pines Retirement Community during CMS and state inspections, most recent first.
A resident with chronic constipation and gastroparesis had a provider order for Linzess 290 mcg, one capsule PO daily, but nurses and medication aides instead honored the resident’s request to take three capsules twice weekly. Staff routinely placed the daily capsule into a bedside bottle and, on designated days, removed three accumulated capsules and left them in a med cup for the resident to self-administer, while continuing to document the drug as given daily per order. Multiple nurses and med aides acknowledged they knew this practice did not match the written order yet did not notify the MD, NP, or DON of the resident’s ongoing refusal of the ordered regimen or the altered dosing schedule, and leadership and the NP reported they were unaware of the deviation until it was discovered during survey.
A resident with chronic constipation, paraplegia, and significant contractures, who was assessed as unable to self-administer medications, was ordered Linzess 290 mcg PO daily along with Magnesium Citrate twice weekly and PRN Simethicone. Instead of administering Linzess once daily and observing ingestion, multiple nurses and medication aides routinely placed each day’s Linzess capsule into an empty Simethicone bottle kept at the bedside, then removed three capsules on certain days and left them in a medication cup for the resident to take later according to her personal bowel regimen. The resident reported and demonstrated how she self-administered the three capsules using her mouth, and surveyors observed a cup with three capsules on her bed and found a Linzess capsule stored in the Simethicone-labeled bottle. Staff interviews confirmed this practice had been ongoing for an extended period, that the MAR was signed as if Linzess had been given daily as ordered, and that there was no provider order authorizing the altered dosing schedule or self-administration.
A resident had multiple medications, including Linzess, Biotin, Simethicone, and Clobetasol spray, stored on a bedside table, with some products expired and a Linzess capsule placed in a bottle labeled for Simethicone. Several nurses and medication aides acknowledged routinely placing the Linzess capsule into the bedside bottle at the resident’s request, despite knowing medications should not be stored in resident rooms. On a medication cart, an opened Novolog insulin pen lacked an open date, and an opened Lantus insulin pen remained available for use beyond the manufacturer’s 28-day discard period, even though staff reported they were responsible for checking carts daily and dating and discarding insulin pens appropriately.
Surveyors found that the outside cleaning area near the kitchen exit was unusable due to scattered debris, leaves, and multiple pieces of broken equipment, including a sauna tub, recliner, and metal racks, along with discarded items from maintenance, housekeeping, and dietary. The drain in this enclosed brick area was blocked by leaves and debris, preventing proper drainage when pressure hoses are used to clean kitchen items, wheelchairs, and beds. The DM and Maintenance Director acknowledged that Dietary, Housekeeping, and Maintenance were responsible for keeping this area clean and functional, but it remained cluttered and open to the elements, creating conditions available to pests and rodents.
A nurse failed to follow the facility’s nephrostomy tube care policy during a dressing change for a resident with a nephrostomy tube. After removing the old dressing, discarding soiled items, and removing her gloves, the nurse did not perform hand hygiene before donning sterile gloves and applying a new sterile dressing. Facility policy required handwashing after glove removal and before putting on sterile gloves. In subsequent interviews, the nurse acknowledged forgetting this step, and the IP, NP, and DON all confirmed that hand hygiene should have occurred between removal of the old dressing and application of the new dressing, with the NP noting this lapse put the resident at risk for bacterial introduction to the ostomy site.
A resident with advanced dementia, Parkinson’s disease, severe cognitive impairment, bowel incontinence, and a history of combative behavior during ADLs and prior falls was receiving incontinence care from a NA around mealtime. After an initial brief change during which the resident remained calm, the resident had another bowel movement. When the NA resumed care, the resident began hitting and pinching, prompting the NA to call for assistance via radio. While other staff were occupied, the NA was able to calm the resident and chose to resume incontinence care alone, despite the resident’s known behavioral history. During this care, with the resident turned away from the caregiver, the resident grabbed the metal bed frame, pulled himself off the bed, and fell, striking his head on a dresser and sustaining a forehead laceration that required treatment in the ED. Interviews and documentation confirmed the resident’s established pattern of aggression during care and that only one staff member was present at the time of the fall.
Staff failed to accurately document the administration and refusals of a constipation medication (Linzess) for a resident. Although the physician ordered a daily oral dose on specific days of the week, multiple nurses and medication aides admitted they charted the drug as given on days when it was not administered and was instead left or stored in the resident’s room. One nurse reported the resident had actually been taking three capsules only on two days per week for an extended period, contrary to the daily order. The NP and consulting pharmacist stated they rely on accurate MAR documentation, including refusals, for clinical decision-making, and the DON confirmed the MAR must be accurate at all times.
A staff member at a facility misappropriated a Duragesic pain patch from a resident with chronic back pain. The staff member, who was not scheduled to work, entered the resident's room and took the patch, leading to his own medical distress. The incident was reported to authorities, and the staff member was terminated. The resident did not report any pain or missing doses, and no adverse reactions were noted.
A dependent resident with cognitive impairment and hemiplegia did not receive a breakfast tray due to a nursing assistant forgetting to provide it. The resident required feeding assistance, and the tray was found in the kitchen warmer later in the morning. The DON confirmed the oversight, and the nursing assistant admitted to forgetting without asking for help.
Failure to Notify Provider of Resident’s Long-Term Deviation From Ordered Linzess Regimen
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when nursing staff were not following a physician’s order for the administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, and rectal paralysis. The resident was cognitively intact and had a physician’s order for Linzess 290 mcg, one capsule by mouth daily. Review of the Medication Administration Record showed the medication was documented as given daily between 7:00 AM and 11:00 AM. However, during an observation of the resident’s room, three capsules were seen in a medication cup on the bed, and the resident reported these were her Linzess capsules, which she took to help move her bowels. Further interviews revealed that the resident did not take Linzess daily as ordered. Instead, nursing staff and medication aides placed the daily capsule into an empty medication bottle kept at the bedside. On specific days of the week, staff removed accumulated capsules from the bottle and placed three capsules into a medication cup for the resident to take together, in accordance with the resident’s request to take three capsules twice weekly rather than one capsule daily. Multiple staff members, including nurses and medication aides, acknowledged they had been following this practice for an extended period, knew it did not match the written physician order, and did not question or clarify the order. Staff interviews also showed that nurses and medication aides did not notify the physician, nurse practitioner, or DON that the resident was refusing the ordered daily dose and instead taking three capsules twice weekly. Nurses stated they understood they should have notified the provider about the resident’s refusal to take the medication as ordered but instead honored the resident’s request. Medication aides stated they believed it was the nurses’ responsibility to notify the provider and did not escalate the issue, despite recognizing that the administration method did not match the order. The DON and nurse practitioner both reported they had no prior knowledge of this altered dosing regimen and that they first became aware only after the DON was informed during the survey.
Failure to Follow Physician’s Order and Improper Medication Storage for Linzess
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, paraplegia, and bilateral upper and lower extremity contractures. The resident had been assessed and determined not to be able to self-administer medications, and her care plan noted a history of refusing medications and care at times based on her personal routine. Despite this, nursing staff and medication aides routinely deviated from the written order for Linzess 290 mcg by mouth daily and instead accommodated the resident’s preferred regimen of taking three capsules twice weekly. The resident reported that staff left three Linzess capsules in a medication cup at her bedside on specific days for her to take later, and she demonstrated how she self-administered them using her mouth due to her hand contractures. Surveyor observations confirmed that a medication cup with three capsules was left on the resident’s bed while she sat in her wheelchair, and that she had significant bilateral hand and wrist contractures. The resident explained that staff placed her daily Linzess capsules into an empty medication bottle labeled for Simethicone kept on her bedside table, and on certain days staff removed three capsules from that bottle, placed them in a medication cup, and left them for her to take at a specific time. The DON later opened the bedside bottle labeled Simethicone and found a Linzess capsule inside. Review of the medical record showed no order from the resident’s gastroenterologist authorizing three Linzess capsules twice weekly, and the current physician’s orders specified a single 290 mcg capsule daily, including Saturdays, as well as Magnesium Citrate twice weekly and Simethicone as needed. Multiple staff interviews revealed that several nurses and medication aides had long been placing the Linzess capsules into the Simethicone bottle at the bedside and allowing the resident to take three capsules on designated days, rather than administering one capsule daily as ordered and observing ingestion. Nurse #1 admitted she had been placing the daily Linzess capsule into the bedside bottle for some time and acknowledged she should not have done so, especially given the resident did not have an order to self-administer medications. Medication Aides #1 and #2 stated they had been trained or told by other nurses to store the Linzess in the bedside bottle and to set out three capsules on the resident’s preferred days, and they acknowledged they did not question the discrepancy with the physician’s order. Another nurse confirmed that the resident had been taking three capsules on two days per week “for as long as she could remember” and that she knew this practice did not follow the written order. In contrast, one night-shift nurse reported she always stayed with the resident until she took the ordered Linzess and refused to leave capsules in the bedside bottle. The Nurse Practitioner and Consulting Pharmacist later confirmed that the dose the resident was actually taking exceeded the recommended maximum daily dose and that the medication should have been administered as prescribed, but there was no documentation in the record authorizing the altered regimen. The facility’s own documentation showed that the Medication Administration Record was being signed to indicate that Linzess was administered daily as ordered, even though staff interviews and resident statements showed that the medication was being stored in a mislabeled bottle at the bedside and taken in a different dose and schedule than prescribed. The resident’s self-administer medication assessment, updated shortly before the survey, continued to show she was not approved to self-administer medications, yet staff left medications in her room and did not consistently remain present to verify ingestion. The DON stated she had no knowledge that staff were leaving Linzess capsules in the Simethicone bottle or that the resident was taking three capsules twice weekly instead of one capsule daily, and she stated she expected staff to follow the five rights of medication administration and the physician’s orders as written.
Improper Medication Storage in Resident Room and Undated/Expired Insulin Pens on Medication Cart
Penalty
Summary
The deficiency involves failure to properly secure, label, and manage medications, including allowing medications to be stored in a resident’s room and maintaining expired medications. One cognitively intact resident had multiple medications stored on her bedside table, including a Simethicone bottle containing a Linzess capsule, two opened Biotin bottles (one with 1,000 mcg tablets and one with 5,000 mcg tablets expired in 04/2024), an opened Simethicone bottle expired in 01/24/2024, and a Clobetasol Propionate 0.05% spray. The Linzess capsule was being placed into an empty Simethicone bottle and left at the bedside, and the resident reported that nursing staff routinely left the daily Linzess capsule in that bottle on her bedside table. Multiple staff interviews confirmed that nurses and medication aides had been placing Linzess capsules into the empty Simethicone bottle and leaving it in the resident’s room at her request, despite knowing medications should not be stored in resident rooms. One nurse acknowledged she had left the Linzess capsule in the Simethicone bottle without realizing the bottle was labeled for a different medication. Two medication aides reported that, over their respective periods of employment, they had routinely placed Linzess capsules into the bottle with the pink cap kept at the bedside. Another nurse stated she was aware that Linzess capsules were being stored in the labeled Simethicone bottle in the resident’s room until administration on specific days and admitted she had placed the capsules there even though she knew residents were not to have medications at the bedside. A separate deficiency was identified on a medication cart, where an opened Novolog insulin pen had no documented open date and an opened Lantus insulin pen remained on the cart past its 11/24/25 expiration date, despite manufacturer instructions to discard 28 days after opening. Observation of the Lantana hall medication cart with a nurse revealed these issues, and the nurse stated that nurses and medication aides were responsible for checking carts daily for expired medications and ensuring insulin pens were dated when opened and discarded when expired. The DON stated her expectation that opened insulin pens be dated so staff could determine if they were still appropriate for use and that expired medications be removed from the cart.
Improper Disposal and Accumulation of Debris in Kitchen Outside Cleaning Area
Penalty
Summary
Surveyors identified a deficiency related to improper disposal and accumulation of garbage, refuse, and broken equipment in the outside cleaning area adjacent to the kitchen exit. During an observation of the kitchen’s outside cleaning area, located approximately four feet from the kitchen exit door, surveyors noted scattered debris and leaves, a broken sauna bathtub, a broken recliner, broken metal racks, and additional discarded items from maintenance, housekeeping, and kitchen departments. The amount of debris and discarded equipment rendered the enclosed brick cleaning area unusable, and leaves and debris were observed blocking the drain that is intended to allow water to drain when pressure hoses are used to clean kitchen items, wheelchairs, and beds. In interviews, the DM stated that Maintenance, Housekeeping, and Dietary were jointly responsible for keeping the outside cleaning area clean and functional, with trash removed so the drain could operate properly during cleaning activities. The DM acknowledged that the area could not currently be used because it was full of discarded broken equipment and debris, and the drain was blocked. A subsequent tour with the Maintenance Director and Administrator confirmed the presence of scattered debris, leaves, broken equipment, and discarded items from multiple departments around the sides and back of the enclosure, which was open to the elements and available to pests and rodents. The Administrator stated an expectation that Maintenance ensure the cleaning area was usable and free of debris and broken facility equipment.
Failure to Perform Hand Hygiene During Nephrostomy Tube Dressing Change
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control procedures during nephrostomy tube care for one resident. The facility’s policy for nephrostomy tube dressing changes specifies that after removing the soiled dressing and discarding it, staff must remove gloves, perform hand hygiene, and then don sterile gloves. During an observed nephrostomy tube dressing change for Resident #15, Nurse #3 donned a gown and gloves, removed the old dressing, discarded it, and cleansed the tubing and connection port with alcohol pads. After discarding the soiled items and removing her gloves, Nurse #3 immediately donned sterile gloves without washing her hands, and then applied a new sterile dressing to the nephrostomy tube insertion site. In interviews following the observation, Nurse #3 acknowledged that she should have washed her hands after removing the gloves used to change the old dressing and before putting on sterile gloves, stating she forgot but understood the importance of proper handwashing in infection control. The Infection Preventionist confirmed that hand hygiene should have been performed after removal of the old dressing and prior to donning sterile gloves and described hand hygiene as one of the most important steps in preventing infections. The NP caring for Resident #15 stated that the nurse should have washed her hands between handling the old dressing and applying the new dressing and explained that failure to follow this protocol put the resident at risk for introduction of bacteria to the ostomy site, which could cause infection. The DON stated that nurses changing any dressing should wash their hands before beginning, after removing the old dressing, before applying the new dressing, and after completing the dressing change, and confirmed that Nurse #3 did not follow this process.
Failure to Provide Safe Incontinence Care to Combative Resident Resulting in Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision was provided during incontinence care. The resident involved had multiple significant diagnoses, including Alzheimer’s disease, Parkinson’s disease, history of transient ischemic attack, chronic pain syndrome, essential hypertension, major depressive disorder, orthostatic hypotension, and non‑traumatic brain dysfunction. A quarterly MDS showed he had severely impaired cognitive skills, no recall ability, dependence on staff for all care, bowel incontinence, and an indwelling urinary catheter. He had a history of falls with minor injury and was receiving hospice care, as well as antibiotic, opioid, and antipsychotic medications. The resident’s care plan identified him as at risk for falls related to use of a mechanical lift and documented a history of recurrent falls. A separate behavior care plan identified him as at risk for behavior problems related to dementia and refusal of care or medications, with a history of anxiety, refusal of care, choking a staff member, restlessness, wandering, suicidal ideation, and combative behavior. Specific documented behaviors in the days prior to the incident included swinging his hands with balled fists, grabbing and squeezing staff hands, being combative during incontinence care, grabbing and digging his nails into staff skin, clenching arms and legs to prevent bathing, throwing offered items such as stuffed animals or washcloths to the floor, and hitting a nurse during a pain patch change. Interventions included assisting with self‑care needs, determining triggers for behaviors, intervening to ensure safety, monitoring hand placement during care, and gently holding the resident’s hands during care as able. On the day of the incident, a nurse aide decided to provide incontinence care around suppertime after the resident had a bowel movement, before meal trays arrived. During the first brief change, the resident remained calm while the aide talked to him. After the brief was applied, the resident had a second bowel movement, and the aide began incontinence care again. At that point, the resident started to hit and pinch the aide, who then stopped care and used her radio to summon a second staff member. She reported that all other staff were occupied providing care in other rooms. While waiting, she was able to calm the resident and, without a second staff member present, resumed incontinence care. The resident, who was facing away from her while she was wiping his rectal area, grabbed the metal bed frame, pulled himself off the bed, and fell, striking his head on a nearby dresser. The aide stated it was normal for him to hold onto the bed frame during care and believed it was a comfort measure. She also stated that the resident was not care planned for a two‑person assist during ADL care and acknowledged that the accident might have been avoided if she had waited for assistance. When the nurse responded to the aide’s call after the fall, the resident was found lying on the floor between the bed and the dresser, bleeding from a forehead laceration. The nurse documented that the aide reported the resident had pulled himself off the bed while she was cleansing him after a large soft bowel movement. The resident’s vital signs were recorded, and he was sent to the emergency department, where he was treated for a soft tissue skin tear to the forehead that required cleansing and steri‑strips. Imaging, including a head CT and pelvic x‑ray, showed no acute injury. Interviews with the nurse, DON, and Administrator confirmed that the resident was known to become combative during ADL care, that the aide had attempted to obtain help but resumed care alone once the resident calmed, and that the resident pulled himself off the bed while holding the bed frame during incontinence care, resulting in the fall and injury.
Inaccurate MAR Documentation for Constipation Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration and refusals of Linzess, a medication for chronic constipation, for one resident. A physician’s order dated 04/16/25 directed that Linzess 290 mcg be given orally once daily on Sunday through Friday. Review of the Medication Administration Records (MARs) for November, December, and January showed multiple entries by several nurses and medication aides indicating that the resident received single capsules of Linzess on numerous dates. However, during interviews, Nurse #1, Medication Aide #1, Medication Aide #2, and Nurse #4 each admitted they had documented that the medication was administered on Sundays, Mondays, Wednesdays, and Thursdays when it was not actually given and was instead left or stored in the resident’s room. Nurse #4 further stated that, for as long as she could remember, the resident had actually been taking three capsules of Linzess only on Tuesdays and Fridays, not daily as ordered. The Nurse Practitioner reported that she relied on the MAR documentation to determine whether medication changes were needed and expected accurate documentation at all times. The Consulting Pharmacist stated she would have expected staff to accurately document refusals of the daily Linzess dose and emphasized that the MAR is used to make clinical decisions and that accurate refusal documentation could have supported earlier intervention, such as a medication change. The DON also stated that nursing staff should have accurately documented refusals of Linzess and that the MAR is an important clinical tool that must be accurate at all times.
Misappropriation of Resident's Pain Patch by Staff Member
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property when a staff member, Nurse #2, took a Duragesic pain patch that was ordered for a resident. The incident involved Resident #29, who was admitted with a diagnosis of chronic back pain and was cognitively intact according to the Minimum Data Set. On the morning of the incident, Nurse #2, who was not scheduled to work, entered the facility and went into Resident #29's room, allegedly to replace a Duragesic patch. However, the patch was not replaced, and Nurse #2 was later found to be hypotensive and exhibiting signs of low oxygenation. The Director of Nursing (DON) was notified of the situation, and an investigation was conducted. It was revealed that Nurse #2 had taken the patch from Resident #29, which was confirmed by Nurse #2 himself. The investigation included interviews with various staff members, including Nurse #3, who had worked with Nurse #2 that morning. Nurse #3 reported that she had given Nurse #2 a new patch to apply to Resident #29, but later discovered that the patch was not on the resident. The Assistant Director of Nursing (ADON) and the Nurse Practitioner (NP) were also involved in assessing the situation and ensuring that Resident #29 received a replacement patch. The incident was reported to the local police department, the North Carolina Board of Nursing, and the North Carolina Department of Health and Human Services. Nurse #2 was terminated from his position, and the facility conducted an in-service for staff on communication, reporting, medication administration, and protecting their licenses. Despite the incident, Resident #29 did not report any pain or recall missing any doses of the pain patch, and there were no adverse reactions noted.
Neglect in Providing Meal to Dependent Resident
Penalty
Summary
The facility neglected to provide a breakfast tray for a dependent resident, identified as Resident #212, who was admitted with diagnoses including hemiplegia following a stroke and aphasia. The resident was assessed as cognitively impaired and dependent on staff for personal hygiene, toileting, oral hygiene, and eating. Her care plan indicated she was at nutritional risk and required staff assistance with feeding at mealtimes. On the morning of the incident, the Director of Nursing (DON) was informed by a Dining Assistant that Resident #212's breakfast tray was still in the kitchen warmer, indicating that the resident had not been fed. Nursing Assistant #1, who was responsible for Resident #212 during the shift, admitted to forgetting to provide the breakfast tray. Interviews with the Dining Assistant and Nurse #1 confirmed that the nursing assistants were responsible for obtaining meal trays for residents who ate in their rooms and required feeding assistance. Despite being aware of the resident's dependency, NA #1 did not retrieve the tray or seek help from other staff members. The DON confirmed that breakfast was typically served between 7:30 AM and 9:00 AM, and NA #1 acknowledged forgetting the task without requesting assistance.
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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