Westwood Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Archdale, North Carolina.
- Location
- 625 Ashland Street, Archdale, North Carolina 27263
- CMS Provider Number
- 345450
- Inspections on file
- 24
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Westwood Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that medications were not consistently dated upon opening and expired drugs were not removed from storage. An open, undated vial of PPD was found in the medication room refrigerator, and multiple insulin pens and nitroglycerin tablets on two medication carts were either expired, opened and undated, or opened beyond the manufacturer’s 28‑day use period. An undated Novolin R FlexPen and expired ibuprofen tablets were also identified. Nursing staff and the DON reported that the nurse who opens a medication is responsible for dating it and that night shift nurses are expected to check carts and the medication room for expired medications, but staff acknowledged these checks had not been completed as expected.
Surveyors found that dietary staff failed to follow required food labeling, dating, and sealing practices, including a loosely covered and partially exposed container of pimento cheese with an obscured date in a reach-in refrigerator, an unsealed and undated 25‑lb box of rice in dry storage, unlabeled and undated cups of orange juice in a walk‑in cooler reportedly prepared by night shift staff, and an unsealed, undated box of frozen biscuits in the walk‑in freezer. Dietary leadership confirmed that all food items are required to be labeled and dated when prepared, opened, or stored after opening, and that staff were aware of this requirement.
A resident with multiple medical and mental health diagnoses, who was cognitively intact and dependent on staff for several ADLs, experienced a prolonged delay in response to an activated call light while repeatedly yelling for help. Over more than 20 minutes of direct observation, the call light remained on and audible near the nurses’ station, where multiple staff members were present. Staff acknowledged the call light but did not promptly assist, and some did not respond when asked if they answered call lights. The resident reported that such delays in response occurred frequently, sometimes lasting up to an hour, and stated this made him upset and frustrated, demonstrating a failure to honor the resident’s dignity and right to timely assistance.
A cognitively intact resident with property scheduled for auction had a truck bed and other items taken after a nurse discussed purchasing a vehicle and viewed the resident’s belongings off-site. The nurse reported she asked her mechanic only to look at a truck bed, but he picked it up and delivered it to her home, where it remained for about two months before being retrieved. The resident stated he initially told the nurse she could have the truck bed, then told her the next day she could not because it was already promised for auction, yet the nurse obtained it after this revocation. The resident’s friend, who managed the resident’s affairs, discovered the truck bed and other items missing and contacted police, and law enforcement confirmed a report involving a truck bed and miscellaneous property that had been taken and later returned. These events show that the facility failed to prevent misappropriation of a resident’s belongings by staff.
A resident with impaired cognition, recent amputation, and dependence for mobility and toileting developed a sacral pressure ulcer that was not fully assessed or consistently treated. Nursing documentation initially described only healed-appearing tissue on the buttocks, but later a nurse noted new sacral skin breakdown, obtained wound care orders from a Medical Wound Provider, and documented that care was done without describing the wound’s stage, characteristics, or pain. The wound care order to cleanse the sacral area and apply calcium alginate did not populate to the MAR/TAR because it was likely not activated in the EMR, and there was no record of the ordered treatment being provided on three subsequent days. Staff interviews confirmed reliance on EMR activation for orders to appear on the MAR/TAR and uncertainty about whether wound care was actually performed during that period.
MDS assessments were not accurately coded for three residents in relation to falls and medication use. A resident with a history of stroke and muscle weakness had a fall that caused a skin tear, but the MDS coded the event as a fall with no injury. Another resident receiving oral and ophthalmic antibiotics during the lookback period was not coded for antibiotic use on the quarterly MDS. A third resident with bipolar disorder and schizophrenia received an IM antipsychotic injection and an oral anticonvulsant, yet the admission MDS indicated no injections and did not reflect anticonvulsant use. These errors were later acknowledged by the MDS consultant and corporate MDS consultant as oversights when reviewing the MAR and coding the assessments.
A resident admitted with bipolar I disorder with psychotic features and schizophrenia, and discharged from the hospital with instructions for psychiatric follow-up and medication management, did not receive behavioral health services after admission. The admission care plan lacked a behavioral focus despite multiple psychotropic medications and a Level II PASRR. Over several weeks, staff documented repeated episodes of calling out and screaming, and an observation showed the resident yelling for assistance with the call light on for an extended period. The admitting nurse did not recall processing a psychiatry referral, the Social Services Director reported no referral or psych consent and that the resident was not on the psychiatric provider’s active list, and leadership stated they expected residents to receive needed behavioral health care but were unaware this resident had not been referred or seen.
A resident with hypertension and heart failure had a physician order for Metoprolol Tartrate with instructions to hold the dose if systolic blood pressure (SBP) was below 110, but review of the MAR showed the medication was administered on multiple evenings when SBP readings were documented below that threshold. The cognitively intact resident received the medication despite SBP values under the ordered parameter, and the MA who gave several of these doses acknowledged it was an oversight. The Medical Director and DON both stated they expected staff to follow the ordered blood pressure parameters for this medication.
The facility did not maintain current survey results in the publicly accessible survey notebook, leaving only an older recertification survey available for review while multiple subsequent complaint, infection control, and recertification surveys were missing. During tours, surveyors observed that the lobby notebook contained outdated information despite more recent surveys being documented in the iQIES system. The Administrator, who started in mid-2025, reported initial technical issues with printing survey results and admitted that although he had the survey reports in his office and knew they were required to be placed in the notebook, he did not update the binder and could not explain the failure to do so.
The facility failed to accurately post daily nurse staffing information, with 22 days showing discrepancies between the posted sheets and the actual staffing schedules. On multiple occasions, the number of NAs, MAs, RNs, and LPNs listed on the daily posting did not match the staff scheduled or who actually worked specific shifts, including both day and night coverage. One nurse who transitioned from LPN to RN was repeatedly misclassified as an LPN on the postings after his RN licensure became effective. The staff scheduler acknowledged not updating postings when staff were absent or when additional staff came in, and leadership confirmed that the posted staffing did not match the actual worked staffing.
A resident with ESRD receiving thrice-weekly hemodialysis lacked any dialysis communication forms or related documentation in the electronic medical record. Although nurses and the dialysis center reportedly used a notebook-based communication form to record pre- and post-dialysis assessments, vital signs, access site condition, and changes in condition, no completed forms or progress note entries reflecting this communication were found. The Medical Records Manager reported no set process or timeframe for removing completed forms from the notebook and uploading them, and believed the notebook may have left with the family at discharge, while the DON confirmed the facility’s responsibility for ensuring these forms were completed and filed but could not explain their absence.
A male resident with moderate cognitive impairment engaged in sexually inappropriate contact with a severely cognitively impaired female resident on two occasions. The incidents occurred in public areas and were witnessed by staff, who intervened to separate the residents. The male resident did not have a care plan addressing sexually inappropriate behaviors prior to the first incident, and supervision was inconsistently maintained, allowing a second incident to occur.
The facility failed to properly label and store medications, with several insulin pens and vials found opened and undated on medication carts, and PPD testing solution improperly stored outside refrigeration. An expired bottle of Allergy Relief tabs was also found in the medication storage room. Staff interviews revealed expectations for proper labeling and storage were not met.
A facility failed to disinfect a glucometer according to the manufacturer's guidelines. A nurse used the glucometer for a resident's blood glucose check and returned it to the medication cart without proper cleaning. The nurse used alcohol swabs instead of the required Sani wipes, as she was unaware of the correct product. The DON confirmed the need for Sani wipes, and the Administrator expected adherence to the policy.
A resident, admitted with muscle weakness and cognitively intact, was unable to have his hair trimmed to his preferred length due to the absence of a beautician at the facility. Despite expressing his preference to staff, the facility had not coordinated a haircut, as confirmed by interviews with nursing staff and the DON. The administrator was aware of the issue but had not yet resolved it.
Two residents in an LTC facility, both cognitively intact, expressed a desire for haircuts as part of their basic hygiene needs. Despite their requests, no staff was available to provide this service, and there was confusion among staff about who was responsible for haircuts. The Director of Nursing and Administrator were unaware that routine hair trimming was a covered service for Medicaid residents, leading to a deficiency in care.
A resident with cognitive impairment and a history of falls experienced repeated falls due to improper footwear. Despite being aware of the issue, the facility failed to ensure the resident had properly fitting shoes, leading to multiple incidents. The care plan interventions were not effectively enforced or monitored, resulting in continued falls.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.9% error rate. Two residents experienced medication errors: one did not receive an antibiotic for urinary tract infection prophylaxis, and another did not receive prescribed eye drops for dry eye. The Unit Manager, acting as a floor nurse, acknowledged the errors, which were confirmed by interviews with the NP, DON, and Administrator.
The facility failed to provide written notification of the bed hold policy to two residents and their responsible parties upon hospital transfer. Interviews with staff revealed a lack of awareness and absence of a process to ensure the policy was communicated, indicating a systemic issue.
The facility failed to provide written notification to residents and/or their responsible parties regarding hospital transfers. Two residents were transferred without receiving the necessary documentation. The Social Worker and Social Services Director admitted to not sending the required notices, and there was confusion among staff about the process. The Administrator was aware of the requirements but did not know the task was incomplete.
The facility failed to maintain complete and accurate wound care documentation for three residents, leading to a deficiency. A resident with a history of amputation and diabetes had missing documentation for wound care on her forearm and leg. Two other residents, one with a femur fracture and another with a pressure ulcer, also had incomplete records. Interviews with staff revealed that while wound care was reportedly completed, documentation was often forgotten, indicating a systemic issue with record-keeping.
A resident was injured during transport from dialysis when her wheelchair was not properly secured in a contracted van, causing it to tip backward and result in a head injury. The resident, who had a history of diabetes, end-stage renal disease, and was on anticoagulant medication, was taken to the hospital for evaluation. The driver admitted to not securing the wheelchair per protocol, leading to his termination and the facility halting the use of the contracted service.
Failure to Discard Expired Medications and Date Open Multi-Dose Drugs
Penalty
Summary
The deficiency involves failure to ensure medications were properly dated upon opening and expired medications were discarded from medication carts and the medication room. During observation of the medication room refrigerator with the DON and a nurse, surveyors found an open, undated vial of Apilsol Tuberculin PPD solution, despite manufacturer instructions that it be discarded within 30 days of opening. On one medication cart, surveyors identified an expired bottle of nitroglycerin 0.4 mg tablets and multiple insulin pens (Humalog, Insulin Glargine, and Basaglar) that were either opened and undated or opened and dated beyond the manufacturer’s 28‑day use period. On another medication cart, surveyors observed a used, undated Novolin R FlexPen and a bottle of 200 mg ibuprofen tablets past the manufacturer’s expiration date. Nursing staff interviewed stated that the nurse who opened a medication was responsible for dating it and that night shift nurses were responsible for routinely checking medication carts and the medication room for expired medications. Staff also described monitoring of medications as a team effort and acknowledged they had not yet checked their carts on the day of observation, despite the DON’s stated expectation that nurses date medications upon opening and discard expired medications as needed.
Failure to Properly Label, Date, and Seal Food Items in Dietary Services
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to failure to properly label, date, and seal food items in accordance with professional standards. During an observation of the reach-in refrigerator, a small metal container of pimento cheese was found loosely covered with plastic wrap, leaving it exposed to air, and the date written on the wrap was obscured. When interviewed, the cook stated the pimento cheese had been made that morning but did not initially respond when asked why it was not sealed; she then re-wrapped and dated it, but it was determined unsafe to serve because the length of time it had been unsealed was unknown. Additional observations showed similar issues in other storage areas. In the dry storage area, a 25‑pound box of white rice was stored in an unsealed bag open to air and was not marked with the date opened, and the dietary staff member present stated she did not know why it was open and undated. In the walk‑in cooler, seven 4‑ounce cups of orange juice were covered with plastic wrap but were unlabeled and undated; the dietary staff member stated night shift staff prepared the orange juice and were responsible for labeling and dating it. In the walk‑in freezer, a box of frozen biscuits was stored in an unsealed bag open to air and was not marked with the date opened, and the dietary staff member again stated she did not know why it was open and undated. The Dietary Manager and District Dietary Manager confirmed that all food items should be labeled and dated when prepared, opened, or stored after opening and that staff were aware of this requirement.
Failure to Respond Promptly to Call Light Resulting in Undignified Treatment
Penalty
Summary
The deficiency involves a failure to treat a resident in a dignified manner by not responding promptly to the resident’s call light. The resident, who had diagnoses including type 2 diabetes mellitus, acute arterial ischemic stroke, bipolar I disorder with psychotic features, and schizophrenia, was cognitively intact and required varying levels of staff assistance for activities of daily living, including being dependent for toileting hygiene and bathing. The resident’s admission care plan did not include a focus area for behaviors. During a continuous observation on 02/16/26 from 11:10 AM to 11:31 AM, the resident’s call light remained on while he repeatedly yelled for assistance, stating, “Hey, someone help me, hey come here, I need help.” At approximately 11:16 AM, the surveyor informed the resident they would get assistance, and a nursing assistant in the adjacent room stated she would get to him as soon as possible, but the resident continued to yell out without receiving help. By approximately 11:30 AM, the surveyor went to the nurses’ station where five staff members (a medication aide, a human resource coordinator/NA, a nurse, and two NAs) were present. The staff acknowledged that the call bell was on but did not know how long it had been activated, even though the call light was visible and audible at the beginning of the hall near the nurses’ station. When the surveyor asked if they assisted with answering call lights, the medication aide initially responded that the resident “does that, he yells out for assistance” and did not go to assist him; the nurse and two NAs did not respond to the surveyor’s repeated questions. The human resource coordinator/NA then approached to assist the resident. In an interview, the resident reported he had been yelling for about 30 minutes with no response, stated he tracked the time using his television, and said this delay occurred frequently, sometimes up to an hour or more, regardless of his needs. He stated this made him upset and frustrated. In a separate interview, the DON reported she was unaware of the wait times and staff not answering this resident’s call bell, acknowledged the resident’s mental health conditions could affect his sense of time, and stated her expectation was that all staff answer call lights.
Failure to Protect Resident Property From Misappropriation by Nurse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident’s property from misappropriation by a staff member. The resident, assessed on a quarterly MDS as cognitively intact without behaviors and with a BIMS score of 12, had personal property including a truck bed and other items that were being handled by a friend and were associated with an auction and probate. An allegation was reported to the State Agency that a nurse had received a truck bed from this resident, and the resident’s contact person notified staff that the nurse was not supposed to receive the truck bed or any other items in her possession. According to the nurse’s interview, she discussed with the resident and the resident’s friend that she needed another vehicle, and the friend told her about a car for sale at auction. She went to look at the car and also discussed a truck bed, then asked her mechanic to look at the truck bed to see if it could be used as a bed for her home. The nurse stated she did not ask the mechanic to pick up the truck bed, but he did so and brought it to her house. She reported that when the resident’s friend wanted the truck bed back, she covered it with a tarp and left it in her yard for about two months until it was picked up. She denied knowledge of a trailer with other items and acknowledged she had been trained not to accept gifts from residents. The resident reported that he had told the nurse she could have the truck bed but did not realize at the time that it was scheduled to go to auction. He stated that the next day he told the nurse she could not have it because it was already promised for auction, but the nurse obtained the truck bed after he revoked permission. The resident’s friend, who handled the resident’s affairs, stated that the nurse had gone alone to the resident’s house to look at buying a car and later had someone pick up the truck bed for her, and that he discovered the truck bed and other miscellaneous items missing from a trailer. Local law enforcement confirmed they were contacted about a 2002 Ford truck bed and other property taken from the resident’s property, and that although the resident had initially told the nurse she could have the items, he later learned from his friend that they could not be given away because they were up for auction. The items were eventually returned and no charges were pressed, but the events demonstrated that the resident’s belongings were not protected from wrongful use or misappropriation by facility staff.
Failure to Assess and Document Sacral Pressure Ulcer and Provide Ordered Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to properly assess and treat a newly identified sacral pressure ulcer for a resident with multiple comorbidities, including a recent left above-knee amputation and history of stroke. On admission, documentation showed a surgical wound with staples to the left thigh, dry and cracked skin on the right foot, discoloration and scarring on the right leg, bruising on the right ankle, and buttocks free of skin breakdown. An admission MDS indicated moderately impaired cognition and dependence on staff for bed mobility, toileting hygiene, and transfers, with no pressure ulcers noted but a surgical wound present. Subsequent skin assessments by a nurse on two dates in December documented only a very thin area of pink and white tissue on the buttocks, consistent with previously healed wounds and no open areas, with staff providing protective skin care after incontinence. On a later date in December, a nurse documented that the resident was noted with a sacral wound, that wound care orders were obtained from the Medical Wound Provider, and that wound care was completed as ordered; however, the note did not include any description of the wound’s stage, characteristics, or presence of pain. A physician order was entered to cleanse the sacral wound with wound cleanser, apply calcium alginate to the wound bed, and cover with a dry dressing daily and as needed, but this order did not appear on the MAR or TAR. Review of the medical record showed no documentation that the ordered sacral wound care was provided on three consecutive days following the initial order. The nurse who obtained the order stated she entered it into the EMR and that it required activation to appear on the MAR or TAR, but she could not recall if she had activated it, could not recall measuring the wound, and only documented the new skin breakdown in a nursing note without detailed description. Interviews and record review confirmed that other nursing staff, including the nurse who later became the wound care nurse, could not recall providing wound care to the resident on the days in question and indicated that, at that time, floor nurses were responsible for wound care and the Medical Wound Provider was responsible for measuring and assessing wounds. The wound care nurse and another nurse explained that if an order was not activated in the EMR, it would not populate to the MAR or TAR, and staff would not know to complete the treatment. Observation of the resident’s buttocks in February showed a small area of pink and white scar tissue on one buttock and a very small, shallow open area with a pink/red wound bed on the other buttock, with wound care then being completed as ordered. The DON, who assumed the role later, stated she was unaware that the sacral wound care orders from late December had not populated to the MAR or TAR and stated she would have expected wound care to be completed as ordered and for the nurse to have documented a description of the wound in the progress note.
Inaccurate MDS Coding for Falls and Medication Use
Penalty
Summary
The deficiency involves inaccurate coding of Minimum Data Set (MDS) assessments for multiple residents in the areas of accidents and medications. One resident with a history of stroke and muscle weakness experienced a fall that caused a skin tear to his right arm. In the subsequent quarterly MDS, his cognition was coded as severely impaired and the fall section was coded as one fall with no injury since the previous assessment, despite documentation in the medical record that the fall resulted in a minor injury. The MDS Consultant who completed the assessment later confirmed that the fall should have been coded as one fall with a minor injury and described the incorrect coding as an oversight. Two additional residents had inaccuracies in the medication sections of their MDS assessments. One resident with neuromuscular bladder dysfunction and age-related cataracts received Macrobid orally once daily and Moxifloxacin eye drops every two hours during the lookback period, but the quarterly MDS did not code any antibiotic use, which the MDS Consultant later acknowledged should have been coded. Another resident with bipolar I disorder with psychotic features and schizophrenia had active orders and documented administration for an intramuscular antipsychotic injection and an oral anticonvulsant medication during the admission MDS lookback period. However, the admission MDS was coded as receiving zero injections and did not reflect anticonvulsant use. The Corporate MDS Consultant confirmed she did not accurately code the injections or the anticonvulsant, stating she overlooked the intramuscular aspect of the antipsychotic and the presence of the anticonvulsant when reviewing the MAR.
Failure to Provide Behavioral Health Services for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to provide behavioral health care services to a resident with diagnosed serious mental illness and ongoing behavioral symptoms. The resident was discharged from the hospital with diagnoses including bipolar I disorder, current manic with psychotic features, and schizophrenia, and the hospital discharge summary documented a need for follow-up psychiatric appointments and medication management. On admission, the resident’s care plan dated 01/23/26 did not include a focus area for behaviors despite these diagnoses and the presence of multiple psychotropic medications, including olanzapine, lamotrigine, and fluphenazine decanoate. The admission MDS indicated intact cognition, no behaviors coded during the lookback period, and a Level II PASRR, and the resident was coded as receiving antipsychotic medications. Behavioral documentation on the MAR from 01/23/26 through 02/13/26 showed repeated episodes of calling out and screaming/calling out on multiple days, yet the medical record from 01/23/26 through 02/16/26 contained no evidence that psychiatric or other behavioral health services were provided. During observation on 02/16/26, the resident’s call light remained on while he yelled for assistance for over 20 minutes, and a med aide acknowledged that he frequently yelled out but did not know how long he had been yelling on that occasion. The admitting nurse stated she did not recall seeing a psychiatry referral, explained that her process was to place such referrals in the social worker’s box, and did not know why the resident had not been seen by psychiatry despite his behaviors. The Social Services Director confirmed she had not received a referral or completed a psych consent for this resident and that the resident was not on the psychiatric provider’s active list. The Medical Director and DON both stated they expected residents to receive necessary behavioral health care services and were unaware that this resident had not been referred to or seen by psychiatric providers.
Failure to Follow Hold Parameters for Antihypertensive Medication
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to hold a blood pressure medication when the resident’s systolic blood pressure (SBP) was below a specified parameter. A resident admitted with hypertension and heart failure had a physician’s order for Metoprolol Tartrate 25 mg, to administer 12.5 mg by mouth every 12 hours, with instructions to hold the dose if SBP was less than 110. Review of the January 2026 MAR showed that the resident received Metoprolol Tartrate for multiple 9:00 PM doses when the SBP was documented below 110, including SBP readings of 109, 109, 99, and 106. The resident’s quarterly MDS indicated the resident was cognitively intact. During an interview, the medication aide who administered several of the doses confirmed that Metoprolol Tartrate was given despite SBP readings below the ordered parameter and stated this was an oversight. Attempts to contact the nurse who administered one of the doses were unsuccessful. The Medical Director stated that, although she did not feel the resident would have suffered serious harm from receiving the medication outside the parameter, she expected nursing staff to follow the blood pressure parameters as written. The DON also stated she expected staff to follow physician orders, including hold parameters for blood pressure medications, and reported she had recently assumed the role and was unaware that the medication had been administered outside the prescribed parameters.
Failure to Maintain and Post Current Survey Results in Public Notebook
Penalty
Summary
The facility failed to make the most recent survey results readily available to residents and visitors by not updating the survey results notebook in the front lobby with multiple completed surveys. On two separate days of the survey, the notebook on a low table in the lobby was observed to contain only the results from a recertification survey completed on 8/16/23, despite the iQIES database showing that the most recent survey was a complaint investigation completed on 11/7/25. Review of records identified that several intervening surveys were missing from the notebook, including a complaint investigation survey dated 1/30/24, a focused infection control survey dated 4/8/24, complaint investigation surveys dated 8/22/24, 12/30/24, 1/15/25, 7/15/25, and 11/7/25, and a recertification survey dated 11/21/24. In an interview, the Administrator reported he began employment at the facility at the end of July 2025 and acknowledged awareness of the regulation requiring that the most recent survey results from any survey be placed in the notebook. He stated that technical issues initially prevented him from printing the survey results when he started, and that while he had the survey results in his office, he had not placed them in the public binder. The Administrator acknowledged that he should have placed the survey results in the notebook once he was able to print them but could not explain why this had not been done.
Inaccurate Daily Posting of Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate daily nurse staffing information when compared to the actual staffing schedules and staff who worked. A review of daily postings and nursing schedules from early January through mid-February showed that on 22 of 46 days, the posted numbers and types of nursing staff did not match the schedule. Examples included discrepancies in the number of nurse aides (NAs), medication aides (MAs), registered nurses (RNs), and licensed practical nurses (LPNs) listed as working specific shifts versus what was reflected on the daily posted nurse staffing sheets. Specific instances of inaccuracy included days when fewer or more NAs were posted than were scheduled for the 7:00 AM–3:00 PM and 11:00 PM–7:00 AM shifts, and days when the number of MAs posted did not match the schedule. On multiple dates, the postings showed different numbers of NAs on day and night shifts than the staffing schedule indicated. There were also days when the postings showed an MA working when none were scheduled, or showed no MA working when one or more were scheduled. Similar inconsistencies occurred with LPN coverage, where the posted sheets sometimes reflected more or fewer LPNs than were actually scheduled for 12-hour shifts. The report also documents repeated misclassification of one nurse’s licensure status on the posted staffing sheets. This nurse was hired as an LPN and later became an RN effective mid-January, but the staff scheduler continued to count him as an LPN and not as an RN on multiple dates after his RN licensure became effective. Interviews with the staff scheduler confirmed that she did not update the daily posted nurse staffing sheets when staff failed to report for work or when additional staff came in to cover, and that she had not adjusted the postings to reflect the nurse’s change from LPN to RN. The administrator and DON acknowledged that the staffing schedules and daily postings did not match the actual staff who worked on given shifts.
Failure to Maintain Dialysis Communication Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain evidence of ongoing communication with a dialysis treatment center in the medical record for a resident with end stage renal disease (ESRD) who was dependent on hemodialysis three times per week. The resident’s significant change MDS assessment showed the resident was cognitively intact, but dialysis was not coded on the assessment in error. Review of the electronic medical record revealed no completed dialysis communication forms, and the facility was unable to locate any such forms for this resident. Progress notes contained no documentation of communication between facility staff and the dialysis center, and there was no documentation that pre-dialysis or post-dialysis assessments were completed and communicated. Nursing staff interviews confirmed that a dialysis communication form and notebook system was in place, with nurses completing pre-dialysis information such as vital signs, weight, access site condition, and changes in condition, and dialysis nurses documenting post-dialysis assessments. However, the Medical Records Manager reported there was no scheduled timeframe for removing completed forms from the notebook and uploading them into the electronic medical record, and she was unable to locate any forms for this resident, suggesting they may have remained in the notebook and possibly left with the family at discharge. The DON stated the facility was responsible for ensuring completion of the forms and placement in the medical record after review, but could not explain why the forms were not present for this resident.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision and Care Planning
Penalty
Summary
The facility failed to protect a severely cognitively impaired female resident from sexual abuse by another resident. On two separate occasions, a male resident with moderate cognitive impairment was observed engaging in sexually inappropriate contact with the female resident, who was unable to consent due to her severe cognitive impairment. In the first incident, the male resident lifted the female resident’s breasts out of her shirt and fondled them in a public area of the facility. In the second incident, the same male resident took the female resident’s hand and rubbed it over his pants in his crotch area. Both incidents were witnessed by staff, who intervened to separate the residents. The male resident had a history of dementia, cognitive communication deficit, and other medical conditions, but there was no care plan in place addressing sexually inappropriate behaviors prior to the first incident. The female resident had Alzheimer’s dementia, was severely impaired in daily decision making, and required total assistance with most activities of daily living. She was dependent on staff for mobility and transfers and was unable to provide a reliable account of the incidents due to her cognitive status. Staff interviews confirmed that the male resident had previously made inappropriate sexual comments to staff but had not been known to touch other residents inappropriately before these events. Despite the initial implementation of one-to-one supervision for the male resident following the first incident, supervision was not consistently maintained, as evidenced by observations of the resident without a sitter at the nurses’ station and in the hallway. Staff were unclear about the requirements for one-to-one supervision, and the male resident was able to approach and have further inappropriate contact with the same female resident. The lack of a care plan addressing the male resident’s behaviors and inconsistent supervision contributed to the recurrence of resident-to-resident sexual abuse.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and store medications, as observed during a survey. On two medication carts, several insulin pens, including Lispro, Lantus, and Basaglar, were found opened and undated, with some not labeled with resident names. Additionally, a vial of Lantus insulin and an Insulin Aspart pen were also opened and undated. The manufacturer's instructions require insulin to be discarded 28 days after opening, which was not adhered to. Furthermore, two vials of tuberculin purified protein derivative (PPD) testing solution were found opened, undated, and improperly stored outside of refrigeration, contrary to the manufacturer's guidelines. In the medication storage room, an unopened bottle of Allergy Relief tabs was found with an expiration date of September 2024, indicating it was expired and should have been discarded. Interviews with the staff, including a pharmacist, the Director of Nursing (DON), and the Administrator, revealed that there was an expectation for nurses to date all medications upon opening and to store them correctly. The pharmacist, who visits monthly, had previously identified expired or undated medications but relied on the nursing staff to dispose of them. The unit managers were responsible for auditing the medication carts for expired medications, but this process was evidently insufficient to prevent the deficiencies observed.
Failure to Disinfect Glucometer as per Guidelines
Penalty
Summary
The facility failed to properly disinfect a glucometer used for checking a resident's blood glucose level, as per the manufacturer's guidelines. The glucometer was individually assigned to a resident and stored in the medication cart. According to the facility's policy, the glucometer should be cleaned and disinfected with disinfecting wipes, specifically Sani cloth wipes, and allowed to remain wet for a full 2 minutes before air drying. However, during an observation, a nurse used the glucometer to check the resident's blood glucose level and then placed it back into the medication cart without cleaning it as required. Upon interview, the nurse acknowledged that the facility's policy was to clean the meters both before and after use, but she used alcohol swabs instead of the required Sani wipes, as she was unaware of the specific product to be used. The Director of Nursing confirmed that the glucometers should be disinfected with Sani wipes, and the Administrator expected the facility policy to be followed. The absence of disinfecting wipes on the cart contributed to the failure to adhere to the proper cleaning protocol.
Failure to Provide Haircut Services to Resident
Penalty
Summary
The facility failed to honor a resident's request for a haircut, which was a preference known to the staff. The resident, who was cognitively intact and admitted with a diagnosis of muscle weakness, expressed frustration over not having his hair trimmed since admission. Despite reporting his preference to multiple staff members, the resident was informed that there was no beautician available at the facility to provide haircuts. Interviews with staff, including a nurse and a nurse aide, confirmed that there had been no beautician available for several months, and staff were not trained or licensed to cut hair. The Director of Nursing acknowledged awareness of complaints regarding the lack of haircuts but was not specifically aware of this resident's preference. The facility administrator also confirmed the absence of a beautician and was in the process of hiring one, but had not addressed the immediate needs of the residents who preferred haircuts.
Failure to Provide Routine Hair Trimming for Medicaid Residents
Penalty
Summary
The facility failed to provide routine hair trimming as part of basic hygiene services for residents whose payor source was Medicaid. This deficiency was identified for two residents who were cognitively intact and expressed a desire for haircuts. Both residents had hair that was longer than they preferred, touching their collars and around their ears. Despite their requests, there was no staff available to provide haircuts, and the residents were unsure of whom to approach for this service. Interviews with various staff members, including the Social Services Director, Nurse, Nurse Aide, Unit Manager, Director of Nursing, and Administrator, revealed a lack of awareness and responsibility regarding the provision of haircuts for residents. The Social Services Director and other staff members were unaware of any concerns regarding the residents' requests for haircuts. The Director of Nursing and the Administrator were also unaware that routine hair trimming was a covered service for Medicaid residents. The staff interviews highlighted a lack of clarity and communication about who was responsible for providing haircuts, with some staff suggesting that residents could have a beautician or family member come in to cut their hair. This lack of coordination and understanding among the staff led to the failure to meet the residents' basic hygiene needs as required by Medicaid coverage.
Failure to Prevent Falls Due to Improper Footwear
Penalty
Summary
The facility failed to implement effective interventions to prevent further falls for a resident with a history of falls and cognitive impairment. The resident, who was admitted with diagnoses including unsteadiness on feet, orthostatic hypotension, osteoporosis, and dementia, experienced multiple falls. Despite being identified as at risk for falls due to cognitive loss, weakness, and poor safety awareness, the interventions in place were insufficient. The resident's care plan included ensuring appropriate footwear and encouraging the resident to call for assistance, but these measures were not effectively enforced or monitored. The resident experienced falls on multiple occasions, with incident reports indicating that improper footwear was a contributing factor. Observations revealed that the resident's shoes were too big, affecting her balance and leading to falls. Despite the facility's awareness of the issue, there was a lack of follow-up to ensure the resident received properly fitting shoes. Interviews with staff, including the DON, highlighted a failure to implement and monitor interventions effectively, resulting in repeated falls due to the same issue of ill-fitting footwear.
Medication Administration Errors Result in 6.9% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 6.9% error rate during a medication administration observation. This was evidenced by two medication errors out of 29 opportunities involving two residents. Resident #16, who was admitted with a diagnosis of retention of urine, had an active physician's order for Macrobid capsules for urinary tract infection prophylaxis. During the medication administration, the Unit Manager, acting as a floor nurse, prepared 11 out of 12 medications for Resident #16, omitting the Macrobid capsule. The error was identified when the Unit Manager was asked to recount the medications, and she acknowledged the oversight and administered the antibiotic subsequently. Similarly, Resident #5, admitted with a diagnosis of dry eye, had an active order for Artificial Tears to be administered twice daily. The Unit Manager prepared 10 out of 11 medications for Resident #5, leaving the Artificial Tears on top of the medication cart and failing to administer them before taking the resident to the cafeteria. The Unit Manager later admitted to forgetting to administer the eye drops. Interviews with the Nurse Practitioner, Director of Nursing, and Administrator confirmed the expectation that all medications should be administered as ordered, within the specified time frame.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents and their responsible parties upon transfer to a hospital, affecting two residents reviewed for hospitalization. Resident #37, who was cognitively impaired, was admitted to the facility and later transferred to the hospital without receiving the required bed hold policy notice. Interviews with the social worker and unit manager confirmed that the policy was not sent with the discharge paperwork. The administrator was unaware of this oversight and acknowledged the absence of a process to inform residents or their representatives about the bed hold policy. Similarly, Resident #30, who was cognitively intact, was transferred to the hospital on two occasions without receiving the bed hold policy notice. Interviews with the Social Services Director and a nurse revealed a lack of awareness regarding the requirement to send the bed hold policy during hospital transfers. The administrator confirmed the absence of a process to ensure residents and their responsible parties were informed of the bed hold policy, indicating a systemic issue within the facility.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and/or their responsible parties regarding the reason for hospital transfers, as required by regulations. This deficiency was identified for two residents who were transferred to the hospital without receiving the necessary documentation. Resident #37, who was cognitively impaired, was transferred to the hospital without a written notice of discharge or transfer. The Social Worker admitted to not sending the required notice and was unsure of the process for issuing such notices. The Unit Manager, who was the nurse assigned to Resident #37 at the time of transfer, confirmed that the discharge paperwork sent with the resident did not include the notice of transfer/discharge. Similarly, Resident #30 was transferred to the hospital on two occasions without the facility providing written notification to the responsible party. The Social Services Director acknowledged not sending a written reason for the hospital transfer and was unaware of this requirement. Interviews with the nursing staff revealed uncertainty about who was responsible for sending the hospital transfer notice. The Administrator confirmed awareness of the notification requirements but was unaware that the Social Services Director had not completed this task.
Incomplete Wound Care Documentation for Three Residents
Penalty
Summary
The facility failed to maintain complete and accurate documentation for wound care for three residents, leading to a deficiency in safeguarding resident-identifiable information and maintaining medical records. Resident #30, who had a history of surgical aftercare for a right below-the-knee amputation and diabetes type 2, had multiple instances where wound care documentation was missing. Despite physician orders for daily wound care on her left forearm and right leg, the Treatment Administration Record (TAR) showed no documentation of completion or refusal on several dates in June 2024. Interviews with the Unit Manager and the Director of Nursing (DON) revealed that while they claimed to have completed the wound care, they forgot to document it. Resident #55, admitted with a right femur fracture, end-stage renal disease, and congestive heart failure, also had incomplete wound care documentation. Physician orders required daily wound care for pressure wounds on the coccyx and left hip. However, the May 2024 TAR lacked documentation of completion or refusal on multiple dates. Interviews with several nurses indicated that while they ensured wound care was completed, they often forgot to document it. The DON reviewed the TAR and acknowledged the expectation for complete and accurate documentation. Resident #56, with diabetes type 2 and a stage 3 pressure ulcer to the sacral region, had similar issues with documentation. The June 2024 TAR showed missing documentation for sacral wound care on numerous dates. The Unit Manager, responsible for wound care, stated that she completed the care but forgot to sign off on it. The DON and the Administrator both expressed expectations for complete and accurate documentation, highlighting a systemic issue with documentation practices in the facility.
Failure to Secure Wheelchair Leads to Resident Injury During Transport
Penalty
Summary
The facility failed to provide safe transportation for a resident when she was being transported by a contracted van transport company from dialysis back to the facility. The resident's wheelchair was not secured to the floor securement system per the manufacturer's instructions. As a result, when the driver accelerated the vehicle, the resident's wheelchair tipped backward, causing her to hit the right back side of her head. Emergency Medical Services (EMS) were called, and the resident was taken to the hospital for evaluation. The resident involved in the incident had a medical history that included diabetes mellitus, end-stage renal disease with hemodialysis, and bilateral below-knee amputations. She was cognitively intact and required extensive assistance with activities of daily living, using a wheelchair for mobility. The resident was on anticoagulant medication, which increased the risk of serious adverse outcomes from head injuries. After the incident, she was diagnosed with a right parietooccipital hematoma but had no acute traumatic pathology on the CT scan. Interviews and records revealed that the driver did not secure the wheelchair according to the manufacturer's instructions, which required four separate floor-mounted restraints. The driver admitted to having issues with the latching mechanism and thought it was secured well. The facility was notified of the incident by the transportation company, and an internal investigation confirmed the driver's failure to follow protocol, leading to his termination. The facility subsequently stopped using the contracted transportation service.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
