White Oak Manor - Charlotte
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 4009 Craig Avenue, Charlotte, North Carolina 28211
- CMS Provider Number
- 345238
- Inspections on file
- 23
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at White Oak Manor - Charlotte during CMS and state inspections, most recent first.
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.
A resident with diabetes, sepsis, and end stage renal disease did not receive ordered twice daily blood sugar checks due to a transcription error when a nurse failed to correctly enter a verbal physician order into the EMR. As a result, no blood sugar monitoring was performed during the resident's admission, despite a care plan identifying the need for such monitoring.
A resident with venous ulcers and impaired cognition, along with a roommate, experienced persistent flies and gnats in their room, leading a family member to purchase a UV insect trap after repeated complaints to staff. Staff and housekeeping confirmed the presence of pests, often linked to open food and trash, while the pest control company had no record of such issues. Surveyors also observed gnats in a conference room, and the administrator was previously unaware of the problem.
A resident with a history of DVT and pulmonary embolus had their anticoagulant, Eliquis, discontinued for a medical procedure and it was not restarted afterward due to oversight by the NP and failure of multiple staff, including the Medical Director, to detect the omission. Over several months, the resident developed symptoms such as leg swelling and shortness of breath, which culminated in hospitalization for bilateral pulmonary emboli and required a thrombectomy. The deficiency was caused by the lack of a restart order for Eliquis and repeated failures to recognize the medication was not being administered.
Medical providers did not accurately review or update the medication list in progress notes for a resident with atrial fibrillation and benign prostatic hyperplasia. Eliquis was discontinued prior to a procedure, but subsequent NP and MD notes continued to list it as active, despite it not being restarted. The medication lists were carried over from previous notes and did not reflect actual medication changes, with staff relying on the MAR for accuracy. The administrator and DON were aware of inaccuracies in the progress note medication lists but did not know how the lists were generated.
A resident with a history of atrial fibrillation and pulmonary embolus experienced a prolonged interruption in anticoagulant therapy after Eliquis was discontinued for a surgical procedure and not resumed for several months. The Consultant Pharmacist did not identify or address this lapse during monthly drug regimen reviews, and facility leadership confirmed the omission should have been detected.
The facility failed to ensure dishware and equipment were clean during a meal service. Observations revealed divided plates with dried egg particles and bowls with dried food particles. The Registered Dietitian and Regional Dietary Manager confirmed these findings. Despite a three-step cleaning process, Dietary Aides did not adequately check the dishes before use, as noted by the Dietary Manager and Administrator.
Two residents in an LTC facility received incorrect oxygen flow rates, contrary to physician orders. One resident with chronic respiratory failure was observed with an oxygen concentrator set higher than prescribed, while another resident with congestive heart failure had a lower than prescribed rate. Nursing staff failed to verify and adjust the oxygen settings, leading to deficiencies in respiratory care.
The facility failed to discard expired medications and allowed a resident to keep and self-administer a prescription topical cream without staff knowledge. An expired bottle of omega-3 vitamins was found in the medication room, and a resident had a lidded container of medicated cream at their bedside, which was not prescribed in-house. The resident, who had intermittent confusion, was not assessed to self-administer medications, and the facility was unaware of the cream's presence.
A Treatment Nurse failed to follow the facility's Hand Hygiene policy during wound care for a resident, neglecting to sanitize hands before donning clean gloves multiple times. This was observed during the treatment of wounds on the resident's legs. Interviews with staff revealed awareness of the error, and the nurse acknowledged forgetting to sanitize due to frequent glove changes.
A resident, dependent on staff for transfers and requiring a sit-to-stand lift, was assisted by a nurse aide in a stand and pivot transfer without the lift, leading to both ending up seated on the bed. The resident had expressed feeling stronger and requested the transfer without the lift, but the nurse aide's actions were deemed unsafe by facility staff.
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 Transcribe Physician Order for Blood Sugar Monitoring
Penalty
Summary
A deficiency occurred when a verbal physician's order for twice daily blood sugar checks was not correctly transcribed into the electronic medical record for a resident admitted with diagnoses including sepsis, diabetes mellitus, failure to thrive, and end stage renal disease requiring hemodialysis. The order, given by the Medical Director, was entered by a nurse who failed to select the appropriate option in the electronic system, resulting in the order not appearing on either the Medication Administration Record or the Treatment Administration Record. As a result, no blood sugar checks were performed during the resident's stay. The resident's care plan identified diabetes mellitus and the risk for related complications, with interventions to monitor for signs and symptoms of hyperglycemia and hypoglycemia. Despite this, a review of the electronic medical record showed no documentation of blood sugar monitoring from admission to discharge. Interviews with facility staff, including the DON and the nurse who entered the order, confirmed the transcription error and lack of blood sugar checks. The Medical Director confirmed the order was given due to the resident's history of low blood sugar episodes prior to admission.
Failure to Effectively Manage Flies and Gnats in Resident Room and Common Area
Penalty
Summary
The facility failed to effectively manage pests, specifically flies and gnats, in at least one resident room and in the conference room. A resident with peripheral vascular disease and venous ulcers, who had moderately impaired cognition, reported seeing flies and gnats in his previous room. His family member confirmed that flies and gnats were present on multiple occasions, leading her to purchase and install a UV insect trap in the room after receiving permission from a previous administrator. The family member stated that the issue was reported to numerous staff members, and another resident who shared the room also reported persistent insect problems, resorting to purchasing spray to address the issue himself. Observations during the survey did not find insects in the room at that time, but staff interviews confirmed the presence of flies and gnats in the past, often attributed to open food and trash left in the room. Nursing and housekeeping staff acknowledged the presence of flies and gnats in the affected room, noting that the residents kept open snacks and trash, which attracted the pests. The wound nurse and nurse aides confirmed that the family had brought in a UV insect trap and that extra cleaning and trash removal were attempted. The Director of Housekeeping reported that the room was cleaned multiple times daily due to ongoing issues with food debris and trash, and she had observed gnats and flies herself. The Maintenance Director stated that he did not keep a log of pest complaints and would address issues as they were reported, but he did not recall being notified about flies or gnats in this particular room. The facility had a contract with a pest control company for monthly treatments, but the pest control representative had no record of complaints about flies or gnats, only treating for rodents and cockroaches during recent visits. Additionally, surveyors observed small winged gnats in the facility conference room during their visit. The new administrator was unaware of any fly or gnat problem prior to the survey but acknowledged that such pests should not be present in resident rooms. The lack of effective pest management and communication regarding pest issues led to ongoing problems with flies and gnats in at least one resident room and a common area, as confirmed by multiple staff, residents, and family members.
Failure to Resume Anticoagulant After Procedure Leads to Adverse Outcome
Penalty
Summary
A facility failed to resume an anticoagulant medication, Eliquis, for a resident with a history of deep vein thrombosis (DVT) and pulmonary embolus after it was temporarily discontinued for a scheduled medical procedure. The resident had been admitted with multiple diagnoses, including atrial fibrillation, type 2 diabetes, urinary retention, and a history of blood clots. Eliquis was discontinued on the instruction of the Nurse Practitioner (NP) prior to a suprapubic catheter placement, and no new order was entered to restart the medication after the procedure. The NP later stated that the electronic health record system required discontinuation rather than holding of medications, and she forgot to re-enter the order to restart Eliquis. The Medical Director and other staff also failed to identify that the medication had not been restarted, despite reviewing the resident's medication records multiple times and documenting that the resident was on Eliquis when he was not. Over the following months, the resident began to exhibit symptoms such as bilateral lower extremity edema, shortness of breath, and required supplemental oxygen. Despite these symptoms and multiple clinical assessments, the omission of Eliquis was not identified until a venous doppler was ordered due to leg swelling, which revealed a non-occluding DVT. Only then did the NP realize that the resident was not on anticoagulation and restarted Eliquis. Shortly after, the resident's condition worsened, leading to increased anxiety, hypoxia, and further clinical decline. The resident was eventually transferred to the hospital, where he was diagnosed with bilateral pulmonary emboli, including a complete occlusion in the right lower lobe, and required a heparin drip and thrombectomy. Throughout this period, documentation and interviews revealed that both the NP and Medical Director repeatedly referenced the resident as being on Eliquis in their notes, despite the medication not being administered. The failure to restart the anticoagulant after the procedure, combined with the lack of detection by multiple clinical staff and the limitations of the electronic health record system, directly led to the resident's adverse clinical outcomes, including hospitalization and invasive intervention for blood clots.
Removal Plan
- Audit of current residents on anticoagulant therapy by running current orders for anticoagulants and reviewing the orders for accuracy to determine whether any changes or adjustments with the anticoagulant were made, and verifying the appropriate administering or discontinuing of the medication as ordered.
- The DON ensures residents have their anticoagulant ordered and administered as required, and verifies that the medication is available in the medication cart.
- Audit of current residents on anticoagulant therapy and residents that had discontinued anticoagulant orders by the DON and the Assistant Director of Nursing (ADON).
- Audit by reviewing the Healthcare Practitioner's progress notes and provider's consultations to identify any other medication that have been discontinued specifically focused on anticoagulant medications and have not been restarted.
- Audit by the DON, ADON and the Pharmacy Consultant.
- If any further concerns are identified from the audit, the Healthcare Practitioner will be notified, and the resident will be evaluated.
- Ensure residents' medications will be administered, discontinued and restarted appropriately.
- Licensed Nurses are re-educated on the importance of ensuring a resident's medication, such as an anticoagulant, that is temporarily discontinued due to a procedure, treatment or hospitalization, has been restarted.
- Licensed Nurse must verify that the medication that the resident was taking prior to being discontinued has been reentered, verified and activated, if still deemed medically necessary.
Failure to Accurately Review and Update Resident Medication List in Progress Notes
Penalty
Summary
Medical providers failed to accurately review and update the total plan of care and medication list for a resident with atrial fibrillation and benign prostatic hyperplasia. The resident was admitted to the facility and had Eliquis, a blood thinner, discontinued prior to a suprapubic catheter placement as ordered by the nurse practitioner. Despite this discontinuation, subsequent nurse practitioner and physician progress notes repeatedly listed Eliquis as an active medication, with each note including a statement that the medication list had been reviewed and that the Medication Administration Record (MAR) should be referenced for an up-to-date list. Multiple progress notes over several weeks continued to include Eliquis on the medication list, even though the medication had not been restarted after the procedure. Addendum clinical clarifications were later electronically signed by the physician, stating that the resident was not taking Eliquis on the dates of the progress notes. Interviews with the nurse practitioner and physician revealed that the medication lists in the progress notes were often carried over from previous notes and may not have accurately reflected current medication orders or changes. Both providers indicated reliance on the MAR for the most accurate medication information. The administrator and DON acknowledged awareness that the medication lists in the progress notes were not always accurate, but were not familiar with the specific process by which the medication list was generated for the notes. The failure to restart Eliquis after the procedure and the continued listing of the medication as active in progress notes were not identified or corrected in a timely manner, resulting in inaccurate documentation of the resident's medication regimen.
Pharmacist Failed to Identify Lapse in Anticoagulant Therapy
Penalty
Summary
The facility's Consultant Pharmacist failed to identify and address a significant lapse in anticoagulant therapy for a resident with a history of atrial fibrillation, type 2 diabetes, and pulmonary embolus. Eliquis, an anticoagulant, was discontinued for a surgical procedure and not resumed for approximately three months. During this period, the Consultant Pharmacist conducted monthly drug regimen reviews but did not recommend restarting the medication or document any follow-up regarding its discontinuation, despite reviewing the resident's medical chart, provider notes, and laboratory results. Interviews with the Consultant Pharmacist, Medical Director, Nurse Practitioner, and Director of Nursing confirmed that the omission of Eliquis from the resident's medication regimen was not identified or addressed in the pharmacy reviews. The Medical Director and facility leadership acknowledged that the monthly pharmacy reviews should have detected the prolonged discontinuation and brought it to the attention of the medical team.
Unclean Dishware and Equipment During Meal Service
Penalty
Summary
The facility failed to ensure that dishware, including divided plates and bowls, were clean for use during a meal service observation. During the lunch meal tray line observation, seven divided plates were found with dried egg particles, and the plate warmer also contained dried egg particles. Additionally, two plastic bowls had dried food particles inside and around them. These observations were confirmed by the Registered Dietitian and the Regional Dietary Manager, who noted that most of the divided plates had crumbs or dried egg particles. Interviews with the Dietary Manager and the Regional Dietary Manager revealed that the facility had a three-step process to ensure dishes were clean before use. This process included checks when dishes were removed from the dishwasher, when they were placed on drying racks or in storage, and when they were moved to the tray line for use. However, the Dietary Aides did not pay close attention to the dishes before placing them on the tray line for meal service. The Administrator expressed that she expected the dishes and equipment to be clean and free of debris and food particles before meal service.
Failure to Administer Oxygen at Prescribed Rates
Penalty
Summary
The facility failed to ensure that oxygen was delivered at the prescribed rate for two residents, leading to deficiencies in respiratory care. Resident #41, who was admitted with chronic respiratory failure and hypoxia, had a physician's order for oxygen at 3 liters per minute via nasal cannula. However, observations over several days revealed that the oxygen concentrator was set at 4 liters per minute. Interviews with nursing staff indicated a lack of adherence to the physician's order, as the nursing assistant did not adjust oxygen settings, and the nurse on duty did not verify the flow rate against the physician's order. The Director of Nursing acknowledged the discrepancy and stated that the nursing staff should have ensured the correct flow rate. Resident #101, diagnosed with congestive heart failure and respiratory failure, had a physician's order for oxygen at 3 liters per minute. Observations showed that the oxygen concentrator was set at 1.5 liters per minute, which was below the prescribed rate. The resident, who had severely impaired cognition, was unable to adjust the oxygen settings independently. Interviews with the assigned nurse revealed that the nurse did not check the oxygen flow rate during the observed days. The Director of Nursing confirmed that the resident could not change the settings and expected the nursing staff to provide oxygen at the prescribed rate. Both residents were observed to have incorrect oxygen flow rates over multiple days, indicating a failure by the facility to follow physician orders for oxygen administration. The Director of Nursing and the Administrator both expressed expectations that staff should adhere to physician orders for oxygen settings. The Physician Assistant reiterated the necessity of following prescribed oxygen flow rates for residents receiving supplemental oxygen.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to properly manage medications in the South Hall Medication Room and for a resident. During an observation, an expired bottle of Red [NAME] Oil, an omega-3 vitamin, was found in the medication storage room. The Director of Nursing (DON) confirmed the expiration date and acknowledged that expired medications should not be present in the storage room or medication carts. The DON stated that nursing staff are responsible for weekly checks to ensure expired medications are discarded, indicating a lapse in this protocol. Additionally, a resident was found to have a lidded container of prescription topical medicated cream for fungal infections on their bedside table. The resident, who was cognitively intact but had intermittent confusion, had been applying the cream independently without staff knowledge. The cream was not prescribed in-house, and the facility was unaware of its presence until it was observed by Unit Manager #1. The medicated cream had an expiration date of January 2024, and the Medical Director confirmed it was not appropriate for the resident to self-administer. The facility's policy requires a physician's order for medications to be kept at a resident's bedside, which was not obtained in this case.
Failure to Follow Hand Hygiene Policy During Wound Care
Penalty
Summary
The facility failed to adhere to its Hand Hygiene policy during wound care for a resident, as observed with the Treatment Nurse. The nurse did not perform hand hygiene before donning clean gloves multiple times while treating wounds on the resident's legs. Specifically, after removing gloves, the nurse did not sanitize her hands before putting on a new pair of gloves, which is a requirement according to the facility's infection control policy. This lapse in protocol was noted during the treatment of wounds on both the right and left legs of the resident. Interviews with the Treatment Nurse, Infection Preventionist, Director of Nursing, and Administrator revealed awareness of the errors made during the wound care procedure. The Treatment Nurse acknowledged forgetting to sanitize her hands due to the frequent glove changes required during the procedure. The Infection Preventionist and Director of Nursing both expressed that the expectation was for the nurse to sanitize her hands after each glove removal and before donning new gloves. The Administrator confirmed that the nurse was expected to follow the Hand Hygiene policy, and it was noted that the nurse had performed another dressing change without errors subsequently.
Unsafe Transfer of Resident Without Required Equipment
Penalty
Summary
The facility failed to provide a safe transfer for a resident who was dependent on staff for transfers. The resident, who was cognitively intact and had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes, required two-person assistance using a sit-to-stand lift for all transfers. On the evening of the incident, a nurse aide assisted the resident in a stand and pivot transfer without using the required lift, as the resident expressed feeling stronger and requested to transfer without the lift. During the transfer, the resident's legs became weak, and both the resident and the nurse aide ended up seated on the bed without injury. Interviews with the nurse aide, the nurse, the Director of Nursing, and the Administrator confirmed that the transfer method used was unsafe and not in accordance with the resident's care plan. The nurse aide acknowledged that she should have used the sit-to-stand lift despite the resident's request. The Director of Nursing and the Administrator both stated that the nurse aide's actions were not safe and that the sit-to-stand lift should have been used to ensure the resident's safety during the transfer.
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.
