Willow Creek Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Goldsboro, North Carolina.
- Location
- 2401 Wayne Memorial Drive, Goldsboro, North Carolina 27534
- CMS Provider Number
- 345113
- Inspections on file
- 25
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Willow Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that food items in the walk-in cooler, including a container of pudding and a pan of turkey sandwiches, were stored without labels or dates. The Dietary Manager reported that these items were not present before the weekend and must have been prepared and stored during that time, but the exact timing could not be determined due to missing labels and dates. She stated that she and the Assistant Dietary Manager monitor for unlabeled items during the week, but no one is assigned this responsibility on weekends, and that staff who place food in the cooler are responsible for labeling and dating it. The Administrator confirmed that there should be no unlabeled or undated food items in the walk-in cooler.
Surveyors identified that the facility failed to maintain clean and properly maintained privacy curtains, medical equipment, and walls in several rooms occupied by severely cognitively impaired residents. In one room, a privacy curtain remained in use despite multiple dark brown/red stains, even though the assigned housekeeper was responsible for replacing soiled curtains. In another room, an oxygen concentrator had visible white particles on its surface on repeated observations, despite a housekeeping schedule that required weekly cleaning and additional cleaning when dirty. In a third room, blood-like drips were present on a wall where a resident’s scabbed knee rested; the NA reported the wall had not been cleaned for at least two weeks and did not notify housekeeping, and the housekeeper stated she only noticed and cleaned the stains the day before the interview.
A resident with dementia, ESRD on HD, diabetes, and anticoagulant therapy was care-planned as totally dependent for transfers and required a mechanical lift. After returning from HD and repeatedly requesting to go to bed, a NA, unable to access a charged lift, attempted a stand-pivot transfer despite knowing a lift was required. The resident’s legs gave out, resulting in an assisted fall to the floor; the NA then lifted the resident back into a wheelchair and later, with another NA and a medication aide, manually transferred the resident to bed without notifying an RN/LPN or obtaining a nurse assessment. Only after the transfer and onset of right shoulder pain was the unit manager notified, and later that evening a nurse identified a large, painful chest wall swelling that led to hospital evaluation and diagnosis of a large right chest wall hematoma with active bleeding.
A resident who was totally dependent for transfers and required a mechanical lift per the care guide returned from dialysis, requested to go to bed due to pain and fatigue, and was assisted by a CNA who found nearby lifts uncharged. Despite knowing a lift was required, the CNA attempted a stand-pivot transfer without a lift, during which the resident’s legs gave out and she was lowered to the floor. Without notifying a nurse, the CNA manually lifted the resident from the floor back into a wheelchair and later, with another CNA and a medication aide, manually lifted the resident from the wheelchair to the bed, again without a lift, while the resident was slumped and at risk of falling. After these transfers, the resident complained of right shoulder pain and was later found to have a large, painful chest wall swelling; hospital evaluation identified a large right chest wall hematoma with active arterial bleeding, and the Medical Director indicated the injury was more likely related to how the resident was transferred than to the assisted fall itself.
A resident was transported to the hospital and admitted for an intestinal obstruction without the responsible party being notified by the facility. The resident, who was moderately cognitively impaired, requested transport to the emergency room. Despite receiving a status update from the hospital, the facility staff failed to inform the responsible party, who only learned of the situation from the hospital social worker.
A resident with a history of falls and recent fall incidents did not have a comprehensive care plan addressing fall risk. The MDS nurse acknowledged the oversight, and both the DON and Administrator were unaware of the missing care plan.
Two residents in the facility did not receive their prescribed Ozempic injections due to the medication being unavailable on multiple occasions. Despite the missing doses, the physician and nursing staff reported no negative outcomes for the residents. The facility's Director of Nursing emphasized the importance of administering medications as prescribed.
A nurse in an LTC facility failed to follow infection control procedures during tracheostomy care for a resident with chronic respiratory failure. The nurse did not perform hand hygiene between glove changes, used contaminated sterile gloves, and utilized a dropped q-tip to clean the tracheostomy site. The resident required complete assistance with daily living activities, including tracheostomy care, and was at risk for ineffective breathing patterns.
A nurse in an LTC facility failed to perform tracheostomy care using proper sterile techniques, as observed during a survey. The nurse did not perform hand hygiene between glove changes and used a dropped q-tip to clean around the tracheostomy stoma. Discrepancies were found in the training provided, as the nurse claimed she was not trained until after the observation, contrary to the facility's statements.
A resident with a history of hemiplegia and back surgery experienced discomfort due to a sagging mattress. Despite a work order and staff awareness, the mattress was not replaced, leading to continued discomfort. Observations confirmed the mattress's poor condition, but the facility failed to take timely action.
Two residents in an LTC facility did not receive their prescribed Ozempic medication due to it being documented as unavailable on multiple occasions. Despite the pharmacy delivering the medication, it was reported as lost, and the facility had to reorder it at their own expense. The facility's investigation revealed discrepancies in medication administration records and packing slips, indicating potential misappropriation or misplacement of the medication.
A resident with impaired vision was mistakenly given ear drops in her eyes by a nurse in orientation, leading to a significant medication error. Despite the resident's concerns about blurry vision, medical evaluations determined the ear drops did not cause vision changes. The facility's investigation involved staff interviews and education on proper medication administration routes.
Unlabeled and Undated Food Items Stored in Walk-In Cooler
Penalty
Summary
Surveyors observed that the facility failed to label or date food items stored in the walk-in cooler, contrary to professional standards and facility expectations. During a kitchen tour, an unlabeled and undated rectangular metal container covered with plastic wrap was found to contain approximately 10 ounces of pudding, and an additional unlabeled and undated metal sheet pan covered with aluminum foil was found to contain about 20 turkey sandwiches. The Dietary Manager stated that when she left at 4:00 PM on the preceding Friday, neither the pudding nor the sandwiches were present in the cooler and that they must have been prepared and placed there over the weekend, but she could not determine exactly when due to the lack of labels and dates. She reported that she and the Assistant Dietary Manager monitored the walk-in cooler for unlabeled or undated food items during the week, but no one was designated to perform this monitoring on weekends, and that whoever placed food in the cooler was responsible for labeling and dating it. The Administrator confirmed in an interview that there should be no unlabeled or undated food items in the walk-in cooler. No specific residents or their medical conditions were mentioned in the report, and the deficiency was described as having the potential to affect food served to residents.
Failure to Maintain Clean Curtains, Equipment, and Walls in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and comfortable environment in multiple resident rooms. In one room on the 300 hall, a severely cognitively impaired resident’s privacy curtain closest to the window was observed on two separate dates with multiple dark brown/red stains. The assigned housekeeper, who was responsible for replacing soiled or stained privacy curtains, acknowledged that the curtain needed to be changed but could not explain why it had not been replaced earlier in the week. The Housekeeping Manager stated that housekeepers were responsible for changing curtains when soiled or stained and agreed that the curtain should have been changed as soon as the markings were noticed. In another room on the 200 hall, a severely cognitively impaired resident’s oxygen concentrator was observed on two separate dates with visible white particles all over the top surface. The housekeeper assigned to that room confirmed that it was her responsibility to wipe down oxygen concentrators in resident rooms and acknowledged that she had not noticed that the concentrator needed to be cleaned prior to the surveyor’s observation. The Housekeeping Manager reported that oxygen concentrators and other medical equipment in resident rooms were supposed to be cleaned weekly and additionally whenever dirty, dusty, or soiled, and that this concentrator should have been cleaned during the scheduled cleaning. In a third room on the 200 hall, a severely cognitively impaired resident was observed lying in bed with his left knee bent and resting on the wall, where dark red marks in a dripping pattern were present. A nurse aide identified the drippings as blood and showed the resident’s knee with three scabbed areas, stating that the wall had not been cleaned since she started working at the facility two weeks earlier. She did not notify housekeeping about the blood stains and could not provide a reason, stating she “just did not think about it.” The housekeeper later reported that she only noticed and cleaned the dark red marks on the wall the day before the interview, and the Housekeeping Manager stated that daily room cleaning was expected to include wiping down vertical and horizontal surfaces, including walls, and that the stains should have been noticed and cleaned during routine cleaning.
Failure to Follow Fall Protocol and Transfer Requirements After Assisted Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow fall protocol and the resident’s care plan by not notifying a nurse immediately after an assisted fall and by moving the resident before a licensed nurse assessment. The resident involved had dementia, ESRD on hemodialysis, diabetes, portal vein thrombosis treated with Eliquis, and an aneurysm of the upper extremity artery. Her MDS and care plan specified that she was totally dependent for transfers and required a one-person mechanical lift with a medium sling for all transfers. On the day of the incident, the resident returned from dialysis, ate lunch, and repeatedly requested to be put to bed due to feeling tired and hurting, which staff reported was usual after dialysis. Around mid-afternoon, NA #1 went to transfer the resident to bed. NA #1 knew from the Resident Care Guide that a mechanical lift was required but found that the two lifts on her section were not charged and unavailable. Despite this and the resident’s insistence on going to bed, NA #1 attempted a stand-pivot transfer from the wheelchair to the bed without a lift. During this attempt, the resident’s legs gave out, she panicked, and NA #1 lowered her to the floor. NA #1 then independently lifted the resident from the floor back into the wheelchair, where the resident appeared slumped, and adjusted her upright. NA #1 did not notify a nurse at the time of the assisted fall and did not obtain a nurse assessment before moving the resident from the floor to the wheelchair. Shortly thereafter, NA #1 called NA #2 and the Medication Aide to help transfer the resident from the wheelchair to the bed but did not inform them that an assisted fall had occurred. All three staff lifted the resident from the wheelchair to the bed using manual assistance. The Medication Aide later stated she did not call a nurse because she had not witnessed a fall and only saw the resident slumped in the wheelchair. After the transfer to bed, the resident complained of right shoulder pain and requested pain medication, which was administered. The Unit Manager was then notified and, upon arrival, found the resident already in bed, reporting 10/10 right shoulder pain. The Unit Manager and DON later confirmed that facility protocol required that residents not be moved after a fall until a licensed nurse assessed them, and that NA #1, NA #2, and the Medication Aide should not have transferred the resident before that assessment. Later that evening, another nurse noted a large, painful swelling on the resident’s right upper chest, and the resident was sent to the ED, where imaging showed a large right chest wall hematoma with active bleeding.
Failure to Use Required Mechanical Lift and Report Assisted Fall Leads to Hematoma After Manual Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistive devices were used during transfers, as required by the resident’s care plan and Resident Care Guide. The resident had dementia, ESRD on hemodialysis, diabetes, was cognitively intact, and was totally dependent on staff for transfers. Her care plan and Resident Care Guide, implemented and revised prior to the incident, specified that she required a one-person assist with a mechanical lift for all transfers, with a medium sling. She was also receiving Eliquis, an anticoagulant that increases the risk of bruising and bleeding, and had an as-needed order for oxycodone for pain. On the day of the incident, the resident returned from dialysis around midday, ate lunch, and requested to be put to bed because she was tired and hurting, which staff reported was usual for her after dialysis. Nursing Assistant (NA) #1, who was passing meal trays, told the resident she would assist after meal service. When NA #1 later attempted to retrieve a mechanical lift, she found that the two lifts in her assigned section did not have any charge. NA #1 informed the resident she would have to wait longer because the lifts were not available, but the resident was adamant about being transferred to bed immediately. Around 2:45 PM, despite knowing from the Resident Care Guide that the resident required a mechanical lift for all transfers, NA #1 decided to accommodate the request and attempted a stand-pivot transfer from the wheelchair to the bed without using a lift. During this attempted manual transfer, the resident’s legs gave out, she began to panic, and she put her full weight on NA #1, who then lowered her to the floor. NA #1 did not notify a nurse at that time and, instead of leaving the resident on the floor for assessment, manually lifted her from the floor back into the wheelchair by placing her arms under the resident’s arms and her knees against the resident’s knees. The resident appeared slumped in the wheelchair, and NA #1 pulled her more upright. NA #1 then called for help without disclosing the assisted fall. NA #2 and the Medication Aide responded; seeing the resident slumped and appearing at risk of falling from the wheelchair, they, together with NA #1, manually lifted the resident from the wheelchair to the bed without a mechanical lift, with two staff at the upper body and one at the legs. After being placed in bed, the resident complained of right shoulder pain and requested pain medication. Later that evening, a large, painful swelling was observed on the right upper chest, and hospital evaluation documented a large, tense right chest wall hematoma with active bleeding, ultimately diagnosed as an arterial hemorrhage requiring interventional radiology embolization and subsequent surgical hematoma evacuation. The Medical Director stated that the hematoma more likely resulted from how the resident was transferred, including pressure applied under the armpits, rather than from the fall itself.
Failure to Notify Responsible Party of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the responsible party (RP) of a significant change in a resident's condition, which included transport and admission to the hospital. The resident, who was initially cognitively intact upon admission, was later assessed as moderately cognitively impaired with a diagnosis of delirium. On the night of the incident, the resident requested to be transported to the emergency room and was subsequently admitted to the hospital for an intestinal obstruction. Despite this significant change, the RP was not informed by the facility and only learned of the situation from the hospital social worker two days later. Interviews with facility staff revealed a breakdown in communication and responsibility. Nurse #1, who was responsible for the resident's discharge to the hospital, did not notify the RP, and Nurse #2, who later received a status update from the hospital, also did not inform the RP, assuming it was Nurse #1's responsibility. The facility's Director of Nursing and Administrator acknowledged the oversight, indicating that the hall nurse should have notified the RP of the resident's transport and hospital admission.
Failure to Develop Comprehensive Fall Risk Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing fall risk for a resident who was admitted with a history of falling, unspecified fracture of the lower end of the left radius, and unspecified dementia. A review of the resident's Minimum Data Set (MDS) indicated a fall in the previous 30 days, yet the comprehensive care plan lacked a section on fall risk. During an interview, the MDS nurse acknowledged the absence of a falls risk care plan, attributing it to an oversight. The Director of Nursing (DON) confirmed that the MDS nurse was responsible for developing comprehensive care plans and was unaware of the missing falls risk care plan. The Administrator also stated she was not aware of the deficiency.
Medication Administration Errors for Ozempic
Penalty
Summary
The facility failed to ensure that two residents received their prescribed Ozempic subcutaneous injections as ordered, resulting in medication errors. Resident #116, who was admitted with a diagnosis of diabetes mellitus, had orders for Ozempic to be administered weekly. However, the Medication Administration Record (MAR) indicated that the medication was not available on multiple occasions, specifically on 4/30/24, 5/7/24, and 5/14/24. Interviews with the nursing staff revealed that they did not recall the incidents but mentioned standard procedures for handling unavailable medications, such as contacting the physician and pharmacy. The pharmacist confirmed that the Ozempic pen dispensed for Resident #116 was reported lost by the facility, and a replacement was provided on 5/15/24. Similarly, Resident #163, also diagnosed with diabetes mellitus, had orders for Ozempic to be administered weekly. The MAR showed that the medication was unavailable on 4/24/24, 5/1/24, 5/8/24, and 5/15/24. Interviews with the nursing staff involved indicated a lack of recollection of the specific incidents but outlined the usual protocol for addressing unavailable medications. The pharmacist reported that the Ozempic pen dispensed for Resident #163 was also reported lost, and a replacement was provided on 5/16/24. The physician involved was aware of the missing Ozempic pens and noted that while the medication was not critical for daily blood sugar control, it was important for stabilizing hemoglobin A1C over time. Despite the medication errors, the physician and nursing staff reported no negative outcomes for the residents due to the lack of Ozempic. The Director of Nursing emphasized that medications should be administered as prescribed, highlighting the facility's expectation for adherence to medication orders.
Infection Control Breach in Tracheostomy Care
Penalty
Summary
The facility failed to adhere to professional standards of practice and infection prevention measures during the provision of respiratory care to a resident with a tracheostomy. The incident involved a nurse who did not perform hand hygiene between the removal of soiled gloves and the application of sterile gloves. Additionally, the nurse touched the outside of the tracheostomy packaging with sterile gloves and did not change them, and used a sterile q-tip that had been dropped onto the resident's nightgown to clean the tracheostomy site. The nurse also contaminated the new sterile inner cannula by touching it with gloves that had contacted the outside of the tracheostomy tray. The resident involved was admitted with acute and chronic respiratory failure with hypoxia, a history of neoplasm of the nasal cavity and mid ear, and a chronic tracheostomy. The resident was cognitively intact and required complete assistance with all activities of daily living, including tracheostomy care. The care plan indicated a risk for ineffective breathing patterns related to the tracheostomy. Interviews with the nurse, the Staff Development Coordinator, the Director of Nursing, the Administrator, the infection preventionist, and the Nurse Practitioner revealed a lack of adherence to infection control procedures. The nurse acknowledged the errors and the importance of maintaining sterile technique to prevent respiratory infections. The facility staff emphasized the necessity of hand hygiene and proper glove use to prevent contamination during tracheostomy care.
Nurse Competency Deficiency in Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a nurse was competent in providing tracheostomy care for a resident. During an observation, Nurse #4, who was an agency nurse, performed tracheostomy care without adhering to proper sterile techniques. She donned sterile gloves without performing hand hygiene after removing soiled gloves, touched the outside of the tracheostomy care tray with sterile gloves, and used a q-tip that had been dropped on the resident's clothing to clean around the tracheostomy stoma. Additionally, she opened the inner cannula package with sterile gloves, which compromised the sterility of the procedure. Interviews revealed discrepancies in the training provided to Nurse #4. The Staff Development Coordinator (SDC) claimed to have completed hands-on tracheostomy training with all nurses, including Nurse #4, before they worked with the resident. However, Nurse #4 stated that she did not receive this training until after the observation. The Director of Nursing and the Administrator also stated that new nurses, including agency nurses, were trained on tracheostomy care before working with the resident, but this was contradicted by Nurse #4's account.
Failure to Replace Damaged Mattress
Penalty
Summary
The facility failed to replace a damaged bed mattress for a resident, leading to discomfort and potential exacerbation of existing medical conditions. The resident, who was cognitively intact and had a history of right-sided hemiplegia, neuropathy, and back surgery, reported feeling like he was lying in a hole due to the sagging mattress. Despite a work order being placed by a medication aide, the mattress was not replaced with a new one, and the resident continued to experience discomfort. Interviews with staff revealed a breakdown in communication and follow-through regarding the replacement of the mattress. The maintenance assistant referred the work order to the central supply manager, who claimed to replace old mattresses if they were in poor condition. However, the central supply manager did not recall replacing the mattress for the resident, and the maintenance director confirmed that the work order was marked as completed without a new mattress being provided. Observations confirmed the poor condition of the mattress, with visible sagging and wear. The resident's family member and a nurse also noted the mattress's poor condition, and the nurse stated that it should be replaced. Despite these observations and complaints, the facility did not take timely action to address the resident's concerns, resulting in the resident sleeping on an uncomfortable and potentially harmful mattress for an extended period.
Misappropriation of Diabetes Medication in LTC Facility
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their medication, specifically Ozempic, which is used to manage diabetes mellitus. Resident #116 was prescribed Ozempic to be administered once a week, but the medication was documented as unavailable on multiple occasions, including 4/23/24, 4/30/24, 5/7/24, and 5/14/24. Despite the pharmacy delivering the medication, it was reported as lost, and the facility had to reorder it at their own expense. Interviews with nursing staff revealed a lack of recollection regarding the incidents, and the facility's initial response did not identify the issue as misappropriation. Similarly, Resident #163 experienced a similar issue with their Ozempic medication. The medication was documented as unavailable on 4/24/24, 5/1/24, 5/8/24, and 5/15/24, despite being delivered by the pharmacy. The facility's investigation revealed discrepancies in the medication administration records and packing slips, indicating that the medication was not administered as prescribed. The facility was unable to determine the location of the missing medication, leading to the conclusion that it was either misplaced or misappropriated. The facility's failure to ensure the availability and administration of prescribed medications resulted in a deficiency related to the misappropriation of resident property. The investigation highlighted issues with the facility's medication management processes, including inadequate tracking and documentation of medication availability and administration. The facility's inability to substantiate the misappropriation of the medication further underscores the need for improved oversight and accountability in medication handling and administration.
Medication Error: Ear Drops Administered in Eyes
Penalty
Summary
The facility failed to ensure that ear drop medication was administered via the correct route, resulting in a significant medication error for a resident. The resident, who was cognitively intact but had impaired vision, was mistakenly given ear drops in her eyes by a nurse who was still in her orientation period. The nurse, while orienting with another nurse, brought both eye and ear drops into the resident's room and handed the ear drops to the resident, who then administered them into her eyes. Despite attempts to stop the resident, the medication had already been administered incorrectly. The incident was reported to the Director of Nursing (DON) and the resident's physician, who instructed that the resident's eyes be flushed with saline. The resident expressed concern about the incident, reporting blurry vision afterward, although two separate eye examinations concluded that the ear drops did not cause any vision changes. The resident was dissatisfied with the explanations provided by the medical professionals and believed the blurry vision was a result of the medication error. Interviews with the involved staff revealed discrepancies in their accounts of the incident. The nurse who administered the medication denied the error, while another nurse observed the administration but could not confirm which drops were used. The facility's consultant pharmacist and the resident's physician both indicated that the ear drops could cause mild irritation but not lasting vision damage. The facility's investigation did not identify a trend of incorrect ear drop administration, and education was provided to the involved nurse regarding proper medication administration routes.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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