Willow Ridge Of Nc
Inspection history, citations, penalties and survey trends for this long-term care facility in Rutherfordton, North Carolina.
- Location
- 237 Tryon Road, Rutherfordton, North Carolina 28139
- CMS Provider Number
- 345197
- Inspections on file
- 30
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Willow Ridge Of Nc during CMS and state inspections, most recent first.
Surveyors found that the facility developed standardized care plans for intimate relationships and sexual activity for several severely cognitively impaired residents, documenting that they wished to have intimate relationships and that responsible parties or family had consented. These care plans included goals about meeting sexual choices/preferences and interventions such as staff education on safe sex practices, provision of private areas for consensual intimate activities, and use of door signage for privacy. However, staff interviews revealed that these residents only held hands, hugged, or danced and did not engage in sexual contact, and that the intimate-relations focus areas were added based on corporate instruction rather than individualized assessment. The DON and Administrator acknowledged that care plans should be individualized and accurate, but the written plans did not reflect the residents’ actual behaviors or their severe cognitive impairment.
Staff failed to protect resident privacy when they entered rooms without knocking, announcing themselves, or waiting for permission, despite residents being cognitively able to grant or deny entry. Two residents reported that staff routinely came into their rooms without knocking, causing them to feel angry, disrespected, and deprived of privacy. During observations behind fully closed doors, a nurse and a NA each opened a resident’s door and entered unannounced. In interviews, both staff members acknowledged they knew from residents’ rights training that they were required to knock and wait for permission, but one stated he did not realize he had failed to knock and the other stated he sometimes forgot when in a hurry. The DON and Administrator confirmed their expectation that all staff knock, announce themselves, and wait for permission before entering.
A resident was admitted with documented bipolar disorder, dementia, and other medical conditions, and was prescribed multiple antidepressant and psychotropic medications. A Level I PASRR completed before admission instructed that paperwork be resubmitted for a Level II PASRR if a mental health diagnosis was suspected or if there was a significant change, and the admission MDS listed bipolar disorder as an active diagnosis. Psychiatry notes and the care plan reflected ongoing treatment and monitoring for bipolar disorder, yet the SW Director only submitted Level I PASRR paperwork and did not include supporting psychiatric or medical documentation. No Level II PASRR request was ever submitted, and facility leadership later acknowledged that a Level II PASRR evaluation should have been completed but was not.
A resident with Alzheimer’s disease and identified nutritional risk experienced significant weight loss while on a mechanically altered, therapeutic diet. An RD and physician initially ordered a fortified nutritional shake BID, which was later discontinued after some weight gain. As the resident’s weight continued to decline, the RD repeatedly documented that the resident was receiving the fortified shake and recommended its continuation and later an increase to TID. However, MAR reviews over several months showed no active orders for the supplement, and interviews revealed that staff assumed the RD, DON, or unit coordinators would enter supplement orders based on risk meeting discussions but did not verify that orders were actually in place. This breakdown in communication and order entry resulted in the resident not receiving the prescribed fortified nutritional shake despite ongoing documented weight loss.
A resident with atrial fibrillation and heart failure, cognitively intact and needing assistance with ADLs, had long, jagged toenails and brown discoloration of the right great toenail that were not addressed by staff. Nursing assessments and the EMR contained no documentation of toenail issues, offers of toenail care, podiatry referrals, or refusals, even though a NA and a nurse both noticed the long, discolored nails and did not report, document, or act on these findings. The resident stated he had repeatedly requested toenail trimming, had not refused such care, and believed a podiatry visit had been promised but never arranged. Review of podiatry schedules showed the resident was not listed, and there were no podiatry consults or visit notes, while leadership acknowledged awareness of the toenail problem without corresponding documentation of care or refusals.
A cognitively impaired male resident with a history of sexualized behaviors was found on top of a female resident in her bed, and later entered another room, allegedly getting on top of a cognitively intact resident. Despite being on one-to-one supervision, the male resident was left unattended, leading to these incidents. The facility failed to protect residents from abuse due to inadequate supervision and monitoring.
A resident with a history of traumatic brain injury and behavioral issues was sent to a hospital for a psychiatric evaluation. Despite being cleared for discharge after three days, the resident remained in the hospital for over a month due to the facility's refusal to readmit him. The facility's Administrator and DON had initially planned to transfer the resident to another facility, but when that fell through, they sent him to a hospital in South Carolina. Multiple attempts by the hospital and the resident's guardian to facilitate his return were unsuccessful until the State Agency intervened.
Three residents in the facility were unable to access their light switches due to broken cords, causing inconvenience and reliance on staff assistance. Despite observations and interviews confirming the issue, nursing staff were initially unaware, and maintenance had not addressed the problem. The residents had varying levels of cognitive and physical impairments, exacerbating the impact of the inaccessible switches.
The facility failed to complete the CAAS of the MDS comprehensively for two residents, leading to deficiencies in addressing the underlying causes and contributing factors of triggered care areas. One resident had six out of eight triggered areas inadequately analyzed, while another had all five triggered areas lacking comprehensive analysis. The MDS Coordinator confirmed the omissions, and both the Administrator and DON expected comprehensive completion of the CAAS.
A Consultant Pharmacist failed to identify a drug irregularity for a resident with anxiety disorder, who had an active PRN Ativan order without a stop date. The Medical Director did not include stop dates in his orders and was unaware of the 14-day duration requirement for PRN psychotropic medications. The oversight was noted during a survey, as the Consultant Pharmacist did not report the irregularity despite conducting medication regimen reviews.
A facility failed to ensure a PRN psychotropic medication order for a resident with anxiety disorder was time-limited and included a rationale for extended therapy. The order for Ativan lacked a stop date, and staff interviews revealed a lack of awareness regarding policy adherence. The Medical Director did not include stop dates and was unaware of the 14-day requirement for PRN psychotropic medications.
A resident with severely impaired cognition was found with an unsecured tube of zinc oxide paste in their room. The paste, which should have been stored in the medication cart, was left unattended on the bedside table. Nursing staff did not notice the paste during their rounds, and the Director of Nursing suggested it might have been brought in by the resident's daughter. The facility's protocol for securing medications was not followed.
A resident was transferred to a hospital in South Carolina for psychiatric evaluation without prior notification to their legal guardian. The facility administrator informed the guardian only after the transfer, citing the need for a geriatric psych unit not available locally.
The facility failed to report an allegation of resident-to-resident abuse to the State Agency, law enforcement, and APS within the required timeframe and did not ensure the report included accurate information. A male resident entered a female resident's room, sat on her bed, and left. Initial reports to law enforcement did not include all details, such as the male resident removing his pants and getting on top of the female resident. The facility's investigation concluded no willful intent or evidence of sexual intercourse, and APS decided not to follow up.
A facility failed to thoroughly investigate an alleged resident-to-resident abuse incident involving a cognitively intact resident and a severely cognitively impaired resident. The investigation lacked a statement from the impaired resident and proper assessments for both involved residents. The Administrator retyped staff statements for clarity but did not retain originals, and the Director of Nursing did not perform a comprehensive physical assessment on the alleged victim.
A resident was transferred to a hospital for psychiatric evaluation without written notification to their legal guardian. The facility informed the guardian by phone but failed to provide the required written notice, as confirmed by interviews with the guardian and Administrator.
The facility failed to post daily nurse staffing information in a location accessible to residents. Observations showed the posting was in a locked lobby, requiring staff assistance for resident access. Interviews with the Scheduler, DON, and Administrator confirmed the posting's location and acknowledged its inaccessibility.
Inaccurate Intimate-Relations Care Plans for Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop accurate, individualized comprehensive care plans for several cognitively impaired residents, specifically related to intimate relationships and sexual activity. Record review showed that four residents with diagnoses including Alzheimer’s disease, unspecified dementia, and neurocognitive disorder with Lewy bodies were all assessed as severely cognitively impaired on their quarterly MDS assessments. Some of these residents also exhibited behaviors such as verbal aggression, rejection of care, and wandering. Despite this, each of these residents had an active care plan focus area indicating a desire for an intimate relationship with a consenting resident partner, with documentation that responsible parties or family had given consent for such relationships. The care plans for these residents included goals stating that the residents would have their psychosocial needs and sexual choices/preferences met with dignity and privacy. Interventions listed in the care plans directed nursing staff to provide education in safe sex practices, including sexually transmitted infection prevention and hygiene, to ensure signage on doors to private areas used for intimate activity to maintain privacy and dignity, and to provide private areas for consensual intimate activities upon request. These interventions were written as if the residents were engaging in or planning to engage in sexual activity and were able to consent to such activity, despite their severe cognitive impairment documented on the MDS. Staff interviews further clarified that the actual resident behaviors did not match the written care plans. The Memory Care Unit Coordinator stated that residents on the secured memory care unit held hands, hugged, and danced, but that no residents engaged in sexual contact. The MDS Nurse reported that she completed the intimate relations care plan focus areas based on corporate instruction and understood that the residents only held hands or danced together, not that they engaged in sexual behaviors; she also stated she did not question whether these care plans were appropriate for the residents involved. The DON and Administrator both acknowledged that care plans should be individualized, accurate, appropriate, and up to date, and the DON explained that the care plans were implemented because responsible parties had given consent for residents to hold hands, hug, and dance, while confirming that no sexual activity occurred between residents. This mismatch between documented care plan goals/interventions and the residents’ actual conditions and behaviors led to the cited deficiency.
Failure to Knock and Obtain Permission Before Entering Resident Rooms
Penalty
Summary
The deficiency involves staff failing to protect residents’ personal privacy by not knocking, announcing themselves, and waiting for permission before entering resident rooms. One cognitively intact resident, admitted on an unspecified date, reported that staff routinely entered his room without knocking, or gave only a single knock while already entering, without announcing themselves or waiting for his permission, regardless of whether the door was open or closed. He stated that this made him very angry, that he had repeatedly asked staff to knock before entering, and that he had given up on having any privacy and felt like a prisoner with no rights. While an observation was conducted with this resident in his room behind a fully closed door, a nurse opened the door and entered without knocking or announcing himself. In a subsequent interview, this nurse acknowledged he did not realize he had entered without knocking, and stated he knew from annual residents’ rights education that he was required to knock and wait for permission from cognitively able residents. Another resident, assessed as moderately cognitively intact, also experienced staff entering his room without knocking. During an observation conducted while sitting with this resident in his room behind a fully closed door, a nurse aide opened the door and entered unannounced. The resident reacted by smacking the mattress, asking the aide what he was doing, pounding his fist on his leg, and repeatedly telling the aide to knock on the door. In an interview, this resident reported that staff never knocked before entering, that this made him feel like a child, and that staff had no respect for him, which made him angry. In a later interview, the nurse aide stated he knew he was supposed to knock before entering a resident’s room and had received training on residents’ rights, including the requirement to knock and wait for permission when residents are able to grant it, but admitted that when he was in a hurry, he forgot to knock. The DON and Administrator both stated in interviews that their expectation, consistent with residents’ rights training, was that staff knock, announce themselves, and wait for permission before entering resident rooms.
Failure to Obtain Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The deficiency involves the facility’s failure to submit a required Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a serious mental illness diagnosis. The resident was admitted with documented diagnoses including bipolar disorder, dementia, hypertension, heart failure, and diabetes mellitus. A Level I PASRR had been completed prior to admission with instructions to resubmit paperwork for a Level II PASRR if a mental health diagnosis was suspected or if there was a significant change in condition. The admission MDS assessment identified bipolar disorder as an active diagnosis and documented that the resident had not been evaluated by a Level II PASRR, despite being on multiple antidepressant and psychotropic medications. Hospital discharge records listed bipolar disorder as a diagnosis and included prescriptions for bupropion XL, duloxetine, rivastigmine, and trazodone, which were continued after admission. Psychiatry notes from the facility’s Psychiatric NP documented ongoing treatment and monitoring for bipolar disorder and dementia, with continued psychiatric oversight deemed medically necessary due to chronic psychiatric illness and the need for structured monitoring. The resident’s care plan included focus areas for antidepressant use related to bipolar disorder and insomnia, as well as a mood problem related to bipolar disorder, with interventions such as administering medications as ordered, monitoring for side effects and effectiveness, and behavioral health consults as needed. Despite these documented mental health diagnoses, medications, and ongoing psychiatric management, there was no evidence in the medical record that a Level II PASRR request was ever submitted. The Social Work Director, who was responsible for PASRR paperwork, reported that he had submitted paperwork only for a Level I PASRR and did not include psychiatric or medical progress notes or a signed FL2 form. The facility received a letter stating that the existing Level I PASRR could be used until it expired, but no expiration date was provided, and no further action was taken to obtain a Level II PASRR. Both the Social Work Director and the Administrator later acknowledged that, based on the resident’s bipolar disorder diagnosis, a Level II PASRR evaluation should have been completed, but it was not submitted.
Failure to Implement RD-Recommended Nutritional Supplement for Resident With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain physician-ordered nutritional supplements in accordance with RD recommendations for a resident with significant weight loss. The resident was admitted with Alzheimer’s disease and had a care plan identifying potential nutritional problems related to a mechanically altered and therapeutic diet, with interventions including RD evaluation and diet changes as needed. The resident’s weight declined from an admission weight of 206 lbs to 185 lbs, with an RD note documenting a 7.8% weight loss in 30 days and recommending fortified foods. A physician subsequently ordered a fortified nutritional shake 120 ml twice daily for weight loss, and the resident’s weight later increased to 186 lbs before the fortified shake was discontinued. Following discontinuation of the fortified shake, the resident’s weight continued to decline, with documented weights of 171 lbs, 173.5 lbs, 168.5 lbs, and 161.5 lbs over subsequent months. RD notes on multiple dates (12/1, 12/8, 1/16, and 2/12) documented ongoing significant weight loss over 30, 90, and 180 days, BMIs in the obese range, and repeatedly indicated that the resident was receiving a fortified nutritional shake 120 ml twice daily, with recommendations to reweigh, monitor, continue the plan of care, and later increase the shake to 120 ml three times daily. However, review of the MARs for December, January, and February showed no active orders for the fortified nutritional shake, either twice or three times daily, despite these RD notes and a progress note from a risk meeting directing continuation and later increase of the supplement. Interviews with nursing staff, the RD, unit coordinator, nurse supervisor, DON, NP, and administrator revealed that floor nurses relied on the MAR to administer supplements and did not see an active order for the fortified shake. Staff reported that supplement orders were generally expected to be entered by the RD, DON, or unit coordinators based on risk meeting discussions and RD recommendations, but no one verified that the orders were actually entered or active. The RD acknowledged that the fortified shake should have been restarted in December and increased in February per her recommendations and that she did not know why the orders were not entered. The DON and unit leadership described a process in which RD recommendations were read aloud and progress notes were written, but they did not confirm that corresponding orders were in place. As a result, the resident did not receive the ordered fortified nutritional shake despite documented significant weight loss and repeated RD recommendations and risk meeting notes indicating that the supplement was or should be in use.
Failure to Provide Toenail and Podiatry Care for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a cognitively intact resident with atrial fibrillation and heart failure who required moderate assistance with ADLs and was dependent for bathing. On admission and in subsequent weekly nursing assessments from late January through mid-March, there was no documentation of issues with the resident’s toenails, despite observations on March 16 that both feet had long, jagged toenails and the right great toenail had brownish discoloration extending from the base toward the middle of the nail. The resident reported having asked several times for toenail trimming, stated he had never refused toenail care, and said he had been told he would see a podiatrist but believed no appointment had been made. The EMR contained no documentation that toenail or podiatry care was offered or refused, although it did show refusals of showers and UNNA boot care. Staff interviews confirmed awareness of the toenail condition but revealed no follow-through. A NA who frequently cared for the resident stated he had noticed the toenails were very long and needed trimming but did not recall reporting this to a nurse and had not asked the resident about toenail trimming. A nurse reported the resident had been admitted with long, discolored toenails, especially the right great toe, but acknowledged he did not document this, notify the provider, or attempt to trim the nails, and he had not informed social work of the need for podiatry. The podiatry clinic schedules for February and March did not list the resident, and there were no podiatry consult notes or visit documentation in the EMR since admission. The Social Work Director stated he was unaware of any podiatry needs for this resident until a nurse requested adding the resident to the podiatry list on the day of the interview. The DON stated she was aware of the toenail issue and believed the resident refused care frequently, including toenail care, but there was no documentation of such refusals in the EMR.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving two residents who were severely cognitively impaired and one resident who was cognitively intact. The first incident involved a male resident with a history of traumatic brain injury and cognitive impairment, who was found on top of a female resident in her bed with his brief pulled down and his penis exposed. The female resident's brief was found sideways but still in place. This incident occurred despite the male resident being placed on one-to-one supervision due to wandering and sexualized behaviors. In a separate incident, the same male resident entered the room of two other residents, one of whom was cognitively intact, and allegedly got on top of one of them. The resident reported that the male resident removed his pants and got on top of her, prompting her to tell him to get off and leave. The male resident was supposed to be under one-to-one supervision at the time, but the assigned staff left him unattended, allowing him to wander into the room. The facility's failure to maintain adequate supervision and prevent these incidents highlights a significant deficiency in protecting residents from abuse. The male resident's care plan included interventions for his sexualized behaviors and wandering, but these measures were not effectively implemented, leading to the incidents. The facility's investigation noted that the male resident's behaviors were not previously documented, and staff were not aware of the potential for such incidents, indicating a lack of proper assessment and monitoring of the resident's behavior.
Facility Fails to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to allow a resident to return to the first available bed after being sent to the hospital for a medical and psychiatric evaluation. The resident, who had a history of traumatic brain injury, altered mental status, and cognitive communication deficit, was admitted to the hospital for a psychiatric evaluation due to wandering and sexual behaviors. Despite being medically and psychiatrically cleared for discharge after three days, the resident remained in the hospital for over a month because the facility refused to readmit him. The hospital case manager and the resident's legal guardian made multiple attempts to communicate with the facility's Administrator and Director of Nursing (DON) to facilitate the resident's return. The facility had initially planned to transfer the resident to another skilled nursing facility, but that placement fell through. The facility's Administrator and DON decided to send the resident to a hospital in South Carolina for a psychiatric evaluation, bypassing the local hospital, which did not have a psychiatric unit. The facility's refusal to readmit the resident persisted despite the hospital's and guardian's efforts to resolve the situation. Interviews with the facility's staff, including the Administrator, DON, and Medical Director, revealed a lack of coordination and communication regarding the resident's discharge and readmission. The facility's Administrator denied refusing to take the resident back, despite documentation from the hospital indicating otherwise. The facility eventually agreed to readmit the resident after intervention from the State Agency, but the delay resulted in the resident remaining in the hospital for an extended period, causing potential distress and disruption to his care.
Inaccessible Light Switches for Residents
Penalty
Summary
The facility failed to ensure that residents had access to their light switches, which were located behind their beds, for three residents reviewed for accommodation of needs. Resident #76, who had intact cognition but was unable to walk more than 10 feet due to medical conditions, could not reach the light switch cord, which was broken and only 10 inches long. Despite expressing the inconvenience during an interview, the issue remained unresolved during subsequent observations. Nursing staff who frequently cared for Resident #76 were unaware of the broken cord until it was pointed out. Resident #364, with intact cognition and impairment on one side of her lower extremity, also faced similar issues. The light switch cord behind her bed was broken and only 3 inches long, making it inaccessible. She expressed frustration over her inability to reach the switch due to recent knee surgery, requiring staff assistance each time she needed the light. Observations confirmed the issue persisted, and nursing staff admitted they had not noticed the problem until it was highlighted. Resident #54, with moderately impaired cognition, was unable to reach the light switch cord, which was broken and 10 inches long. Despite being able to walk independently in the corridor, she found it inconvenient to reach the switch from her bed. Nursing staff, including a nurse who had noticed the issue and reported it to maintenance, confirmed the cord was still inaccessible. The Maintenance Director acknowledged the need for immediate repairs but could not recall addressing the issue, highlighting a gap in communication and timely response to repair needs.
Incomplete CAAS for Two Residents
Penalty
Summary
The facility failed to complete the Care Area Assessment Summary (CAAS) of the Minimum Data Set (MDS) comprehensively for two residents, leading to deficiencies in addressing the underlying causes and contributing factors of triggered care areas. Resident #48, who was admitted with diagnoses including dementia, anxiety disorder, and depression, had an MDS assessment that triggered eight care areas. However, the facility did not provide comprehensive analysis for six of these areas, including cognitive loss/dementia, activities of daily living functional/rehabilitation potential, falls, dental care, pressure ulcer/injury, and psychotropic drug usage. The CAAS lacked detailed information on the nature of the resident's problems, possible causes, contributing factors, and reasons for care planning. Similarly, Resident #82, admitted with Alzheimer's disease, bipolar disorder, and chronic pain, had an MDS assessment that triggered five care areas. The facility again failed to provide comprehensive analysis for all five areas, which included activities of daily living functional/rehabilitation potential, falls, nutritional status, pressure ulcer/injury, and psychotropic drug use. The MDS Coordinator confirmed the omissions and acknowledged the error, noting that the assessments were submitted by a former coordinator. The Administrator and Director of Nursing both expressed expectations for comprehensive completion of the CAAS, including underlying causes and contributing factors.
Consultant Pharmacist Fails to Identify PRN Psychotropic Drug Irregularity
Penalty
Summary
The Consultant Pharmacist failed to identify drug irregularities related to the use of a PRN psychotropic drug for a resident with an anxiety disorder. The resident was admitted with moderately impaired cognition and had an active physician's order for Ativan without a stop date. The Consultant Pharmacist conducted medication regimen reviews on two occasions but did not identify the lack of a stop date for the PRN Ativan order, attributing the oversight to human error. The Medical Director, who was responsible for the order, admitted to not writing stop dates and was unaware of the 14-day duration requirement for PRN psychotropic medications. The Director of Nursing and the Administrator both expected the Consultant Pharmacist to identify and report drug irregularities in a timely manner. However, the Consultant Pharmacist's failure to do so resulted in a deficiency being noted during the survey. The Medical Director's practice of not including stop dates and relying on medication reviews at refill requests contributed to the oversight, as did the Consultant Pharmacist's failure to notice the irregularity during the medication regimen reviews.
Failure to Time-Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a physician's order for a PRN psychotropic medication for a resident was time-limited and included a rationale for therapy exceeding 14 days. The resident, who was admitted with an anxiety disorder and had moderately impaired cognition, received Ativan as needed for anxiety without a stop date on the order. The order was not reviewed for accuracy, and the rationale for extending the therapy beyond 14 days was not documented in the resident's medical records. Interviews with staff revealed a lack of awareness and adherence to the facility's policy regarding PRN psychotropic medications. Nurses working the third shift, who were expected to review orders for accuracy, were unaware of this responsibility. The Director of Nursing and the Administrator both expected orders to be written per facility policy, but the oversight was not caught during the review process. The Medical Director admitted to not writing stop dates on his orders and was unaware of the 14-day duration requirement for PRN psychotropic medications.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to secure an opened tube of zinc oxide paste for a resident with severely impaired cognition. During an observation, the tube was found unattended on the bedside table in the resident's room. The resident was unable to provide information about how long the paste had been there. Interviews with the nursing staff revealed that the paste should have been stored in the medication cart, but neither the nurse nor the nurse aide noticed it during their rounds. The Director of Nursing suggested that the resident's daughter might have brought the paste to the facility, but reiterated that it should have been kept in the medication cart. The Administrator also expressed the expectation that nursing staff should ensure no medications are left unattended in residents' rooms. This incident highlights a lapse in the facility's medication storage protocol, as the zinc oxide paste was not secured as required.
Failure to Notify Legal Guardian Before Resident Transfer
Penalty
Summary
The facility failed to communicate with and obtain authorization from a resident's legal guardian before transferring the resident across state lines to a hospital in South Carolina. The resident, who was under the guardianship of the local Department of Social Services, was transferred for an in-patient psychiatric evaluation and treatment due to wandering and sexualized behavior. The facility's medical director ordered the transfer, but there was no written or verbal notification to the legal guardian prior to the transfer. The legal guardian was informed by the facility administrator only after the resident had already been transferred. The guardian expressed a desire to have been notified beforehand, especially since there was a local hospital nearby that could have provided treatment. The administrator acknowledged the lack of prior notification and explained that the decision to transfer the resident to a hospital in South Carolina was due to the availability of a geriatric psych unit, which the local hospital did not have.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Agency, law enforcement, and Adult Protective Services (APS) within the required timeframe and did not ensure the report included accurate information. The incident involved a male resident entering the room of a female resident, sitting on her bed, and then leaving. The facility became aware of the incident on 12/19/24 at 1:30 AM, but the initial report to the State Agency was not submitted until 12/26/24. The initial report indicated that law enforcement had been contacted on 12/19/24 at 3:00 AM, but it did not specify if APS had been contacted. Interviews with the Director of Nursing (DON) and the Administrator revealed that they were informed of the incident around midnight on 12/18/24 and arrived at the facility between 12:30 AM and 1:00 AM on 12/19/24 to begin their investigation. The initial information provided to law enforcement was that the male resident had entered the room, sat on the bed, and left without any inappropriate contact. However, a later police report indicated that the male resident had removed his pants and got on top of the female resident, which was not initially reported by the Administrator. The facility's 5-day investigation report, completed on 12/26/24, concluded that there was no willful intent by the male resident and no evidence of sexual intercourse. The report also noted that the female resident's responsible person alleged she had been raped, but the facility did not substantiate this claim. The report was sent to APS, who decided not to follow up and forwarded it to the state for further review. The Administrator admitted to not being aware of the need to send a new report or contact APS prior to the 5-day investigation, as they had no evidence of abuse.
Incomplete Investigation of Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of an alleged resident-to-resident abuse incident involving three residents. The incident involved a cognitively intact resident who reported seeing another resident, who was severely cognitively impaired, attempting to climb onto her roommate's bed. The facility's policy required a comprehensive investigation, including interviews with all involved parties and assessments of the residents, but these steps were not fully completed. The investigation was incomplete as it did not include a statement from the cognitively impaired resident involved in the incident, nor were assessments documented for either the alleged victim or the alleged perpetrator. The Director of Nursing (DON) conducted a skin assessment on the alleged victim but did not perform a more thorough physical assessment. The Administrator retyped staff statements for clarity but did not retain the original handwritten statements, and the cognitively impaired resident was not assessed or interviewed in a documented manner. The Administrator and DON were involved in the investigation but did not follow the facility's policy requirements for a thorough investigation. The Administrator acknowledged not typing up an interview statement for the cognitively impaired resident and not being aware of the need for a documented assessment. The lack of comprehensive documentation and adherence to the investigation policy led to the deficiency in handling the alleged abuse incident.
Failure to Provide Written Notification of Resident Transfer
Penalty
Summary
The facility failed to provide written notification to the legal guardian of a resident regarding the resident's transfer to a hospital in South Carolina. The resident, who had a legal guardian appointed through the local Department of Social Services, was transferred for an in-patient psychiatric evaluation and treatment due to safety concerns related to wandering and sexualized behavior. The transfer was ordered by the Medical Director, but the facility did not issue a written notification to the guardian, as required. The legal guardian was informed of the transfer via a telephone call from the Administrator, but no written notification was provided. This oversight was confirmed during a telephone interview with the legal guardian, who stated that she did not receive any written communication prior to the transfer. The Administrator acknowledged the lack of written notification during an interview, despite having communicated the transfer verbally.
Inaccessible Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a location that was readily accessible to residents on four out of five days during the survey. Observations on multiple days revealed that the daily nurse staffing sheet was placed on a wall in the front lobby, which was only accessible through a door with keypad access. Residents needed to request a staff member to enter the code to view the posting, making it not readily visible or accessible to them. Interviews with facility staff, including the Scheduler, Director of Nursing (DON), and Administrator, confirmed the location of the posting and acknowledged that it was not easily accessible to residents. The Scheduler, who was responsible for posting the daily staffing information, stated that the posting had been in the lobby for a long time. The DON and Administrator both recognized that the current location did not meet the requirement for being readily accessible to residents.
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.
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