Willow Valley Center For Nursing And Rehabilitatio
Inspection history, citations, penalties and survey trends for this long-term care facility in Winston-salem, North Carolina.
- Location
- 1900 W 1st Street, Winston-salem, North Carolina 27104
- CMS Provider Number
- 345092
- Inspections on file
- 34
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Willow Valley Center For Nursing And Rehabilitatio during CMS and state inspections, most recent first.
Two hospice residents receiving Hydrocodone-Acetaminophen for pain experienced misappropriation and poor control of their narcotic medications. For one resident, multiple supplies of Hydrocodone-Acetaminophen from a local pharmacy and the facility pharmacy were only partially documented on the MAR, with missing medication monitoring/control records and staff reports that tablets seen on the cart during one shift were gone by the next count with an RN. For the second resident, pharmacy records showed that the quantity dispensed should have lasted much longer than it did, but a full 30-tablet card was missing from the cart, the resident ran out of medication early, and only one missed dose was documented on the MAR. In both cases, the DON and other staff could not produce complete narcotic control records or investigation documentation, while hospice staff confirmed that the medications belonged to the residents and identified unexplained discrepancies consistent with missing Hydrocodone-Acetaminophen.
Two residents receiving Hydrocodone-Acetaminophen for pain experienced missing narcotic doses after pharmacy deliveries that were signed for by a nurse, with med aides later discovering that medication cards and corresponding control records were absent from the med cart. The DON identified only a small group of staff with access to the cart, interviewed them, and suspended and ultimately terminated the nurse who had signed for the narcotics after she reported no recollection of the missing drugs, but the facility lost or could not produce investigation documentation and could not locate key narcotic control records. Hospice staff for both residents confirmed that the medications belonged to the residents and that hospice did not investigate or report diversion, while the Administrator and DON believed hospice ownership as payer meant the events were not misappropriation from residents and therefore did not report the allegations to the state agency, APS, law enforcement, or licensing authorities as required by facility policy.
A resident had an order for scheduled Hydrocodone–Acetaminophen doses, and the pharmacy dispensed a quantity that should have lasted several weeks, but the facility could not locate the control record for one medication card and the remaining control record showed the resident ran out early. Documentation by an RN on the narcotic control record reflected tablet removals at unscheduled times and with unclear time entries that did not match the MAR, while the MAR showed scheduled administrations that were not supported by corresponding control record entries. During an internal review, the DON identified these discrepancies and reported that the nurse involved could not explain or recall whether the medication had actually been administered, resulting in a lack of clear, accurate accounting for the narcotic medication.
A nurse failed to follow infection control protocols by using a glucometer assigned to one resident to check another resident's blood glucose without cleaning or disinfecting the device before or after use, despite facility policy and manufacturer instructions requiring specific disinfection procedures.
Surveyors found that kitchen equipment, food prep areas, and meal carts were not properly cleaned, with heavy grease, dried food, and debris present on multiple surfaces. Ceiling vents above food prep and service areas were covered in black dust and debris, which was observed blowing over food and clean dishware. Staff interviews confirmed that required cleaning procedures were not followed, and responsibilities for vent cleaning were unclear.
Facility staff failed to properly dispose of garbage and maintain cleanliness around four dumpsters and a grease interceptor container, resulting in overflowing refuse, scattered debris, and leaking grease. Multiple staff interviews confirmed that the area had not been consistently cleaned or maintained for an extended period, with unclear responsibilities and inconsistent cleaning schedules.
A resident with dementia and an indwelling catheter, dependent on staff for ADL care, was observed wearing the same soiled socks for multiple days, despite care plan interventions requiring clean and comfortable footwear. Staff interviews revealed inconsistencies in changing the resident's socks, and management was unaware of the prolonged use of soiled footwear.
The facility did not document or communicate actions taken in response to multiple grievances raised by residents during consecutive Resident Council meetings, including concerns about housekeeping, staff responsiveness, and missing personal items. Staff interviews confirmed a lack of awareness and follow-up regarding these grievances.
The facility did not notify the state mental health authority or request PASRR Level II re-evaluations for two residents with mental disorders after significant changes in their conditions, including new diagnoses and changes in psychiatric treatment. Staff were unaware of the updated diagnoses and did not initiate required screenings following these changes.
A resident's responsible party reported concerns about room cleanliness and wound care, as well as an unclean bathroom. Although the facility verbally communicated investigation results and resolutions, it failed to provide the required written documentation of grievance conclusions and resolutions, as mandated by facility policy and federal regulations. The responsible party reported a lack of communication, and the Social Services Director confirmed that written grievance responses had been discontinued and was unaware of the written notification requirement.
Surveyors observed multiple resident rooms and common areas with significant dirt buildup, damaged walls, missing baseboards, soiled trash cans, exposed electrical wires, and ongoing water leaks. Staff interviews revealed a lack of awareness and communication about these issues, with environmental services and maintenance staff citing staffing shortages and inconsistent reporting through the facility's electronic system. A resident reported ongoing inconvenience due to a bathroom leak, and the administrator was not aware of many of the deficiencies found.
A resident with a suprapubic catheter was observed twice with the urinary drainage bag lying on the floor, despite staff being aware that the bag could not be attached to the bed frame. The nurse aide and nurse both acknowledged the issue but did not secure the bag or replace it in a timely manner, contrary to infection control protocols confirmed by the IP and DON.
A resident with severe cognitive impairment and requiring two-person assist for bed mobility fell and sustained a hip fracture when a nurse aide attempted to provide incontinence care alone. The resident's care plan was not followed, leading to the accident. Staff interviews revealed a misunderstanding of the required assistance level.
A resident was left in soiled briefs during breakfast despite requesting a change, leading to feelings of neglect. The resident, who was cognitively intact, was found with three soiled briefs, and staff failed to provide timely incontinence care. The facility's policy does not support using multiple briefs, and staff are trained on resident rights and dignity.
A resident was neglected when left with three soiled and urine-saturated briefs during breakfast and was not assisted to the bathroom after informing an NA of the need to urinate. The resident felt dirty, angry, and neglected. The Administrator confirmed that the NA should have provided incontinence care when responding to the call light.
The facility failed to maintain proper kitchen sanitation and food storage standards. The dishwasher's sanitizing solution was below required levels, and kitchen equipment was unclean. Food items were improperly stored, and dietary staff had uncovered facial hair during food preparation, risking cross-contamination.
The facility failed to maintain a clean and safe environment, with observations revealing unclean and damaged areas across various rooms, including stained curtains, dislodged shower rods, and broken furniture. Interviews highlighted a disconnect between expected cleaning protocols and actual practices, with staff unaware of the conditions in their areas. Maintenance issues were also prevalent, with broken fixtures and a lack of communication leading to prolonged disrepair. Residents reported issues to staff, but these were not effectively communicated to maintenance, compromising resident safety and comfort.
The facility failed to serve palatable and properly heated meals to residents on the 200 Hall. Observations revealed that food temperatures exceeded acceptable levels, and the meal delivery cart lacked doors, potentially causing food to cool during transport. The Dietary Manager admitted to not conducting meal test tray surveys and acknowledged issues with meal palatability and temperature.
Handrails on three floors were found to be detached, with broken brackets and missing end caps, exposing sharp edges. Despite awareness, the Maintenance Director lacked a system to monitor and repair these issues, leaving staff and residents to use the unsafe handrails.
The facility failed to update PASRR evaluations for three residents who received new mental health diagnoses after admission. A resident with traumatic brain injury and dementia exhibited increased agitation and aggression, but no new PASRR application was completed. Another resident was diagnosed with schizoaffective disorder, yet no Level II PASRR review was made. A third resident with a new diagnosis of paranoid schizophrenia also lacked a referral for a new PASRR. The Social Worker was unaware of some changes, and the audit process to ensure compliance was ineffective.
A facility failed to act on a consultant pharmacist's recommendations and retain documentation of a physician's review and response for a resident's diazepam orders. The resident had multiple PRN diazepam orders without documented clinical rationale or duration for continuation beyond 14 days. Despite the pharmacist's repeated recommendations, the facility did not provide adequate documentation of physician responses, leading to a deficiency.
The facility failed to properly label medications, discard expired medications, and store medications according to manufacturer's instructions. Observations revealed insulin pens with illegible or missing labels, expired medications, and improper storage of unopened Humalog KwikPens and budesonide inhalation suspension ampules. Nurses confirmed these issues during observations.
A facility failed to honor a resident's request for a smoking assessment, violating her right to self-determination. The resident, with conditions like Parkinson's and congestive heart disease, was cognitively intact and repeatedly asked to be assessed for smoking. Staff consistently told her they lacked time for the assessment. Nurse #2 completed the initial assessment without confirming the resident's smoking status and later admitted an updated assessment was needed once the resident's request was known.
A resident's grievance was not properly documented or addressed after the guardian reported inappropriate behavior by the resident's roommate. The SW Assistant failed to complete a grievance form or follow up with the guardian, and the DON was unaware of the issue due to unread emails. The facility's grievance records showed no documentation of the grievance.
A resident, who was cognitively intact and required substantial assistance with toileting, reported feeling neglected after being left in three soiled and urine-soaked briefs while eating breakfast. The facility's Administrator was informed of the incident but failed to report it as neglect to the state agency within the required 2-hour timeframe, and the investigation into the incident remained unresolved.
A resident, admitted with multiple diagnoses and assessed as cognitively intact, was not involved in care plan meetings for four months. The facility staff acknowledged missing the comprehensive care plan meeting, and the Social Worker Director did not recall sending invitations. The Administrator confirmed that care plan meetings should involve the resident and/or their representative, but this was not followed.
Two residents in an LTC facility did not receive adequate care. One resident was left in a soiled brief for an extended period despite requests for assistance, while another resident did not receive proper nail care during bathing. Staff interviews revealed communication lapses and failure to adhere to care protocols, highlighting deficiencies in incontinence and personal hygiene care.
A resident with multiple diagnoses, including pneumonia and chronic kidney disease, missed a scheduled infectious disease clinic appointment due to a malfunctioning transportation van. The appointment was not rescheduled before the resident's discharge, as confirmed by the Resident Appointment Coordinator and acknowledged by the Administrator.
A resident with cirrhosis of the liver did not receive a prescribed 2% miconazole antifungal powder due to the facility's failure to ensure its availability. Despite a physician's order, the medication was not on the med cart, leading to 20 missed doses. The facility staff did not communicate effectively about the need for the OTC medication, and the contracted pharmacy did not provide it, as they do not supply OTC products. The DON expected nursing staff to contact the pharmacy if medications were not received.
The facility exceeded the acceptable medication error rate with two errors: a resident received carvedilol without required vital sign checks, and another resident did not receive prescribed miconazole powder due to its unavailability. These incidents resulted in a 6.9% error rate.
A resident's privacy was compromised during incontinence care when staff left the door open and did not fully draw the privacy curtain, exposing the resident to the hallway. The resident, who was severely cognitively impaired, required extensive assistance. Staff interviews revealed that the door latch was broken and had not been reported, and the standard procedure of ensuring privacy was not followed.
A facility failed to notify the ombudsman of a resident's transfer to the hospital. The resident, who was cognitively intact, was transferred due to pain and discomfort in his lower extremities. The ombudsman did not receive any discharge summaries for the month, and the Director of Social Work admitted to not sending the required list of discharged residents for May.
A facility failed to accurately code the MDS assessment for a resident with paranoid schizophrenia, omitting their PASRR Level II status. The resident's care plan noted the PASRR Level II status, confirmed by a determination letter. Interviews revealed that the on-site MDS Nurse only assessed new admissions, while remote staff handled other assessments. The DON acknowledged the need for accurate coding.
A facility failed to provide cautionary signage for a resident receiving continuous oxygen therapy for COPD. Observations revealed the absence of required signage on the resident's room door. Staff interviews confirmed the oversight, with uncertainty about who was responsible for placing the signage. The DON stated it was the responsibility of the admissions or floor nurse.
The facility failed to limit the duration and document the rationale for extending PRN psychotropic medication orders for two residents. One resident received PRN diazepam without a 14-day stop date or documented rationale, despite recommendations from the consultant pharmacist. Another resident received multiple doses of PRN Haloperidol without a stop date, due to an oversight by the Nurse Practitioner.
A facility failed to document education and consent for the pneumococcal vaccine for a resident who was severely cognitively impaired. There was no record of the resident receiving the vaccine at the facility or prior to admission. The Infection Preventionist and Corporate Nurse Consultant confirmed the absence of documentation, which should have been part of the resident's medical record.
The facility did not deliver mail to residents on Saturdays, affecting 211 residents. Interviews revealed that mail was only delivered Monday through Friday, as the Business Office, responsible for sorting mail, was closed on Saturdays. The Activities Department, tasked with delivering mail, only operated on weekdays, despite mail being received by the facility on Saturdays.
The facility failed to convey funds within 30 days to a discharged resident and to the estate of a deceased resident. A resident's estate did not receive $984.79 timely, and another resident did not receive a refund of $1,984.13 after discharge. The previous Business Office Manager did not complete necessary audits or communicate with families, leading to financial inconvenience.
Misappropriation and Poor Control of Hydrocodone-Acetaminophen for Two Hospice Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their prescribed narcotic medication, Hydrocodone-Acetaminophen, for two hospice residents receiving pain management. One resident with Alzheimer’s disease was started on Hydrocodone-Acetaminophen as needed for left hip pain after an after-hours hospice nurse obtained a 30-tablet supply from a local pharmacy. The local pharmacy confirmed dispensing 30 tablets, and the resident’s MAR showed three doses administered over three days, leaving 27 tablets unaccounted for in that container. The facility’s DON reported that the medication monitoring/control record for this initial supply could not be located. Later, the facility pharmacy delivered an additional 30 tablets for the same resident, signed for by Nurse #1, but the facility again could not locate the corresponding medication monitoring/control record. A further 13 tablets were dispensed on a separate date, and only two doses were documented as administered in October, with no other administrations recorded. Staff interviews revealed inconsistent accounts and missing documentation related to the narcotic counts and the whereabouts of the Hydrocodone-Acetaminophen for this resident. Med Aide #1 stated that when she assumed the cart from Nurse #1, she saw 25 tablets in the local-pharmacy container and 30 tablets on a medication card for the resident, but during the narcotic count with Nurse #1 the following morning, the Hydrocodone-Acetaminophen for this resident was missing. She initially assumed the medication had been discontinued and did not question Nurse #1, later discovering the order was still active and then notifying the supervising nurse and DON. The DON’s written statement and subsequent interview contained conflicting dates about when she was notified of the missing narcotic, and she reported that all documentation of the facility’s investigation was lost or misplaced. Hospice staff from the resident’s hospice provider confirmed that the Hydrocodone-Acetaminophen belonged to the resident, not hospice, and that they were informed by the facility of a diversion involving 30 tablets on a medication card and an unknown quantity from the local pharmacy. The second resident, who had cerebrovascular disease and was on hospice services, had an order for Hydrocodone-Acetaminophen every eight hours for pain. The facility pharmacy dispensed 43 tablets (30 on one card and 13 on another), signed for by Nurse #1, and the quantity should have lasted until a later date. The facility could not locate the medication monitoring/control record for the 30-tablet card, though the record for the 13-tablet card showed the resident ran out of medication on a specific date, with the last dose given at 2:00 AM. The MAR documented scheduled dosing three times daily and noted one missed dose with a comment that the facility was awaiting pharmacy. Hospice Nurse #2 received an after-hours call that the resident had run out of Hydrocodone-Acetaminophen and, after reviewing orders and dispensing records, determined the resident should not have run out until a much later date. She confirmed with the facility that the resident had run out earlier than expected, documented a medication error, and was told by facility leadership that there was an active investigation into narcotic diversion and that a nurse was suspected. Unit Manager #1 and hospice staff confirmed that a whole 30-tablet card for this resident was missing from the medication cart, and the DON acknowledged she had no evidence of an investigation specific to this resident’s missing medication. Throughout both cases, required narcotic control records were missing, narcotic counts and documentation were inconsistent, and the facility did not maintain or produce complete investigative records regarding the missing Hydrocodone-Acetaminophen for either resident.
Failure to Investigate and Report Alleged Misappropriation of Narcotic Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy regarding investigation and reporting of alleged misappropriation of narcotic medications for two residents receiving Hydrocodone-Acetaminophen. The written policy required the facility to exercise caution in handling potential evidence, focus investigations on whether misappropriation occurred, thoroughly document investigations, and report all alleged violations to the state agency, APS, and law enforcement when applicable within 24 hours. Despite these requirements, the facility did not complete or retain thorough investigative documentation and did not report the allegations to required external agencies. The Administrator and DON instead treated the events primarily as a human resources issue involving a nurse, and the Administrator believed that the payer source (hospice) determined whether misappropriation from a resident had occurred. For one resident, a physician’s order for Hydrocodone-Acetaminophen 5-325 mg every 4 hours as needed for pain was initiated, and the local pharmacy dispensed 30 tablets that were picked up, followed by another 30 tablets delivered later and signed for by a nurse. During a narcotic count, a med aide discovered that the Hydrocodone-Acetaminophen for this resident was missing from the medication cart. The DON’s written statement referenced missing narcotic medication in October but did not identify the resident, and the DON later could not recall which resident was affected. The facility was unable to locate the medication monitoring/control records for the Hydrocodone-Acetaminophen delivered for this resident. The DON reviewed staffing and identified that only one nurse and two med aides had responsibility for the cart during the relevant period, interviewed them, and confirmed that the medication container had previously been on the cart. The nurse who had signed for the narcotics reported no recollection of what happened to the medication, and her response was described as unprofessional. The DON suspended and ultimately terminated this nurse, but the facility did not report the misappropriation to the state agency, APS, law enforcement, or a licensing authority. For the second resident, a physician’s order for Hydrocodone-Acetaminophen 5-325 mg every 8 hours for pain was initiated, and the pharmacy dispensed 43 tablets (30 on one card and 13 on another), which were delivered and signed for by the same nurse. MAR documentation showed scheduled administration three times daily, and a med aide later documented that the resident did not receive a scheduled dose because the facility was awaiting pharmacy delivery. Hospice staff reported that this resident should not have run out of Hydrocodone-Acetaminophen until a later date, but on one day in October they were informed the resident had run out and that an active investigation into narcotic diversion was underway. Hospice personnel clarified that the medication belonged to the resident, not hospice, and that hospice did not have responsibility for investigating or reporting diversion within the facility. The DON could not locate the medication monitoring/control record for the 30-tablet card and only produced the record for the 13-tablet card, which showed the medication ran out earlier than expected. The DON stated she had initiated a diversion investigation, checked all medication carts, and interviewed staff, but no discrepancies were found on the carts at that time because the 30-tablet card and its record were not present. The DON and Administrator acknowledged that documentation of the investigation was lost or misplaced, that the nurse involved was suspended and later terminated, and that they did not report the misappropriation to external authorities, based on their belief that hospice ownership of the medication meant it was not misappropriation from a resident. Hospice staff from both hospice providers consistently reported that the Hydrocodone-Acetaminophen belonged to the residents, not to hospice, and that hospice nurses did not have the responsibility or ability to investigate or report narcotic diversion within the facility. One hospice nurse reported being told by the Administrator that there was an open investigation into drug diversion and a suspected nurse, but no follow-up information was provided. The DON and Administrator both stated that they believed hospice would conduct its own investigation and reporting because hospice was the payer source. The facility’s inability to identify the affected resident in one case, the missing medication monitoring/control records for both residents’ narcotics, the loss of all investigative documentation, and the failure to report the allegations to the state agency, APS, law enforcement, or licensing authorities demonstrate that the facility did not follow its own abuse, neglect, and exploitation policy regarding investigation, documentation, and reporting of alleged misappropriation of resident medications.
Inaccurate Documentation and Control of Narcotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to accurately document the administration and control of Hydrocodone–Acetaminophen, a narcotic medication, for Resident #2 in accordance with professional standards. Resident #2 had a physician’s order for Hydrocodone–Acetaminophen 5–325 mg, one tablet every eight hours at scheduled times of 2:00 AM, 10:00 AM, and 6:00 PM. The pharmacy dispensed 43 tablets (one 30‑tablet card and one 13‑tablet card) on 9/26/2025, and the pharmacist stated this supply should have lasted until 11/4/2025 if given as ordered. The facility was unable to locate the medication monitoring/control record for the 30‑tablet card. The available monitoring/control record for the 13‑tablet card showed the resident ran out of the medication on 10/5/2025, with the last documented dose removed at 2:00 AM. On the 13‑tablet card’s monitoring/control record, Nurse #1 documented removing the first dose at an unclear date at 8:00 PM, which was not a scheduled administration time for the resident, and this removal did not match the September MAR, which showed Nurse #1 administering a dose at 2:00 AM on 9/26/2025 with no further doses documented by her that month. The same monitoring/control record showed Nurse #1 removing doses on 10/2/2025 at 8:00 PM and again at “060,” an unclear military time, both unscheduled times, with no documentation of a 2:00 AM removal on that date. In contrast, the October MAR documented that Nurse #1 administered Hydrocodone–Acetaminophen at 2:00 AM on 10/2/2025. During an interview, the DON stated she observed that Nurse #1 documented tablet removals at unscheduled times that were not reflected on the MAR, and that Nurse #1 could not recall whether the medication had been administered or explain the discrepancies. The DON acknowledged that documentation on the monitoring/control record should match the MAR for clear accounting of the narcotic medication.
Failure to Disinfect and Appropriately Assign Glucometer During Blood Glucose Monitoring
Penalty
Summary
Facility staff failed to follow infection prevention and control protocols during blood glucose monitoring for a resident with diabetes. Specifically, a nurse was unable to locate the assigned glucometer for a resident and instead used a glucometer labeled for another resident without cleaning or disinfecting it before or after use. The nurse did not follow the facility's policy or the manufacturer's instructions for cleaning and disinfecting the glucometer, which required the use of two germicidal wipes—one for cleaning and one for disinfecting, with a two-minute wet contact time. The incident was observed during a medication administration, where the nurse retrieved a glucometer from the medication cart, which was stored in a plastic bag labeled for a different resident. The nurse proceeded to check the blood glucose level of the intended resident using this device, then placed the glucometer and its storage bag on a table in the resident's room. Upon questioning, the nurse stated she believed the glucometer was new and unused, but a review of its history showed several previous blood glucose readings had been recorded. The nurse acknowledged she should have obtained a replacement glucometer from the facility's supply room but did not do so due to feeling anxious during the observation. Interviews with facility leadership confirmed that each resident was supposed to have a personal, labeled glucometer, and that staff were expected to follow strict cleaning and disinfection protocols after each use, regardless of whether the glucometer was intended for single or multiple residents. The nurse involved was aware of the correct procedures but failed to implement them during the incident. The facility's policy and the manufacturer's instructions for both the glucometer and disinfectant wipes were not followed, resulting in a breach of infection control standards.
Removal Plan
- Identify all residents who require blood glucose monitoring with a glucometer as potentially affected.
- Interview current nurses and medication aides to confirm no other instances of improper glucometer use.
- Interview alert and oriented residents to confirm no observed improper glucometer use.
- In-service Nurse #1 on manufacturer’s recommendations for disinfectant wipes and glucometer cleaning/disinfection, including observed return demonstration.
- Educate Nurse #1 on potential consequences of improper glucometer cleaning/disinfection.
- Remove and discard Resident #141’s glucometer; provide new, labeled glucometers for Resident #11 and Resident #141.
- Notify Resident #11 of the incident and offer bloodborne pathogen screening.
- Notify Medical Director and discuss education and system changes to prevent recurrence.
- Provide education to all nurses and medication aides on manufacturer’s recommendations for disinfectant wipes and glucometer cleaning/disinfection, and system for keeping glucometers in resident rooms labeled.
- Audit all residents requiring glucometers to ensure each has a labeled glucometer in their room.
- Provide education to staff not present via telephone and require return demonstration before next shift.
- Include glucometer cleaning/disinfection education in orientation for new nurses and medication aides.
- Direct staff to retrieve a new glucometer from Central Supply if a resident’s glucometer cannot be located, label it, and notify Unit Manager.
- Assess, clean, and disinfect all glucometers according to manufacturer recommendations.
- Conduct audit to verify all residents requiring glucose monitoring have individualized, labeled glucometers available.
- Place glucometer policy on every medication cart.
- Move glucometers from medication carts to resident rooms, stored in labeled containers.
- Educate staff on new glucometer storage locations and policy.
- Institute disciplinary action for any staff found sharing glucometers.
- Notify County Department of Health of the incident.
Failure to Maintain Cleanliness in Kitchen and Food Service Areas
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen sanitation practices during two separate kitchen tours. The stove burners, walls, and front of the stove had heavy grease build-up, with large amounts of burnt food, dried liquids, and splatters present. The plate warmers, steam table, fryer, and meal carts all contained dried food particles, spills, and grease both inside and outside. The floor under kitchen equipment was sticky and covered with old food debris. Additionally, the microwave was found with large amounts of dried food and liquid residue. Three ceiling vents located over food preparation and service areas had significant accumulations of black dust and debris, which was observed blowing over food prep surfaces and clean dishware storage racks. Interviews with the Dietary Manager, Maintenance Assistant, and Regional Director of Dietary Services revealed that staff were required to clean kitchen equipment after each meal and perform weekly deep cleaning according to a checklist. However, the Dietary Manager acknowledged that the cleaning had not been performed as required, and the Maintenance Assistant was unaware of the cleaning process for the kitchen vents. The Regional Director of Dietary Services confirmed that both dietary and maintenance staff were responsible for cleaning the vents, but could not confirm when this had last occurred. The deficiencies in cleaning and maintenance of food preparation areas and equipment had the potential to affect the safety of food served to residents.
Improper Disposal and Maintenance of Garbage and Grease Interceptor
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by observations of four dumpsters and one grease interceptor container overflowing with garbage and surrounded by various debris, including paper products, boxes, food items, mattresses, furniture, pallets, clothing, and a blanket. The grease interceptor container was also found leaking grease onto the ground and parking lot. These conditions were observed during an initial tour, with additional observations confirming that while some trash bags had been removed, the area remained littered with debris and grease. Interviews with the Dietary Manager, Administrator, Regional Consultant for Maintenance and Environmental Services, and Regional Director of Dietary Services revealed that housekeeping, dietary, and maintenance staff were all responsible for cleaning and maintaining the dumpster area and grease interceptor. However, it was acknowledged that the area had been in this condition for some time and that the grease interceptor had not been cleaned consistently for several months. There was also uncertainty regarding the last time the grease interceptor was cleaned, despite the expectation that it should be cleaned monthly.
Failure to Provide Clean Footwear for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with dementia and an indwelling catheter, who was dependent on staff for activities of daily living (ADL) care, was not provided with clean footwear over multiple days. Observations revealed the resident wearing the same yellow socks with purple stripes that were saturated with a liquid substance and stained, from one day to the next. The resident was also observed with wet pajama pants and visible wet footprints leading from his room, indicating prolonged exposure to soiled clothing and footwear. Documentation showed the resident required substantial to maximum assistance for toileting and personal hygiene, and his care plan included ensuring comfortable and non-slippery shoes. Interviews with nursing assistants and other staff revealed inconsistencies in the changing of the resident's socks, with one nursing assistant stating she applied the socks and removed them two days later, while another reported changing the socks but could not recall the details. The unit manager and assistant director of nursing were unaware that the resident had worn the same socks for multiple days, despite instructions for staff to replace socks as needed. These findings demonstrate a failure to provide clean footwear as required for a resident dependent on staff for ADL care.
Failure to Address and Communicate Resident Council Grievances
Penalty
Summary
The facility failed to act upon and communicate efforts to address grievances reported by the Resident Council over a two-month period. Resident Council meeting minutes from June and July 2025 documented multiple grievances, including issues with housekeeping not removing trash, nursing assistants delaying in putting residents to bed, night shift nurses sleeping and not responding to call bells, delayed laundry delivery, lack of assistance from second shift staff, unfair television time sharing, and missing personal items. Despite these grievances being raised during meetings, there was no documentation of the facility's response or resolution to these concerns in the subsequent months. During a Resident Council meeting in August, the council president stated that grievances voiced in the previous two months had not been fully addressed and that staff had not communicated any efforts to resolve them. Interviews with the Activities Director and the Administrator confirmed that grievances were not documented or followed up on as required. The Activities Director was unaware of the need to document and communicate actions taken regarding Resident Council grievances, and the Administrator acknowledged that proper documentation and follow-up should have occurred.
Failure to Notify State Authority and Request PASRR Level II After Significant Change in Condition
Penalty
Summary
The facility failed to notify the North Carolina Medicaid Uniform Screening Tool (NC MUST), the State Mental Health or Intellectual Disability Authority, when residents with mental disorders experienced a significant change in condition, and did not request a Preadmission Screening and Resident Review (PASRR) Level II re-evaluation for two residents. For one resident with a history of schizoaffective disorder, bipolar type, and post-traumatic stress disorder, the medical record showed a decline in mental status and worsening anxiety symptoms, as well as changes in psychiatric medications. Despite these changes and the addition of new diagnoses after the initial PASRR Level I screening, the social services staff were unaware of the updates and did not initiate a Level II PASRR screening as required. Another resident, originally admitted with moderate dementia and anxiety, had their diagnoses updated to include bipolar disorder and was prescribed antipsychotic medication for mood disorder. The facility did not refer this resident for a Level II PASRR evaluation after the diagnosis change. Interviews with the Director of Social Services confirmed a lack of awareness regarding the updated diagnoses and the need for PASRR re-evaluation following significant changes in mental health status and treatment.
Failure to Provide Written Grievance Resolutions to Resident Representative
Penalty
Summary
The facility failed to provide written conclusions and resolutions of grievances reported by a responsible party for a resident with end-stage renal disease and diabetes mellitus, who was moderately cognitively impaired. According to the facility's own policy, the Grievance Official is required to issue a written decision to the resident or their representative at the conclusion of any grievance investigation, including details such as the date received, investigative steps, findings, confirmation status, corrective actions, and the date the decision was issued. However, for two grievances reported by the resident's responsible party—one regarding room cleanliness and wound treatment, and another concerning an unclean bathroom—investigation results and resolutions were only communicated verbally, with no written documentation provided to the responsible party as required. Interviews revealed that the responsible party felt the facility frequently failed to communicate regarding concerns about the resident's care, and that grievances submitted to Social Services did not receive written follow-up. The Director of Social Services confirmed that written grievance response letters had been discontinued after a certain point and was unaware of the federal requirement to provide written notification of grievance conclusions and resolutions. This lack of written communication constituted a failure to honor the resident's right to receive a written decision regarding grievances, as outlined in both facility policy and federal regulations.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by multiple observations of unclean and poorly maintained resident rooms and common areas. Surveyors found significant dirt buildup, stains, debris, and damaged walls, floors, and baseboards in at least nine resident rooms across six of eight resident halls. Specific issues included dry black and brown material on floors, visible dirt in bathrooms, trash and wrappers under beds, missing toilet seals, splattered matter on walls and tiles, broken or missing baseboards, holes in walls, and soiled trash cans without liners. In several cases, privacy curtains were found on the floor, and exposed electrical wires were observed in one room. Common areas and hallways also had heavy dirt buildup, particularly on metal threshold plates and ceilings with brown stains and flaking paint. Staff interviews revealed a lack of awareness and communication regarding the cleanliness and maintenance issues. The Environmental Services (EVS) Director and Acting Maintenance Director were often unaware of the specific problems in the rooms, and both cited ongoing staffing shortages as a contributing factor. Housekeepers were expected to clean rooms daily, including wiping down walls and baseboards when visibly dirty, but this was not consistently done. Maintenance staff relied on housekeeping and nursing assistants to report issues through an electronic tracking system, but many deficiencies were not entered, resulting in delayed or missed repairs. The EVS Director acknowledged that the rooms were not cleaned to expectations and that routine rounds were conducted, but significant issues persisted. One resident reported that a bathroom leak had been ongoing for two months, requiring her to use alternative facilities, which was inconvenient. The maintenance assistant confirmed awareness of the leak but had not entered a formal work order, relying instead on verbal communication. The facility administrator expected staff to report maintenance issues but was not aware of many of the specific deficiencies observed. The report documents a pattern of unaddressed environmental concerns, lack of systematic reporting, and insufficient staffing, leading to the failure to provide residents with a safe and clean living environment.
Failure to Keep Urinary Catheter Drainage Bag Off Floor
Penalty
Summary
A deficiency occurred when staff failed to keep a urinary catheter drainage bag off the floor for a resident with a suprapubic catheter due to neurogenic bladder. The resident, who was moderately cognitively impaired and had a history of overactive bladder and neuromuscular dysfunction, was observed twice in one day with the catheter drainage bag lying directly on the floor, first when it was half full and later when it was full. The care plan for this resident specified that the catheter bag should be positioned below the bladder and away from the entrance, with tubing checked for kinks each shift. Staff interviews revealed that the assigned nurse aide was aware the drainage bag could not be attached to the bed frame and had notified the nurse at the beginning of the shift, but did not take further action to secure the bag or obtain a privacy bag until prompted. The assigned nurse also acknowledged awareness of the issue but had not changed the drainage bag due to lack of time. Both the Infection Preventionist and the DON confirmed that catheter drainage bags should not be on the floor for infection control reasons, and the Administrator was unable to explain why the issue had not been addressed despite staff awareness.
Failure to Provide Adequate Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to safely assist a resident with incontinence care, resulting in an accident that caused injury. The resident, who was severely cognitively impaired and required extensive assistance with two-person assist for bed mobility, was being cared for by a nurse aide who attempted to provide care alone. During the process, the resident fell from the bed and sustained a closed fracture of the right hip. The resident's care plan clearly indicated the need for a two-person assist, but this was not followed by the nurse aide. The incident occurred when the nurse aide was providing incontinence care and attempted to change the resident's linen while the resident was sitting up in bed. The resident rolled over and fell off the bed, landing on her right side. The nurse aide, who was alone, was unable to prevent the fall. The resident was assessed by a nurse who found a small skin tear and later, a mobile x-ray confirmed a right femur fracture. The resident was subsequently sent to the emergency room for further evaluation and treatment. Interviews with staff revealed a misunderstanding regarding the level of assistance required for the resident. Both the nurse aide and a nurse believed the resident was a one-person assist due to her small size, despite the care plan indicating otherwise. The Director of Nursing and the Administrator confirmed that the resident was documented to require a two-person assist, and staff were expected to follow the care guides to ensure resident safety.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to protect a resident's dignity by not providing timely incontinence care and by leaving the resident in soiled briefs during a meal. Resident #209, who was cognitively intact and required assistance with toileting, was left in a urine-saturated brief from 8:15 am until after breakfast, despite requesting to be changed. The resident expressed feelings of neglect and dirtiness, and it was observed that the resident had three briefs on, which were all soiled, along with the bedding. Nursing Assistant (NA) #8 did not change the resident when requested, citing the arrival of breakfast trays as a reason, and did not inform the incoming NA #4 about the resident's need for care. Further investigation revealed that NA #9, who worked the night shift, claimed to have changed the resident between 6:00 am and 6:30 am and denied placing three briefs on the resident. However, the resident stated that NA #9 insisted on using three briefs due to being a heavy wetter. Additionally, NA #10 failed to provide a bed pan or assist the resident to the bathroom when the resident expressed the need to urinate, instead adjusting the brief and leaving the room. The unit manager later intervened and provided a bed pan, acknowledging that it was not dignified to expect the resident to urinate in a brief when capable of using a bed pan. Interviews with the Director of Nursing (DON) and the Administrator highlighted that staff are trained annually on incontinence care and resident rights, and it is not the facility's policy to use more than one brief unless care planned. The DON and Administrator both stated that residents who are aware of their need to use the bathroom should be assisted accordingly, and the situation with Resident #209 was not in line with facility expectations or policy.
Neglect of Resident's Incontinence Care
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by the case of Resident #209. The resident was left wearing three soiled and urine-saturated briefs during the breakfast meal. Additionally, the resident was left to urinate in a brief after informing Nursing Assistant (NA) #10 of the need to urinate. The resident expressed feelings of being dirty, angry, and neglected due to these incidents. This deficiency was identified through observations, record reviews, and interviews with staff and the resident. The Administrator confirmed that NA #8 had responded to Resident #209's call light at 8:15 am but did not provide the necessary incontinence care. The Administrator acknowledged that if Resident #209 required incontinence care at that time, NA #8 should have provided it. This incident was reviewed under the context of neglect and incontinence care, highlighting a failure to maintain the resident's dignity and meet their care needs.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper sanitization and cleanliness standards in the kitchen, as observed during a survey. The sanitizing solution in the low temperature dishwasher was not at the required concentration of 50 ppm, leading to dishware being inadequately sanitized. Additionally, the kitchen had several maintenance issues, including meal delivery carts without doors and food service equipment that was not clean or in good working condition. The floor was littered with food particles and grease, and the kitchen equipment, such as convection ovens and deep fryers, had accumulated grease and food debris. A fan covered in lint was used near a food preparation area, and the facility lacked a documented cleaning policy, with no records of completed sanitation checklists. The facility also failed to properly store food items, with several instances of unsealed, undated, and unlabeled food in the walk-in cooler and freezer. Dietary staff were observed with uncovered facial hair while preparing food, which could lead to cross-contamination. These deficiencies indicate a lack of adherence to professional standards for food storage, preparation, and service, potentially compromising the safety and quality of food served to residents.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by multiple observations of unclean and damaged areas across various rooms. Observations revealed issues such as stained and improperly attached privacy curtains, dislodged shower curtain rods, exposed plumbing, and broken furniture. Additionally, there were reports of dried brown matter and sticky residues in several rooms, indicating a lack of thorough cleaning. Interviews with housekeeping staff and the Environmental Services Director highlighted a disconnect between expected cleaning protocols and actual practices, with some staff unaware of the conditions in their assigned areas. Further deficiencies were noted in the maintenance of the facility, with several rooms having broken or missing fixtures, such as shower heads and closet doors. The Maintenance Director admitted to not being aware of the extent of the disrepair, citing a lack of a comprehensive system to monitor and address maintenance issues. The report also indicated that staff were not consistently entering work orders for necessary repairs, leading to prolonged periods of disrepair that affected the residents' living conditions. The report also highlighted communication breakdowns between residents, nursing staff, and maintenance personnel. Residents reported issues such as running faucets and unaddressed maintenance concerns to staff, but these were not effectively communicated to the maintenance team. This lack of communication and follow-through resulted in ongoing deficiencies that compromised the safety and comfort of the residents. Interviews with the Administrator and Director of Nursing revealed an awareness of the issues but also a lack of effective systems to ensure timely resolution of these deficiencies.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to serve food that was palatable and at acceptable temperatures to residents on the 200 Hall. During an observation of the meal tray line service, it was noted that the temperatures of the food items on the steamtable exceeded the acceptable 135 degrees Fahrenheit. The plated meals were covered with lid covers but lacked insulated bottoms due to the large plate size. Additionally, the stainless-steel meal delivery cart used for transporting meals to the 200 Hall was missing doors, which could have contributed to the food cooling down during transport. The Dietary Manager (DM) revealed that the doors to four of the ten meal delivery carts had been in need of repair for approximately three months, and there were insufficient insulated bottom plate covers for the large plates. Smaller plates had been ordered several months prior but had not yet been delivered. The DM also admitted to not conducting any meal test tray surveys. Upon testing a meal tray, the shepherd's pie and green beans with corn were found to be lukewarm and bland, with the vegetables not thoroughly cooked. The DM acknowledged these findings during the meal tray testing.
Handrails in Disrepair Across Multiple Floors
Penalty
Summary
The facility failed to ensure that handrails in the corridors were properly secured, repaired, and free from sharp edges on three of the four floors where handrails were present. Observations revealed that on the 500 floor, handrails were detached from the walls and required repairs due to broken or cracked support brackets and missing end caps, leaving sharp edges exposed. Similar conditions were observed on the 300 floor, where handrails were loose and detached, with broken brackets and exposed sharp edges. On the 200 floor, handrails were also loose, with unpatched holes in the walls, broken brackets, and missing end caps, exposing sharp edges and screws. Despite the awareness of the Maintenance Director regarding the condition of the handrails, no system was in place to monitor or replace the newly broken handrails. The Maintenance Director had submitted an invoice for replacement parts, but the repairs had not been completed by the time of the follow-up observation. Staff and residents continued to use the handrails in their current condition, indicating a lack of timely action to address the safety concerns.
Failure to Update PASRR Evaluations for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit requests for updated Preadmission Screening and Resident Review (PASRR) evaluations for three residents who received new mental health diagnoses after admission. Resident #37, who was admitted with traumatic brain injury, dementia with agitation, and major depressive disorder, exhibited increased agitation and aggressive behaviors, including hallucinations and verbal aggression. Despite these changes, no new PASRR application was completed after the resident was diagnosed with PTSD and demonstrated a change in behaviors. Resident #102, admitted with dysphagia and hypertension, was later diagnosed with schizoaffective disorder. However, the facility did not make a referral for a Level II PASRR review following this new diagnosis. The Social Worker was unaware of the change in diagnosis, indicating a lapse in communication and oversight within the facility's processes. Resident #103, admitted with anxiety, depression, respiratory failure, and diabetes mellitus, was diagnosed with paranoid schizophrenia. Despite corporate direction to refer for a new PASRR, the Social Worker had not completed the referral, citing being behind and the sole person with PASRR logon access. The Administrator acknowledged the need for a new PASRR evaluation for such diagnoses, but the audit process intended to ensure compliance was ineffective, resulting in missed referrals.
Failure to Act on Pharmacist Recommendations and Document Physician Responses
Penalty
Summary
The facility failed to act on recommendations made by the consultant pharmacist and retain documentation of the physician's review and response to the pharmacist's findings for a resident whose medications were reviewed. The resident, who was admitted with a diagnosis of adjustment disorder with anxiety, had multiple orders for diazepam, a psychotropic and controlled substance medication. These orders included both scheduled and PRN (as needed) dosages, with the PRN orders lacking documented clinical rationale or duration for continuation beyond the standard 14-day limit. The consultant pharmacist conducted monthly medication regimen reviews and made several recommendations regarding the PRN diazepam orders, emphasizing the need for a clinical rationale and duration if the orders were to be extended. Despite these recommendations, the facility did not provide documentation showing that the physician reviewed or responded to these recommendations. The facility only provided one relevant pharmacist report, dated 2/29/24, which was signed by a nurse practitioner but did not address the required clinical rationale or duration for the PRN diazepam. Interviews with the facility's consultant pharmacist and Director of Nursing (DON) revealed that the facility failed to retain the pharmacist's consult reports and provider responses. The consultant pharmacist confirmed making multiple recommendations, and the DON acknowledged awareness of the requirement for a stop date on PRN psychotropic medications. However, the facility did not maintain adequate documentation to demonstrate compliance with these requirements, leading to the deficiency.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly label medications with the minimum required information, including the resident's name, on one of the five medication carts observed. During an observation of the 300 Short Med Cart, it was found that an insulin glargine pen was not labeled with a resident's name or the date it was opened. Additionally, an insulin lispro pen had an illegible name and was stored in a bag labeled for a different resident. An insulin aspart pen was labeled with a resident's name but had an illegible date. These labeling issues were confirmed by Nurse #9 during the observation. The facility also failed to discard expired medications and single-dose vials (SDVs) after their initial use. Observations revealed that several insulin pens on different medication carts were either past their expiration dates or had illegible dates, making it impossible to determine their validity. Furthermore, opened SDVs of sterile water and lidocaine were found on the 300 Long Med Cart, which should have been discarded after a single use. Nurses #5 and #9 acknowledged these issues during the observations. Additionally, the facility did not store medications according to the manufacturer's instructions. For instance, unopened Humalog KwikPens were not stored in the refrigerator as required, and budesonide inhalation suspension ampules were not dated when their envelopes were opened. These storage issues were observed on the 200 Long Med Cart and confirmed by Nurse #6. The Director of Nursing and Administrator acknowledged the findings and indicated that nursing staff required education on proper medication storage.
Failure to Honor Resident's Request for Smoking Assessment
Penalty
Summary
The facility failed to honor a resident's request to be assessed for smoking, which is a violation of the resident's right to self-determination and choice. Resident #128, who was admitted with conditions including osteomyelitis of the vertebra, Parkinson's disease, and congestive heart disease, was cognitively intact according to the admission Minimum Data Set. Despite the resident's repeated requests to be assessed for smoking, staff consistently told her they did not have time to conduct the assessment. The facility's Safe Smoking Screening initially documented that the resident did not smoke, but this was not updated despite the resident's requests. During an interview, Nurse #2 admitted to completing the initial smoking assessment without recalling if she asked the resident about her smoking habits. The nurse practitioner involved determined that the resident would not be a safe smoker due to her inability to hold a cigarette without burning herself and her chronic pain issues. Although nicotine patches were offered, the resident refused them. Nurse #2 acknowledged that an updated smoking assessment should have been conducted once the resident's request to smoke was known.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to honor a resident's right to voice grievances without discrimination or reprisal, as required by regulations. The incident involved a resident with severe cognitive impairment whose guardian observed inappropriate behavior by the resident's roommate during a visit. The guardian reported the incident via email to the Social Worker (SW) Assistant, requesting a room change for the resident. The SW Assistant acknowledged the email and forwarded it to the Director of Nursing (DON) and the Unit Manager (UM) but did not complete a grievance form or follow up with the guardian regarding the resolution of the concern. The DON was unaware of the grievance due to not checking emails during a recertification survey and was not verbally informed of the issue. The facility's grievance records showed no documentation of the grievance for the resident. The Administrator confirmed that the SW Assistant should have documented the grievance immediately and followed the grievance process, which includes providing a copy of the Grievance/Concern Form to the resident or their representative upon resolution.
Failure to Report Suspected Neglect in a Timely Manner
Penalty
Summary
The facility failed to report a suspected case of neglect involving a resident to the State Regulatory Agency within the required 2-hour timeframe. The resident, who was cognitively intact and required substantial to maximum assistance with toileting, expressed feelings of neglect and anger after being left in three soiled and urine-soaked briefs while eating breakfast. The incident was brought to the attention of the facility's Administrator by a surveyor, but the Administrator had not completed an Initial Allegation Report or reported the incident as neglect to the state agency. The investigation into why the resident was left in such a condition had not been resolved at the time of the report.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to involve a resident and/or their representative in the care planning process, as required by regulations. The resident, who was admitted with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and major depression, was assessed as cognitively intact and able to communicate needs effectively. Despite this, the resident reported not being invited to participate in care plan meetings for the past four months, and there was no record of a comprehensive care plan meeting being completed with the resident or their representative. Interviews with facility staff revealed that the baseline care plan was completed with the resident's representative over the phone, but the comprehensive care plan meeting was missed. The Social Worker Assistant acknowledged the oversight, and the Social Worker Director admitted to not recalling sending out invitations for the comprehensive care plan meeting. The facility's Administrator confirmed that care plan meetings should involve the resident and/or their representative and be conducted in accordance with state and federal regulations, but this was not adhered to in this case.
Deficiencies in Incontinence and Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident who was dependent on staff assistance. Resident #209, who was cognitively intact and required substantial assistance with toileting, was left in a soiled and urine-saturated brief from the previous night until late morning. Despite the resident's repeated requests for assistance, staff failed to provide timely care, resulting in the resident being found with multiple briefs and soiled bedding. Interviews with nursing assistants revealed a lack of communication and adherence to care protocols, contributing to the resident's prolonged discomfort. Additionally, the facility did not provide proper nail care for another resident who was dependent on staff for personal hygiene. Resident #14, who had hemiplegia and was moderately cognitively impaired, was observed with unclean fingernails over a two-day period despite receiving baths from both facility staff and hospice. The nursing assistant responsible for the resident's care admitted to forgetting to clean the resident's nails during the bathing process, indicating a lapse in the comprehensive care expected during personal hygiene routines. Interviews with the Director of Nursing and the Administrator highlighted a disconnect between staff training and execution of care duties. The DON confirmed that incontinence and nail care were part of the staff's training, yet these were not consistently applied in practice. The Administrator acknowledged that staff might focus too narrowly on specific tasks, neglecting other aspects of resident care, such as nail hygiene, which should be integrated into the overall bathing process.
Missed Infectious Disease Clinic Appointment
Penalty
Summary
The facility failed to ensure that a resident attended a scheduled infectious disease clinic appointment. The resident, who was admitted with diagnoses including pneumonia, diabetes, latent tuberculosis, and chronic kidney disease, had an appointment scheduled for March 11, 2024, as per the hospital discharge summary. However, there was no evidence in the medical record that the resident attended this appointment. The resident was discharged from the facility on March 13, 2024, without having attended the clinic. The failure to attend the appointment was due to a malfunction in the transportation van's wheelchair lift on the morning of the scheduled appointment. The Resident Appointment Coordinator confirmed that the appointment was missed and was not rescheduled before the resident's discharge. The Coordinator explained that rescheduling was sometimes delayed due to her responsibilities in escorting residents to appointments. The Administrator acknowledged that the appointment should have been rescheduled in a timely manner.
Failure to Provide Prescribed Antifungal Medication
Penalty
Summary
The facility failed to ensure the availability of a prescribed medication, a 2% miconazole topical antifungal powder, for a resident who was discharged from a hospital with a diagnosis including cirrhosis of the liver. The resident's hospital discharge medication list indicated the discontinuation of oral terbinafine and the initiation of miconazole powder to be applied twice daily. Despite the physician's order being confirmed by a nurse, the medication was not available on the medication cart, resulting in 20 missed doses over a period of nearly two weeks. The nurse documented the unavailability of the medication in the resident's Medication Administration Record (MAR). Interviews with facility staff and a representative from the contracted pharmacy revealed a lack of communication and understanding regarding the provision of over-the-counter (OTC) medications. The Central Supply clerk was unaware of the order until informed by the Unit Manager, and the pharmacy representative confirmed that the facility should have known that OTC medications were not provided by the pharmacy. The facility did not inquire about the missing medication with the pharmacy, and the Director of Nursing expressed an expectation that nursing staff should contact the pharmacy if a medication was not received. This oversight led to the resident not receiving the prescribed treatment as ordered by the physician.
Medication Error Rate Exceeds 5% Due to Administration and Omission Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by two medication errors out of 29 opportunities, resulting in a 6.9% error rate. One incident involved a resident with hypertension and a history of stroke, who was administered carvedilol without prior vital sign checks, despite physician orders requiring blood pressure and heart rate parameters to be observed before administration. The nurse responsible did not notice the requirement for vital signs to be taken before administering the medication. Another incident involved a resident with cirrhosis of the liver, where a prescribed topical antifungal powder, miconazole, was not administered because it was unavailable on the medication cart. The nurse confirmed the order for the medication but failed to ensure its availability for administration. The omission of the medication was acknowledged as an error by the nursing staff.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The facility failed to maintain personal privacy for a resident during incontinence care, as observed by surveyors. Resident #168, who was severely cognitively impaired and required extensive assistance for toileting, was exposed when Nurse Aide #1 provided care with the door open and the privacy curtain not fully drawn. This resulted in the resident's bare buttocks being visible from the hallway. Nurse Aide #13 entered the room to assist without closing the door or adjusting the curtain to ensure privacy. Interviews with staff revealed that it was not standard procedure to leave the door and curtain open during such care. Nurse Aide #2 admitted to not closing the door due to a broken latch, which had not been reported to Maintenance. Nurse #1 confirmed that the door and curtain should be closed during incontinence care. Nurse Aide #1 acknowledged the oversight, stating she usually propped the door shut and thought the curtain was adequately positioned. The Administrator also confirmed that the privacy curtain should have been fully drawn, regardless of the door's condition.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide written notification to the ombudsman regarding the transfer of a resident to the hospital. The resident, who was cognitively intact, was transferred to the hospital due to pain and discomfort in his bilateral lower extremities, as per his request and physician's order. Despite the transfer occurring, there was no documentation indicating that a written notice of the transfer was provided to the ombudsman. An interview with the ombudsman revealed that she had not received any discharge summaries from the facility for May 2024, including the resident's discharge to the hospital. The Director of Social Work, responsible for sending a monthly list of discharged residents to the ombudsman, acknowledged that she had not sent the list for May 2024. The last email sent to the ombudsman was in April 2024, covering discharges from March 2024.
Inaccurate MDS Coding for PASRR Level II Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident regarding their Preadmission Screening and Resident Review (PASRR) Level II status. The resident, who was admitted with a diagnosis of paranoid schizophrenia, had a comprehensive MDS assessment that did not report their PASRR Level II determination. This oversight was identified during a review of the resident's electronic medical record, which included a care plan noting the resident's PASRR Level II status due to serious mental illness. Interviews with facility staff revealed gaps in the MDS assessment process. The Director of Social Work confirmed the resident's PASRR Level II status with a determination notification letter. The on-site MDS Nurse stated she was only responsible for assessments of newly admitted residents, while remote nursing staff handled other assessments. An attempt to interview the remote MDS Nurse responsible for the inaccurate coding was unsuccessful. The Director of Nursing acknowledged the need for accurate coding of the resident's MDS assessment.
Failure to Provide Cautionary Signage for Oxygen Use
Penalty
Summary
The facility failed to provide appropriate cautionary signage for oxygen use for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident was admitted with a physician's order for continuous oxygen therapy at 3 liters per minute via nasal cannula. Observations on two separate occasions revealed that there was no cautionary signage on the resident's room door indicating the use of oxygen, which is a requirement for residents receiving oxygen therapy. Interviews with staff, including a nurse assigned to the resident and the Unit Supervisor, confirmed the absence of the required signage. The nurse was unsure whether it was the responsibility of the maintenance department or the Unit Supervisor to place the signage. The Unit Supervisor acknowledged the missing signage after being prompted by the Director of Nursing to check for it. The Director of Nursing confirmed that it was the responsibility of the admissions nurse or the floor nurse to ensure that cautionary signage was posted for residents utilizing oxygen.
Failure to Limit Duration and Document PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to adhere to regulations regarding the duration and documentation of PRN psychotropic medication orders for two residents. For Resident #97, the facility did not limit the duration of a PRN diazepam order to 14 days, nor did it document a rationale for extending the order beyond this period. Despite multiple recommendations from the consultant pharmacist to address this issue, the PRN diazepam order continued without the necessary documentation. Resident #97, who had diagnoses including COPD and adjustment disorder with anxiety, received eight doses of PRN diazepam over several months without proper documentation or a stop date. Similarly, for Resident #28, the facility failed to include a 14-day stop date for a PRN Haloperidol order, which was administered multiple times over a month. The Nurse Practitioner who wrote the order confirmed the omission of the stop date, although she intended for it to be included. Resident #28, who had diagnoses including dementia and major depressive disorder, received numerous doses of Haloperidol without the required stop date. Interviews with facility staff revealed a lack of awareness regarding the requirement for a stop date on PRN psychotropic medications.
Lack of Documentation for Pneumococcal Vaccine Education and Consent
Penalty
Summary
The facility failed to document the provision of education regarding the influenza and pneumococcal vaccines, as well as the resident's or their representative's refusal to receive the pneumococcal vaccine for one of the residents reviewed for immunizations. Resident #182, who was admitted to the facility, was identified as severely cognitively impaired according to a quarterly Minimum Data Set (MDS) assessment. There was no documentation in the electronic medical record indicating that Resident #182 had received the pneumococcal vaccine at the facility, nor was there any reported history of the resident receiving the vaccine outside the facility prior to admission. The facility was unable to provide written documentation that Resident #182 or their representative had received education to consent to or refuse the administration of the pneumococcal vaccine. Attempts to interview the resident's responsible party were unsuccessful. During interviews, the Infection Preventionist, who had been in the role since July 2023, acknowledged that the focus had been on updating COVID and influenza vaccines, with less attention on pneumococcal status. The Corporate Nurse Consultant also confirmed the absence of documentation for consent or refusal of the pneumococcal vaccine, stating that such documentation should have been a permanent part of the resident's medical record.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to deliver mail to residents on Saturdays, affecting 211 residents. Interviews with six members of the Resident Council revealed that they did not receive mail on Saturdays, as the facility only delivered mail from Monday to Friday. The Activities Director confirmed that mail was sorted by the Business Office and then given to the Activities Department for delivery, which occurred only on weekdays. Although mail was delivered to the facility on Saturdays, the Business Office was closed, preventing mail from being sorted and delivered to residents on that day. The Director of Nursing stated that the Activities Department was responsible for mail delivery and that mail should be delivered to residents on Saturdays.
Failure to Convey Resident Funds Timely
Penalty
Summary
The facility failed to convey funds within 30 days to a discharged resident and failed to forward the balance of funds to the estate of an expired resident. For Resident #619, who was admitted and later expired, the facility did not convey the amount of $984.79 to the resident's estate within the required 30 days. The check was not sent to the Clerk of Court until much later, and the family was not informed about the status of the funds. Interviews with the family and staff revealed that the previous Business Office Manager did not complete the necessary audit and communication regarding the funds. For Resident #620, who was admitted and later discharged home, the facility failed to refund the amount of $1,984.13 within 30 days of discharge. The previous Business Office Manager did not submit a request for the refund, and the billing system failed to respond to the request for funds. The family member reported that the previous Business Office Manager misinformed them about the status of the funds, leading to unpaid bills and financial inconvenience for the resident. Interviews with the Business Office Manager, Regional Business Office Director, and the Administrator confirmed that the facility's policy required financial records for expired and discharged residents to be reviewed and audited monthly, with refunds dispersed within 30 days. However, these procedures were not followed, resulting in the deficiencies noted in the report.
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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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