Windsor Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Windsor, North Carolina.
- Location
- 1306 South King Street, Windsor, North Carolina 27983
- CMS Provider Number
- 345339
- Inspections on file
- 33
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Windsor Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain accurate TAR and MAR/EMAR documentation for several residents, including those receiving wound care, lymphedema treatments, insulin, and Ozempic. In multiple instances, nurses and the ADON reported that ordered wound and leg treatments were performed but were not signed off on the TAR. For another resident, scheduled insulin doses appeared on the EMAR without signatures or codes, and the nurses later stated they likely forgot to sign after administration. In a separate case, a nurse documented that a weekly Ozempic injection was given even though she later recalled she had been unable to locate the medication, meaning the MAR reflected administration that did not occur. The DON and Administrator confirmed that treatments and medications were expected to be documented accurately and in real time.
A resident with HTN, HF, and coronary/peripheral artery disease experienced a significant medication error when a nurse entered and staff administered a carvedilol dose far below the cardiologist’s intended increase. Hospital discharge and admission orders reflected carvedilol 25 mg BID, and a later cardiology consult included conflicting directions: a handwritten recommendation to increase to 37.5 mg BID, a printed instruction for 3.125 mg BID, and a medication list specifying 37.5 mg BID. The assigned nurse recognized the discrepancy but did not contact a provider and instead ordered 3.125 mg BID, which was administered for an extended period while BP readings remained suboptimal. A consulting pharmacist later noted the inconsistency between the prior 25 mg BID dose, the recommended 37.5 mg BID, and the facility’s 3.125 mg BID order and requested clarification, and facility leadership acknowledged that the order discrepancy should have been identified and clarified.
Staff failed to follow established infection prevention and control policies for Contact Precautions, Enhanced Barrier Precautions (EBP), and COVID-19 exposure testing. A nurse aide entered a resident’s room under Contact Precautions without performing hand hygiene or wearing a gown and gloves while handling a meal tray. Another aide provided a bed bath to a resident on EBP for a chronic wound without a gown, placed soiled linens on the floor, later held them against her body, and handled her personal clothing while still wearing dirty gloves. After a resident’s roommate tested positive for COVID-19, the exposed resident was not tested in accordance with CDC and facility guidance and only received testing after filing a grievance. In a separate incident, a nurse administered enteral nutrition via gastrostomy tube to a resident on EBP wearing only gloves and no gown, despite posted EBP signage and facility policy requiring gown and gloves for high-contact care such as feeding tube activities.
A resident with stroke and non-Alzheimer’s dementia, assessed as severely cognitively impaired and without behaviors, was started on mirtazapine and trazodone for depression and received these medications daily without documented informed consent from the responsible party regarding risks, benefits, or alternatives. The medical record lacked any evidence of such consent, and attempts to reach the responsible party were unsuccessful. Interviews with the ADON, DON, SW, NP, and Administrator showed confusion and inconsistent practices about who was responsible for obtaining psychotropic consents and how new psychotropic orders were communicated, leading to missed consents.
A resident with type 2 DM was inaccurately coded on a quarterly MDS as receiving insulin injections on all 7 days of the look-back period, when MAR review showed she was actually receiving daily liraglutide, a non-insulin injectable for diabetes. The MDS nurse reported she coded the medication section as insulin based on a reference sheet that incorrectly listed liraglutide under insulins. The DON and Administrator confirmed that the resident was coded as receiving insulin due to the liraglutide injections and acknowledged that MDS assessments are expected to accurately reflect medications administered.
A resident with Type 2 DM did not receive Ozempic (semaglutide) injections as ordered over multiple weeks due to a series of failures in medication handling, documentation, and communication. Pharmacy records showed the initial supply was delivered and signed for, and a nurse reported placing it in the medication refrigerator, but subsequent nurses often could not locate the medication when doses were due. Some nurses erroneously documented administration, others documented that the drug was not given without required progress notes, and several did not notify leadership when the medication was unavailable. The pharmacy later reported that a refill was delayed because a required preauthorization fax sent to the facility was not returned, and the DON and Administrator acknowledged there was no clear process for managing such pharmacy communications, leading to repeated missed doses.
A resident with hypertension, heart failure, and documented coronary and peripheral artery disease had conflicting carvedilol dosing instructions from a cardiology visit, while the facility entered a significantly reduced carvedilol dose on the MAR. During the medication regimen review, the consultant pharmacist identified the discrepancy and emailed a recommendation to the DON to clarify the carvedilol order, but the DON did not review the email or forward the recommendation to a provider. As a result, neither the NP nor the Medical Director received the pharmacy recommendation or had the opportunity to address the carvedilol dose discrepancy.
A treatment cart was observed unlocked and unattended in a hallway outside an open resident room while a Wound Care Nurse was behind a privacy curtain providing wound care and unable to see the cart. A surveyor was able to stand between the doorway and the cart without touching it, confirming it was accessible while unsupervised. The cart contained multiple topical medications and treatment products, including A&D ointment, Manuka Honey, Cadexomer Iodine Gel, diclofenac gel, triamcinolone creams, Collagenase Santyl, nystatin powder, and chlorhexidine solution. The nurse acknowledged the cart was unlocked and out of her sight, and the DON stated that any treatment or medication cart out of a nurse’s view should be locked.
A resident received an influenza vaccine without documented consent. Review of the MAR showed the flu vaccine was administered, but the only immunization consent form in the chart had the influenza option left blank and lacked the resident’s signature. In an interview, the DON confirmed there was no consent on file for the flu shot and acknowledged that vaccine consents are expected to be obtained before administration and kept in the medical record.
Surveyors found that nurses failed to notify a provider when a cognitively intact resident with DM II repeatedly did not receive ordered weekly Ozempic because it was documented as unavailable, despite pharmacy records showing delivery and multiple missed administrations recorded on the MAR. In a separate case, staff and a wound care NP identified and treated a new right heel DTI in a severely cognitively impaired resident, with orders entered for skin prep and offloading devices, but there was no documentation that the resident’s RP was informed, and the RP later reported learning of the wound only after a hospital transfer. Leadership interviews confirmed that provider and RP notifications, as well as documentation of those notifications, did not occur as required.
Three cognitively intact residents requested cash from their personal funds accounts, but the money was not available when they asked for it. According to the facility’s investigation and staff interviews, an administrative assistant stated she withdrew the requested amounts, placed the cash in individually labeled envelopes in an unlocked desk or cabinet, and left the area unattended. When she returned, the envelopes were empty and the residents’ funds were missing, leading to allegations of misappropriation of resident property and notification of state authorities and law enforcement.
The facility failed to ensure residents’ right to timely mail delivery when mail was not distributed to residents on Saturdays. During a Resident Council meeting, several residents reported that mail was only delivered Monday through Friday and on some Saturdays if the Activities Director was present. The Activities Director stated that on weekends the manager on duty retrieved mail from the outdoor mailbox and placed it in the Business Office Manager’s office, but it was not taken to residents’ rooms until Monday. The Business Office Manager confirmed that weekend managers did not distribute mail because they were unsure which items belonged to residents and instead passed all mail to her for Monday handoff to the Activities Director. The Administrator reported that her expectation was that the manager on duty deliver mail Monday through Saturday, including Saturdays.
A resident and the Administrator engaged in a loud, public argument in a hallway, witnessed by staff and another resident, resulting in a situation described as undignified and unprofessional. The incident was not deescalated, occurred within hearing distance of others, and led to law enforcement being called, reflecting a failure to uphold resident dignity and rights.
A resident with intact cognition struck another resident with moderately impaired cognition in the dining room, resulting in a facial bruise. The altercation began after one resident attempted to help the other, leading to verbal abuse and a physical slap, despite staff intervention. The incident was witnessed by the ADON and resulted in police involvement.
Staff failed to follow infection control protocols for Enhanced Barrier Precautions (EBP) during high contact care for a resident with chronic wounds, as neither the nurse nor the nurse aide wore gowns and no EBP signage or PPE was present. Interviews revealed that staff, including the Infection Preventionist, had not received training on EBP and were unaware of which residents required these precautions. A review identified 41 residents with chronic wounds or indwelling devices who should have been on EBP, but the facility had not implemented the required measures.
The facility did not have a certified Infection Preventionist overseeing its infection control program, as the ADON assigned to the role had not completed the required CDC certification. Leadership staff, including the DON and Administrator, were unaware that full certification was required prior to assuming the IP position.
The facility did not provide mandatory infection control training or verify staff competency regarding Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. The ADON, responsible for infection prevention training, had not started a training program and was unaware of EBP requirements. During wound care, a nurse and a nurse aide failed to wear gowns as required, affecting residents needing EBP and revealing a lack of adherence to infection control policies.
A resident was not given timely notice of an outside medical appointment, resulting in her attending the appointment in a nightgown without the opportunity to complete her usual hygiene and grooming routine. Staff interviews confirmed the resident's preference for being prepared, and facility leadership acknowledged residents' rights to choose their attire.
Three residents filed grievances regarding staff responsiveness, food quality, missing personal items, and lack of assistance, but the facility failed to document investigations, outcomes, or corrective actions as required by policy. Interviews with staff revealed uncertainty about how incomplete grievance forms were filed, highlighting a breakdown in the grievance handling process.
A cognitively impaired resident, fully dependent on staff, was physically abused by a family member who struck her with a belt, causing visible injuries. Multiple staff, including a nurse and two nurse aides, heard the abuse and the resident's cries but did not immediately intervene, instead delaying action until a manager was notified. The family member admitted to the act, stating she was unaware it was considered abuse. The incident resulted in documented injuries and police involvement.
A resident with severe cognitive impairment was physically abused by a family member, resulting in visible injuries and an ER visit. Facility staff, including a nurse and two nurse aides, heard distressing sounds but did not immediately intervene or protect the resident. The incident was not reported to the state agency within the required two-hour timeframe, as staff believed notifying local police was sufficient. This resulted in a failure to follow abuse identification, intervention, and reporting procedures.
A facility failed to follow its abuse and misappropriation policy when two nurses reported concerns about a resident's morphine appearing tampered with and a nurse appearing impaired. Despite staff observations and written statements, the incident was not reported to authorities or thoroughly investigated, and the accused nurse was not suspended or drug tested.
A resident with paranoid schizophrenia missed six doses of Clozapine due to a failure in obtaining and faxing required lab results to the pharmacy, leading to an acute psychotic event and a fall causing severe injuries. The facility's staff were aware of the medication's importance but failed to ensure timely lab work and communication with the pharmacy.
A resident with paranoid schizophrenia did not receive necessary lab tests for Clozapine monitoring, leading to missed doses and a psychotic episode. The oversight occurred when a nurse failed to complete lab paperwork, preventing the pharmacy from dispensing the medication. The resident experienced a psychotic event, resulting in a fall and serious injuries.
A facility failed to protect residents from abuse, with incidents involving a male resident with schizophrenia and dementia physically assaulting two female residents. Despite having a care plan for aggressive behaviors, interventions were ineffective, and staff were afraid of the resident. Additionally, a male resident verbally threatened a female resident, with no care plan addressing his behaviors.
The facility failed to provide RN coverage for 8 consecutive hours per day, 7 days a week, on 9 specific days in May and June 2024. This was confirmed through PBJ Staffing Data and payroll punches, with no available staffing records for those months. Current staff were not employed during the deficiency period and could not account for the lack of coverage.
A resident, who was cognitively intact and required meal assistance, was referred to as a 'feeder' by a nurse aide, causing the resident to feel like an animal. The nurse aide admitted the term should not have been used, and the DON confirmed that staff were instructed to avoid such terminology to maintain resident dignity.
Two residents experienced deficiencies in self-determination and equipment availability. A resident dependent on mechanical lift pads was unable to get out of bed due to a shortage of clean pads, affecting his daily routine and strength maintenance. Another resident, assessed as a safe independent smoker, was restricted to smoking only during supervised times, despite her ability to smoke safely without supervision. These deficiencies were linked to facility policies and practices that did not align with the residents' preferences and needs.
A facility failed to provide a complete SNF ABN for a resident by omitting the estimated cost of non-covered services. The resident, admitted with metabolic encephalopathy and dementia, was assessed as severely cognitively impaired. Interviews with staff revealed that the estimated cost should have been included to inform the resident or family about care decisions.
The facility failed to report and investigate allegations of misappropriation of property for two residents. One resident's missing bank card and cash were not properly reported with a 5-day investigation report, and another resident's missing purse, containing identification and cash, was not reported to the State Agency, APS, or law enforcement. The facility assumed the purse was misplaced and did not conduct a formal investigation.
A resident with dementia was not assessed for cognition, mood, and behavior in their most recent MDS assessment, resulting in a deficiency. The Social Worker responsible for this section could not recall why the assessment was not completed, suggesting it may have been an oversight. The facility Administrator confirmed that the assessment should have been accurate.
A resident with generalized muscle weakness required a mechanical lift for transfers, but this was not documented in their care plan. Despite being cognitively intact and dependent on others for transfers, the care plan lacked details on the use of a mechanical lift and two-person assistance. Interviews with staff revealed a lack of responsibility and communication regarding the resident's transfer needs.
The facility failed to update care plans and conduct care plan meetings for three residents. One resident's care plan inaccurately included one-on-one supervision, which was not provided. Two other residents, who were cognitively intact, were not invited to care plan meetings as required. Staff interviews confirmed these deficiencies, and there was a lack of documentation for the meetings.
A cognitively impaired resident with dementia exited a facility without staff knowledge due to inadequate security measures. The resident, identified as at risk for elopement, was found outside a back door that lacked a Wanderguard system. The door was sometimes left ajar and did not alarm if left open. The resident was safely returned inside by staff after being found by an Administrative Assistant.
A resident with an acquired absence of her right leg missed a scheduled medical appointment to have staples removed due to a transportation delay. The transportation company arrived late, causing the resident to miss her appointment, which had to be rescheduled for the following week. The resident was upset about the delay in her care.
An opened vial of Flucelvax influenza vaccine was found in the medication room refrigerator without an open date or discard date. The ADON admitted the vial should have been labeled with the nurse's initials, the date opened, and a discard date. The Administrator and DON confirmed the expectation for proper labeling and acknowledged the oversight.
A resident with severe cognitive impairment did not receive a pneumococcal vaccine despite having a signed consent form. The ADON prioritized influenza vaccinations due to the flu season and delayed ordering the pneumococcal vaccine, which was not in stock. The resident's physician indicated there was no reason for the delay, and both the DON and Administrator acknowledged the resident should have been vaccinated upon admission and after consent.
A resident with a stage 4 pressure ulcer on the left heel did not have their treatment documented in the TAR from July 1st to July 12th, despite the treatment being administered by the nurses. The treatment order, which involved applying sodium hypochlorite solution (dakins) once daily, was not reflected in the electronic records, and the nurses were unsure why it disappeared from the system.
Incomplete and Inaccurate TAR/MAR Documentation for Wound Care and Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate Treatment Administration Records (TARs) and Medication Administration Records (MARs) for multiple residents. For one resident with a surgical left foot incision, physician orders dated 8/26/25 directed daily and as-needed wound care using Dakin’s solution, collagen particles, Dakin’s-moistened gauze, and abdominal gauze roll. Review of the September 2025 TAR showed no documented wound care on several specific dates, despite wound care notes from 8/27/25 through 9/18/25 indicating the wound was improving. The previous Wound Care Nurse and the Assistant Director of Nursing each stated in interviews that they had completed the ordered wound care on the dates in question but had failed to document it on the TAR. Another resident with bilateral lower extremity lymphedema had physician orders dated 4/28/25 for leg treatments twice weekly on Mondays and Thursdays, including cleansing with soap and water, application of triamcinolone, special gauze with calamine, rolled gauze, and an ace wrap from the base of the toes to one inch below the knee. TAR reviews for August, September, November, and December 2025 showed that these treatments were not marked as completed on several specific dates. Nurses interviewed, including Nurse #11, Nurse #8, and the Assistant Director of Nursing, each stated they had completed the treatments as ordered but forgot to mark them as complete on the TAR. The DON and Administrator both stated that treatments should be documented as complete in real time when finished. For another resident with an order for Lispro insulin 3 units subcutaneously three times daily with meals, the EMAR for November 2025 showed missing nurse signatures for multiple scheduled insulin administration times. Nurses assigned on those dates stated they did not recall the specific days but indicated that if insulin had not been given, the EMAR should have been coded with a reason, and that blank EMAR boxes likely meant they had forgotten to sign. The DON and Administrator explained that the EMAR system highlights resident names in red when medications are not signed off and green when they are, and there was no stated reason for the lack of signatures. In a separate case, a resident with DM II had an order for weekly Ozempic injections; the October 2025 MAR showed documentation by a nurse that the medication was administered on a specific date and time. In a later interview, that nurse stated the documentation was an error, recalling that she had looked for the medication but could not find it, and both the DON and Administrator stated that the nurse should not have documented administration when the medication had not actually been given.
Failure to Clarify Conflicting Carvedilol Orders Resulting in Significant Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to clarify and correctly implement a carvedilol dosage order for a resident with hypertension, heart failure, and coronary and peripheral artery disease, resulting in a significant medication error. The resident was discharged from the hospital with an order for carvedilol 25 mg by mouth twice daily and admitted to the facility with that same dose ordered for essential hypertension. The Medication Administration Record (MAR) shows that this 25 mg twice-daily dose was administered from 12/3/25 through 12/4/25. On 12/5/25, the resident was seen by a cardiologist (Physician #2). The cardiology consultation documents contained conflicting information: the handwritten portion recommended increasing carvedilol to 37.5 mg twice daily with a systolic blood pressure goal of 110–130 mmHg; a printed “After Visit Summary Instructions” section stated to increase carvedilol to 3.125 mg twice daily; and a printed medication list specified carvedilol 25 mg, 1.5 tablets (37.5 mg) in the morning and 37.5 mg in the evening. Nurse #12, who was assigned to the resident that day, reviewed these documents, recognized the discrepancy among the handwritten recommendation, the printed instructions, and the medication list, but did not contact a provider for clarification. Instead, she entered an order for carvedilol 3.125 mg by mouth twice daily based on the printed instructions portion, despite knowing she should have called to clarify the conflicting information. Following this order entry, the MAR shows that carvedilol 3.125 mg twice daily was administered from the evening of 12/5/25 through the end of December and continued into January until 1/7/26. During this period, the resident’s blood pressure was monitored twice daily, with systolic readings ranging from 100 to 180 mmHg in December and 111 to 172 mmHg in early January, and diastolic readings ranging from 48 to 94 mmHg in December and 55 to 87 mmHg in early January. The consulting pharmacist identified the discrepancy between the original 25 mg twice-daily dose, the cardiologist’s recommendation to increase to 37.5 mg twice daily, and the facility’s significantly reduced 3.125 mg twice-daily order during an initial medication regimen review on 12/8/25 and sent a recommendation to the DON to clarify it. The Medical Director later acknowledged that someone at the facility should have identified and clarified the discrepancy, and the DON stated that Nurse #12 should have immediately clarified the carvedilol order when she saw the conflicting information, characterizing the situation as a significant medication error.
Failure to Follow Contact Precautions, EBP, and COVID-19 Testing Protocols
Penalty
Summary
The deficiency involves multiple failures by staff to follow the facility’s infection prevention and control policies for Contact Precautions and Enhanced Barrier Precautions (EBP), as well as failure to follow CDC guidance and facility policy for COVID-19 testing after exposure. For a resident on Contact Precautions due to a communicable disease, signage on the door instructed all persons to perform hand hygiene and don gloves and a gown before entering, and to remove them and perform hand hygiene upon exit. Despite this, a nurse aide entered the resident’s room without performing hand hygiene or donning a gown or gloves, picked up the resident’s meal tray, exited the room, placed the tray on the cart, and did not perform hand hygiene afterward. The aide later stated she had received infection control and contact precautions training, acknowledged she should have followed the posted instructions, and explained she was in a hurry and did not look for the sign. The facility also failed to follow its EBP policy for a resident with a chronic wound who was on EBP. The policy and door signage required staff to perform hand hygiene and wear a gown and gloves for high-contact care such as bathing, dressing, and handling linens. An aide was observed in this resident’s room wearing gloves but no gown after providing a bed bath, handling what appeared to be soiled linens. She dropped the linens on the floor at the end of the bed, later picked them up, held them against her body, carried them across the room, and dropped them on the floor near the trash can. While still wearing the same dirty gloves, she put on her personal fleece jacket. The aide stated she did not notice the EBP sign because she was in a hurry, acknowledged she should have worn a gown, and stated that soiled linens should not be placed on the floor but directly into a plastic bag. The ADON/IP and DON confirmed that EBP had been implemented for this resident due to a chronic wound and that the aide had been trained on EBP and safe linen handling. The report further describes a failure to follow CDC and facility guidance for COVID-19 testing after exposure. CDC guidance and the facility’s COVID-19 policy required testing residents exposed to COVID-19 no earlier than 24 hours after exposure and as soon as possible thereafter, with CDC recommending a series of three tests after close contact. One resident’s roommate tested positive for COVID-19, and the resident later filed a grievance stating he felt he should be tested because of this exposure. He was not tested until several days after the roommate’s positive result, when the grievance was addressed, and the test was negative. The current ADON, who was a floor nurse at the time, stated the resident should have been tested prior to the grievance date according to facility policy. The previous ADON, who was then responsible for infection control, stated she had been told by the previous Administrator that residents were not tested for COVID-19 unless symptomatic, and she acknowledged that in other facilities she had worked, entire halls were tested after a positive case. The current DON, who was not employed at the time, reviewed the timing and stated the previous infection preventionist did not follow the facility’s COVID testing policy, which reflected CDC guidance. Another deficiency occurred when staff failed to implement EBP requirements during high-contact care for a resident receiving enteral nutrition via gastrostomy tube. The facility’s isolation policy for EBP required the use of gown and gloves for high-contact resident care activities in the resident’s room, including feeding tube care, and specified that signage above the resident’s bed would inform staff of PPE instructions. During an observation of enteral nutrition administration, a nurse entered the resident’s room, which had an EBP sign posted on the exterior of the door, performed hand hygiene, and donned clean gloves but did not don a gown. She then administered nutrition through the gastrostomy tube using a feeding syringe. In a subsequent interview, the nurse stated she forgot to put on a gown and acknowledged she should have worn one. The DON and Administrator both stated they expected a gown to be worn when providing enteral nutrition in a room with EBP signage.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain informed consent and notify the responsible party (RP) prior to initiating psychotropic medications for a resident. The resident was admitted with diagnoses including stroke and non-Alzheimer’s dementia and was assessed as severely cognitively impaired, with no behaviors, and receiving antidepressant medications. Physician orders showed mirtazapine 7.5 mg at bedtime starting on 10/7/25 and trazodone 100 mg in the afternoon starting on 11/13/25 for depression, and the Medication Administration Record for January 2026 indicated these medications were administered daily. The medical record contained no documentation that the RP was informed in advance of the risks and benefits of these psychotropic medications, the treatment alternatives available, or that consent was obtained, and attempts to reach the RP were unsuccessful. Interviews with facility staff revealed confusion and inconsistency regarding responsibility for obtaining psychotropic medication consents. The ADON stated she was unsure who was responsible for obtaining consent. The DON acknowledged awareness that some psychotropic consents were not signed because the SW, who had been responsible for obtaining consents, was not always informed by nursing when new psychotropic medications were ordered. The SW confirmed she had been responsible for obtaining consents and relied on nursing staff to notify her of new psychotropic orders, which did not always occur, resulting in missed consents. The NP stated that nursing staff were responsible for obtaining consent for newly prescribed psychotropic medications. The Administrator stated she was not aware that this resident lacked signed consents for mirtazapine and trazodone, although she knew consents should have been obtained prior to implementation of these medications.
Inaccurate MDS Coding of Non-Insulin Diabetes Medication as Insulin
Penalty
Summary
The facility failed to ensure an accurate MDS assessment in the medication section for one resident with type 2 diabetes mellitus. The resident’s quarterly MDS with an ARD of 9/25/25 was coded to show that she received insulin injections on all 7 days of the look-back period. However, review of the September 2025 MAR showed that during this period she was administered liraglutide, a non-insulin injectable medication for type 2 diabetes, once daily at 8:00 AM from 9/18/25 through 9/25/25. In a telephone interview, the MDS nurse who completed the assessment stated she coded insulin injections for 7 of 7 days because the resident received daily liraglutide injections and she relied on a reference sheet she had found that listed liraglutide under insulins. In separate interviews, the DON and the Administrator acknowledged that the MDS nurse had coded the resident as receiving insulin based on the liraglutide injections and both stated that MDS assessments should be coded accurately to reflect the medications residents actually received.
Failure to Administer Ordered Ozempic Doses Due to Medication Handling and Communication Breakdowns
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed medication, Ozempic (semaglutide), as ordered for a cognitively intact resident with Type 2 diabetes mellitus. The physician’s order directed that the resident receive 1 mg subcutaneously every 7 days, starting in late October and continuing through mid-December. Pharmacy records showed that a 28‑day supply of Ozempic was delivered to the facility and signed for by a nurse, who stated she would have passed the medication to the nurse assigned to the resident. The ADON reported receiving the medication and placing it in the medication refrigerator because the dose was not due on her shift. The resident later reported that she was supposed to receive her first dose in October but did not receive a dose until December. The October Medication Administration Record (MAR) contained documentation by one nurse that the Ozempic dose was administered, but that nurse later stated this entry was an error and that she had not been able to locate the medication and did not call the pharmacy as she should have. On another October date, the MAR showed the dose was not given with a direction to see a progress note, but no corresponding progress note existed to explain the omission. Another nurse reported that on multiple occasions when the medication was due, it was not available despite searching medication storage areas, and that she had been told by the pharmacy that a 28‑day supply had already been sent and no additional supply could be sent at that time. She acknowledged not notifying anyone that the medication was unavailable. In November, the MAR showed one documented administration of Ozempic by another nurse, who could not recall where she obtained the medication or what happened to the pen afterward. Subsequent November MAR entries by different nurses documented that the medication was not administered, sometimes with instructions to see a progress note, but in several instances there was no corresponding progress note explaining why the dose was missed. One nurse documented speaking with the pharmacy and learning that a 28‑day dose had been sent in October and that a new supply could not be sent until mid‑November, and she reported this to the resident. In late November and early December, additional MAR entries showed the medication was not given with no explanatory notes. The DON and ADON later stated that nurses had documented the medication as unavailable and, in some cases, contacted the pharmacy, but had not notified facility leadership or a provider, and there was no established process for handling pharmacy preauthorization forms related to this medication, contributing to ongoing missed doses. The Medical Director stated he had been made aware that the resident had not been receiving Ozempic as ordered by the NP and reported that the resident had not experienced specific adverse outcomes such as blurred vision, recurrent UTIs, or hospitalizations related to this incident. The pharmacist reported that after the initial 28‑day supply was delivered, the next fill was delayed because a required preauthorization sent to the facility was not returned, and the next supply was not sent until December. The Administrator and DON both indicated that nurses documented unavailability of the medication and, at times, contacted the pharmacy, but did not escalate the issue to leadership or ensure follow‑through on pharmacy communications and preauthorizations, resulting in repeated missed doses of the ordered medication.
Failure to Communicate Pharmacist’s Recommendation to Clarify Carvedilol Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the attending physician was informed of a consultant pharmacist’s recommendation to clarify a carvedilol order for a resident reviewed for unnecessary medications. The resident was admitted with hypertension and heart failure, and a cardiology consultation documented coronary and peripheral artery disease. The cardiologist’s documentation contained conflicting instructions: a handwritten recommendation to increase carvedilol to 37.5 mg twice daily, an after-visit summary stating 3.125 mg twice daily, and a medication list specifying 37.5 mg in the morning and evening. The facility’s admission order, entered by a nurse, was for carvedilol 3.125 mg twice daily, representing a significant decrease from the resident’s prior 25 mg twice daily dose. During the monthly medication regimen review on 12/8/25, the consultant pharmacist identified the discrepancy between the prior 25 mg twice daily dose, the cardiologist’s recommendation to increase to 37.5 mg twice daily, and the facility’s order for 3.125 mg twice daily. The pharmacist documented a recommendation to clarify the carvedilol dose and order on the MAR and reported sending this recommendation by email to the DON on the same date. The DON acknowledged that she did not check her email daily, had not reviewed the December medication regimen reviews, and was unaware of the recommendation until 1/7/26, and therefore did not forward it to a provider. The NP and Medical Director both reported they had not received the pharmacy recommendation and indicated they would have addressed it if it had been provided to them, with the Medical Director stating it should not have taken a month for him to receive such a recommendation.
Unlocked Treatment Cart Left Unattended and Out of Nurse’s View
Penalty
Summary
The deficiency involves a failure to keep medications stored in a locked treatment cart when not under direct supervision. During an observation on 1/5/26 at 8:32 AM, Treatment Cart #1 on the 100-hall was found with its locking mechanism in the unlocked position while positioned outside an open resident room. The cart was oriented toward the resident’s room, and the resident’s privacy curtain was drawn around the resident and the Wound Care Nurse, who was providing care inside the room. A transport driver was approximately 15 feet away from the unlocked cart, and no other individuals were observed nearby. The surveyor was able to stand between the resident’s doorway and the unlocked cart without touching it, confirming that the cart was unattended and accessible while unlocked. At 8:35 AM, the Wound Care Nurse returned from behind the privacy curtain and acknowledged that she had been unable to visualize the treatment cart while in the resident’s room and was unaware of the surveyor’s presence near the cart. Upon inspection, she confirmed that the cart was unlocked and stated it should be locked when unattended, also confirming it had been out of her sight while she was providing care. At 8:36 AM, the contents of Treatment Cart #1 were observed to include multiple topical medications and treatment products, such as A&D ointment, Manuka Honey, Chymosin topical, Cadexomer Iodine Gel, diclofenac sodium 1% gel, triamcinolone 0.5% cream, Collagenase Santyl ointment, triamcinolone acetonide 0.1% cream, nystatin topical powder, and Dyna-hex 4% chlorhexidine gluconate solution. At 8:41 AM, the DON stated that any treatment or medication cart that is out of view of the nurse should be locked, confirming that the observed situation did not meet facility expectations for medication security.
Failure to Obtain Documented Consent Prior to Influenza Vaccination
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document consent prior to administering an influenza vaccination. Record review showed that Resident #80 was admitted on an unspecified date and received an influenza vaccine on 9/22/25, as documented on the September 2025 Medication Administration Record. However, the only immunization consent form in Resident #80’s medical record, dated 11/20/25, had the influenza vaccination option left blank and did not contain the resident’s signature consenting to the flu vaccine. During an interview on 1/8/26 at 10:18 AM, the Director of Nursing confirmed there was no consent on file for the flu vaccination given on 9/22/25 and stated that consents should always be obtained before vaccine administration and maintained in the resident’s medical record. This lack of documented consent prior to vaccination for Resident #80, as confirmed by both record review and staff interview, constitutes the identified deficiency.
Failure to Notify Providers of Unavailable Medication and RP of New Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify medical providers when an ordered medication was unavailable for administration to a resident with diabetes mellitus type 2. The cognitively intact resident had a physician’s order for weekly subcutaneous Ozempic for DM II and weight loss. Pharmacy records showed the medication had been delivered and signed for, but the Medication Administration Records (MARs) for October, November, and December documented multiple dates when nurses did not administer the Ozempic because it was not available. On at least three separate dates, different nurses documented the medication as unavailable yet did not notify the resident’s physician or other medical provider, and they were unable to explain why they had not done so. Facility leadership, including the ADON, DON, NP, Medical Director, and Administrator, all stated that a provider should have been notified immediately when the medication was not available so that alternative medications or orders could be obtained. The deficiency also includes the facility’s failure to notify a resident’s responsible party (RP) when a new deep tissue injury (DTI) developed on the resident’s right heel. The resident was severely cognitively impaired and had an existing unhealed pressure ulcer. A wound progress note documented that care was reestablished due to a new right heel DTI, with measurements and a treatment plan that included daily skin prep and offloading pressure, and indicated the plan was discussed with staff and the resident. Subsequent physician orders were entered for skin prep and Prevalon boots to offload pressure. However, there was no documentation in the medical record that the RP was notified of the new DTI. Interviews and record review confirmed the lack of required notifications. The RP later reported that she had not been informed of the right heel DTI and only became aware of the pressure wound when the resident was transferred to the hospital months later. The ADON and DON, after reviewing the medical record, confirmed there was no documentation of RP notification regarding the new DTI. The interim Administrator stated she had been unaware that RPs were not being informed of new skin concerns and acknowledged that RPs should be notified after the physician is called and treatment orders are obtained, with such notification documented in the record.
Failure to Safeguard Residents’ Personal Funds
Penalty
Summary
The deficiency involves failure to protect residents from misappropriation of their personal funds. Three cognitively intact residents had personal funds requested from their trust accounts that were not available when requested. One resident reported that in November her $50.00 in personal funds was not available when she asked for it and that she only received the money on a later day after repeated requests. Another resident reported being told by the Business Office Manager that the facility did not have the $30.00 in cash he requested from his personal funds and that he had to wait until later in the month to receive his money. A third resident was identified in the investigation as having $50.00 in requested funds that were also not available when requested. According to the facility’s investigation and staff interviews, on the date of the incident the previous Administrative Assistant stated she placed cash from the three residents’ personal trust accounts into individually labeled envelopes and put them in her desk or file cabinet, which she left unattended and unlocked while she went outside to supervise residents who were smoking. When she returned, the envelopes were empty and the residents’ funds were missing. The Business Office Manager, Social Services Director, and Regional Business Office Manager all reported that the previous Administrative Assistant had described placing the residents’ cash in labeled envelopes and leaving the area, after which the money was no longer there. Law enforcement was notified, and the facility reported the allegation of misappropriation of resident property to the state agency, but attempts to interview the previous Administrator and the law enforcement officer who took the report were unsuccessful.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents’ right to receive mail delivered on Saturdays, affecting the reasonable access to communication methods for all 67 residents. During a Resident Council meeting on 1/6/26 at 1:00 PM, multiple residents reported that mail was not delivered on Saturdays, explaining that the Activities Director delivered mail Monday through Friday and only on Saturdays if she happened to be in the facility. In an interview at 1:16 PM, the Activities Director stated that on weekends the manager on duty retrieved mail from the outdoor mailbox and placed it in the Business Office Manager’s office, but mail was not delivered to residents’ rooms on Saturdays and was instead given to her on Monday for distribution. At 1:25 PM, the Business Office Manager confirmed that weekend managers retrieved mail but did not distribute it because they were unsure which mail belonged to residents, and that they gave all mail to her so she could pass it to the Activities Director on Mondays. In an interview at 1:30 PM, the Administrator stated that her expectation was that staff deliver mail Monday through Saturday, including Saturdays, by the manager on duty. These actions and inactions resulted in residents not receiving their mail on Saturdays, despite the Administrator’s stated expectation that mail be delivered six days a week.
Failure to Maintain Resident Dignity During Public Argument
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence and self-determination, as evidenced by an incident involving a loud and public argument between the Administrator and a cognitively intact resident. The confrontation began when the resident requested to speak with the Administrator regarding nursing care and became verbally aggressive. The Administrator responded in a similarly elevated tone, and the argument escalated in the hallway, drawing the attention of multiple staff members and other residents. The situation was not deescalated by staff, and the exchange continued in a manner that was loud and disruptive. Several staff members, including the ADON, Nurse Aide, Activities Director, Rehabilitation Program Manager, PT Assistant, and DON, witnessed the event. Staff interviews confirmed that the argument was conducted in a public area, within hearing distance of other residents, and that the Administrator and the resident were both raising their voices. The ADON instructed a nurse aide to call the police, and the PT Assistant eventually led the Administrator outside to separate her from the situation. Law enforcement was called and spoke with the resident following the incident. Another cognitively intact resident, who was in the hair salon nearby, reported hearing the entire exchange and described the behavior of both the Administrator and the resident as undignified and unprofessional. Multiple staff corroborated that the argument was loud, public, and not appropriate for the setting. The incident demonstrated a failure to maintain resident dignity and to manage conflict in a manner that respected the rights and privacy of those involved and those who witnessed the event.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with intact cognition struck another resident with moderately impaired cognition, resulting in a bruise to the right side of the face. The incident took place in the dining room area after one resident attempted to assist the other, who was stuck in a doorway in his wheelchair. The situation escalated when the resident being assisted began to curse and use racially charged language toward the other resident. Despite the Assistant Director of Nursing (ADON) intervening and instructing the resident not to hit, the resident proceeded to slap the other on the face. Documentation and interviews confirmed that the altercation was witnessed by the ADON, who heard yelling and responded to the scene. The resident who was struck did not recall the incident during a subsequent interview, while the resident who struck claimed he did not make contact, though the ADON and documentation confirmed otherwise. The incident resulted in a physical injury (bruise) and was reported to the police, with the resident who struck being charged with assault.
Failure to Implement Enhanced Barrier Precautions for Residents with Chronic Wounds and Indwelling Devices
Penalty
Summary
The facility failed to follow its infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. During an observation of wound care provided to a resident with chronic wounds, neither the nurse nor the nurse aide wore gowns as required for high contact care activities under EBP. Additionally, there was no signage indicating the need for EBP in the resident's room, and personal protective equipment (PPE) for EBP was not readily available. Interviews with staff revealed a lack of awareness and training regarding EBP. The wound care nurse and nurse aide both stated they had not received education on EBP and were unaware of which residents required these precautions. The Assistant Director of Nursing, who also served as the Infection Preventionist, admitted she had not implemented EBP in the facility and was unfamiliar with the requirements for residents with chronic wounds or indwelling devices. The Director of Nursing was aware of the EBP requirements but was unsure why they had not been implemented, and the Administrator could not explain the lack of EBP implementation or staff training. A review of the facility's resident list identified 41 residents with chronic wounds or indwelling medical devices who should have been on EBP but were not. The facility's policy required EBP for such residents, including the use of gowns and gloves during high contact care, appropriate signage, and staff notification, none of which were in place at the time of the survey.
Lack of Certified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist (IP) who was certified in infection prevention and control to oversee the Infection Control and Prevention Program. The Assistant Director of Nursing (ADON), who was assigned as the facility's IP, had not yet completed the required certification, having finished only 13 out of 20 modules in the CDC IP program. Both the ADON and the Director of Nursing (DON) were unaware that full certification was required before assuming the IP role, believing that working toward certification was sufficient. The Administrator was also unaware that the ADON lacked the necessary certification. This deficiency had the potential to affect all 72 residents in the facility.
Failure to Train Staff and Implement Enhanced Barrier Precautions for Residents with Chronic Wounds
Penalty
Summary
The facility failed to implement an effective infection prevention and control training program for nurses and nurse aides, specifically regarding Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. The Assistant Director of Nursing (ADON), who was responsible for staff training on infection prevention, was unaware that EBP was required for residents with these conditions during high contact care. Additionally, the ADON had not initiated any training program for staff on infection control practices and procedures. This lack of training and awareness extended to the Director of Nursing (DON) and the facility Administrator, both of whom were unaware that staff had not been trained or deemed competent in EBP protocols. During observations, it was noted that a nurse and a nurse aide provided wound care to a resident with chronic wounds without wearing gowns, which was a direct violation of the facility's infection control policy. The facility had 41 residents who required EBP due to chronic wounds or indwelling medical devices, and the failure to follow proper precautions was identified in all three staff members reviewed for competency. These findings were based on staff interviews, record reviews, and direct observation.
Failure to Maintain Resident Dignity During Medical Appointment Preparation
Penalty
Summary
A cognitively intact resident was not informed in advance of a scheduled outside medical appointment. The transportation driver received notice of the appointment early in the morning and notified the facility nurse, but the resident was only awakened by two night shift aides shortly before departure. As a result, the resident did not have sufficient time to perform her usual morning routine, which included bathing, selecting appropriate clothing, and applying makeup. Instead, she attended the appointment in her nightgown and underwear, using wipes for personal hygiene, and was unable to prepare herself as she preferred. Interviews with staff confirmed that the resident typically liked to be prepared for appointments and would request to be awakened early if she was aware of them. The scheduler maintained a personal planner with all resident appointments, and the appointment in question was documented. The resident expressed feeling angry and unimportant due to the lack of notice and inability to present herself as she wished for the appointment. Facility leadership acknowledged that residents have the right to choose their attire when leaving the facility.
Failure to Document Grievance Investigations and Outcomes
Penalty
Summary
The facility failed to maintain evidence of grievance investigations and decisions for three residents who filed grievances. Each grievance form reviewed was incomplete, lacking documentation of the investigation, outcome, or recommendations for corrective action. The facility's grievance policy requires that investigations include employee accounts of alleged incidents and recommendations for corrective action, but these elements were missing from the records for all three residents. The grievances included concerns about staff responsiveness, food quality, missing personal items, and lack of assistance with toileting. Interviews with the Social Worker and Administrator revealed a breakdown in the grievance handling process. The Social Worker assisted residents in filling out the initial grievance forms and then forwarded them to the appropriate department head for investigation. After the department head completed the investigation, the Administrator was supposed to review and sign off before the forms were filed. However, both the Social Worker and Administrator were unsure how incomplete grievance forms ended up being filed, indicating a lack of oversight and follow-through in the grievance process.
Failure to Protect Resident from Physical Abuse by Family Member
Penalty
Summary
A severely cognitively impaired resident, dependent on staff for all activities of daily living and with a history of intellectual disability and neurological condition, was subjected to physical abuse by a family member while in the facility. The family member entered the resident's room and struck her with a belt three to five times, resulting in visible whip-like marks on the resident's left upper thigh and abdomen. Multiple staff members, including a nurse and two nurse aides, heard the sounds of the abuse and the resident's cries of pain but did not immediately intervene or enter the room to stop the incident. The nurse, after hearing the sounds and confirming with the aides, chose to inform the Unit Manager rather than directly intervening, citing shock and the presence of a family member as reasons for her inaction. The nurse aides also heard unusual noises and looked into the resident's room but did not witness the act directly due to a pulled curtain and did not take further action, returning to their duties with other residents. One aide later admitted not knowing that a family member hitting a resident constituted abuse within the facility. The family member later confirmed during an interview that she had hit the resident with a belt to discipline her for undressing, stating she was unaware that this was considered abuse or that it would result in police involvement. The incident was eventually reported to the Unit Manager, who entered the room, observed the family member with a belt, and found the resident with red, raised marks consistent with being struck. The resident was assessed for pain and skin injury, with documentation noting whip-like marks but no ongoing pain or skin breakdown. The event was witnessed and reported by staff, and the police were called to investigate. The resident, due to her cognitive impairment, was unable to express her recollection of the event. The deficiency centers on the failure of staff to immediately protect the resident from abuse by not intervening when the abuse was occurring, despite clear auditory evidence and the presence of multiple staff members nearby.
Failure to Immediately Intervene and Report Physical Abuse by Family Member
Penalty
Summary
Facility staff failed to immediately identify and intervene in an incident of physical abuse involving a severely cognitively impaired resident who was dependent on staff for all activities of daily living. The incident occurred when the resident was struck multiple times with a belt by a family member, resulting in visible whip-like marks on the resident's thigh and abdomen and necessitating a visit to the emergency room. Multiple staff members, including a nurse and two nurse aides, heard sounds consistent with physical abuse and cries of pain coming from the resident's room but did not enter the room to intervene or protect the resident at the time of the incident. Instead, the nurse sought out the Unit Manager, and the nurse aides returned to their duties without further investigation. The staff's response was delayed, as neither the nurse nor the nurse aides immediately entered the room to stop the abuse, despite hearing distressing sounds and being aware that a family member was present. The nurse later admitted that she did not intervene because she was in shock and had never encountered a family member abusing a resident, although she acknowledged she would have acted differently if another resident had been the perpetrator. The nurse aides also did not recognize that a family member hitting a resident constituted abuse within the facility. The Unit Manager eventually entered the room, confronted the family member, and observed the physical injuries on the resident. Additionally, the facility failed to notify the state agency within the required two-hour timeframe after becoming aware of the abuse. The initial allegation report was not sent to the state agency until the following day, well beyond the mandated reporting window. The facility administrator believed that notifying the local police department fulfilled the reporting requirement, but later confirmed that the state agency was not contacted until the next day. This delay in reporting, combined with the lack of immediate intervention, constituted a failure to adhere to the facility's abuse policies and procedures.
Failure to Report and Investigate Alleged Medication Tampering and Staff Impairment
Penalty
Summary
The facility failed to implement its policy for reporting and investigating allegations of abuse, neglect, and misappropriation of property when concerns were raised about possible tampering with a resident's liquid morphine and the apparent impairment of a nurse. Two nurses observed that the morphine appeared diluted and a different color, and that a new bottle's seal appeared tampered with. These concerns were reported to the Unit Manager, Assistant Director of Nursing (ADON), and Director of Nursing (DON), but the allegations were not reported to the State Agency, law enforcement, or Adult Protective Services as required by facility policy and regulations. Additionally, a thorough investigation was not conducted, and the accused nurse was not suspended or drug tested despite multiple staff observations of impairment. The resident involved had a history of prostate cancer, was on comfort measures, and was receiving scheduled opioid medication for pain and air hunger. The medication administration records and narcotic count sheets did not show discrepancies, and the resident did not display signs of pain or distress during the period in question. However, staff noted that the morphine's appearance was unusual and that the seal on a new bottle was not intact. The pharmacy was contacted but could not dispense a new bottle without a new prescription, which was subsequently obtained from the Medical Director. Despite written statements from staff and direct reports to nursing leadership, the DON did not initiate a formal investigation or report the incident to the required authorities. The DON expressed uncertainty about the policy regarding drug testing staff and did not follow up with the accused nurse, who resigned shortly after the incident. The Administrator later acknowledged that the appropriate steps to investigate and report the allegation were not completed because the facility believed the medication was accounted for.
Medication Error Leads to Resident's Acute Psychotic Event and Injury
Penalty
Summary
The facility failed to administer six doses of a required antipsychotic medication, Clozapine, to a resident diagnosed with paranoid schizophrenia. This resident, who was stable and adhering to his medication regimen, experienced an acute psychotic event after missing these doses, resulting in a fall that caused a broken shoulder and hip, requiring surgical repair. The incident occurred because the necessary laboratory tests, required by the pharmacy to dispense the medication, were not completed and sent in a timely manner. The resident had a physician's order for Clozapine to be administered twice daily, but the medication was put on hold due to missing laboratory results needed for pharmacy approval. Despite the order for a STAT lab test, the results were not faxed to the pharmacy promptly, leading to a delay in medication delivery. The resident's behavior deteriorated significantly during this period, culminating in a fall while attempting to confront staff, which resulted in severe injuries. Interviews with staff revealed a lack of communication and follow-through regarding the medication and laboratory requirements. The medication aide and nurses involved were aware of the importance of the medication and the need for lab work but failed to ensure the necessary steps were taken to prevent the medication error. The facility's failure to manage the medication administration process effectively led to the resident's acute psychotic episode and subsequent injuries.
Removal Plan
- Resident #11's medication of Clozapine was administered to the resident as ordered by the provider.
- An audit of all current residents was completed by the Director of Nursing to determine if any other residents required lab work previous to medication distribution from pharmacy.
- Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated of the new process by the Director of Nursing. When the order appears on the Medication Administration record, the licensed nurse will ensure the lab results are faxed to the pharmacy.
- Education was provided by the Director of Nursing to licensed staff and licensed agency staff that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record, the licensed nurse will ensure the lab results are faxed to the pharmacy.
- The Quality Assurance team met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; the results were received and faxed to pharmacy when applicable; and the medication is administered as ordered by the provider to prevent a significant medication error; and when the order appears on the Medication administration record, the licensed nurse will ensure the lab results are faxed to the pharmacy. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent a significant medication error with ordered lab work through the weekend reviewed for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee for review and, if warranted, further action.
Failure to Obtain Lab Tests Leads to Resident's Psychotic Episode and Injury
Penalty
Summary
The facility failed to obtain and provide necessary laboratory tests for a resident on Clozapine, an antipsychotic medication, which led to a significant health event. The resident, diagnosed with paranoid schizophrenia, had a physician's order for regular blood tests to monitor potential side effects of Clozapine. However, the required laboratory tests were not conducted as ordered on the specified date, and the results were not sent to the pharmacy, which was necessary for the medication's renewal. The oversight occurred when a nurse failed to place the necessary paperwork in the laboratory book, resulting in the phlebotomist not having the information needed to draw the resident's blood. Consequently, the pharmacy did not receive the required lab results, leading to the medication being put on hold. The resident missed several doses of Clozapine, which is known to cause rebound psychosis if abruptly stopped. This resulted in the resident experiencing an acute psychotic event, during which he fell and sustained serious injuries, including a broken shoulder and hip. Interviews with staff, including the nurse practitioner and pharmacist, revealed that the facility was aware of the requirement for lab tests before dispensing Clozapine. Despite this, the necessary steps were not taken to ensure the tests were completed and communicated to the pharmacy. The failure to follow through with the lab orders and communicate results led to the resident's medication being withheld, contributing to the resident's psychotic episode and subsequent injuries.
Removal Plan
- Resident #11's medication could not be administered as ordered by the provider due to it not being available. The nurse notified the pharmacy of the medication not being available to administer. The pharmacy stated the medication required lab work to be completed and faxed to the pharmacy prior to dispensing the medication. The provider was notified, and an order was obtained to draw stat lab work. The results of the labs were received and the provider failed to place a physician order to fax the results to the pharmacy so the medication could be dispensed. The nurse notified the pharmacy the medication was not available to administer. Upon notifying the pharmacy, the pharmacy stated they had not received the lab results to dispense the medication. The provider was notified and stated the lab work had been completed and needed to be faxed to the pharmacy. The lab results were faxed to the pharmacy and received by the pharmacy. The pharmacy dispensed the medication. The facility received Resident #11's medication. Resident #11's medication of Clozapine was administered to the resident as ordered by the provider.
- An audit of all current residents was completed by the Director of Nursing to determine if any other residents required lab work previous to medication distribution from pharmacy. No other residents required lab work prior to medication distribution indicating that there were no other residents affected by the deficient practice of not obtaining lab services as ordered by the provider.
- Licensed nurses were educated on the new process that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider is notified to review. When applicable, a separate order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. The providers were educated on the new process by the Director of Nursing. When the order appears on the Medication Administration record the licensed nurse will ensure the lab results are faxed to the pharmacy.
- Education was provided by the Director of Nursing to licensed staff and licensed agency staff that the provider will enter a physician order for lab work. The order will be on the Medication Administration Record. The Licensed Nurse will ensure a lab form is completed and placed in the lab book for the lab to be drawn. Results of the lab are integrated with the electronic medical records system and once the results are received the provider when applicable will order for lab results to be faxed to the pharmacy. The order will be placed on the medication administration record when a lab is required to be faxed to the pharmacy for medication distribution. When the order appears on the medication administration record the licensed nurse will ensure the lab results are faxed to the pharmacy.
- The Quality Assurance team met and a decision was made that the Director of Nursing or Designee will audit that includes the following: the provider entered a physician order for lab work; the order was placed on the Medication Administration Record; a lab form was completed and placed in the lab book for the lab to be drawn; an order was placed to fax the results to pharmacy for medication distribution when applicable; when the order appears on the medication administration record the licensed nurse ensured the lab results were faxed to the pharmacy, and the results were received and faxed to pharmacy when applicable. All ordered lab work will be reviewed from the previous day to ensure results have been reviewed by the provider and as applicable faxed to the pharmacy timely to prevent an omission of ordered lab services with ordered lab work through the weekend reviewed for two weeks and then weekly for ten weeks. Results of these audits will be presented by the Director of Nursing or Designee to the facility Quality Assurance and Performance Improvement (QAPI) Committee monthly for review and, if warranted, further action.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving three residents. One male resident, who had a history of aggressive behaviors and was diagnosed with schizophrenia and dementia, physically assaulted two female residents on separate occasions. The first incident involved the male resident entering a female resident's room and punching her multiple times in the legs. The second incident occurred at the nurse's station, where the same male resident punched another female resident in the face, believing she was cheating on him. Both female residents were vulnerable and unable to protect themselves due to cognitive impairments and physical limitations. The male resident had a care plan that identified his behavioral issues, including aggression towards staff and other residents. Despite this, the facility's interventions, such as administering medications and attempting to redirect the resident, were ineffective in preventing the assaults. The male resident's behavior was unpredictable, and staff were reportedly afraid of him due to his strength and tendency to lash out without warning. The facility's failure to adequately manage the male resident's behaviors and protect other residents from harm resulted in a deficiency. Additionally, another incident of verbal abuse was reported, where a male resident threatened to kill a female resident and others in the facility. The female resident felt threatened and reported the incident to staff. The male resident involved in this incident was also assessed as cognitively intact, yet there was no care plan addressing his behaviors. This further highlights the facility's failure to protect residents from abuse and ensure their safety.
Removal Plan
- Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.
- Staff immediately removed Resident #222 from the resident's room. Residents were assessed for injuries by the staff nurse. No injuries were noted. Resident #2's physician was notified. All attempts to calm Resident #2 were unsuccessful. Resident #2 was sent to the hospital emergency department for further evaluation. Social Services offered emotional support to Resident #222 and documented no signs of distress, discomfort or pain noted. Upon Resident #2 returning to the facility resident was placed on increased supervision and assessed by psychiatric nurse practitioner.
- Resident #2 was observed punching Resident #61 in the nose with a closed fist twice while both were in their wheelchairs at nurses' station. Staff immediately separated the residents. Resident #2 was sent to emergency room for further evaluation. Resident #61 was assessed with no injuries noted.
- Resident #2 continues to reside at the facility under psychiatric care and services. Resident #2 continues to receive medications as ordered and has not had any further altercations. He has shown a decrease in overall aggressive behaviors. Resident #222 no longer resides in the facility. Resident #61 continues to reside in the facility without further concerns.
- All Staff were interviewed by the Scheduler and Administrative Assistant. All residents that were able to participate in an interview were interviewed by the Social Services and Admissions Director. The questions that they were asked were the following: Do you know about abuse? Do you know who to report abuse to? Do you feel safe in the facility? Do you have any concerns about abuse (physical, verbal, emotional, sexual, financial)? Any further allegations made will be investigated towards resolution by the Administrator and/or Director of Nurses. All residents were assessed by nurses via skin sweeps for suspicious injuries. No suspicious injuries (those injuries that would be evident without a reasonable or rational explanation for the injury) were noted at those times. All residents were assessed by the Director of Nursing, Assistant Director of Nursing and Unit Manager for behaviors including verbal abuse, physical aggression to ensure appropriate care plans were in place to prevent resident to resident altercation.
- Education - All staff including nurses, certified nursing assistants, agency/contract staff, all ancillary staff, and all newly hired employees will be educated on the Abuse Prevention Policy. The policy describes the right for residents to be free from abuse, neglect, exploitation or mistreatment. Staff will receive education on managing residents who have aggressive behaviors. Staff will be educated on verbal and nonverbal signs of aggression such as increased agitation, yelling out and clenching of fists. Staff will be educated on techniques to de-escalate residents displaying increased agitation such as removing the residents from the trigger and providing a quiet place for de-escalation. Staff will be trained to use the behavioral monitoring forms to document any aggressive behavior, including what happened before, during, and after the incident.
- All education will be completed by the DON/ADON designee. This education will include 1:1, and group training sessions. The Administrator/designee will be the person who will ensure all licensed nurses, certified nursing assistants, agency/contract staff, all ancillary staff, and all newly hired employees will be educated. No staff will work until education has been received.
Deficiency in RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for 8 consecutive hours per day, 7 days per week, for 9 out of 163 days reviewed. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 3, 2024, which showed no RN coverage on specific dates in May and June 2024. Additionally, there were no daily assignment schedules or daily nursing postings available for review for these months, and payroll punches confirmed the absence of RN coverage on the specified dates. Interviews with facility staff revealed that the current Staffing Coordinator and Administrator were not employed by the facility during the period in question and were unable to locate the necessary staffing records. The Staffing Coordinator, who started in August 2024, stated that RN coverage had been consistent since she took over scheduling. The Administrator also confirmed that RN coverage had been maintained since her employment began in July 2024, using the Assistant Director of Nursing (ADON) to cover any RN callouts. However, neither could account for the lack of RN coverage during the months of May and June 2024.
Resident Dignity Compromised by Inappropriate Terminology
Penalty
Summary
The facility failed to treat a resident in a dignified manner when staff referred to a resident who needed assistance with eating as a 'feeder.' This incident involved a resident who was cognitively intact and required setup assistance with meals. During a dining observation, a nurse aide referred to the resident as a 'feeder' within the resident's hearing range, which made the resident feel like an animal. The nurse aide acknowledged that staff were not supposed to use the term 'feeder' to avoid making residents feel disabled. The Director of Nursing confirmed that staff were instructed not to use the term for the dignity of the residents.
Deficiencies in Resident Self-Determination and Equipment Availability
Penalty
Summary
The facility failed to ensure a sufficient number of clean mechanical lift pads were available for a resident, identified as Resident #65, who was dependent on these pads for transfers. Despite being cognitively intact and expressing a preference to get out of bed every morning, Resident #65 was unable to do so for several days due to the unavailability of clean lift pads. Interviews with Nurse Aides (NAs) revealed that the lift pads were often unavailable at the beginning of the month due to increased usage for monthly weight checks, and the pads were not being returned to the laundry promptly after use. The Housekeeping Manager confirmed the shortage and noted that the pads were left in residents' rooms instead of being returned for cleaning. Another deficiency involved a resident, identified as Resident #41, who was assessed as a safe independent smoker but was not allowed to smoke according to her preference. Despite being cognitively intact and having a care plan that acknowledged her ability to smoke safely without supervision, the resident was restricted to smoking only during supervised times. This change was implemented by the new Administrator, who enforced set smoking times for all residents, regardless of their independent smoking status. The resident expressed frustration and anger over this restriction, feeling it treated her like a child. The Director of Nursing (DON) and the Administrator both confirmed the enforcement of these restrictions, citing safety concerns as the reason for the policy change. The DON intervened when the resident attempted to smoke outside of the designated times, reinforcing the policy despite the resident's independent smoking status. This enforcement led to the resident feeling as though her autonomy was being unnecessarily restricted, contributing to her dissatisfaction with the facility's policies.
Incomplete SNF ABN Notice for Resident
Penalty
Summary
The facility failed to provide a complete CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for a resident, identified as Resident #49, by omitting the estimated cost of services not covered by Medicare. Resident #49 was admitted with diagnoses including metabolic encephalopathy and dementia and began receiving Medicare Part A services on the day of admission. The SNF ABN dated 6/22/24 lacked the estimated cost, despite the last covered date being 6/26/24, and the resident remained in the facility. The admission Minimum Data Set assessment indicated that Resident #49 was severely cognitively impaired. During interviews, Social Worker #1 acknowledged that the estimated cost should be included on the SNF ABN to ensure residents or their families are informed about the costs to make decisions regarding care. Administrator #1 also confirmed that the SNF ABN should be completed with the estimated cost to allow informed decision-making by the resident or family.
Failure to Report Misappropriation of Property
Penalty
Summary
The facility failed to submit required investigation reports to the State Agency, Adult Protective Services (APS), and local law enforcement following allegations of misappropriation of property involving two residents. For Resident #172, the facility did not provide a 5-day investigation report after the resident reported a missing bank card and $10. Although the initial 24-hour report was submitted, there was no evidence of the 5-day report being sent. The Director of Nursing (DON) at the time recalled the incident and stated that the missing items were found quickly, but could not confirm if the final report was submitted. In the case of Resident #3, the facility did not submit an initial 24-hour or 5-day investigation report after the resident's purse went missing, which contained her Social Security card, state identification, and $60 in cash. The Social Worker and Administrator assumed the purse was misplaced rather than stolen, and no formal investigation was conducted. The facility assisted the resident in replacing her identification documents but did not report the incident to the appropriate authorities as required by their abuse policy.
Failure to Accurately Assess Cognition, Mood, and Behavior
Penalty
Summary
The facility failed to accurately assess a resident for cognition, mood, and behavior, leading to a deficiency in the Minimum Data Set (MDS) accuracy for one of the residents reviewed. The resident in question was admitted with a diagnosis of dementia, which necessitates careful monitoring and assessment of cognitive and behavioral health. However, the most recent quarterly MDS assessment did not include evaluations for these critical areas. During an interview, the facility's Social Worker, who was responsible for this section of the assessment, admitted to not assessing the resident for cognition, mood, and behavior, attributing the omission to a possible oversight. The facility Administrator acknowledged that the assessment should have been completed accurately.
Failure to Include Mechanical Lift in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who required the use of a mechanical lift device for transfers. The resident, who was admitted with a diagnosis of generalized muscle weakness, was cognitively intact and dependent on others for transfers. Despite this, the resident's care plan, last revised on September 16, 2024, did not include any information about the use of a mechanical lift or the need for two-person assistance during transfers. This omission was confirmed through interviews with the resident, a nurse aide, a nurse, and the MDS nurse, all of whom acknowledged the resident's need for a mechanical lift and two-person assistance. The MDS nurse, who worked part-time, stated that she was not responsible for including the resident's transfer status in the care plan, indicating that it was the nursing staff's responsibility. Both the nurse aide and the nurse admitted to not having reviewed the care plan recently, despite being aware of the resident's transfer needs. The facility's administrator and the Director of Nursing also acknowledged that the use of a mechanical lift should have been included in the care plan, highlighting a breakdown in communication and responsibility among the staff involved in the resident's care planning process.
Failure to Update Care Plans and Conduct Meetings
Penalty
Summary
The facility failed to update care plan interventions and invite residents to care plan meetings for three of the five residents reviewed. Resident #2, who was admitted with dementia and schizophrenia, had a care plan indicating the need for one-on-one supervision due to behavioral issues. However, interviews with various staff members, including nurse aides, nurses, the Director of Nursing, and the physician, revealed that Resident #2 did not receive one-on-one supervision, and there was no physician order for such supervision. The care plan had not been updated to reflect the actual interventions being provided. Resident #43, who was cognitively intact, reported not being invited to a care plan meeting since admission. The social worker confirmed that there was no record of a care plan meeting for this resident, and the administrator was unaware of this oversight. The social worker planned to schedule a meeting and deliver an invitation to the resident, acknowledging the requirement for quarterly care plan meetings. Resident #11, also cognitively intact, did not recall being invited to a care plan meeting recently. The social worker and MDS nurse confirmed that there was no documentation of a care plan meeting following the resident's most recent MDS assessment. The Director of Nursing and the administrator both stated that residents should have care plan meetings at least every three months, with documentation in the resident's records, but this was not done for Resident #11.
Resident Elopement Due to Inadequate Security Measures
Penalty
Summary
The facility failed to prevent a cognitively impaired resident from exiting the building without staff knowledge. The resident, who was diagnosed with dementia and identified as severely cognitively impaired, was admitted with a care plan that included interventions for exit-seeking and wandering. Despite being assessed as at risk for elopement and equipped with a Wanderguard bracelet, the resident managed to exit through a back door that was not connected to the Wanderguard system. On the evening of the incident, the resident was last seen at the nurses' station before being found outside by an Administrative Assistant. The back door, which had a key code lock system but no Wanderguard, was sometimes left ajar and did not alarm if left open. The resident was found sitting in his wheelchair outside the door, facing the building, and was calm and uninjured. The Administrative Assistant, unsure of protocol, sought help from a Nurse Aide to bring the resident back inside. Interviews and observations revealed that the double doors leading to the back door did not have a keypad lock system at the time of the incident, allowing the resident to access the area. The Maintenance Director later installed a keypad lock on these doors. The incident highlighted a gap in the facility's security measures, as only the front door was connected to the Wanderguard system, which failed to prevent the resident's elopement.
Resident Misses Medical Appointment Due to Transportation Delay
Penalty
Summary
The facility failed to ensure that a resident was transported to her physician's office in time for a scheduled medical appointment. The resident, who was cognitively intact and had an acquired absence of her right leg, was scheduled to have staples removed from her leg. However, due to a delay in transportation, she arrived one and a half hours late, and the physician was unable to see her, necessitating a rescheduling of the appointment for the following week. Interviews revealed that the transportation company arrived at the facility at 11:30 AM, despite the need to leave by 10:00 AM to make the 11:00 AM appointment. The transportation company attempted to contact the physician's office to accommodate the delay, but upon arrival at 12:36 PM, the office could not see the resident. The resident expressed upset over having to retain the staples for an additional week due to the missed appointment.
Failure to Label and Date Opened Influenza Vaccine Vial
Penalty
Summary
The facility failed to properly label and date an opened vial of influenza vaccine stored in the medication room refrigerator. During an observation on October 9, 2024, an opened 5 milliliter multidose vial of Flucelvax 2024-2025 influenza vaccine was found in the refrigerator without an open date or discard date marked on it. The Assistant Director of Nursing (ADON) acknowledged that the vial should have been labeled with the nurse's initials, the date it was opened, and a discard date 28 days after opening. The ADON was unsure of the exact date the vial was opened but estimated it was two weeks prior. The opened, unlabeled vial was subsequently discarded. Interviews with the Administrator and Director of Nursing confirmed the expectation that all medications should be dated when opened, and they acknowledged the oversight in this instance.
Failure to Administer Pneumococcal Vaccine Despite Consent
Penalty
Summary
The facility failed to provide a pneumococcal vaccine to a resident who had a signed consent form for the vaccination. The resident, who was severely cognitively impaired, was admitted to the facility, and her pneumococcal vaccine status was not up to date as it had not been offered. The Assistant Director of Nursing (ADON) conducted an audit of all residents' pneumococcal immunization status and found that some residents, including this resident, had not received their vaccines. Despite having consent from the resident's Responsible Party (RP) dated 9/10/24, the vaccine was not administered because the facility did not have any pneumococcal vaccines in stock at that time. The ADON prioritized influenza vaccinations due to the upcoming flu season and planned to administer pneumococcal vaccines afterward, with an understanding that the resident's physician preferred a two-week interval between the two vaccines. However, the physician later indicated that there was no reason the pneumococcal vaccine could not have been administered sooner. The Director of Nursing confirmed the plan to update all residents' immunization statuses and acknowledged that the resident should have been offered the pneumococcal vaccine upon admission and after consent was obtained. The Administrator also stated that the resident should have received the vaccine when consent was given.
Failure to Document Pressure Ulcer Treatment
Penalty
Summary
The facility failed to accurately document treatments on a resident's Treatment Administration Record (TAR) for pressure ulcer care. A resident with a stage 4 pressure wound on the left heel was admitted to the facility and had a treatment order from the wound care physician to apply sodium hypochlorite solution (dakins) once daily. However, from July 1st to July 12th, there was no documentation of this treatment on the TAR, despite the treatment being administered by the nurses. Interviews with the treatment nurses revealed that they were aware of the treatment order and had been applying the prescribed treatment, but the order was not reflected in the electronic records. The nurses were unsure why the order disappeared from the system, and the Director of Nursing confirmed that treatment orders should be documented accurately. The wound care physician corroborated that the treatment was being applied as ordered, based on the wound's progression during his visits.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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