Autumn Care Of Myrtle Grove
Inspection history, citations, penalties and survey trends for this long-term care facility in Wilmington, North Carolina.
- Location
- 5725 Carolina Beach Road, Wilmington, North Carolina 28412
- CMS Provider Number
- 345507
- Inspections on file
- 25
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Autumn Care Of Myrtle Grove during CMS and state inspections, most recent first.
A nurse physically restrained a cognitively impaired resident by holding her arms down during incontinence care, resulting in the resident screaming, sustaining bruises, scratches, and pain that required medication. The incident was witnessed by two nurse aides, who also observed the nurse cursing and spitting at the resident and placing a pillow over her face. The resident, who had a history of combative behaviors and required non-restrictive interventions, was left with visible injuries and increased anxiety following the event.
A nurse failed to administer prescribed as-needed pain medication to a cognitively impaired resident with chronic pain after the resident exhibited combative behaviors, including spitting. Instead of attempting to calm or reapproach the resident, the nurse left the room, wasted the medication, and did not reassess or attempt to provide pain relief later in the shift. Facility leadership confirmed this constituted neglect.
Two nurse aides failed to immediately report an incident in which a nurse physically restrained, cursed at, and spit on a resident with severe dementia during care, resulting in the nurse completing her shift and remaining assigned to the resident. The delay in reporting prevented timely investigation and removal of the accused staff, contrary to facility abuse prevention policies.
Two residents did not receive care in accordance with their comprehensive care plans: one resident with a feeding tube did not have a care plan developed for tube care as indicated by the MDS assessment, and another resident with severe cognitive impairment and a history of falls did not have bilateral fall mats in place as ordered and care planned after a room transfer. The DON and Administrator confirmed these deficiencies during observations and interviews.
Staff failed to discard expired insulin pens and did not record an opened date on an in-use insulin pen on a medication cart. Multiple insulin pens were found past their discard date, and one Lantus pen was missing an opened date despite partial use. Nurses were responsible for checking and labeling insulin, but these steps were missed.
Staff failed to follow infection control protocols by not donning required PPE when providing care to two residents on transmission-based precautions for wound care. In one case, a medication aide entered a resident's room on contact precautions without gloves or a gown, and in another, a nurse aide provided high-contact care to a resident on Enhanced Barrier Precautions wearing only gloves. Both incidents occurred despite posted signage, available PPE, and prior staff training.
A mechanical lift was left unattended in a hallway, creating an accident hazard that resulted in a cognitively impaired resident with a history of falls tripping over the equipment while ambulating independently. The resident sustained a minor injury, and staff interviews confirmed that the lift should have been stored in the utility room when not in use.
A resident with a surgically placed j-tube experienced tube dislodgement that was not immediately reported to a physician. Instead, a nurse inserted an indwelling urinary catheter tube into the site without a physician order, after a nurse aide failed to report finding the tube on the floor. The nurse only notified the DON and provider after the replacement tube also became dislodged, resulting in the resident being sent to the hospital for surgical intervention. Staff interviews confirmed that proper notification and procedures were not followed.
A nurse failed to provide appropriate care when a resident's recently placed j-tube became dislodged, inserting a urinary catheter into the site without a physician's order and without recognizing the need for hospital treatment. The tube became dislodged again, and the resident was later sent to the hospital for surgical reinsertion. Facility policy did not permit nurses to replace j-tubes, and the incident resulted in a deficiency related to improper management of enteral feeding tubes.
An agency LPN, lacking documented training and competency in jejunostomy tube (j-tube) care, improperly replaced a dislodged j-tube with a urinary catheter tube without physician orders or appropriate guidance, after failing to recognize the need for hospital treatment. The facility's orientation and competency verification processes for agency nurses did not include specific instruction on j-tube care, leading to this deficiency for a resident requiring specialized feeding tube management.
Over a six-month period, the facility did not address or communicate follow-up on concerns raised by the Resident Council, including issues with meal tickets, food quality, staffing during mealtimes, and menu item availability. Despite concern forms being completed and meeting minutes signed by the Administrator, there was no evidence of follow-up or resolution, leading to resident frustration and a lack of documented action by facility management.
Nursing staff failed to follow Enhanced Barrier Precautions by not wearing gowns while providing tracheostomy and gastrostomy tube care to two residents with indwelling devices. Despite posted signage and available PPE supplies, nurses performed high-contact procedures with only gloves and masks, contrary to facility policy and infection control protocols.
A nurse administered 2 units of sliding scale insulin to a resident with a blood sugar of 103, despite a physician order specifying no insulin for levels below 150. The error occurred after the nurse became distracted by multiple aides and was only realized after the resident's family questioned the need for insulin. The incident was reported to the DON, and the resident did not experience any adverse effects.
A resident with chronic kidney disease and symptoms of UTI did not have an ordered urinalysis and C&S completed because the urine sample, though collected and entered into the EMR and lab website, was not recorded in the lab book used for lab pickups. This omission resulted in the sample not being collected by the lab and no test results being available, as confirmed by staff interviews.
Two residents experienced deficiencies in medical record documentation, including incomplete incident reporting for a resident with a feeding tube and inaccurate medication administration records for a diabetic resident. In both cases, a nurse failed to accurately document care provided, including not recording actual medication administration and leaving required forms incomplete, despite expectations from the DON for thorough and accurate recordkeeping.
A resident with a recent knee replacement fell and exhibited signs of a fracture, including severe pain and inability to bear weight. Despite these symptoms, staff failed to assess and report the condition, attributing the pain to dementia-related behaviors. The fracture was only identified after a family member raised concerns, leading to a delayed diagnosis and treatment.
A resident experienced inadequate pain management following a total knee replacement and a subsequent fall. Despite high pain levels and difficulty bearing weight, staff failed to communicate these issues to the medical provider, attributing the pain to dementia. The resident was later found to have a femur fracture, highlighting a lack of thorough pain assessment and communication within the facility.
A cognitively impaired resident in an LTC facility was sexually abused by another resident with a history of inappropriate behavior. The victim, unable to consent or protect himself, was found with the perpetrator's hand inside his brief. Despite the perpetrator's known history, the facility failed to update care plans or implement effective interventions, leading to the incident.
A severely cognitively impaired resident exited an LTC facility unsupervised after a receptionist unlocked the door, assuming the resident could go outside alone. The resident, who had a history of dementia and falls, was found over an hour later in the parking lot, posing a high risk of harm. The facility failed to provide adequate supervision, as the resident was not previously identified as an exit-seeker.
A resident with a history of stroke and dysphagia experienced severe health complications after a facility failed to follow a physician's order to hold tube feeding following vomiting. The order was not correctly entered into the electronic MAR, leading to continued feeding and subsequent respiratory distress. The resident was hospitalized with aspiration pneumonitis and acute hypoxic respiratory failure.
A facility failed to accurately document the administration of Hydrocodone-Acetaminophen for a resident. The medication was signed out on the declining count sheet but not documented in the MAR. Attempts to contact the responsible nurses were unsuccessful, as one nurse went on leave, another was an agency nurse no longer at the facility, and a third was suspended. The DON acknowledged the issue, revealing inaccuracies in the MARs and missing narcotic count sheets.
The facility failed to maintain a clean and safe environment, with a black greenish substance and foul odor found around commodes in multiple rooms, and broken or missing bathroom door thresholds posing safety hazards. Interviews revealed a lack of communication and responsibility among staff, with no documentation of maintenance follow-up or cleaning schedules.
A long-term care facility failed to obtain and record accurate weights for several residents, leading to significant discrepancies in their weight records. This affected the monitoring and management of residents with complex medical conditions, such as diabetes and congestive heart failure. Staff interviews revealed a lack of consistency and communication regarding weight changes, highlighting gaps in adherence to the facility's weight policy.
A resident on immunosuppressive therapy did not receive monthly CBCs as ordered due to a failure in the lab requisition process. The facility's transition to a new electronic medical record system led to a missed step in notifying the lab vendor, resulting in no CBCs being documented from December to July. The Nurse Practitioner was unaware of the order and relied on external lab results, while the Director of Nursing confirmed the new process but was unaware of the specific order.
A long-term care facility failed to protect residents from the misappropriation of Hydrocodone-Acetaminophen tablets. Two residents, both cognitively impaired, had discrepancies in their medication records, with missing tablets and incomplete documentation. Nurse #6 was implicated in both cases, leading to her indefinite suspension. The facility's inadequate handling and documentation of narcotic medications resulted in this deficiency.
The facility failed to maintain accurate records for controlled drugs, specifically Hydrocodone-Acetaminophen, for two residents. Missing declining count sheets and discrepancies in medication administration records were identified, with no system in place to reconcile narcotic documents. Attempts to contact responsible nurses were unsuccessful, and staff interviews confirmed the lack of proper documentation and reconciliation processes.
The facility failed to ensure a safe environment in the 700-hall by using a floor scrubber with a broken squeegee, leaving water puddles without wet floor signs. Staff interviews confirmed the issue, and budget constraints prevented equipment repair. The absence of signage posed a fall risk.
The facility failed to date two insulin pens, Lantus and Novolog, on a medication cart, which should be discarded 28 days after opening. A nurse, not typically assigned to the cart, was unaware of the missing dates and did not administer the pens. The DON confirmed the requirement for dating insulin pens upon opening.
A resident with severe cognitive impairment was flicked on the forehead by a Medication Aide during care, compromising her dignity. The incident occurred while two Nurse Aides were cleaning the resident after she smeared feces in her room. Witnesses reported the flicking action, which the Medication Aide claimed was a joke. The resident expressed surprise but was not hurt or afraid. The facility investigated the incident, and the Administrator confirmed the action was inappropriate.
Resident Physically Restrained and Injured During Care by Nurse
Penalty
Summary
A cognitively impaired resident with severe vascular dementia, psychotic disturbance, anxiety, delusional disorder, depression, and chronic pain was subjected to physical restraint by a nurse during incontinence care. The resident, who had a history of combative behaviors such as hitting, scratching, and rejecting care, required two-person assistance for personal care. During an episode of care, a nurse entered the room while two nurse aides were assisting the resident and proceeded to hold the resident's arms down, crossing them over her body to restrict movement. The nurse used a technique previously employed in an emergency department setting, despite not being familiar with the facility's policies and procedures regarding restraints in LTC settings. The nurse's actions were witnessed by two nurse aides, who reported that the nurse also cursed and spit at the resident, further escalating the resident's agitation. The nurse placed a pillow over the resident's face, though it was not held down, and the aides removed it. The resident screamed during the restraint and subsequently developed bruising and scratches on her hands, wrists, and forearm, as well as pain that required as-needed pain medication. The nurse aides recognized the actions as abusive and reported the incident, though one aide delayed reporting due to being in shock. Medical assessments following the incident documented new bruising, scratches, and complaints of pain in the resident's hands and wrists. The resident expressed fear and stated that her hand was broken and hurt. X-rays were performed, revealing no fractures, but the resident continued to experience pain and anxiety, requiring additional medication. Staff interviews confirmed that the nurse's actions constituted physical restraint and were not in accordance with the resident's care plan, which emphasized non-restrictive interventions and re-approaching the resident if care was refused.
Neglect Due to Withholding of Pain Medication Following Resident Behavioral Symptoms
Penalty
Summary
A deficiency occurred when a nurse failed to protect a resident's right to be free from neglect by withholding prescribed as-needed pain medication. The resident, who had severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder, depression, and chronic pain due to peripheral neuropathy, requested pain medication. The nurse documented that the resident exhibited behaviors such as scratching, biting, and spitting when she entered the room. In response, the nurse left the room without attempting to calm the resident or reapproach, and did not administer the ordered pain medication. The nurse subsequently wasted the medication and did not attempt to administer it later in the shift, nor did she reassess the resident's pain. The nurse acknowledged being aware of the resident's combative and agitated behaviors but chose not to tolerate them, resulting in the resident not receiving pain relief as ordered. Documentation showed the resident had reported a pain level of 6 out of 10, but there was no record of the pain medication being given during the relevant shift. Interviews with facility leadership confirmed that the nurse's actions were inappropriate and constituted neglect. The Director of Nursing and the Nurse Practitioner both stated that pain should have been addressed and the medication administered as ordered, regardless of the resident's behavioral symptoms. The failure to provide pain relief as requested and ordered, and the lack of further assessment or intervention, led to the finding of neglect for this resident.
Failure to Immediately Report and Protect Resident Following Staff-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse policies and procedures regarding the immediate reporting of an allegation of staff-to-resident abuse and the protection of the resident involved. According to the facility's abuse policy, all staff are required to report any allegations, suspicions, or incidents of abuse or neglect to the Administrator or Abuse Coordinator immediately, but no later than two hours after the event. In this incident, two nurse aides witnessed a nurse physically restrain a resident, curse and spit at the resident, and place a pillow over the resident's face during incontinence care. Both aides acknowledged awareness of the abuse policy and recognized the actions as abuse, but neither reported the incident until the following day when they returned for their next shift, well beyond the required reporting timeframe. The resident involved had severe vascular dementia with psychotic disturbance, cognitive communication deficit, anxiety, delusional disorder, depression, and chronic pain with peripheral neuropathy. During the incident, the resident became agitated, screamed, and attempted to resist care, leading to the nurse's inappropriate actions. The nurse aides reported feeling shocked and needing time to process the event, which contributed to their delay in reporting. As a result of the delayed reporting, the accused nurse was able to complete the remainder of her shift and continued to be assigned to the resident, contrary to the facility's policy that requires immediate removal of staff accused or suspected of abuse. The deficiency was further evidenced by the fact that the incident was not reported to the administration until the next day, delaying the initiation of an investigation and the removal of the accused nurse from duty. The resident was later assessed and found to have discoloration and a small scratch on her right wrist. The failure to immediately report the abuse and protect the resident was confirmed through staff interviews and record review, demonstrating noncompliance with the facility's established abuse prevention policies.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required. For one resident admitted with a gastrostomy (feeding) tube and documented cognitive impairment, the Minimum Data Set (MDS) assessment indicated the need for a care plan addressing the feeding tube. However, a review of the medical record over an eleven-month period revealed that no such care plan was created. The MDS nurse was unaware of the omission, attributing responsibility to a previous nurse who was no longer employed, and the Director of Nursing confirmed that care plans should have been developed according to guidelines. For another resident with severe cognitive impairment, hemiplegia, and a history of falls, the care plan and physician orders required bilateral fall mats to be placed on both sides of the bed. After a fall, the care plan was updated to include this intervention. However, following a room transfer, only one fall mat was present, and the resident was unable to locate the second mat. Observations confirmed the absence of the required fall mat, and both the DON and Administrator acknowledged that the care plan was not being followed as written.
Expired Insulin Pens and Missing Opened Date on Medication Cart
Penalty
Summary
Facility staff failed to properly manage insulin pens on one of four medication carts reviewed for medication storage. Specifically, four insulin pens (three Insulin Lispro/Humalog and one Insulin Glargine/Lantus) were found on the 700-hall medication cart with expiration dates that had passed according to the manufacturer's guidelines, which require pens to be discarded 28 days after opening. Additionally, one Insulin Glargine (Lantus) pen was found in use without an opened date recorded, despite 60 of 300 units having been administered. Interviews with staff revealed that medication aides were not responsible for administering insulin and therefore did not check for expired insulin, while nurses were expected to check for expired medications and record opened dates on insulin pens. The Unit Manager and DON both confirmed that nurses were responsible for checking medication carts for expired medications at least weekly, and that insulin pens should be checked daily and prior to use. The expired insulin pens and the pen lacking an opened date were not identified or discarded as required.
Failure to Follow Infection Control Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures in two separate instances involving staff members providing care to residents on transmission-based precautions. In the first instance, a medication aide entered the room of a resident who was on contact precautions due to a wound infection, without donning the required personal protective equipment (PPE), specifically gloves and a gown. Despite a clearly posted sign on the resident's door and a stocked PPE cart outside the room, the aide proceeded to take the resident's blood pressure without the necessary protective attire. The aide later stated she was unaware of the resident's contact precaution status and did not notice the sign, although she acknowledged having received infection control training and understanding the requirements for contact precautions. In the second instance, a nurse aide provided high-contact care activities, including changing bed linens, assisting with activities of daily living, and transferring a resident with a surgical wound and a lower leg dressing, who was on Enhanced Barrier Precautions (EBP). The nurse aide wore gloves but failed to wear a gown, as required by the facility's EBP policy for high-contact care activities. A sign indicating the need for gloves and a gown was posted on the resident's door, and PPE supplies were available at the entrance. The nurse aide admitted to not reading the entire EBP sign and believed a gown was only necessary for wound care, not for other high-contact activities, despite having received training on EBP protocols. Both incidents were confirmed through staff interviews, review of facility policies, and direct observation. The residents involved had active wound care needs, with one on antibiotics for a wound infection and the other requiring daily and periodic wound dressings. The failures to follow established infection control protocols occurred despite the presence of clear signage, available PPE, and prior staff training.
Mechanical Lift Left in Hallway Causes Resident Fall
Penalty
Summary
A deficiency occurred when a mechanical lift, not in use, was left unattended in the hallway by a staff member. This created an accident hazard, resulting in a cognitively impaired resident with Alzheimer's disease, dementia, agitation, and a history of falls, tripping over the lift while ambulating independently. The resident had poor safety awareness, impaired memory, confusion, and was at high risk for falls, as documented in her care plan and assessments. The incident led to a minor injury, with the resident sustaining a small amount of blood from her left nostril after the fall. Staff interviews and record reviews confirmed that the mechanical lift was supposed to be stored in the utility room when not in use, and that staff had been educated on fall hazards and the importance of maintaining clear hallways. Despite these protocols, the lift was left in the hallway, directly contributing to the resident's fall. The resident continued to ambulate independently and required frequent redirection due to her severe cognitive impairment and impulsivity.
Failure to Immediately Notify Physician and Inappropriate Tube Replacement
Penalty
Summary
A facility failed to immediately notify a physician when a resident's jejunostomy tube (j-tube) became dislodged. The resident, who had a history of stroke, dysphagia, and was severely cognitively impaired, relied on the j-tube for nutrition and medication administration. On the day of the incident, a nurse aide observed a tube on the bathroom floor but did not report it to the nurse. Hours later, the assigned nurse discovered the j-tube was missing and, without contacting the physician, inserted an indwelling urinary catheter tube into the j-tube site, following advice from the wound nurse who was unaware it was a j-tube. There was no physician order for this action. The nurse was not aware that the tube was a j-tube rather than a gastrostomy tube and did not recognize the need for immediate hospital transfer or physician notification. The nurse only notified the DON after the replacement tube became dislodged a second time, at which point the DON instructed her to contact the provider and send the resident to the hospital. The resident was subsequently transferred to the hospital, where surgical intervention was required to replace the j-tube. Interviews with facility staff, including the nurse, nurse aide, wound nurse, DON, nurse practitioner, and medical director, confirmed that the nurse did not follow proper protocol for physician notification and tube replacement. The medical director and nurse practitioner both stated that it was inappropriate and unsafe for a nurse to replace a j-tube in the facility, especially without a physician's order, due to the risk of serious complications. Documentation review showed that the physician was not notified until after the second dislodgement and inappropriate tube replacement had occurred.
Removal Plan
- The DON, Assistant Director of Nursing (ADON), and Unit Managers re-educated Licensed Nurses and Nurse Aides (NA) on Resident Change in Condition Policy with emphasis on changes that require immediate physician notification and documentation.
- Nurse Aides were educated to notify the charge nurses if any devices, such as enteral feeding tubes, were displaced or not in resident at time of care.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty.
- New Licensed Nurses, Agency Nurses, and Nurse Aides will be educated by the DON or ADON during the orientation process.
- The Director of Nursing will review the Facility Activity Report for any Interact SBAR, Interact Nursing Home to Hospital Transfer Forms, or any Events in the morning Clinical Morning Meeting, which will be held seven days a week, to verify prompt and/or immediate notification is communicated to the Physician and/or Provider.
- If notification to the physician has not occurred, the DON will notify the physician at that time.
Improper Replacement of Dislodged Jejunostomy Tube by Nursing Staff
Penalty
Summary
A deficiency occurred when a nurse failed to provide appropriate care for a resident with a recently placed jejunostomy tube (j-tube) after it became dislodged. The resident, who had a history of stroke, global aphasia, dysphagia, and was fully dependent on tube feeding, was found without his j-tube in place. The nurse, who was an agency nurse unfamiliar with the specific type of tube, did not recognize the need for hospital treatment and instead inserted an indwelling urinary catheter tube into the j-tube site without a physician's order. This action was taken after consultation with the Wound Nurse, who advised replacing the tube with a similar-sized enteral tube or urinary catheter, but also instructed to call the provider for an order. The nurse did not obtain a physician's order before proceeding. The replacement tube became dislodged again within a short period, and the resident was subsequently sent to the hospital for reinsertion. Interviews revealed that the nurse was unaware the tube was a j-tube rather than a gastrostomy tube and stated she would have sent the resident to the hospital if she had known. The Wound Nurse and DON both confirmed that facility policy did not permit nurses to replace j-tubes in the facility, only gastrostomy tubes with a physician's order. The DON and Medical Director emphasized that j-tubes require surgical or radiological placement and that the site was not mature, increasing the risk of complications. The nurse did not complete documentation related to the incident, and the DON had to document the event after being notified. Additional interviews with staff and the responsible party confirmed that the tube was found on the floor, and the resident was bleeding from the site. The responsible party found the resident attempting to stop the bleeding and called for assistance. The resident was transferred to the hospital, where multiple attempts were made to replace the tube, ultimately requiring surgical intervention. The incident was identified as affecting one resident reviewed for feeding tubes, and the facility's failure to follow proper procedures for j-tube dislodgement led to the deficiency.
Removal Plan
- The Director of Nursing, Assistant Director of Nursing, and Unit Managers will provide education to Licensed Nurses on Enteral Feeding Tube(s) Policy, including what to do if a j-tube becomes dislodged, physician notification, not to attempt reinsertion of the j-tube, and sending the resident to the hospital for surgical reinsertion.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence, vacation, agency staff or PRN staff will be re-educated prior to returning to duty by the DON or ADON.
- New hires and Agency Nurses will be educated by the Director of Nursing or Assistant Director of Nursing during the orientation process.
- The DON or ADON will review all new admissions in the Clinical Morning Meeting to determine if any admissions have a j-tube present and ensure all Licensed Nursing staff are made aware of the presence of a j-tube and the process for physician notification and treatment if a j-tube becomes dislodged.
- Licensed nurses will be made aware of residents that are admitted with a j-tube via the Admission Notification Form that is provided by the Admission Director for all pending admissions.
- Admission Notification Form will be delivered to the admitting nurse with the hospital discharge summary by the Admission Director prior to resident arrival.
Failure to Ensure Agency Nurse Competency in J-Tube Care
Penalty
Summary
The facility failed to ensure that agency nurses were properly trained and competent to care for residents with jejunostomy tubes (j-tubes). An agency LPN, who was hired without documented competency or specific training on j-tubes, was involved in an incident where a resident's j-tube became dislodged. The nurse did not recognize the need for hospital treatment and instead inserted a urinary catheter tube into the j-tube site, mistakenly assuming it was a gastrostomy tube. This action was performed without a physician's order and without the necessary radiographic or surgical guidance required for j-tube replacement. Record review confirmed that the nurse's employee file lacked evidence of j-tube competency or training, and the facility's orientation for agency nurses did not include specific instruction on j-tubes at the time of her employment. Interviews with the nurse revealed she did not recall receiving j-tube training during orientation at this facility, despite having prior experience elsewhere. The DON stated that the agency was responsible for verifying nurse competencies, and acknowledged that the facility's orientation did not cover j-tube care for agency nurses. The incident was identified during a review of three nurses for competency and three residents with feeding tubes. The nurse's improper handling of the dislodged j-tube created a high likelihood of serious harm, as confirmed by interviews with the nurse practitioner, medical director, staff, and the responsible party. The deficiency was limited to one resident with a j-tube, and no other residents with j-tubes were identified in the facility during the review period.
Removal Plan
- The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers will provide education to Licensed Nurses on Gastrostomy Tube Reinsertion Policy, including what to do if a j-tube becomes dislodged, physician notification, not to attempt reinsertion of the j-tube, risks, and sending the resident to the hospital for surgical reinsertion.
- A quiz was created to validate staff understanding of the material that was taught. Any nurse that cannot answer the quiz questions appropriately will be retrained by the DON or ADON on the material.
- The Director of Nursing will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty.
- New hires and Agency Nurses will be educated by the DON or ADON during the orientation process using the Gastrostomy Tube Reinsertion Policy.
- The quiz will be given at the end of their training to validate understanding on what to do if a j-tube becomes dislodged, including physician notification, not to attempt reinsertion of the j-tube, risks, and sending the resident to the hospital for surgical reinsertion.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to act upon and communicate follow-up regarding concerns raised by the Resident Council over a six-month period. Resident Council meeting minutes consistently documented concerns about meal tickets not matching what was served, the taste of food, insufficient staff during mealtimes, and the unavailability of always available menu items. Although concern forms were reportedly filed and meeting minutes were signed by the Administrator, there was no documentation or evidence that these concerns were addressed or that any follow-up was communicated back to the Resident Council. Interviews with the Resident Council President and the Activity Director confirmed that concerns were regularly recorded and concern forms were completed, but no resolutions or responses were provided to the council. The Resident Council President expressed frustration over the lack of follow-up, stating that management did not address the council's concerns. The Activity Director indicated that she submitted concern forms and meeting minutes to the Administrator but did not see any follow-up or action taken. The Social Services Director reported not being involved in the process and had not seen any concern forms or attended meetings. The Administrator acknowledged that the Social Services Director was previously responsible for addressing Resident Council concerns, but after the previous Social Services Director left, the process lapsed. The Administrator admitted to not attending Resident Council meetings, not being involved in addressing concerns, and having no documentation to show that grievances were addressed. Despite signing the meeting minutes, the Administrator could not confirm awareness of the repeated concerns expressed by residents.
Failure to Follow Enhanced Barrier Precautions During High-Risk Resident Care
Penalty
Summary
The facility failed to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during direct care activities for residents with indwelling devices. Specifically, two nurses were observed providing tracheostomy care, including suctioning, and administering tube feedings to residents without donning the required protective gown, despite wearing gloves and masks. Facility policy and posted signage clearly indicated that gowns and gloves were required for high-contact care activities involving residents with tracheostomies and gastrostomy tubes. Both nurses performed these procedures without a gown, and one nurse stated she was unaware of the requirement, while the other acknowledged the omission as an error. Observations confirmed that EBP signage and PPE supplies were present outside the residents' rooms, and interviews with the Infection Control Preventionist and Director of Nursing confirmed that staff had received education on EBP and PPE use. The residents involved had tracheostomies and gastrostomy tubes, placing them at higher risk for transmission of multi-drug-resistant organisms, which the EBP policy was designed to address. The failure to follow established infection control protocols was directly observed during care activities for these residents.
Insulin Administered Contrary to Physician Order Due to Nurse Distraction
Penalty
Summary
A deficiency occurred when a nurse administered 2 units of fast-acting sliding scale insulin to a resident with a blood sugar level of 103, despite a physician's order specifying that no insulin should be given for blood sugar levels below 150. The resident, who was nonverbal and unable to assess cognition, had a diagnosis of diabetes and was receiving insulin therapy. The nurse became distracted by multiple nurse aides while at the medication cart, which led to the administration of insulin in error. The nurse initially documented 0 units administered but later confirmed that 2 units had been given. The error was discovered when the resident's family questioned the need for insulin, prompting the nurse to realize the mistake. The nurse reported the incident to the Director of Nursing the same day. The Medical Director confirmed that the physician's orders for sliding scale insulin were not followed, and the Director of Nursing acknowledged that the nurse should not have administered insulin for a blood sugar reading less than 150. The resident did not experience any negative outcome from the medication error.
Failure to Obtain Ordered Urinalysis and Culture Due to Process Breakdown
Penalty
Summary
A deficiency occurred when the facility failed to obtain an ordered urinalysis and culture and sensitivity for a resident who was experiencing symptoms of a urinary tract infection, including burning, urgency, and decreased urinary output. The resident, who had a history of chronic kidney disease and moderately impaired cognition, was admitted with frequent incontinence. On the day symptoms were noted, a physician ordered a urinalysis and culture and sensitivity, and an antibiotic was started. The nurse collected the urine sample and entered the order into the electronic medical record and the lab services website, but did not record it in the lab book, which is used by the lab service to identify samples for pickup. As a result, the urine sample remained in the facility refrigerator and was not picked up by the lab, and no test results were available for the period reviewed. The breakdown in the process was confirmed by staff interviews, which revealed that the required step of recording the order in the lab book was missed. The Director of Nursing and other staff acknowledged that the established process for obtaining laboratory tests was not followed in this instance.
Incomplete and Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident with a jejunostomy tube, physician orders included tube feeding and multiple medications to be administered via the feeding tube. On a specific date, the Medication Administration Record (MAR) indicated that several medications were administered by a nurse during the morning medication pass. However, the nurse later stated that she did not actually administer these medications, despite having signed them off as given. Additionally, documentation related to the resident's change in condition and subsequent transfer to the hospital was incomplete, with significant portions of the SBAR form left unfilled, including vital signs, evaluations, and appearance sections. The nurse did not return to the facility to complete the required documentation despite multiple requests from the Director of Nursing (DON). For another resident with diabetes, there was a physician's order for sliding scale insulin, specifying no insulin should be given for blood sugar readings below 150. On a particular date, the MAR showed that zero units of insulin were administered when the resident's blood sugar was 103. However, the nurse later admitted to administering 2 units of insulin in error and stated that the documentation on the MAR was incorrect. The nurse attributed the error to being distracted by other staff and acknowledged that the record should have reflected the actual administration of insulin. Interviews with the DON confirmed awareness of the medication error and the incomplete documentation. The DON stated that nursing staff are expected to ensure documentation is complete and accurate, but in these cases, the records did not accurately reflect the care provided or the events that occurred.
Failure to Assess and Report Resident's Condition Post-Fall
Penalty
Summary
The facility failed to comprehensively assess a resident who experienced a fall, leading to a significant delay in identifying a serious injury. The resident, who had a recent total knee replacement, fell on the night of admission and exhibited signs of a potential fracture, including external rotation and shortening of the leg, severe pain, and inability to bear weight. Despite these symptoms, the nursing staff did not report these findings to the on-call provider, nor did they conduct a thorough assessment to determine the cause of the resident's pain and mobility issues. Throughout the resident's stay, multiple staff members, including nurses, nursing assistants, and therapists, observed the resident's pain and difficulty with mobility but failed to communicate these observations effectively. The resident's pain was often attributed to behavioral issues related to dementia, and assumptions were made that the pain was related to the recent knee surgery. The physical therapist and therapy assistant noted the resident's inability to bear weight and external rotation of the leg but did not report these findings to the nursing staff or medical provider. The lack of communication and failure to assess the resident's condition led to a delay in diagnosing a comminuted right intertrochanteric femur fracture. It was not until a family member expressed concern and a physician was called to evaluate the resident that the fracture was identified, and the resident was sent to the emergency room for treatment. This deficiency highlights a significant breakdown in the facility's processes for assessing and responding to changes in a resident's condition.
Inadequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide thorough and ongoing pain assessments for a resident who was admitted after a total knee replacement and experienced a fall shortly after admission. The resident's pain levels were inadequately managed, with pain ratings ranging from 6 to 10 over several days. Despite the resident's increased pain and inability to bear weight, the facility staff did not effectively communicate these issues to the medical provider, nor did they reassess the resident's pain management regimen. The resident's electronic health record indicated orders for pain medications, but the administration of these medications did not consistently result in effective pain relief. Nursing staff and therapists observed the resident's high pain levels and difficulty with mobility, yet these observations were not adequately reported to the medical provider. The resident's pain was often attributed to behavioral issues related to dementia, leading to a lack of appropriate medical evaluation. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's pain and condition. Several staff members assumed the resident's pain was related to his recent surgery or dementia, and did not report significant changes in the resident's condition. Ultimately, the resident was found to have a comminuted right intertrochanteric femur fracture, which was not identified until the resident was evaluated at the hospital.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a vulnerable male resident from sexual abuse by another cognitively impaired male resident. The incident occurred when the family member of the victimized resident observed the perpetrator with his hand inside the victim's brief while the victim was lying in bed. The victim, who had severe cognitive impairment and was unable to give consent or protect himself, experienced increased agitation and restlessness following the incident, leading to an increase in his antidepressant medication. The perpetrator had a history of inappropriate sexual behavior, including disrobing in public and inappropriate touching of other residents. Despite this, the care plan for the perpetrator had not been updated since July 2024, and interventions to protect other residents were not effectively implemented. The perpetrator was able to propel himself in a wheelchair independently and was observed wandering the hallways, which ultimately led to the incident in the victim's room. Staff interviews revealed that the perpetrator frequently used sexually inappropriate language and exhibited sexually suggestive behavior. However, there was no indication that staff had taken adequate measures to prevent such incidents from occurring. The facility's failure to provide adequate supervision and intervention for the perpetrator's known behaviors directly contributed to the incident of sexual abuse.
Removal Plan
- The facility failed to protect Resident #1's right to be protected from sexual abuse perpetrated by Resident #2. Resident #2 was redirected by his assigned certified nursing assistant once the nurse was made aware of the interaction. Resident #1 was assessed by the Director of Nursing with no signs of injury or emotional distress. Resident #1 was then moved to another room on the opposite side of the building. The Director of Nursing started continuous monitoring with Resident #2 while he was out of bed since Resident #2 cannot transfer independently. The continuous monitoring is one to one and is being performed by clinical and non-clinical staff members. This monitoring is ongoing. The Nursing Home Administrator notified the local police department, the Department of Health and Human Services and Adult Protective Services of the incident. Resident #1 was referred to psychiatric services and is pending Veteran Affair approval. Resident #2 was referred to psychiatric services and was seen in the facility. A root cause analysis was completed and it was determined that Resident #2 had poor impulse control and needed increased supervision while out of bed.
- The Director of Nursing, Unit Manager #1 and Unit Manager #2 interviewed all alert and oriented residents to ensure that no additional incidents had occurred in the facility. There were no additional incidents reported. The Director of Nursing, Unit Manager #1 and Unit Manager #2 assessed all cognitively impaired residents to ensure there were no signs of abuse. There were no negative findings on the physical assessments. The Interdisciplinary Team, consisting of the Director of Nursing, Unit Manager #1, Unit Manager #2, Nursing Home Administrator and the Minimum Data Set nurse reviewed resident care plans to identify any additional residents with similar behaviors. One additional resident was identified with like behaviors but had no documented behaviors. The additional resident was also placed on hourly visual observations that are conducted by the assigned nurse and certified nursing assistant.
- The Director of Nursing educated all staff on the North Carolina Abuse Policy and Procedure as well as Management of Sexual Behaviors Policy. The education reinforced documentation of behaviors, implementing immediate intervention to ensure the safety of other residents from inappropriate or unwanted sexual behaviors or conduct. The education also reviewed the development of individualized care plans and notification to the Director of Nursing and the Provider. All staff that were not educated face to face were educated via phone. Any staff member that the Director of Nursing was unable to reach will be required to sign the education prior to working their next scheduled shift. All newly hired staff will be educated by the Director of Nursing, upon hire, prior to working in resident care areas.
- The facility decided to monitor and take the plan of correction to the Quality Assurance Committee which consisted of the Director of Nursing, Nursing Home Administrator, Unit Managers, Wound Care Nurse, Minimum Data Set Nurse and the Social Worker. To monitor and maintain ongoing compliance, the Director of Nursing or designee will conduct 5 resident interviews weekly for 4 weeks, then 3 resident interviews weekly for 4 weeks, then 1 resident interview weekly for 4 weeks to ensure there are no allegations of inappropriate sexual touching. In addition, the Director of Nursing or designee will conduct 5 skin assessments on cognitively impaired residents weekly for 4 weeks, then 3 skin assessments on cognitively impaired residents weekly for 4 weeks, then 1 skin assessment on cognitively impaired residents weekly for 4 weeks to ensure there are no signs of inappropriate sexual touching. Audits will be reviewed by the Quality Assurance Performance Improvement Committee, which consist of the Director of Nursing, Nursing Home Administrator, Unit Managers, Wound Care Nurse, Minimum Data Set Nurse and the Social Worker monthly for 3 months.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a severely cognitively impaired resident, who was able to exit the building without the knowledge of the nursing staff. The incident occurred when the Weekend Receptionist unlocked the front door and allowed the resident to go outside unsupervised. The resident was outside for over an hour before being found by a nurse in the facility's parking lot, attempting to navigate her wheelchair up a curb. The resident had a history of non-traumatic brain dysfunction, unspecified dementia, and a history of falls, but was not coded for wandering and required supervision for activities of daily living. The resident's care plan included interventions for impaired cognitive function and a risk for falls, but did not include measures for preventing elopement, as she was not previously identified as an exit-seeking individual. The Weekend Receptionist, who was new to the facility, did not check with the nursing staff before allowing the resident to exit, assuming she could go outside by herself. The receptionist was called away from the desk, and upon returning, found the resident was no longer on the porch. The nursing staff was unaware of the resident's absence until she was found outside by Nurse #5. Interviews with staff revealed that the resident did not exhibit exit-seeking behaviors prior to the incident and was usually content staying in her room. The facility's failure to supervise the resident adequately and the receptionist's lack of awareness regarding the resident's cognitive status contributed to the deficiency. The resident was found safe and uninjured, but the situation posed a high likelihood of serious harm due to the proximity of a busy highway.
Removal Plan
- Nurse #5 assigned to Resident #7 notified the Unit Manager that Resident #7 needed a wander guard band because resident #7 was in the side parking lot of the building.
- Resident #7 was assisted back into the facility by Nursing Assistant #3 and assessed for injuries by Nurse #5.
- The wander guard was placed on Resident #7 by Nurse #5.
- The responsible party and provider were notified by Nurse #1.
- Resident #7's elopement assessment prior to the unauthorized departure was reviewed by the Director of Nursing and it was determined that the resident was not at risk for elopement at the time of the assessment.
- The Director of Nursing reviewed the progress notes between the date of the last elopement assessment and the date of the unauthorized departure to ensure there was no documentation of wandering behaviors.
- The root cause of the incident was discussed by the Interdisciplinary team and it was determined that Resident #7 displayed new onset of exit seeking behaviors not reported to nurse #5 by the receptionist.
- The Receptionist was re-educated by the DON to consult with the nurse before letting residents onto the porch and checking the wander guard book located at the reception desk.
- The Director of Nursing, Unit Manager #1, Unit Manager #2 and the Infection Control nurse completed a new Brief Interview for Mental Status assessment and an Elopement assessment on all residents in the facility that had not been assessed.
- The Director of Nursing reviewed all progress notes to ensure all residents with documented wandering behavior had a wander guard and care plan in place.
- The wander guard books were updated by the Director of Nursing, following the completion of the Elopement assessments.
- Staff education was started by the Director of Nursing on the Elopement Policy and Procedure and Immediately reporting exit seeking behaviors to the nurse and administration.
- Education included consulting the wander guard books which were placed at all three nurse stations and the reception desk.
- All newly hired staff will be educated by the Director of Nursing on the Elopement Policy and Procedure and Immediately reporting exit seeking behaviors to the nurse and administration before the end of their employee orientation.
- The Director of Nursing also validated there was a sign on the main entrance informing visitors and staff to talk with a nurse prior to assisting residents out of the facility.
- The facility decided to take the elopement incident and the plan of correction to the Quality Assurance Performance Improvement team.
- The Director of Nursing will review all progress notes to ensure all residents with wandering behaviors have a wander guard in place and that there are no other instances of other unsafe residents being outside of the facility without supervision.
- The Director of Nursing will interview 3 employees weekly to ensure all staff understand the elopement drill process.
- Elopement books will be reviewed weekly during resident review to ensure the books are up-to-date and all residents at risk for elopement are listed in the books.
- The audits will be reviewed by the Quality Assurance Performance Improvement Committee.
Failure to Hold Tube Feeding Leads to Resident Hospitalization
Penalty
Summary
The facility failed to follow a physician's order to hold a tube feeding for a resident after an episode of vomiting, leading to severe health complications. The resident, who had a history of stroke, dysphagia, and was dependent on a feeding tube, experienced vomiting after a bolus tube feeding was administered. Despite a subsequent order from a Nurse Practitioner to hold the tube feeding due to intolerance, the order was not correctly entered into the electronic Medication Administration Record (MAR), resulting in the feeding continuing overnight. The resident was found the next morning with symptoms of respiratory distress, including coughing, struggling to breathe, and emesis of tube feeding from the nose and mouth. The resident's condition was critical, with low oxygen saturation and elevated heart rate, necessitating emergency medical intervention and hospitalization. The failure to hold the tube feeding as ordered and to maintain the resident's head of the bed elevated contributed to the resident's aspiration and subsequent hospitalization. Interviews with staff revealed that the order to hold the tube feeding was not communicated effectively, and the electronic MAR did not reflect the hold order, leading to the continuation of the feeding. The incident highlighted a breakdown in communication and procedural adherence, resulting in significant harm to the resident.
Removal Plan
- The Nurse Practitioner ordered a diagnostic imaging for the Kidneys, Ureters and Bladder, a complete blood count, basic metabolic panel, Zofran 4 mg every 6 hours as needed for nausea and to hold tube feedings.
- The Assistant Director of Nursing reviewed the electronic medical record and determined that the tube feeding order was never placed on hold and Resident #98 received enteral tube feeding.
- Root cause was discussed by the Interdisciplinary team and it was determined that an additional order to hold the tube feeding was entered into the Electronic Medical Record but the actual tube feeding order was not placed on hold.
- The Assistant Director of Nursing reviewed the electronic medical records for all other residents that had received enteral feeding to ensure the tube feeding orders were correct and there were no missed hold orders and that each resident had an order to maintain the head of the bed at 30-40 degrees during feeding and for 30 minutes after, if tolerated.
- The Assistant Director of Nursing provided education to the nurses on appropriately placing an order on hold instead of entering an additional hold order.
- The nurse who failed to enter the order correctly received one on one education on appropriately placing an order on hold instead of entering an additional hold order by the Assistant Director of Nursing.
- Unit Managers, the Wound Care Nurse and the Minimum Data Nurse were educated during the Interdisciplinary Team meeting by the Assistant Director of Nursing.
- The Assistant Director of Nursing contacted all nurses and certified nursing assistants and provided education on ensuring residents with enteral tube feeding are kept at a 30-40-degree angle when in bed. 100% education was completed via telephone.
- The Director of Nursing or designee will review all new orders to ensure any orders to hold tube feedings, medications or treatments were applied to the actual tube feeding, medication or treatment order instead of only entering an additional hold order.
- Weekend orders will be reviewed during the Clinical Morning Meeting.
- The facility determined the need to take the plan of correction to the Quality Assurance Performance Improvement Committee.
- A meeting was held with the Medical Director and the Quality Assurance Performance Improvement committee to review the plan of correction and the monitoring plan.
- The facility conducts concierge rounds for all residents. Residents with enteral feeding are assigned the Minimum Data Set nurse.
- The concierge document includes resident bed positioning and are discussed in the administrative meeting.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to accurately document the administration of a narcotic pain medication, Hydrocodone-Acetaminophen, for a resident. A physician's order indicated that the resident was to receive one tablet every six hours as needed for pain. However, upon reviewing the controlled substance declining count sheet, it was found that the medication was signed off as administered on several dates, but there was no corresponding documentation in the Medication Administration Record (MAR) for those dates. Attempts to contact the nurses responsible for signing out the medication on the declining inventory count sheet were unsuccessful. Nurse #8, who signed out the medication on one occasion, was unreachable as the contact number was invalid, and it was later revealed that this nurse went on leave and never returned. Nurse #19, who signed out the medication on multiple occasions, was an agency nurse who no longer worked at the facility and did not respond to contact attempts. Nurse #6, who signed out the medication on two occasions, was suspended indefinitely and also did not respond to contact attempts. The Director of Nursing (DON) acknowledged the issue during an interview, stating that upon discovering the missing Hydrocodone-Acetaminophen tablets, a full investigation was initiated. It was found that the MARs were not accurate, leading to the initiation of a corrective action plan. The facility identified missing declining narcotic count sheets and a lack of a system to reconcile narcotic documents, which contributed to the deficiency.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of a black greenish substance with a foul sewage odor around the base of commodes in multiple resident rooms. Observations revealed that this substance was present in rooms across three hallways, affecting a significant number of commodes. Interviews with housekeeping and maintenance staff indicated a lack of communication and responsibility regarding the issue. Housekeeper #1 acknowledged the problem but did not report it, assuming maintenance was already aware. The Maintenance Assistant and Director were also interviewed, with the Assistant dismissing the issue due to the absence of leaks, while the Director admitted ignorance about the substance and acknowledged the need for repairs. Additionally, the facility failed to address broken or missing bathroom door threshold strips in several resident rooms, posing potential safety hazards. The Maintenance Director could not provide documentation of completed or pending work orders, indicating a lack of oversight and follow-up on maintenance issues. The Housekeeping Supervisor was unaware of the black substance and lacked a cleaning schedule or documentation to verify daily cleaning checks. The Administrator, upon a follow-up tour, confirmed the presence of the substance and missing thresholds, expecting these issues to have been addressed.
Inaccurate Weight Monitoring in LTC Facility
Penalty
Summary
The facility failed to obtain and record accurate weights for four residents, leading to significant discrepancies in their weight records. Resident #83, who had severe cognitive impairment and a diagnosis of cirrhosis of the liver, experienced significant weight fluctuations that were not accurately recorded or verified. Despite having orders to monitor weight weekly, there were multiple instances where weights were not recorded, and significant changes were not reweighed as per facility policy. Interviews with staff revealed that the nursing assistants were responsible for obtaining weights, but there was a lack of consistency and communication regarding significant weight changes. Resident #63, admitted with diabetes, did not have a weight recorded upon admission, contrary to physician orders. Subsequent weights showed an increase, but the initial baseline was missing, complicating the assessment of the resident's nutritional status. The unit manager admitted to not checking if admission weights were obtained, highlighting a gap in the facility's adherence to its weight policy. Resident #91, with a history of pulmonary embolism and diabetes, also had discrepancies in weight records, with significant fluctuations that were not addressed. The lack of accurate weights made it difficult for the nurse practitioner to adjust medications appropriately. Similarly, Resident #29, with congestive heart failure, had missing daily weights despite orders, affecting the monitoring of their condition. The facility's failure to consistently obtain and verify weights as ordered compromised the ability to monitor and manage the residents' health conditions effectively.
Failure to Obtain Monthly CBCs for Resident on Immunosuppressive Therapy
Penalty
Summary
The facility failed to obtain a monthly complete blood cell count (CBC) for a resident receiving immunosuppressive drug therapy, as ordered by the physician. The resident, who was admitted with diagnoses including rheumatoid arthritis and heart failure, had a physician's order dated 11/27/23 for monthly CBCs. A CBC was collected on 11/30/23, but from 12/31/23 through 07/08/24, there was no documentation or results of the required monthly CBC tests in the resident's electronic medical record. The Nurse Practitioner, who began working at the facility in January 2024, was unaware of the order for monthly CBCs and relied on lab results from the resident's Rheumatologist, which were accessible through the hospital's electronic medical record system. The issue arose because the Unit Manager, who entered the initial order for monthly CBCs, did not complete the necessary requisition form to notify the lab vendor to draw the labs. The facility had recently transitioned to a new electronic medical record system, which included a new process for ordering labs. This process required entering the order into the electronic medical record and then directly into the vendor's website, bypassing the previous method of using a handwritten requisition form. The Director of Nursing confirmed that the new process was in place and that nurses had been educated on it, but was unaware of the specific order for the resident's monthly CBCs.
Misappropriation of Narcotic Pain Medication in LTC Facility
Penalty
Summary
The facility failed to protect residents from the misappropriation of narcotic pain medication, specifically Hydrocodone-Acetaminophen oral tablets. This deficiency was identified for two residents who were reviewed for medication misappropriation. Resident #20, who was severely cognitively impaired, had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain. However, a shipment of 30 tablets received on 05/03/24 was unaccounted for, with no record of administration or declining count sheet. The issue was discovered during a transition to a new electronic medical record system, and the missing medication was never found. Similarly, Resident #61, who was on hospice care and also cognitively impaired, had a physician's order for the same medication. A shipment of 30 tablets was received on 04/05/24, but only 10 doses were documented as administered, and the declining inventory sheet was missing. Further investigation revealed that additional tablets were ordered and received, but again, the documentation was incomplete, and the medication was unaccounted for. The facility's investigation pointed to discrepancies in the handling and documentation of narcotic medications, with Nurse #6 being a central figure in both cases. Despite attempts to contact her, Nurse #6 did not respond, and she was suspended indefinitely. The facility's failure to maintain accurate records and secure narcotic medications led to the misappropriation of these controlled substances, compromising the residents' rights and safety.
Failure to Maintain Controlled Drug Records
Penalty
Summary
The facility failed to maintain a system of records for the receipt and disposition of controlled drugs, specifically Hydrocodone-Acetaminophen 5-325 mg, for two residents. For Resident #20, there was no declining count sheet for 30 tablets received on multiple occasions, and attempts to contact the nurses responsible for receiving these medications were unsuccessful. The Medication Administration Record (MAR) showed that 18 of the 30 tablets were administered without proper documentation, and the facility's investigation revealed missing declining count sheets, indicating a lack of reconciliation for narcotic documents. Similarly, for Resident #61, the facility was unable to locate the declining inventory sheets for Hydrocodone-Acetaminophen tablets received on two separate occasions. The MAR indicated that 15 of the 45 doses were administered, but the absence of declining count sheets made it impossible to reconcile the medication records. The Director of Nursing confirmed that the missing sheets were discovered during audits initiated due to discrepancies found with Resident #20's medication records. Interviews with staff, including the Pharmacy Manager, Consultant Pharmacist, and Director of Nursing, highlighted the absence of a system to reconcile narcotic documents and the failure to maintain accurate records of controlled substances. The Consultant Pharmacist admitted to not reviewing declining count sheets regularly, and the Director of Nursing acknowledged the lack of a system to track and reconcile narcotic medications, which led to the discrepancies and missing documentation.
Failure to Maintain Safe Environment Due to Broken Equipment and Lack of Signage
Penalty
Summary
The facility failed to maintain a safe environment in the 700-hall by using a floor scrubber with a broken squeegee attachment, which left large puddles of water on the floor. This issue was observed during a tour on 07/08/24, where no wet floor signs were posted despite the presence of staff. Interviews with the Unit Manager and the Director of Nursing confirmed the presence of water puddles and the absence of wet floor signs, acknowledging the situation as a potential fall hazard. The Maintenance Director and Housekeeping Supervisor both noted that the scrubber was worn out and needed replacement, but budget constraints prevented this. Further interviews revealed that the Floor Technician was aware of the malfunctioning squeegee, and Housekeeper #1, who mopped the 700-hall, did not place wet floor signs as she believed the floor was dry. The Administrator acknowledged the oversight of not posting wet floor signs on the observed wet floors, which posed a fall risk. The deficiency was due to the failure to address the broken equipment and the lack of proper signage to warn of the wet floors, leading to unsafe conditions in the facility.
Failure to Date Insulin Pens
Penalty
Summary
The facility failed to record an opened date on two insulin pens, specifically Lantus and Novolog, which have a shortened expiration date of 28 days after opening. This deficiency was identified during an observation of the 200/300 hall medication cart, where the insulin pens were found without the required opened dates. Nurse #7, who was present during the observation, stated she was unaware that the insulin pens were not dated and confirmed she did not administer them to residents that day. She also mentioned that she was not typically assigned to that medication cart and acknowledged that it was the responsibility of the nurse who initially opened the insulin pen to label it with an opened date. The Director of Nursing confirmed that insulin pens should be labeled with opened dates when initially opened.
Resident Dignity Compromised by Medication Aide's Inappropriate Action
Penalty
Summary
The facility failed to maintain a resident's dignity when a Medication Aide flicked a severely cognitively impaired resident's forehead with her finger during care. The resident, who was admitted with a diagnosis of dementia, was known to have severely impaired cognition and exhibited physical behavioral symptoms directed toward others several times a week. On the day of the incident, the resident had a large bowel movement and was found smearing feces around her room, which was not typical behavior for her. During the incident, two Nurse Aides were cleaning the resident when the Medication Aide entered the room with towels. Witnesses, including the two Nurse Aides, reported that the Medication Aide flicked the resident on the forehead and made a comment about the resident's behavior. The resident responded verbally, indicating surprise and discomfort, although she later stated that the flick did not hurt her and she was not afraid. The Medication Aide claimed the action was a joke and denied any intent to harm, stating that the flicking motion was to remove feces from her gloves. The facility conducted an investigation following the incident, with interviews from the involved staff and the resident. The Medication Aide admitted to the action during an interview with the Administrator, although she later denied it to the Director of Nursing. The Administrator emphasized that such actions are inappropriate and should not occur, regardless of intent. The incident was documented as a failure to uphold the resident's right to dignity and respect.
Latest citations in North Carolina
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
A resident with dementia, stroke, dysphagia, and severe cognitive impairment, who was edentulous and dependent for ADLs, was care planned and listed on the NA Kardex to receive assisted oral care at least twice daily. Over nearly a month, NA documentation showed denture care was provided only three times, and surveyors observed the resident’s upper and lower dentures with brown stains and debris buildup. One NA, assigned on several day shifts, believed the resident did not have dentures and only offered mouthwash and a basin, while another NA, aware the resident wore dentures, usually did not perform denture care because the resident was already in bed and did not want to remove them. The DON later confirmed the dentures had visible debris and staining and that the care plan required regular oral care and proper denture cleaning.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Date and Discard Opened Nutritional Supplements per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to properly date and discard opened containers of nutritional supplements stored in nourishment room refrigerators on the North and South Units. During observations of these refrigerators with the Dietary Manager, surveyors found a one-quart nutritional shake in the North Unit refrigerator with no date indicating when it was opened, despite the manufacturer’s label stating it must be used within four days after opening if refrigerated. In the South Unit refrigerator, surveyors observed two one-quart nutritional shakes dated 4/24 and 4/28, both beyond the manufacturer’s four-day use-by period, as well as an opened and undated 8-ounce diabetic nutritional shake whose label required use within 48 hours of opening. In interviews, the Dietary Manager stated that dietary staff did not stock the nutritional shakes in the nourishment refrigerators and that nurses were responsible for the nutritional shakes given to residents, including dating them when opened and discarding them when past the use-by date. The Dietary Manager also explained that dietary staff checked the nourishment refrigerators twice daily only for items provided by the kitchen, including restocking and checking expiration dates on those snacks and drinks. A nurse confirmed that a physician’s order was required for a resident to receive a nutritional shake and that nurses were responsible for dating the shakes when opened and ensuring they were used and discarded according to the manufacturer’s instructions. The Administrator stated that the person who opened a nutritional shake was responsible for writing the date opened on the container and noted that historically dietary staff checked dates on food and drinks stored in the nourishment refrigerators.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Failure to Provide Ordered Denture and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide ordered assistance with denture and oral care for a dependent resident with severe cognitive impairment, dementia, stroke, dysphagia, and edentulism. The resident’s admission MDS documented severely impaired cognition, a need for setup or clean-up assistance with oral hygiene, and no refusal of care or behaviors. The care plan and NA Kardex both directed staff to provide or assist with oral care at least twice daily using a soft toothbrush or foam swabs, and identified the resident as at risk for oral and dental health problems and dependent in ADL self-care. However, NA documentation showed denture care was recorded as provided only three times over nearly a month-long period. During observation, the resident reported wearing upper and lower dentures and displayed dentures with brown stains and debris buildup around the teeth and gums, stating he could brush his dentures if he had a toothbrush and toothpaste. One NA, assigned on multiple day shifts, stated she provided only mouthwash and a basin because the resident had difficulty brushing, believed the resident did not have dentures, and confirmed she had not provided denture care. Another NA on night shift acknowledged knowing the resident wore dentures, having seen them on the bed or nightstand, but stated she usually did not perform denture care because the resident was already in bed and did not want to remove them, and described denture care only as soaking them overnight. When the DON later observed the dentures, he confirmed visible debris and brown staining, and acknowledged that the care plan and Kardex required oral care at least twice daily and that dentures should be brushed and soaked overnight.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
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