Blumenthal Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 3724 Wireless Drive, Greensboro, North Carolina 27455
- CMS Provider Number
- 345006
- Inspections on file
- 26
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Blumenthal Health And Rehabilitation Center during CMS and state inspections, most recent first.
Three residents experienced missed doses of essential medications due to failures in medication acquisition, dispensing, and administration processes. One resident did not receive antiretroviral therapy for several days because of prescription and insurance delays, another missed a scheduled dose of Ozempic due to unavailability and documentation issues, and a third did not receive Fluticasone nasal spray as ordered because it was not on the correct medication cart and was incorrectly documented as administered.
A resident with HIV did not receive prescribed antiretroviral medication for several days due to exhaustion of the initial supply, insurance denial, and delays in obtaining and administering a refill. Multiple staff, including nurses, the Medical Director, and pharmacy personnel, were aware of the lapse, but the medication was not administered as ordered, and some staff inaccurately documented administration on the MAR.
A resident with HIV and cognitive impairment did not attend a scheduled infectious disease clinic appointment due to miscommunication and scheduling errors by staff. As a result, the resident missed doses of prescribed antiretroviral medication because the pharmacy required a clinic visit before refilling. The resident's guardian was not properly notified of the appointment changes, and the resident was placed on a waiting list for a new appointment.
A resident with a chronic unstageable pressure ulcer and multiple comorbidities experienced significant pain during a dressing change, as evidenced by facial grimacing, increased breathing rate, and verbal complaints. Despite having an as-needed order for pain medication, staff did not assess or administer pain relief before or during the procedure, and the dressing change was completed before pain medication was given. Staff interviews confirmed that pain management was not provided as expected.
Surveyors identified deficiencies in food service sanitation, including staff handling clean dishware with soiled gloves, improper storage of personal items in food prep areas, and significant grease and debris buildup on kitchen equipment. Wet and dirty plates were also found on the trayline, and staff training on cross-contamination was incomplete.
The facility did not consistently document whether COVID-19 vaccine education was provided or whether the vaccine was administered or declined for several residents and staff. In some cases, consent forms were incomplete or lacked signatures, and there was no evidence that education about the vaccine's benefits and side effects was given. Additionally, immunization records for two staff members were missing.
Three residents dependent on staff for ADLs did not receive required care, including incontinence care, meal assistance, and personal hygiene support. One resident with severe cognitive and physical impairments was left with an untouched meal tray and remained soiled for hours. Another resident on hospice care missed a meal due to lack of staff communication, and a third resident with hemiplegia did not receive needed help with shaving or nail care, despite repeated requests.
A resident with hemiplegia and psychosis, assessed as needing supervision and a smoking apron while smoking, was observed smoking in the designated area without staff supervision or the required apron. Staff and leadership interviews revealed inconsistencies in the implementation of smoking safety measures, confusion about resident requirements, and lapses in supervision, resulting in a failure to ensure accident prevention.
Surveyors found that the facility did not maintain accurate medical records for three residents, including missing or incorrect documentation of a PICC line dressing change, IV antibiotic administration, and blood sugar checks with insulin administration. Nurses confirmed that some care was provided but not properly recorded in the MAR, and facility leadership acknowledged that documentation should be accurate and complete.
A resident with multiple diagnoses, including a cognitive communication deficit, was found to be self-administering physician-ordered eye drops without an assessment or care plan for self-administration. Nursing staff were aware that the resident had eye drops at the bedside, brought in by the spouse, but did not report this or secure the medications. The DON and unit manager confirmed that medications should not be left at the bedside without a care plan, and the PA had not authorized self-administration.
The facility did not provide the required SNF-ABN notification to two residents who remained in the facility after their Medicare Part A skilled services ended. Record review and staff interviews confirmed that neither the residents nor their responsible parties received the necessary notice about the end of Medicare coverage and potential financial liability, as required by CMS guidelines.
Two residents did not have their annual MDS assessments completed within the required 14-day period after the ARD. Staff interviews confirmed that the assessments were delayed due to a backlog when new MDS nurses started, and the issue was known to facility leadership.
Two residents did not have their significant change in status MDS assessments completed within the required 14-day timeframe after the ARD. Staff interviews and record reviews confirmed that the assessments were completed late due to the MDS team being behind on their workload when they started their positions, and the facility was aware of the delays.
Surveyors identified that MDS assessments were inaccurately coded or left incomplete for three residents. One resident who was bedbound and on hospice was incorrectly documented as only occasionally incontinent, another was marked as having received antibiotics when none were administered, and a third had missing cognitive and pain assessments. Staff interviews confirmed these errors and omissions.
A resident with dementia and severe cognitive impairment, dependent on staff for bed mobility, did not have a fall mat in place as required by the care plan. Observations found the fall mat rolled up in the bathroom instead of beside the bed, and interviews with staff and the DON revealed a lack of awareness about the intervention, despite the resident's history of attempting to get out of bed.
The facility did not update the care plans for two residents to reflect changes in code status and the initiation of Hospice services. Despite physician orders and interdisciplinary team meetings intended to review and revise care plans, the documentation continued to show outdated information, such as a full code status instead of DNR, and lacked a care plan for Hospice care.
A resident with hemiplegia and hemiparesis following a stroke did not receive an activity assessment or individualized activities program to address his interests, such as reading and coloring, due to lack of staff awareness and documentation. The resident reported difficulty participating in preferred activities and was not offered accommodations or supplies to support his engagement.
A resident with multiple chronic conditions had a PICC line dressing that was not changed as ordered by the provider. Nursing documentation incorrectly indicated the dressing had been changed, but observations and staff interviews confirmed the dressing remained unchanged for over two weeks. The issue was identified when the dressing was finally changed and the original date was still present on the label.
Surveyors found expired medications, unlabeled and loose pills, and improper storage of drugs on medication carts and in the medication room. Staff confirmed that medications were not labeled with resident information, expired drugs were not discarded, and some medications were not stored according to manufacturer instructions.
The facility did not consistently document education on influenza and pneumococcal vaccines or record acceptance or declination of these vaccines for several residents. Incomplete or missing consent forms and lack of signatures, dates, and education records were identified, with one resident reporting not being offered the vaccines despite records indicating otherwise.
The facility did not maintain required documentation or provide written responses for grievances submitted by two residents' responsible parties regarding delays in incontinent care. Over a six-month period, no grievances were logged, and staff interviews revealed confusion and lack of accountability for grievance management following a transition to a new computer system and the departure of the Social Worker.
Two residents experienced sexual abuse from other residents, including unwanted touching and explicit comments, due to the facility's failure to identify behavioral risks and implement appropriate care plan interventions. Care plans lacked specific strategies to address or prevent inappropriate behaviors, and there was no evidence of a corrective action plan to address these deficiencies.
A resident with multiple health conditions experienced an unwitnessed fall and, despite initial assessment by a CNA and Unit Manager, did not receive required neurological checks or follow-up from nursing staff due to a communication breakdown. The incident was not documented or reported as required, and the lapse was only discovered after the resident filed a grievance.
Three residents received oxygen therapy without proper physician orders, with one resident receiving oxygen at a higher flow rate than prescribed and two residents using oxygen without any current order. Additionally, required cautionary signage for oxygen use was not posted for one resident. Staff interviews confirmed a lack of oversight and documentation regarding oxygen administration.
A resident with severe cognitive and physical impairments, including a stage 4 pressure ulcer, did not receive timely assistance with eating and incontinence care due to chronic short staffing. Staff interviews and documentation confirmed that nurse aides were assigned to care for an excessive number of residents, resulting in missed or delayed essential care tasks such as feeding and hygiene.
Staff failed to follow infection control policies during incontinence, ostomy, and wound care for two residents. A soiled brief was left on a nightstand after incontinence care, and a nurse did not use proper hand hygiene or PPE while providing ostomy and wound care, including not wearing a gown, not washing hands between glove changes, and using bare hands to apply an ostomy appliance. Facility leadership confirmed these actions did not comply with infection control protocols.
A facility with a census of 130 failed to employ a qualified full-time social worker after the previous social worker left, leaving the position vacant. The social work department assistant and regional social worker were not qualified, and although the President of Operations, who is qualified, assisted the department, she did not serve as the full-time social worker.
The facility did not provide written transfer/discharge notifications or bed hold policy information to representatives for three residents who were hospitalized. In each case, required documentation was missing or incomplete, and staff interviews revealed confusion about responsibility for these notifications. The affected residents included individuals with severe cognitive impairment and one who was cognitively intact.
Several quarterly MDS assessments were not completed within the required 14-day period after the ARD for multiple residents. Staff interviews and record reviews confirmed that assessments were overdue, with some not completed at all by the time of review. The MDS team reported inheriting a significant backlog and were still working to catch up, while facility leadership acknowledged awareness of the ongoing delays.
Two residents' discharge MDS assessments were not completed and submitted to the State within the required 7-day timeframe after discharge. Interviews with MDS staff and the Administrator confirmed that the assessments were completed late due to a backlog when new MDS nurses started their roles.
The facility did not accurately post daily nurse staffing information, with multiple discrepancies found between posted sheets and actual schedules for RNs, LPNs, and NAs. The Scheduler, responsible for updating these sheets, often made corrections after the fact and was unsure if other staff were trained to do so, leading to ongoing inaccuracies.
A resident with multiple chronic conditions and a recent surgical procedure developed a suspected deep tissue injury on the left heel, which was identified by the Wound Nurse but not promptly reported or treated due to a lack of immediate provider notification and treatment order. The delay in initiating care was confirmed through documentation and staff interviews, revealing a breakdown in the facility's protocol for pressure ulcer management.
A resident with cognitive impairment and a history of falls underwent a second x-ray for suspected illness without a documented provider order, and the results—showing multiple rib fractures—were not promptly communicated to the NP. The NP only became aware of the findings after the resident was transferred to the hospital for a change in condition. Staff interviews revealed gaps in the process for ensuring provider notification of radiology results.
A resident with a history of vascular dementia and other conditions experienced an unwitnessed fall, leading to a delayed diagnosis of a femur fracture due to the facility's failure to notify the physician of the resident's pain and a STAT x-ray delay. The resident's pain was not managed during night shifts, and the physician was not informed until days later, resulting in delayed medical intervention and surgery. The facility's communication failures contributed to the resident's prolonged pain and risk of complications.
A resident experienced neglect after an unwitnessed fall, where the facility failed to notify the physician immediately about the resident's pain and delayed a STAT x-ray. The x-ray revealed a left femur fracture, but the Nurse Practitioner did not communicate this to the Medical Director, delaying necessary orthopedic evaluation and surgery. The resident's pain was not managed effectively, and the Medical Director was unaware of the fracture until days later, leading to further complications.
A resident with a history of vascular dementia and muscle weakness fell and reported hip pain. A STAT x-ray revealed a nondisplaced femur fracture, but the facility delayed urgent orthopedic evaluation. The Medical Director was not informed until days later, leading to a delay in hospital transfer and surgery. Staff communication and timely action were lacking, contributing to the deficiency.
A resident with a history of vascular dementia and other health issues suffered a femur fracture after a fall. The NP failed to consult with the Medical Director, delaying appropriate medical intervention. The resident's pain became unmanageable, leading to a hospital transfer and surgery. The delay in treatment increased the risk of complications.
A resident with multiple health issues experienced inadequate pain management following a fall. Initially, the resident denied pain, but later reported hip pain, leading to delayed x-ray and pain relief orders. Inconsistent pain assessments and documentation, along with poor communication among staff, resulted in insufficient pain management, despite a confirmed femur fracture.
A facility failed to report an allegation of neglect to the state agency in a timely manner. A resident sustained a fall and did not receive necessary care for a fracture. The Administrator was informed of the neglect allegation but delayed reporting it to the state agency, assuming it was unnecessary as all parties were already aware.
A resident in an LTC facility experienced a fall resulting in a nondisplaced femur fracture. Post-fall documentation was found to be inaccurate, as the Night Nurse Supervisor and another nurse copied previous notes without conducting proper assessments. The resident, who was nonverbal, was not assessed for pain on multiple occasions, leading to a deficiency in maintaining accurate medical records.
The facility failed to implement a broad-based COVID-19 testing approach during an outbreak, leading to numerous cases among residents and staff. Infection control practices were inadequate, with staff not wearing masks properly and a nurse aide entering a COVID-positive room without eye protection. The facility's policies did not align with CDC guidelines, and vaccinations were not administered timely, increasing the risk of transmission.
The facility did not maintain licensed nursing coverage 24 hours a day for 17 days in a 120-day period, as required. Staffing data indicated gaps in coverage, and the facility could not provide documentation to verify staffing levels. Interviews with staff revealed a change in management and reliance on agency staff prior to June 2024, but current staff could not confirm past staffing practices.
The facility failed to maintain RN coverage for at least 8 consecutive hours per day for 17 days in a reviewed period. Staffing data indicated missing RN coverage, and the facility could not provide supporting documentation. Interviews with staff revealed a lack of confirmation on RN coverage and issues with record-keeping during a management transition.
A resident with diabetes and dementia experienced a significant medication error when their prescribed Humalog Insulin was administered over 2.5 hours late. The insulin, scheduled for 7:30 AM before breakfast, was given at 9:55 AM due to a heavy medication pass workload and COVID-related tasks. The DON noted that nurses have enough time to administer medications on schedule and can seek assistance if needed.
Two residents, both cognitively intact, were not assessed for self-administration of medications, leading to nurses leaving medications at their bedsides without supervision. This was against the facility's policy, which requires nurses to stay with residents during medication administration. The Unit Manager and DON confirmed no residents were authorized for self-administration.
A facility failed to complete a Significant Change in Status MDS assessment for a resident admitted to hospice services with a diagnosis of malignant neoplasm of the right lung. The MDS Coordinator, new to the facility, acknowledged the oversight, noting the absence of a dedicated MDS Coordinator for over a year, with reliance on traveling MDS Nurses and various staff for assessments.
The facility failed to accurately code MDS assessments for three residents, leading to deficiencies in areas such as range of motion and comprehensive assessments. A resident with hemiplegia was inaccurately coded as having no range of motion impairments, while another with Alzheimer's was not assessed for cognition and other critical areas. Additionally, a resident's psychiatric diagnoses were omitted from their MDS assessment. The lack of a consistent MDS Coordinator contributed to these inaccuracies.
A facility failed to apply a recommended right-hand grip splint for a resident with a contracture following a cerebrovascular accident. Despite occupational therapy recommendations, the care plan lacked instructions for the splint, and no physician order was present. Observations showed the resident's hand was fisted without a visible splint, and staff were unsure of its location. The Rehabilitation Director later found and applied the splint, but the resident's POA noted it hadn't been used in two years.
A resident with hypoxemia and congestive heart failure was observed receiving oxygen at 3.5 liters per minute instead of the prescribed 2 liters per minute. Despite no signs of respiratory distress, the discrepancy was noted, and staff did not document vital signs or check the concentrator settings due to visitor presence. The NP confirmed no symptoms of dyspnea, and the DON and Administrator emphasized adherence to physician orders.
A facility failed to maintain a complete medical record for a resident admitted with a fractured pelvis and septic shock. The resident's electronic medical record lacked the diagnoses of schizophrenia and PTSD, which were documented in the hospital discharge summary. This deficiency was identified during a review of the resident's medical records.
Failure to Ensure Timely Acquisition and Administration of Critical Medications
Penalty
Summary
The facility failed to provide uninterrupted pharmaceutical services for three residents, resulting in missed doses of critical medications. One resident with HIV did not receive the prescribed antiretroviral medication, Biktarvy, for several days due to a lapse in obtaining a new prescription and insurance approval. The medication was initially supplied by a hospital pharmacy, but when the supply was depleted, the facility pharmacy could not provide a refill without a new prescription and insurance authorization. Multiple staff members, including nurses, the Medical Director, and pharmacy personnel, were aware of the issue, but there was a lack of coordinated action to secure the medication in a timely manner. Documentation showed that the resident missed multiple doses, and there was confusion and miscommunication among staff regarding responsibility for obtaining the medication and ensuring its availability on the medication cart. Another resident with diabetes missed a scheduled dose of Ozempic because the medication was not available at the time of administration. The nurse reported the absence of the medication and contacted the pharmacy, but the medication was not delivered in time for the scheduled dose. Subsequent attempts to locate the medication for the next scheduled dose were unsuccessful, and the pharmacy indicated that a refill could not be processed because the facility should have had a dose available from a previous delivery. Despite documentation indicating delivery of the medication, there was no evidence that the resident received the dose, and staff interviews confirmed the medication was not administered as ordered. A third resident with allergic rhinitis did not receive the prescribed Fluticasone nasal spray as ordered. Although the medication administration record indicated that the medication was given, interviews with staff and the resident revealed that the medication was not available on the medication cart and had not been administered. Staff reported inadvertently documenting administration when the medication was not present, and pharmacy records showed that the facility had requested the medication before it was eligible for refill. The medication was eventually located in another unit's storage, but the resident had gone without the prescribed treatment for several days.
Failure to Administer Prescribed Antiretroviral Medication
Penalty
Summary
A significant medication error occurred when a resident with HIV did not receive their prescribed antiretroviral medication, Biktarvy, for several consecutive days. The resident was admitted with a hospital-supplied bottle of Biktarvy, but the facility staff were unsure of the quantity provided. Once the initial supply was exhausted, the facility was unable to obtain a refill due to insurance denial and lack of timely payment approval. Multiple staff members, including nurses, the Medical Director, the ADON, and the facility pharmacist, were aware of the medication lapse, but the issue persisted for several days. Documentation on the Medication Administration Record (MAR) showed that Biktarvy was not administered on multiple days, with progress notes indicating the medication was unavailable. Some staff documented administration of the medication when it had not actually been given, and others noted the medication was not on the cart. The facility pharmacy could not dispense the medication until insurance approval was obtained, and even after delivery, there was a delay in administration as the medication was not promptly placed on the medication cart. Interviews with staff confirmed that the medication was not available or administered as ordered during this period. The resident's medical history included HIV with an uncontrolled viral load and a low CD4 count, requiring strict adherence to antiretroviral therapy. The lapse in medication administration was known to several staff members, including the Medical Director, ADON, and pharmacist, but no effective action was taken to ensure the resident received the medication as prescribed. The infectious disease clinic provider was unable to determine the clinical consequences of the missed doses without recent laboratory testing, but the interruption in therapy was confirmed by multiple sources.
Failure to Ensure Resident Attended Infectious Disease Clinic Appointment
Penalty
Summary
The facility failed to ensure that a resident with HIV attended a scheduled infectious disease clinic appointment as ordered. The resident was discharged from the hospital with instructions for close follow-up at the infectious disease clinic and a prescription for Biktarvy, an antiretroviral medication. The resident, who had moderate cognitive impairment and a mental health disorder, was admitted to the facility with orders to continue Biktarvy and to manage chronic disease. The care plan included medication administration and monitoring for HIV complications. The Transportation Coordinator was responsible for arranging the resident's appointments and was aware that accompaniment was required per administrative policy. Attempts to contact the resident's guardian prior to the appointment were unsuccessful, and the appointment was cancelled and rescheduled. However, the Transportation Coordinator recorded the wrong date for the rescheduled appointment, resulting in the resident missing the actual clinic visit. The guardian was not notified of the correct appointment date and only learned of the cancellation and rescheduling after the fact. The resident was subsequently placed on a waiting list for a new appointment. Due to the missed appointment, the resident ran out of Biktarvy, as the pharmacy required a clinic visit before dispensing additional medication. Nursing staff and the nurse practitioner confirmed that the resident did not receive the medication for several days, and the infectious disease physician declined to refill the prescription without a recent clinic evaluation. The resident eventually resumed therapy after the facility pharmacy was able to obtain the medication, but the lapse in care occurred as a result of the missed appointment and communication failures among facility staff.
Failure to Provide Pain Management During Dressing Change
Penalty
Summary
A deficiency occurred when a resident with a chronic unstageable pressure ulcer on the left heel did not receive appropriate pain management during a dressing change procedure. The resident, who had a history of multiple medical conditions including recent fractures, atrial fibrillation, coronary artery disease, congestive heart failure, hypertension, dementia, and a significant pressure ulcer, was observed to experience significant pain during the dressing change. Despite having an as-needed order for hydrocodone-acetaminophen for pain, no pain assessment was conducted prior to the procedure, and pain medication was not administered before or during the dressing change, even as the resident exhibited clear signs of pain such as facial grimacing, increased breathing rate, shifting position, and verbal expressions of discomfort. During the observed dressing change, the staff involved were not familiar with the resident's wound care orders or pain management needs. The nurse and unit manager present did not assess the resident's pain before starting the procedure and proceeded with the dressing change despite the resident's repeated verbal and non-verbal indications of pain. The surveyor had to intervene and suggest pain medication, but the dressing change was completed before the medication was administered. The resident later rated his pain as an 8 out of 10 during the procedure. Interviews with staff, including the nurse, unit manager, DON, administrator, and nurse practitioners, confirmed that the expected practice was to assess and manage pain during such procedures. The staff involved acknowledged that pain management was not provided as it should have been, and the nurse admitted to being focused on the wound care rather than the resident's comfort. The deficiency was identified through direct observation, record review, and interviews, highlighting a failure to provide safe and appropriate pain management during a painful procedure.
Deficiencies in Food Service Sanitation and Cross-Contamination Prevention
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. Dietary staff were seen handling soiled dishware and then immediately handling clean glassware without removing soiled gloves or washing hands, indicating a lack of training on cross-contamination prevention. The staff member involved had only been employed for three days and had not yet received proper training due to the Dietary Manager's focus on timely meal delivery. Additionally, personal items such as travel mugs were found stored in food preparation areas, and staff were observed placing and using these items inappropriately within the kitchen environment. Further observations revealed significant cleanliness issues with food service equipment, including thick grease buildup on the stove and inside ovens, as well as dried stains inside the plate warmer where clean plates were stored. During meal service, wet and dirty plates with dried food particles were found stacked on the trayline. The Dietary Manager stated that deep cleaning was scheduled weekly, but the last cleaning of the ovens had occurred nearly two weeks prior. Audits of kitchen sanitation and safety were reportedly conducted weekly by the Registered Dietitian.
Failure to Document COVID-19 Vaccine Education and Status for Residents and Staff
Penalty
Summary
The facility failed to properly document the administration or refusal of the COVID-19 vaccine and the provision of education regarding its benefits and potential side effects for both residents and staff. For three out of five residents reviewed, there was either no documentation of vaccine education, no record of consent or refusal, or incomplete consent forms lacking signatures or identification of the responsible party. In one case, a resident's family member verbally declined the vaccine, but the consent form only had the word 'verbal' written on the signature line without the family member's name, and there was no documentation of education provided. Another resident, who was moderately cognitively impaired, was reported to have declined the vaccine, but the consent form was unsigned and undated, and the resident stated she was not offered the vaccine. For a third resident, there was no documentation of vaccine education, consent, or refusal in the medical record, and the facility could not provide evidence of these actions. Additionally, the facility was unable to provide evidence of COVID-19 immunization status or education for two of five staff members reviewed. The Infection Preventionist stated that she offered the vaccine to residents and recorded verbal responses but did not always obtain signatures, and she did not offer the vaccine to staff but kept records of their immunization status, which were missing for the two staff members in question. The Director of Nursing confirmed that all residents should be offered the vaccine and that documentation of education and consent should be maintained, but acknowledged that records were incomplete or missing.
Failure to Provide ADL Assistance, Incontinence Care, and Meal Support
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three residents who were dependent on staff. One resident with dementia, contractures, dysphagia, aphasia, and a stage 4 sacral pressure ulcer was observed to have not received assistance with lunch, as her meal tray remained untouched for hours. Staff interviews confirmed that the resident was not offered or assisted with her meal due to short staffing and lack of communication among staff. Additionally, this resident was found saturated in urine, with soiled linens and night clothes, and had not been cleansed or repositioned for an extended period, despite being dependent on staff for all ADLs and having a high risk for skin breakdown. Another resident, who was dependent on staff for all ADLs and on hospice care, experienced a failure in receiving assistance with meals. Although staff provided assistance during some meals, there was an incident where the resident's lunch tray was not served, and the meal was not offered until surveyor intervention. Staff interviews revealed a lack of communication regarding meal assistance assignments, resulting in the resident not being fed until the issue was brought to staff attention. The resident had a history of significant weight loss, and her family expressed concerns that she was not always being fed her meals. A third resident, with a history of stroke and hemiplegia, required set-up assistance for personal hygiene and was dependent on staff for bathing. Observations showed that the resident's facial hair was overgrown, fingernails were excessively long with debris underneath, and he had not received assistance with shaving or nail care despite requesting help from staff. The resident reported frustration at being unable to maintain his grooming due to lack of assistance. Staff interviews confirmed that shaving and nail care had not been offered or completed, and unit management was not monitoring the completion of these ADLs.
Failure to Provide Required Supervision and Safety Equipment for Smoking Resident
Penalty
Summary
A deficiency occurred when a resident with a history of stroke resulting in hemiplegia/hemiparesis and unspecified psychosis, who was assessed as requiring supervision and the use of a smoking apron for safety, was not provided with the necessary supervision or safety equipment while smoking. The resident's care plan and smoking safety assessment both indicated the need for supervision and a smoking apron, yet inconsistencies were found in the documentation, with the assessment at one point incorrectly stating the resident could smoke independently. The resident confirmed that he was not wearing a smoking apron and that aprons were not available in the courtyard until the morning of the survey, despite the requirement for their use. Observations revealed that the resident was present in the designated smoking courtyard without staff supervision and without wearing a smoking apron, even though his name was listed among those requiring supervision. Staff interviews confirmed that supervision and the use of smoking aprons were required for certain residents, but the implementation of these safety measures had only recently begun, and staff were unclear about which residents required which interventions. The facility had only started using smoking aprons the day before the survey, and there was confusion among staff regarding the supervision and safety requirements for smokers. Further interviews with facility leadership acknowledged inconsistencies in the implementation of smoking safety practices, including errors in the resident's assessment and care plan. The resident was able to access the smoking area and smoke without the required supervision or safety equipment, as staff responsible for supervision were not always present, and the resident did not notify staff before going out to smoke. This lack of supervision and failure to provide required safety equipment constituted a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Maintain Accurate Medical Records for PICC Line, IV Antibiotics, and Insulin Administration
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents in relation to PICC line dressing changes, intravenous antibiotic administration, and blood sugar assessment with insulin administration. For one resident with a peripherally inserted central catheter (PICC) line, the dressing was observed to be unchanged for an extended period, with the hand-labeled date on the dressing not matching the documentation in the Medication Administration Record (MAR). The nurse responsible confirmed that she had not performed the dressing change as documented, indicating an error in recordkeeping. Both the Administrator and Director of Nursing acknowledged that documentation should be accurate. For another resident receiving intravenous antibiotics, there were two instances where the MAR was not signed to indicate administration of the medication, despite nurses later confirming that the medication had been given but not documented. Similarly, a third resident with diabetes had multiple occurrences where blood sugar checks and insulin administration were not documented on the MAR. The nurses involved could not recall the reasons for the missing documentation. Interviews with the Physician's Assistant and Director of Nursing confirmed that medications and assessments should have been accurately documented as ordered.
Failure to Assess and Care Plan for Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including progressive supranuclear ophthalmalgia, type II diabetes, and cognitive communication deficit was admitted with active physician's orders for two types of eye drops. The resident was assessed as cognitively intact but required supervision or touching assistance with personal hygiene. Despite this, there was no assessment in the medical record for the resident's ability to self-administer medications, nor was there a care plan addressing self-administration of medication. Observations revealed that multiple bottles of eye drops, both opened and unopened, were present on the resident's nightstand, and the resident reported self-administering the drops as needed. Nursing staff were aware that the resident had eye drops at the bedside, with one nurse stating the resident's spouse brought them in, but did not report this to management or ensure the medications were secured. The unit manager and DON confirmed that medications should not be kept at the bedside without a care plan for self-administration, and the resident did not have such an order. The physician assistant also confirmed that no order had been written for self-administration and expressed uncertainty about the resident's ability to administer the drops correctly.
Failure to Provide SNF-ABN Notification to Residents Ending Medicare Part A Coverage
Penalty
Summary
The facility failed to provide the required Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 to two residents prior to the end of their Medicare Part A skilled services. Both residents were admitted to Medicare Part A skilled services and remained in the facility after their skilled coverage ended. Record reviews showed no documentation that either resident or their responsible parties received the SNF-ABN, which is necessary to inform them of the end of Medicare coverage and potential financial liability for continued services. Interviews with the previous facility Social Worker confirmed that issuing the SNF-ABN was her responsibility when a resident's Medicare Part A skilled services were about to end and the resident was staying in the facility. The Social Worker could not provide a reason for the oversight in both cases. The Administrator also confirmed that the Social Worker was responsible for issuing the SNF-ABN and acknowledged that both residents should have received the notice as required by federal guidelines.
Failure to Complete MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete annual Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for two residents. For one resident, the annual comprehensive MDS assessment had an ARD of 7/30/25 but was not signed as completed by the Registered Nurse (RN) MDS Coordinator until 9/3/25. Staff interviews confirmed that this assessment was completed late. For another resident, the annual MDS assessment had an ARD of 6/26/25 and was not completed until 8/15/25, with the Care Area Assessment (CAA) also completed on the same late date. Interviews with the MDS Coordinator and MDS Nurse #2 revealed that they were two months behind on completing MDS assessments when they began their positions at the facility and were still working to catch up. The facility's Administrator acknowledged awareness of the issue, noting that the new MDS nurses were behind on assessments upon starting. The Vice President of Operations confirmed that there was not a fully implemented Plan of Correction regarding the MDS assessments at the time of the survey.
Failure to Complete Significant Change MDS Assessments Timely
Penalty
Summary
The facility failed to complete significant change in status Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for two residents. For one resident, the significant change in status MDS assessment had an ARD of 6/26/25 but was not signed as completed until 8/18/25. For another resident, who was admitted to hospice care, the significant change in status MDS assessment had an ARD of 8/7/25 and was not completed until 9/8/25. These delays were confirmed through staff interviews and record reviews. Interviews with the MDS Coordinator and MDS Nurse revealed that they were behind on completing MDS assessments when they began their positions, and were still working to catch up. The facility's Administrator acknowledged awareness of the issue and confirmed that the new MDS nurses were behind on assessments upon starting. The VP of Operations also confirmed that a Plan of Correction had not yet been fully implemented regarding the MDS assessment process.
Inaccurate and Incomplete MDS Assessments Identified
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for three residents in several key areas. For one resident with acute respiratory failure, non-Alzheimer's dementia, and who was bedbound and on hospice, the MDS inaccurately coded the resident as only occasionally incontinent of bladder and frequently incontinent of bowel, when in fact the resident was always incontinent of both. This was confirmed by the MDS nurse during an interview, who acknowledged the coding was incorrect. Another resident with chronic kidney disease and respiratory failure was incorrectly documented as having received an antibiotic during the 7-day look back period on the MDS, despite medication administration records showing no antibiotics were given during that time. Additionally, a third resident with multiple diagnoses, including gout, diabetes with polyneuropathy, and hemiplegia, had an annual MDS assessment that was incomplete, with cognitive and pain assessments marked as "not assessed, no information." Staff interviews confirmed these inaccuracies and omissions in the MDS assessments.
Failure to Implement Fall Mat Intervention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident with dementia and hypertension, who was assessed as severely cognitively impaired and dependent on staff for bed mobility. The resident's care plan, last revised on 7/9/25, included the use of a fall mat on the left side of the bed as a fall precaution. However, during multiple observations on 9/8/25 and 9/10/25, the fall mat was not in place as directed by the care plan; instead, it was found rolled up in the bathroom. The resident was observed positioned in the center of the bed, with the bed in the low position, and was reported by her representative and staff to be able to roll in bed. Interviews with the unit manager and nursing assistants revealed a lack of awareness regarding the fall mat intervention. The unit manager was unaware that the fall mat was not in place and could not explain why it had been removed. One nursing assistant was not aware that a fall mat was required, while another, who provided care almost daily, had not seen the fall mat in use and reported that the resident had attempted to get out of bed in recent months. The DON also confirmed he was not aware the fall mat was not in place and stated it should have been on the floor as per the care plan.
Failure to Update Care Plans for Code Status and Hospice Services
Penalty
Summary
The facility failed to revise and update the care plan for two residents as required. For one resident with diagnoses including diabetes and chronic lung disease, the Minimum Data Set (MDS) assessment documented that the resident was cognitively intact and had a life expectancy of less than six months, and was receiving Hospice services. Despite a physician order changing the resident's code status from full code to Do Not Resuscitate (DNR), the care plan continued to reflect the previous full code status and did not address the new DNR order. Additionally, after a physician order for a Hospice referral and subsequent admission to Hospice, there was no care plan in place addressing Hospice services for the resident. Interviews with the MDS nurse and the DON revealed that care plans were expected to be reviewed and updated daily during clinical care meetings with the interdisciplinary team. However, both staff members acknowledged that the care plan for this resident had not been updated to reflect the changes in code status or the initiation of Hospice services. The DON was not aware of the omissions until the time of the interview, despite regular care plan reviews being part of the facility's process.
Failure to Assess and Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide a record of an activity assessment and did not implement an ongoing, resident-centered activities program to meet the interests of a resident who did not participate in activities outside of his room. The resident, who was admitted with hemiplegia and hemiparesis following a stroke affecting his right dominant side, was cognitively intact and had documented preferences for books, music, animals, and being outside. The care plan noted a preference for self-directed activities such as reading and watching television in his room, but interventions were limited to reviewing these preferences as needed. During observation, the resident was found awake in his room with the lights and television off, and he reported difficulty engaging in reading due to his physical limitations and was unaware of available art supplies or accommodations for his interests. Interviews revealed that the Activity Director, who had recently started at the facility, was unaware of the resident's specific interests in coloring and reading and could not locate a completed activity assessment for the resident, which should have been done at admission. The resident stated that no one had discussed his activity preferences with him or offered supplies to support his interests, particularly in coloring, which he missed most. The lack of assessment and individualized activity planning resulted in the resident's needs and preferences not being addressed.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
A deficiency occurred when nursing staff failed to change the dressing for a peripherally inserted central catheter (PICC) line as ordered by the provider for a resident admitted with diagnoses including congestive heart failure, diabetes, chronic kidney disease, and cellulitis. Physician orders specified that the PICC line dressing should be changed on admission and then every seven days on the day shift, as well as as needed. Documentation on the Medication Administration Record (MAR) indicated that the dressing change was completed on a specific date, but the nurse responsible later confirmed that this was an error and the dressing had not been changed as documented. Observations over several days revealed that the PICC line dressing remained unchanged, with the original date still visible on the label. Interviews with nursing staff indicated a lack of familiarity with the resident's orders, and both the Administrator and DON confirmed that the expectation was for orders to be followed as written. The Nurse Practitioner and Medical Director also stated that weekly dressing changes were expected to prevent infection and maintain catheter integrity. The deficiency was identified when the dressing was finally changed, and it was confirmed that the previous dressing had not been changed for over two weeks.
Deficient Medication Storage, Labeling, and Expired Drug Removal
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of medications and biologicals. On one medication cart, there were expired medications, including a bottle of calcium carbonate with an expiration date that had passed, and a bubble-pack card of nitroglycerin tablets without resident identification. Additionally, an unopened bottle of latanoprost eye drops, which should have been refrigerated according to manufacturer instructions, was found stored on the cart instead. Loose and unidentified pills of various shapes, sizes, and markings were also found in the drawers of two medication carts, with staff confirming that these should have been properly labeled with resident information. In the medication room, expired doses of meropenem, an antibiotic, were found stored in the refrigerator, with pharmacy labels indicating expiration dates that had already passed. Staff interviews confirmed that these expired medications should have been returned to the pharmacy. Throughout the observations, staff acknowledged that medications were not labeled or stored according to professional standards and manufacturer instructions, and that expired or unidentified medications were not properly discarded.
Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to properly document education regarding the benefits and potential side effects of influenza and pneumococcal vaccines, as well as the acceptance or declination of these vaccines, in the medical records of three out of five residents reviewed. For one resident who was severely cognitively impaired, the family refused both vaccines, but there was no documentation that education was provided to the family, and the consent form was incomplete, lacking a signature, date, and the name of the family member who declined. Another resident, who was moderately cognitively impaired, had a consent form indicating both vaccines were declined, but the form was missing a signature, date, and family member identification. This resident also reported not being offered the vaccines, despite the record indicating a declination. A third resident, who was cognitively intact, had no documentation in the medical record regarding education about the vaccines or a record of consent or declination. The Infection Preventionist stated that she would write 'verbal' on the consent form after speaking with residents, but not all forms were signed or dated, and some residents' records lacked any documentation of vaccine education or decision. The DON and Administrator both acknowledged that all residents should be offered the vaccines and that proper documentation should be maintained, but these requirements were not met for the residents reviewed.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain documentation of resolved grievances and evidence of the results of all grievances for multiple residents and over several months. Specifically, there was no documentation of resolved grievances for two residents who were not cognitively intact, despite their responsible parties reporting concerns about delays in incontinent care and submitting grievances to staff. The responsible parties did not receive any communication or written response from the facility regarding their grievances. Additionally, the facility's grievance log showed no entries for a six-month period, and the required documentation as outlined in the facility's grievance policy was not maintained. Interviews with staff revealed that the previous Social Worker was responsible for handling paper grievances and distributing them to department heads, but after the transition to a new computer system, there was confusion about who was responsible for managing grievances. The Social Worker left the facility, and no one was assigned to the role during the survey. The administrator confirmed that grievances from the specified period could not be located, and there was a lack of clarity regarding grievance management and documentation during the transition period.
Failure to Protect Residents from Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident sexual abuse, resulting in two separate incidents involving inappropriate sexual contact and comments. In the first incident, a cognitively intact male resident made sexually explicit statements and touched a female resident's breasts without her consent on multiple occasions, both in the courtyard and near a nurse's station. The female resident reported that she had told the male resident to stop and had not consented to any such contact or conversation. Despite the male resident's care plan noting behavioral issues, it did not specify the nature of these behaviors or include targeted interventions to address the risk of inappropriate sexual conduct. The female resident's care plan also lacked any focus on behaviors or risk of abuse, despite her reports of ongoing unwanted attention and sexual comments from the male resident. In the second incident, a moderately cognitively impaired male resident was observed by a nurse aide with his hand on the genital area of a severely cognitively impaired, non-verbal female resident in the dining room. Both residents were fully clothed, and the female resident did not display any reaction or distress due to her advanced dementia. The male resident denied any inappropriate intent, claiming he was shooing a fly, and had no prior documented history of inappropriate behaviors toward other residents. The care plans for both residents did not address the risk of inappropriate behaviors or include interventions to prevent such incidents. In both cases, the facility's documentation and care planning failed to identify or mitigate the risk of resident-to-resident sexual abuse. There was a lack of specific behavioral interventions or monitoring for residents with known or potential behavioral issues. The facility did not provide evidence of a corrective action plan regarding its failure to protect residents' rights to be free from abuse, and the care plans did not reflect the residents' behavioral risks or needs for supervision in communal areas.
Failure to Monitor and Assess After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with a history of respiratory failure, generalized muscle weakness, and unsteadiness experienced an unwitnessed fall. The resident was found on the floor by a CNA and the Unit Manager, who performed an initial assessment and took vital signs. The Unit Manager instructed the hall nurse to conduct neurological checks, notify the resident's family and physician, and complete the necessary documentation and reporting. However, the hall nurse did not follow up with the resident as directed. The resident later reported that after the fall, no nurse came to assess her or follow up, and her fall was not documented in the facility's list of unwitnessed fall incidents. Interviews with staff revealed a breakdown in communication: the Unit Manager believed she had relayed the necessary information to the hall nurse, while the nurse stated she was not made aware of the fall until days later when the resident herself reported it. As a result, the required post-fall assessments, including neurological checks and notifications, were not completed in accordance with professional standards. The Director of Nursing confirmed that the facility failed to monitor and report the resident's unwitnessed fall, and that the expected protocol—comprehensive assessment, neurological checks, and proper documentation—was not followed. The incident was only brought to the facility's attention after the resident filed a grievance, highlighting the lack of immediate and appropriate follow-up care after the fall.
Failure to Ensure Safe and Ordered Oxygen Administration and Signage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents by not obtaining physician orders for oxygen administration, not administering oxygen at the prescribed rate, and not posting required cautionary signage. For one resident with a diagnosis of dyspnea, there was no physician order, care plan, or documentation supporting the use of oxygen therapy, yet the resident was observed with an oxygen concentrator in use on multiple occasions. Staff interviews confirmed a lack of awareness regarding the absence of an order, and no communication was found in the medical records or communication logs to justify the ongoing use of oxygen. Another resident, admitted with cardiac and dementia diagnoses, was also found to be using oxygen without a current physician order. Both the resident and her representative stated that oxygen was used primarily at night and during episodes of shortness of breath. Staff interviews revealed that the resident had been using oxygen for several months, but the physician assistant declined to provide a new order without supporting oxygen saturation data, and the DON could not locate a relevant protocol or standing order. A third resident with chronic respiratory failure and congestive heart failure had a physician order for continuous oxygen at 2 liters per minute, but observations showed the oxygen was being administered at 3.5 liters per minute. Additionally, there was no cautionary signage posted to indicate oxygen was in use. Staff interviews confirmed that nurses were responsible for checking oxygen flow rates and posting signage, but these actions were not performed as required. The DON and nurse practitioner both acknowledged the discrepancies in oxygen administration and signage.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of a resident who required extensive to total assistance with activities of daily living (ADLs), including toilet hygiene and eating. The resident, who had diagnoses such as dementia, contractures, dysphagia, aphasia, and a stage 4 pressure ulcer, was dependent on staff for all ADLs and was always incontinent. On one occasion, the resident's lunch tray remained untouched for several hours, and staff interviews confirmed that the resident had not been offered or assisted with lunch due to short staffing. The nurse aide responsible for the resident stated she was unable to provide timely assistance because she was assigned too many residents and did not ask for help as all staff were busy. Further documentation revealed that the resident was found saturated in urine and still in night clothes late in the day, with soiled linens and no evidence of having been cleansed or repositioned. The wound nurse who discovered this reported the incident, and the resident's roommate confirmed that care had not been provided throughout the day. Staff interviews indicated that nurse aides were frequently assigned to care for 20 to 40 residents per shift, making it difficult to complete essential care tasks such as bathing, feeding, and incontinence care in a timely manner. Multiple staff members, including nurse aides and unit managers, acknowledged that chronic short staffing led to delays in providing care, with some tasks being missed or only partially completed. The direct care staff reported that it was impossible to complete all required care for their assigned residents, especially when there were call outs and no additional help available. These staffing shortages directly resulted in the resident not receiving necessary assistance with eating and incontinence care.
Failure to Follow Infection Control Policies During Resident Care
Penalty
Summary
The facility failed to implement its infection prevention and control policies in several instances involving both incontinence and wound care. In one case, a nurse aide provided incontinence care to a resident and left a soiled brief on the resident's nightstand for approximately 45 minutes, rather than disposing of it immediately in a trash bag as required by policy. The aide acknowledged she intended to return with a bag but did not do so until prompted. Facility leadership confirmed that the brief should not have been placed on the nightstand and that the surface should have been disinfected after the incident. In another instance, a nurse failed to follow proper hand hygiene and personal protective equipment (PPE) protocols while providing ostomy and wound care to a resident on enhanced barrier precautions. The nurse did not don a gown as required, used bare hands to measure the resident's stoma and apply the ostomy appliance, and failed to clean scissors after use. During wound care, the nurse did not consistently wash hands between glove changes and reached into a package of gauze with contaminated gloves, later discarding the remaining gauze. The nurse also did not always wash hands before donning new gloves during the procedure. Interviews with facility staff, including the unit manager, DON, and infection preventionist, confirmed that the observed actions were not in compliance with facility policies regarding regulated medical waste, standard precautions, hand hygiene, and enhanced barrier precautions. The staff involved were aware of the policies but did not adhere to them during the observed care activities.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker despite having a census of 130 residents, which exceeds the threshold requiring such a position. According to staff interviews, the previous social worker's last day was 8/15/25, and the position had not been filled at the time of the survey. The social work department assistant was not a qualified social worker, and the regional social worker also did not meet the qualifications. The President of Operations, who is a qualified social worker, had been assisting the department but was not serving as the full-time social worker. The deficiency was identified through interviews with staff and administration, confirming the absence of a qualified full-time social worker in the facility.
Failure to Provide Required Transfer/Discharge Notices and Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification to resident representatives regarding the reason for unplanned transfers or discharges to the hospital and did not supply the required bed hold policy information for three out of four residents reviewed for hospitalizations. In the case of one resident with severe cognitive impairment, there was no documentation that the bed hold policy had been provided to the resident or their representative, and the notice of transfer form was incomplete, with the section for mailing to the representative left blank. The resident's representative confirmed that neither a bed hold notice nor a letter of transfer was received during the hospitalization. For another resident who was cognitively intact, the clinical records did not show that the bed hold policy was provided when the resident was transferred to the hospital after becoming nonresponsive. Nursing staff reported that the bed hold policy was not included in the transfer packet, and the admissions director stated she was not responsible for providing this information at the time of hospital discharge. This resident did not return to the facility and was later admitted to hospice care. A third resident, also severely cognitively impaired, was transferred to the hospital and later returned, but there was no documentation of the reason for transfer or that bed hold information was sent to the representative. Interviews with staff revealed confusion and lack of clarity regarding responsibility for providing the bed hold policy and completing transfer/discharge notifications. The administrator acknowledged awareness of the need for such documentation but noted that recent staff changes had contributed to lapses in providing required notifications and bed hold information.
Failure to Complete Quarterly MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD) for eight residents. Record reviews and staff interviews confirmed that the MDS assessments for these residents were completed late, with some assessments being overdue by several weeks. In one case, an assessment had not yet been completed as of the date of the review, making it six days overdue. The MDS Coordinator and another MDS nurse confirmed during interviews that these assessments were not completed on time. The deficiency was identified through a combination of medical record reviews and staff interviews. The MDS Coordinator and MDS Nurse #2 reported that when they began their positions, they inherited a backlog of MDS assessments that were already two months behind schedule. Despite their ongoing efforts to catch up, several assessments continued to be completed outside the required timeframe. The Administrator and the company's VP of Operations were aware of the issue and acknowledged that the facility was behind on MDS assessment completion. Specific examples included assessments for multiple residents that were signed as completed well beyond the 14-day window after the ARD, and in one instance, an assessment was not completed at all by the time of the survey. The report documents that the facility did not have a fully implemented Plan of Correction regarding the timely completion of MDS assessments at the time of the survey.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to submit discharge Minimum Data Set (MDS) assessments within the required timeframe for two residents. For one resident, the discharge MDS assessment was completed and submitted more than a month after the resident was transferred to the hospital. For another resident, the discharge MDS was completed and submitted over a month after the resident was discharged to home. In both cases, the assessments were not encoded and transmitted to the State within the mandated 7-day period following the assessment reference date (ARD). Interviews with the MDS Coordinator and MDS Nurse revealed that they were behind on completing MDS assessments when they began their positions, and were still working to catch up. The facility's Administrator confirmed awareness of the backlog and stated that new MDS nurses had been hired due to the issue. The late completion and submission of the discharge MDS assessments were acknowledged by both the MDS staff and the Administrator during interviews.
Inaccurate Daily Nurse Staffing Information Posted
Penalty
Summary
The facility failed to accurately report daily nurse staffing information as required, as evidenced by discrepancies between the posted nurse staffing sheets and the actual nursing schedules for five reviewed dates. On each of these dates, the numbers and types of staff (RNs, LPNs, and NAs) listed on the posted sheets did not match the facility's internal schedules. For example, on one date, the posted sheet indicated more RNs and fewer NAs than were actually scheduled, while on another, the posted sheet showed fewer staff than were present according to the schedule. These inconsistencies were found across all reviewed shifts and dates. Interviews with the Scheduler revealed that she was responsible for updating and correcting the posted nurse staffing sheets, typically making adjustments during regular business hours and sometimes returning on weekends or the following Monday to finalize corrections. The Scheduler also reported uncertainty about whether nursing staff had been trained to update the posted sheets in her absence. The Administrator confirmed the expectation that posted nurse staffing sheets should accurately reflect actual staffing. No information about residents' medical history or conditions was included in the report.
Failure to Timely Obtain Treatment Order for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to obtain a treatment order for a suspected deep tissue injury (DTI) on a resident's left heel at the time it was first observed, resulting in a delay in the initiation of treatment. The resident had multiple chronic health conditions, including diabetes, chronic kidney disease, obesity, and recent left total knee arthroplasty, and was identified as being at risk for pressure ulcers. The care plan included interventions such as regular skin assessments and preventative measures, but when the DTI was identified during a skin assessment, no immediate treatment order was obtained or implemented. The Wound Nurse observed the suspected DTI on the resident's left heel during a skin assessment and believed an order had been placed, but there was no evidence of a treatment order in the resident's Treatment Administration Record (TAR) for January. The Wound Nurse was unsure why the order was not present. The Wound Nurse Practitioner (NP) was only informed of the DTI several days later during wound rounds, at which point a treatment order was finally placed and initiated. Interviews with facility staff, including the NP, DON, and Administrator, confirmed that the expected protocol was to notify a provider and obtain a treatment order immediately upon identification of a pressure ulcer. Documentation review showed that the resident's care plan was not updated to reflect the DTI until several days after its initial observation, and treatment was not started until after the Wound NP was notified. The delay in obtaining a treatment order and initiating care for the pressure ulcer was confirmed through interviews and record review, constituting a failure to provide timely and appropriate pressure ulcer care as required.
Failure to Obtain Provider Order and Notify Practitioner of X-ray Results
Penalty
Summary
The facility failed to obtain a provider's order prior to requesting radiology testing for a resident and did not notify the Nurse Practitioner (NP) when x-ray results revealing multiple rib fractures became available. A resident with a history of stroke, muscle weakness, and dementia experienced a fall and subsequently underwent x-rays. The initial x-ray did not show acute fractures, and the NP reviewed these results during a post-fall evaluation. Later, another x-ray was performed without a documented provider order, and this x-ray revealed multiple right-sided rib fractures. The nurse who requested the second x-ray did so based on her own assessment of the resident's symptoms, believing the resident might have similar symptoms to her own, but did not document a provider order. The nurse also could not confirm if she communicated the pending x-ray results to the oncoming nurse. The NP was only made aware of the x-ray results after the resident was sent to the hospital for a change in condition, at which point he discovered the rib fractures in the resident's electronic medical record. Interviews with facility staff confirmed that there was no system in place to ensure provider notification of radiology results when they became available, and the process relied on verbal handoff between nursing shifts. The Director of Nursing stated that all lab or radiology results should be communicated to the provider, but this was not consistently done in this case.
Failure to Notify Physician of Resident's Pain and X-ray Delay
Penalty
Summary
The facility failed to notify the physician at the onset of pain and when a STAT x-ray could not be completed immediately after a resident experienced an unwitnessed fall. The resident, who had a history of vascular dementia, muscle weakness, and other medical conditions, fell on a Sunday and was found sitting on the floor next to her bed. Initially, no injuries were noted, and the resident reported no pain. However, when the resident's responsible party arrived, the resident complained of pain, and a STAT x-ray was ordered. The x-ray was not performed until the following day, revealing an acute nondisplaced transverse left femur fracture. The physician was not informed of the fracture until several days later, delaying necessary medical intervention. The facility also failed to notify the physician when the resident's pain was not manageable during night shifts on two occasions. Despite the resident showing signs of pain and discomfort, such as refusing care and grabbing the aide's arm to stop, the nursing aides did not report these observations to the nurse or physician. This lack of communication further delayed the resident's care and treatment, as the medical director was not aware of the fracture or the resident's condition until he saw her days later. The delay in notifying the physician and the failure to manage the resident's pain appropriately resulted in the resident being sent to the hospital for surgery only after the medical director intervened. The resident underwent surgery for the fracture and experienced complications, including an aspiration event leading to acute hypoxic respiratory failure. The facility's inaction and communication failures contributed to the resident's prolonged pain and delayed treatment, putting her at high risk for further complications.
Removal Plan
- An incident report was completed by the charge nurse, based on information obtained from certified nursing aide.
- The Director of Nursing and Nurse Managers reviewed residents who have fallen to confirm that the Medical Director had been notified.
- The Director of Nursing and Nurse Managers reviewed diagnostic and laboratory testing to ensure they were obtained as ordered and the Medical Director had been notified.
- The Director of Nursing/Staff Development Coordinator began in person education for all nursing staff on the facility policy and procedures for physician notification.
- Licensed nurses were educated on utilization of the MD communication book to report diagnostic reports and other non-emergent resident issues.
- All nurse aides were educated on the process of notification to licensed nurse of any identified resident issues such as pain or other resident concerns.
- The licensed nurses will document in the residents' electronic medical record the notification to the medical provider and the plan of care.
- The Nurse Managers will review the residents electronic medical record daily and the documentation to ensure the medical provider was notified.
- Education will be provided for all new nursing staff and agency staff prior to the beginning of their first shift.
- Nurse Aides can report directly to the nurse or use the computer system which serves as an alert system within the resident's electronic record.
- The Director of Nursing educated Licensed Nurses regarding the requirements for notification of the Physician following a fracture and/or a significant change of condition.
- The Director of Nursing or designee will complete in person review with any staff that receive education by telephone to assure their understanding of the education received.
- The Staff Development Coordinator will be responsible for tracking which employees have received their education.
- The Director of Nursing and Administrator completed an Ad-Hoc QAPI to ensure that all components of the credible allegation were completed and followed.
- The Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.
Neglect in Timely Medical Intervention After Resident Fall
Penalty
Summary
The facility failed to protect a resident from neglect following an unwitnessed fall. After the fall, the resident reported pain in her left hip, but the facility did not notify the physician immediately. A STAT x-ray was ordered but not completed until the following day, revealing a nondisplaced transverse left femur fracture. The Nurse Practitioner did not communicate the x-ray results to the Medical Director, delaying the necessary orthopedic evaluation and surgical intervention. The resident's pain was not adequately managed, and the facility failed to notify the physician when the resident's pain was unmanageable during night shifts. The Medical Director was unaware of the fracture and the scheduled orthopedic consultation until several days later. Upon discovering the fracture, the Medical Director ordered the resident to be sent to the emergency department if she could not be seen by an orthopedist that day. The resident was eventually seen by an orthopedist and underwent surgery. The delay in treatment and lack of communication between the facility staff and medical providers resulted in the resident experiencing an aspiration event while hospitalized, leading to acute hypoxic respiratory failure. The facility's neglect in providing timely and appropriate care put the resident at high risk for complications, including deep vein thrombosis, pneumonia, and bed sores.
Removal Plan
- The Director of Nursing/Staff Development Coordinator began in-person education for all facility staff in all departments including agency and contract staff. Education included review of policy regarding abuse/neglect.
- Recognizing signs of abuse and neglect.
- Examples of neglect, including not providing necessary care and services.
- Reporting of abuse and neglect.
- Facility policy and procedures for physician notification to include notification of physician to any complaints of unrelieved pain by residents to be reported to the physician immediately.
- Notification to physician of any delays in physician orders including stat orders and delay in any physician ordered appointments and x-rays.
- Education to certified nurse aides on reporting identified pain and other abnormal events identified during delivery of care.
- Any nursing staff member that did not receive education will receive education by the beginning of the next shift by the DON or designee. The Staff Development Coordinator will be responsible for tracking staff that still require education. Any staff that has not received education will not be allowed to work until education is received.
- All newly hired licensed staff will be educated by the Staff Development Coordinator on this policy. This education will be added to the orientation process.
- The DON or designee will verify the understanding of education through oral discussion and feedback with all staff and notate this on a tracking tool. The SDC will also do this in orientation.
- In person education was completed by the Director of Nursing to current medical providers including on-call providers, Nurse Practitioners and Medical Director. Education consisted of communication between all providers should be clear, concise and collaborative. Communication should include a discussion of treatment plans and seeking advice when necessary. Providers should participate in decision making in a timely manner.
- The Medical Director and the Physician Extenders agreed to meet with the Director of Nursing weekly to discuss abnormal labs, radiology or test results as a team.
- The Regional Director of Clinical Services informed the Staff Development Coordinator and/or the Director of Nursing to complete monthly training on abuse and neglect for 3 months and then quarterly ongoing. Education will ensure abuse and neglect is explained to all staff per federal guidelines, Neglect as defined at 483.12, the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
- The Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.
Delayed Orthopedic Evaluation After Resident Fall
Penalty
Summary
The facility failed to recognize the seriousness of an injury sustained by a resident following a fall, which led to a delay in urgent orthopedic evaluation and treatment. The resident, who had a history of vascular dementia, muscle weakness, and other medical conditions, fell and reported pain in her left hip. A STAT x-ray was ordered but not completed until the following day, revealing a nondisplaced transverse left femur fracture. Despite the x-ray results, the resident remained in the facility awaiting an orthopedic consultation, which was initially scheduled for a week later. The Medical Director was not informed of the fracture until several days later, at which point he ordered the resident to be sent to the emergency department if she could not be seen by an orthopedist that day. The resident was eventually seen by an orthopedist and sent directly to the hospital for surgery. The delay in recognizing the need for urgent care and the failure to act promptly on the x-ray results contributed to the deficiency. Interviews with staff revealed a lack of communication and timely action regarding the resident's condition. The nurse who initially assessed the resident did not notify the on-call provider of the delay in obtaining the x-ray, and the NP did not send the resident to the hospital despite the fracture. The facility's failure to act on the x-ray results and the lack of immediate orthopedic evaluation put the resident at risk for complications.
Removal Plan
- The Director of Nursing, Unit Managers, and Regional Director of Clinical Services reviewed diagnostic results and progress notes for all residents to identify any instances of delay in carrying out orders, changes in condition, abnormal results, refusals, or other clinical conditions that had not been properly identified and acted upon.
- The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for Licensed Nurses, including agency nurses, on recognizing when to seek medical treatment for residents with fractures and changes in condition and notification to the Physician/Medical Director following an incident or change of condition and when receiving ordered diagnostic test results.
- Education included reporting of abnormal labs and x-ray results, if an order is not to be carried out as ordered by the physician or nurse practitioner, refusal of treatment plan by the resident or responsible party, and knowing the risk and benefits of not sending a resident out for treatment when needed.
- The Director of Nursing will ensure that no staff member works without receiving this education. The Staff Development Coordinator is responsible for tracking that all staff received the required education. Any new hires, including agency staff, will receive education prior to the start of their shift.
- The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers initiated in-person training for all Licensed Nurses, including agency nurses, to ensure they understand the requirements for orders received for diagnostic tests. If the diagnostic test is ordered stat and the mobile diagnostic company is unable to perform the study stat or in an acceptable time at the direction of the medical provider, the resident is to be sent to the hospital.
- The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift.
- The Staff Development Coordinator was informed of her responsibility. This education will also become a part of the new hire orientation process for all newly hired licensed nurses.
- The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers conducted in-person education for all Licensed Nurses, including agency nurses, on the procedure for handling abnormal x-ray results. The training emphasized that abnormal results must be reported to the Medical Director for further orders.
Failure in Communication and Collaboration Delays Resident's Fracture Treatment
Penalty
Summary
The deficiency involved a failure in communication and collaboration between a Nurse Practitioner (NP) and the Medical Director regarding the medical management of a resident who suffered an acute nondisplaced transverse left femur fracture following an unwitnessed fall. The NP did not consult with the Medical Director before deciding that the resident was probably not a surgical candidate and attempted to treat the resident in-house. This lack of communication resulted in the Medical Director being unaware of the fracture until several days later, delaying appropriate medical intervention. The resident, who had a history of vascular dementia, muscle weakness, and other significant health issues, experienced an unwitnessed fall and was initially assessed with no injuries noted. However, the resident later reported pain, and an x-ray confirmed a fracture. Despite this, the NP chose to manage the condition conservatively without consulting the Medical Director, who only became aware of the fracture days later when the resident's pain became unmanageable. The delay in appropriate medical management led to the resident being sent to the hospital for surgery only after the Medical Director intervened. The resident subsequently experienced complications, including an aspiration event resulting in acute hypoxic respiratory failure while hospitalized. The deficiency affected the resident's timely access to necessary orthopedic care and increased the risk of further complications.
Removal Plan
- The MD reviewed the NP's notes for the previous 30 days, including the on-call providers, to ensure the plan of care was appropriate for the residents. Any opportunities identified during this audit were corrected by the MD.
- The Regional Director of Clinical Services, Nurse Practitioner, Medical Director, and the Director of Nursing reviewed Resident #1's plan of care and collaborated on what the best course of treatment should have been for the resident.
- The Regional [NAME] President educated the Medical Director, NPs, and covering providers on collaborating/consulting following a fracture and/or a significant change of condition. The Medical Director, Nurse Practitioners and covering providers will collaborate 3 times a week via phone, in-person, or virtual to discuss the plan of care for the residents that have obtained a fracture or a significant change in condition.
- The Regional [NAME] President educated The Director of Nursing and the Administrator to participate in the meeting.
- The Medical Director reviewed the guidelines for how the Nurse Practitioners and other covering providers to communicate with the Medical Director. The Medical Director and Regional [NAME] President discussed this agreement with the NPs and other providers.
- The Regional Director of Clinical Services educated the Nurse Management Team and the Director of Nursing regarding the nurse practitioners' notes, including on call to ensure communication and collaboration is completed. The Director of Nursing, unit managers, staff development nurse and Assistant Director of Nursing will review and print the nurse practitioner notes, including the on-call providers daily and place them in the Medical Director's communication book. When the Medical Director is not in the facility, he will receive an electronic HIPAA compliant copy of the medical progress notes generated each day. Any new hires, including agency staff, will receive education prior to the start of their shift via telephone or in person.
- The Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance.
Inadequate Pain Management Following Resident Fall
Penalty
Summary
The facility failed to effectively manage a resident's pain following an unwitnessed fall. The resident, who was admitted with multiple diagnoses including vascular dementia and a history of traumatic brain injury, was found on the floor by a nurse aide. Initially, the resident denied any pain or injury, and no immediate pain management was initiated. However, when the responsible party arrived, the resident reported pain in the left hip, prompting a delayed order for a STAT x-ray and Tylenol for pain relief. Despite the order for regular pain assessments, documentation revealed inconsistencies and omissions in pain management. Pain assessments were not thoroughly conducted, with some entries lacking numerical values or specific pain locations. The resident's pain levels fluctuated, with reports of significant pain on certain days, yet the administration of pain medication was not consistently documented. Interviews with staff indicated a lack of communication and follow-up regarding the resident's pain status, contributing to inadequate pain management. The resident's condition worsened, with a confirmed nondisplaced fracture to the left femur. Despite this, the resident remained in bed for several days, with limited mobility and ongoing pain. The facility's failure to conduct thorough and ongoing pain assessments, coupled with inadequate documentation and communication among staff, resulted in insufficient pain management for the resident. This deficiency highlights the need for improved protocols and staff training in pain assessment and management to ensure resident well-being.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency in a timely manner for a resident who was reviewed for neglect. The incident involved a resident who sustained a fall on November 17, 2024, and did not receive the necessary care and services for a fracture. The Administrator was informed of the neglect allegation on January 3, 2025, at 8:48 AM. However, the initial allegation report was not submitted to the state agency until January 6, 2025, at 2:15 PM. During an interview on January 6, 2025, the Administrator stated that the report was not sent on January 3, 2025, because he assumed it was unnecessary since all parties involved, including the state agency, were already aware of the allegation.
Inaccurate Post-Fall Documentation for Resident
Penalty
Summary
The facility failed to ensure accurate medical record documentation for a resident following a fall. The resident, who was nonverbal, was admitted to the facility and experienced a fall, resulting in a nondisplaced fracture to the left femur. Documentation of the resident's condition post-fall was inconsistent and inaccurate, with several notes being copied from previous entries without proper assessment. Specifically, the Night Nurse Supervisor and Nurse #3 copied information from previous notes without conducting their own assessments of the resident's pain or condition. The Night Nurse Supervisor admitted to copying details from previous shifts' documentation to ensure some form of record was completed, despite not assessing the resident for pain on multiple occasions. Nurse #3 also failed to recall the documentation note and did not receive any notification from Nurse Aides regarding the resident's pain. The Director of Nursing confirmed that the nurses were expected to assess and document the resident's pain accurately during each shift, which was not done, leading to the deficiency in maintaining accurate medical records.
Inadequate COVID-19 Testing and Infection Control Measures
Penalty
Summary
The facility failed to implement a broad-based COVID-19 testing approach for staff and residents despite being in outbreak status since a staff member tested positive. Initially, only symptomatic individuals, roommates of positive residents, and staff who requested testing were tested. This approach did not align with CDC guidelines, which recommend a broad-based testing approach during outbreaks. As a result, the facility did not initiate broad-based testing until several days after multiple residents across different halls tested positive, leading to a significant number of COVID-19 cases among residents and staff. Additionally, the facility's infection control practices were inadequate, as observed by surveyors. Many staff members failed to wear surgical masks properly, with masks not covering both the mouth and nose, which is essential for source control to prevent transmission. Furthermore, a nurse aide entered a resident's room under transmission-based precautions without wearing the required eye protection. These lapses in infection control measures contributed to the potential for continued transmission of COVID-19 within the facility. The facility's policies and procedures for infection prevention and control did not conform to CDC guidance, particularly regarding outbreak testing and the use of personal protective equipment (PPE). The Infection Preventionist and Director of Nursing were aware of the outbreak but did not implement the necessary measures to control the spread effectively. The facility also failed to initiate the administration of the 2024-2025 COVID-19 vaccinations for residents in a timely manner, further exacerbating the risk of transmission.
Removal Plan
- The Director of Nursing and Infection Preventionist completed broad-based testing on all staff and residents within the facility. The facility will complete testing on all residents and staff twice per week until there is a 14-day interval of no new positive cases.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator/Infection Preventionist, and the Unit Managers regarding Special Droplet Contact Precautions when a resident tested positive for COVID-19.
- All staff, including medical director and Nurse Practitioner, will perform hand hygiene using soap and water and/or alcohol-based hand rub before entering and before exiting the room.
- All staff, including medical director and nurse practitioner will wear a gown when entering the room, remove before exiting the room.
- All staff, including medical director and nurse practitioners, will wear an N95 when entering the room and remove before exiting the room.
- All staff, including the medical director and nurse practitioner will wear eye protection such as a face shield or goggles when entering the room and remove them before exiting the room.
- All staff, including the medical director and nurse practitioner will wear gloves when entering the room and remove them before leaving the room.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding source control to include wearing face mask throughout the building during outbreak status regardless of if they are in a covid positive room or not.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education with current staff and providers, including the medical director and nurse practitioners, regarding Special Droplet Contact Precautions when a resident test positive for COVID-19.
- The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift in person.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly don Personal Protective Equipment.
- The Regional Nurse Consultant educated the Director of Nursing, Staff Development Coordinator, and the Unit Managers regarding how to properly doff Personal Protective Equipment.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly don Personal Protective Equipment with current staff.
- The Director of Nursing, Staff Development Coordinator, and the Unit Managers initiated education regarding how to properly doff Personal Protective Equipment with current staff.
Failure to Maintain 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to maintain licensed nursing coverage 24 hours a day for 17 out of 120 days reviewed, as required by regulations. This deficiency was identified through a review of staffing data submitted via the CMS Payroll-Based Journal system for the third quarter of 2024. Specific dates in April and May 2024 were noted where there was no licensed nurse coverage for the entire day. The facility was unable to provide supporting documentation such as staff schedules, timecard reports, or payroll reports for the period in question, which could have confirmed the presence or absence of licensed nursing staff. Interviews with facility staff revealed that there was a transition in management when a new company took over in June 2024. The Staff Development Coordinator, who also served as the Infection Preventionist and Assistant Director of Nursing, acknowledged the previous reliance on agency staff but could not confirm the staffing situation prior to the takeover. Similarly, the Facility Scheduler, who assumed her role in June 2024, was aware of the regulatory requirement for 24-hour licensed nurse coverage but was unable to provide information on staffing issues before her tenure.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours per day, 7 days a week, for 17 out of 120 days reviewed. This deficiency was identified through a review of staffing data submitted via the CMS Payroll-Based Journal system for the third quarter of 2024. The specific dates without adequate RN coverage were listed, but the facility was unable to provide supporting documentation such as staff schedules, RN timecard reports, or payroll reports for the period from April 1, 2024, to June 30, 2024. Interviews with facility staff revealed that the Staff Development Coordinator, who also served as the infection preventionist and assistant director of nursing, could not confirm RN coverage for the specified days. The Facility Scheduler, who assumed her role in June 2024, was aware of the regulatory requirement but could not provide information on scheduling issues before her tenure. The facility Administrator, also new since June 2024, was unable to locate any relevant staffing documentation prior to that time, indicating a lack of continuity and record-keeping during the transition to new management.
Significant Medication Error Due to Late Insulin Administration
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident with diabetes mellitus and dementia. The resident was prescribed Humalog Insulin to be administered according to a sliding scale before meals and at bedtime. On a specific day, the resident's blood glucose level was checked at 9:50 AM, revealing a level of 252 mg/dL, which required the administration of 7 units of insulin. However, the insulin was not administered until 9:55 AM, more than 2.5 hours after the scheduled time of 7:30 AM, which was prior to the resident's breakfast. Nurse #4, responsible for administering the insulin, attributed the delay to a heavy medication pass workload and the additional time required to manage COVID-positive residents. The Director of Nursing (DON) later stated that nurses have sufficient time to pass medications within the required timeframes and that administrative nurses are available to assist if needed. The late administration of insulin was identified as a significant medication error due to the deviation from the prescribed schedule.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility's interdisciplinary team failed to assess and document the ability of two residents to self-administer medications. Resident #6, who was cognitively intact, did not have a care plan addressing self-administration of medications. Despite this, a medicine cup containing two stool softener tablets was left on Resident #6's overbed table by a nurse, who did not stay to observe the resident taking the medication. The nurse's actions were contrary to the facility's policy, which requires nurses to stay with residents while they take their medications. Nurse #9, who was not the administering nurse, later discarded the tablets, acknowledging that leaving medications in a resident's room was not standard practice. Similarly, Resident #12, also cognitively intact, did not have a care plan for self-administration of medications. A nurse left a medication cup containing gabapentin and a probiotic on Resident #12's overbed table while the resident was on a phone call. The resident took some of the pills independently, which was against the facility's policy. Interviews with the Unit Manager and the Director of Nursing confirmed that no residents were authorized to self-administer medications, and nurses were expected to stay with residents during medication administration. The facility's failure to assess and authorize self-administration of medications led to these deficiencies.
Failure to Complete Significant Change in Status MDS Assessment
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for a resident who was reviewed for hospice services. The resident was admitted to the facility with a diagnosis of malignant neoplasm of the right lung and was later admitted to hospice services. However, a review of the MDS assessments revealed that a Significant Change in Status MDS Assessment was not completed after the resident's admission to hospice services. During an interview, the MDS Coordinator, who had been working at the facility for two months, acknowledged that the assessment should have been completed within fourteen days of the resident's admission to hospice. It was also revealed that the facility had not had a dedicated MDS Coordinator for over a year, relying instead on traveling MDS Nurses and various facility staff to conduct assessments and observations.
Inaccurate MDS Coding and Assessment Deficiencies
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the areas of falls, range of motion, and comprehensive assessments. Resident #59, who was admitted with hemiplegia and a right-hand contracture, was inaccurately coded as having no range of motion impairments despite recommendations for a Functional Maintenance Program and the use of a splint. Observations revealed the resident's right hand was fisted, and the splint was not in use until located by the Rehabilitative Director. The MDS Director, who had been in the role for two months, was unable to explain the inaccuracies due to the previous use of traveling MDS nurses and lack of a consistent MDS Coordinator. Resident #69, diagnosed with Alzheimer's disease, was not assessed for several critical areas including cognition, mood, and functional abilities in their quarterly MDS assessment. The MDS Director acknowledged the absence of a dedicated MDS Coordinator for over a year, which contributed to the incomplete assessments. Additionally, Resident #42's admission MDS assessment failed to include psychiatric diagnoses of schizophrenia and PTSD, despite these being documented in the medical records and medication administration records. The MDS Coordinator recognized the error and was in the process of correcting it, while the Director of Nursing emphasized the need for accurate and complete diagnoses in resident charts.
Failure to Apply Recommended Splinting Device for Resident
Penalty
Summary
The facility failed to apply the right-hand grip splinting device as recommended by the occupational therapist for a resident with a contracture of his right hand. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebrovascular accident affecting the right dominant side and a right-hand contracture. Despite the occupational therapy discharge summary recommending a functional maintenance program with a right grip splint, the care plan did not include the application of the splinting device, and there was no physician order for it in the medical record. Observations revealed that the resident's right hand was fisted, and the splinting device was not visible in the room. Interviews with staff indicated uncertainty about the location and application of the splint. The Rehabilitation Director found the splint in the resident's nightstand and applied it, noting it fit comfortably, suggesting the resident's range of motion had been maintained. However, the resident's POA reported not seeing the splint on the resident's hand in two years, indicating a lapse in the consistent application of the recommended splinting device.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to administer oxygen at the physician-prescribed rate for a resident diagnosed with hypoxemia and congestive heart failure. The resident was moderately cognitively impaired and required oxygen therapy at 2 liters per minute via nasal cannula, as per physician orders. However, during observations, the oxygen concentrator was set to deliver 3.5 liters per minute. Despite the resident showing no signs of respiratory distress, the discrepancy in oxygen delivery was noted. Nurse #4, who was responsible for the resident's care, did not document the resident's vital signs or check the oxygen concentrator settings due to the presence of visitors and the absence of respiratory distress. The Nurse Practitioner confirmed the resident had no symptoms of dyspnea and instructed staff to adhere to the prescribed oxygen rate. The Director of Nursing and the Administrator both emphasized the expectation for nursing staff to follow physician orders and monitor oxygen therapy settings.
Incomplete Medical Record for Resident Diagnoses
Penalty
Summary
The facility failed to maintain a complete medical record for a resident who was admitted following a fractured pelvis and septic shock, which resulted in generalized muscle weakness. Upon review, it was found that the resident's electronic medical record did not include the diagnoses of schizophrenia and post-traumatic stress disorder (PTSD) as noted in the hospital discharge summary. This omission was identified during a review of the resident's medical records, highlighting a deficiency in maintaining accurate and complete diagnoses in the resident's chart.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
