River Bend Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Asheville, North Carolina.
- Location
- 213 Richmond Hill Drive, Asheville, North Carolina 28806
- CMS Provider Number
- 345432
- Inspections on file
- 28
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at River Bend Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia was allegedly struck on the side of the head by a nurse aide, but the witnessing NA did not report the incident at the time, despite believing it could be abuse. Months later, the NA informed an agency nurse, who also failed to notify facility leadership as required by the abuse policy and instead only contacted APS after her shift. Facility policy required immediate reporting of all abuse allegations to the Administrator and other agencies within specified time frames, as well as immediate investigation and protective measures. Due to these inactions, the Administrator and DON were not promptly informed, and the facility’s investigation and protection of the resident were delayed.
A resident with dementia and severe cognitive impairment fell while handling meal tray lids and was assisted up and back to bed by a NA without immediate RN/LPN assessment. The NA did not clearly report the fall to the assigned nurse, who, after hearing a scream, found the resident already in bed and was told only that the resident had been taking tray lids off a cart. No focused post-fall assessment occurred at that time. Later that night, another NA and nurse noted the resident could not walk and had a swollen right elbow, leading to x-ray orders. X-rays completed the next day revealed acute fractures of the right olecranon and right hip/femoral neck, and the resident was transferred to the hospital for surgical repair. Leadership and the NP confirmed that NAs were expected not to move residents after a fall and to notify nursing for assessment, which did not occur in this case.
An agency nurse signed out multiple doses of controlled narcotics for six residents on narcotic control sheets during a single night shift without corresponding entries on the MARs, despite residents having orders for scheduled and PRN Oxycodone, Hydromorphone, Tramadol, and Hydrocodone‑Acetaminophen. In one case, a resident with both scheduled and PRN Oxycodone had doses signed out at non‑scheduled times and on multiple narcotic sheets, including an unexplained tablet count change without dates or signatures, while the MAR lacked matching administration records. Another nurse later noticed that PRN narcotics were signed out for a resident who usually did not request pain medication, and that resident denied receiving the medication. A second agency nurse admitted signing as a witness to narcotic waste at the first nurse’s request without observing the disposal, and a pharmacist later confirmed that resident narcotics had been misappropriated and required replacement.
The facility failed to ensure accurate reconciliation and proper witnessing of wasted narcotic medications when an agency nurse signed as a witness to oxycodone waste without visually observing the disposal. One resident had scheduled oxycodone for pain and another had PRN oxycodone, with an agency nurse signing out multiple doses for both on the same evening. A staff nurse later noticed missing PRN oxycodone for a resident who typically did not request pain medication and saw that the doses were not documented as administered on the MAR, and the resident denied receiving them. Review of narcotic sheets confirmed that the waste entries were co-signed by another agency nurse who later reported she had signed as a witness at the first nurse’s request without actually seeing the medications being wasted.
A resident with a history of stroke and right-sided paralysis suffered a fall during an assisted transfer, resulting in severe pain and later-confirmed leg fractures. Due to ineffective staff communication and lack of interpreter use, the resident's pain was not properly assessed or managed for two days, and pain medication was delayed and initially ineffective. The resident did not have a pain care plan, and staff failed to notify a provider or use an interpreter until the nurse practitioner intervened and ordered appropriate pain relief.
A resident who experienced a fall and acute leg pain had x-rays performed, which revealed nondisplaced fractures of the proximal tibia and fibula. Although the x-ray results were received and acknowledged by nursing staff and the DON, the results were not communicated to a medical provider until the following day, resulting in delayed medical intervention and hospital evaluation.
A resident with a history of stroke and right-sided hemiplegia reported a fall in the bathroom and experienced severe pain, bruising, and swelling in her right leg. Despite multiple staff members being made aware of the incident and the resident's acute pain, there was a breakdown in communication and no physician was notified until the following day. This delay resulted in postponed x-rays, medical intervention, and hospital evaluation, with subsequent diagnosis of acute tibia and fibula fractures.
A resident who spoke Spanish fell during a staff-assisted transfer, resulting in acute leg fractures and significant pain. Staff failed to promptly notify a medical provider, did not use an interpreter to assess the resident's pain, and delayed both pain management and communication of x-ray results. The resident was not properly assessed after the fall and required hospitalization for her injuries.
A resident who required substantial assistance for transfers fell during a staff-assisted transfer, resulting in acute pain and undetected fractures. Staff failed to report the fall, did not assess or document the injury, and did not notify a medical provider in a timely manner. Communication breakdowns and lack of adherence to protocol led to delayed diagnosis and treatment, with the resident ultimately requiring hospitalization for fractures.
A resident with right-sided hemiplegia, dependent for transfers, was assisted off the toilet by staff using a stand and pivot transfer instead of the required mechanical lift. During the transfer, one staff member left to get a wheelchair and the other was not attentive, resulting in the resident falling and sustaining acute right tibia and fibula fractures. The incident was not immediately reported or documented, and the resident's pain and injury were not promptly addressed, leading to delayed medical intervention.
Multiple MDS assessments were inaccurately completed, including failure to document a swallowing disorder for a resident with documented symptoms, incorrect coding of pressure ulcers as present on admission for a resident who developed them after admission, and failure to note edentulism despite clinical evidence. Additionally, two residents were incorrectly coded as using physical restraints, although neither was actually restrained, and the facility was restraint free. These errors were confirmed by staff and attributed to remote completion of assessments and lack of a dedicated MDS Coordinator.
A resident with intact cognition was not invited to participate in care plan meetings following multiple MDS assessments. The resident expressed a desire to be involved in these meetings, but staff interviews confirmed that care plan meetings had not been held or documented for this individual during the current year.
A resident with severe cognitive impairment and limited mobility was unable to access the light switch in their room due to a broken and unreachable switch cord. Nursing staff were unaware of the issue because the cord was hidden by a lamp, and the maintenance director relied on staff reports to identify such problems. The resident had to repeatedly request assistance from staff to control the light, highlighting a failure to accommodate the resident's needs.
Two residents with significant mobility and self-care deficits did not have their needs for transfers, bathing, and personal and oral hygiene addressed in their care plans. One resident with cerebral palsy and another with a below-knee amputation both required substantial staff assistance, but their care plans lacked interventions for these ADL needs due to staff oversight and absence of an MDS Coordinator.
Two residents with cognitive impairment and mobility limitations had bed rails installed without documented risk assessments or informed consent. Staff interviews confirmed that required assessments and consents were not completed prior to bed rail use, and leadership acknowledged the lack of a clear process for ensuring these steps were followed.
A resident with dementia and dysphagia, who was ordered to receive nectar thick liquids, was served thin tea during a meal. Staff failed to remove the inappropriate liquid from the resident's reach, and a staff member unaware of the dietary order provided a straw, allowing the resident to drink the thin liquid and cough. The deficiency was confirmed through staff interviews and review of the resident's care plan and diet order.
A resident who was cognitively intact and had signed consent to receive the influenza vaccine did not receive it, as the vaccine was not administered or documented. The resident was absent during the scheduled vaccination clinic, and despite the facility having vaccines available, the dose was missed due to process changes and leadership turnover.
A resident with intact cognition and Managed Medicaid coverage was issued a 30-day discharge notice for non-payment after the facility failed to submit a claim to the insurance due to an incorrect payer source designation. The resident and their representative were not prepared for the discharge, and ongoing billing statements were received despite insurance approval for the stay. Staff interviews confirmed that required processes for insurance billing and Medicaid transition were not followed, leading to the deficiency.
A resident was discharged to the community without a completed discharge summary, as only the Therapy section was filled out while other required sections, including Nursing, Dietary, Social Services, Activity, Reason for Discharge, Medical Summary, and Acknowledgement, were left blank. The Social Worker confirmed the oversight and lack of consistent documentation, and the Administrator was unaware of the incomplete record.
A resident with hypertensive heart disease missed three scheduled doses of prazosin hydrochloride after nursing staff failed to request a timely refill from the pharmacy. The medication was not available on the cart, and staff did not follow up with the pharmacy or notify the DON, resulting in a gap in administration and increased blood pressure readings for the resident.
A resident with a history of stroke and right-sided hemiplegia, whose primary language was Spanish, was unable to effectively communicate her needs due to the facility's lack of a consistent and reliable translation system. Staff relied on the resident's roommate, who had dementia, or used gestures and personal translation apps without formal guidance. The resident reported distress over not being understood, and staff and leadership confirmed there was no established process for providing translation services.
A resident with osteoporosis missed three consecutive days of scheduled tramadol due to nursing staff failing to timely request a prescription refill, inadequate documentation, and unsuccessful attempts to access the medication from the Pyxis system. Despite available pharmaceutical resources, the medication was not obtained or administered as ordered, resulting in a gap in pain management.
Nursing staff failed to administer a prescribed opioid pain medication to a resident for three consecutive days due to delays in refilling the medication and obtaining necessary signatures, despite the resident being at risk for pain and having a care plan in place. The resident received as-needed acetaminophen during this period, and pain assessments indicated minimal discomfort. The facility's emergency medication supply contained the needed medication, but it was not used. Staff interviews confirmed the error and identified missed opportunities to prevent the lapse.
A resident reported falling and experiencing acute knee pain while being assisted in the bathroom. Although the incident was communicated among nursing staff and assessed by a supervisor, no documentation, assessment, or incident report was completed in the medical record. Each nurse assumed the other would handle the required post-fall protocol, resulting in a lack of recorded follow-up.
Survey results were kept in a binder in the lobby, but there was no signage indicating its location, and all resident rooms were behind a locked, coded door. Residents were unaware of where to find the survey results and would need staff assistance to access the binder.
A resident with a history of traumatic brain injury and impulse control disorder physically assaulted two other residents with severe cognitive impairment, resulting in one resident sustaining a head injury and requiring emergency evaluation. Both incidents occurred in common areas with staff nearby, and the aggressive resident's behavioral triggers were known but not effectively managed, leading to physical abuse and harm.
A resident with intact cognition and a history of anxiety and depression reported being attacked and cursed at by a male nurse aide, but the allegation was not immediately reported to the nurse, DON, or Administrator as required by policy. The accused aide remained on shift with access to other residents, and the incident was not reported to Adult Protective Services in a timely manner. Staff interviews revealed confusion about reporting protocols and a lack of immediate protective action for the resident.
A facility failed to protect residents from misappropriation of controlled medications, involving two nurses who appeared impaired on duty. One resident's morphine was taken by a nurse who tested positive for the drug, while another nurse fraudulently signed out oxycodone for two residents, including one deceased. The incidents were confirmed through investigations and reported to authorities.
The facility failed to implement recommended nutritional interventions for two residents. One resident with severe protein-calorie malnutrition did not receive the prescribed liquid protein supplement, while another resident with dysphagia received less enteral feeding than ordered. Despite communication of the RD's recommendations, the orders were not consistently followed, leading to deficiencies in care.
The facility failed to ensure that physician visits were conducted every 30 days for the first 90 days of admission for several residents. This deficiency was identified through record reviews and staff interviews, revealing that six out of twelve sampled residents did not receive the required physician visits. The issue was compounded by a lack of awareness among the Medical Records staff regarding the specific regulatory requirements for MD visits.
The facility failed to provide RN coverage for at least 8 consecutive hours on six occasions due to the resignation of the weekend RN supervisor and instability in the nurse administration team after a corporate change.
The facility failed to secure and store medications properly, with an opened Silvadene cream left unattended in a resident's room and expired medications found in storage areas. Insulin and eye drops were improperly stored at room temperature. Staff interviews revealed a lack of regular checks and awareness, attributed to leadership turnover.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices and did not follow hand hygiene protocols. Staff were observed not using required gowns and gloves during high-contact care activities, and there was a lack of EBP signage and PPE near residents' rooms. Interviews revealed staff were not trained on EBP, and improper glove use and hand hygiene practices were noted during incontinence care.
A resident with severe cognitive impairment and multiple diagnoses was not invited to participate in care planning meetings, nor was their Resident Representative (RR). The oversight occurred after a change in facility management, leading to missed meetings due to unclear responsibilities for scheduling. The Social Worker acknowledged the issue and was working on improving the process.
The facility failed to protect the private health information of two residents by leaving their medical records visible on an unattended medication cart. A nurse admitted to being distracted, despite having completed HIPAA training. The facility expects staff to follow HIPAA guidelines to safeguard resident information.
A facility failed to prevent resident-to-resident abuse when a cognitively impaired resident with a history of aggression hit another resident, causing injuries. Despite being aware of the aggressive resident's history, the facility did not implement specific interventions or increased supervision. The incident was witnessed by a visitor, and the facility substantiated the abuse allegation.
A facility failed to report and investigate an alleged abuse incident involving a resident with moderate cognitive impairment. A resident reported witnessing another resident being held down and provided care against her will by a male staff member. The Medical Records Director informed the Administrator, who dismissed the report, stating it did not count as abuse. The facility's policy requires immediate investigation and reporting, but the Administrator did not take the necessary steps, resulting in a delayed response.
The facility failed to develop comprehensive care plans for two residents, one with urinary retention and dementia, and another with diabetes and end-stage renal disease. Both residents had specific dietary and medical needs that were not addressed in their care plans. The Regional MDS Consultant, responsible for completing MDS assessments remotely, acknowledged the oversight and confirmed that these areas should have been included in the care plans.
A resident's PICC line was flushed with heparin by a nurse without a physician's order, despite the resident being on anticoagulant therapy. The nurse stated it was facility policy, but the NP confirmed an order was necessary.
A facility failed to remove and return controlled medications after a resident's death, leading to drug diversion. A nurse fraudulently signed out oxycodone tablets under other nurses' names, which was discovered when another nurse noticed discrepancies in the medication count. Interviews revealed that the facility's protocol for handling medications of deceased residents was not followed, contributing to the incident.
A facility failed to document the refusal or acceptance of flu and pneumonia vaccinations for a resident. The resident, who was cognitively intact, had no records of receiving, being offered, or refusing the vaccinations. Interviews revealed that consent forms were lost during a company ownership transition, leading to the documentation lapse.
The facility failed to complete daily nurse staffing sheets for 27 days, leaving columns for staff numbers and hours worked blank, only noting total hours. The Scheduling Coordinator, who took over in March 2024, could not find the original sheets and filled them retroactively. The Regional Clinical Nurse Consultant cited instability in the nursing administration team since a corporate takeover as a contributing factor.
The facility failed to complete baseline care plans for two residents within 48 hours of admission, affecting their dialysis and nutritional needs. One resident with diabetes and end-stage renal disease did not have a care plan addressing dialysis and nutrition, while another with diabetes and malnutrition lacked a timely care plan. The issue arose from nurses being unaware of the need to print and review the care plan with residents or their Responsible Parties.
A resident with dementia and other medical conditions experienced significant weight loss due to the facility's failure to obtain weekly weights and implement recommended nutritional supplements. The resident's weight fluctuated significantly, and staff interviews revealed confusion and lack of follow-up on the resident's weights. The Director of Nursing confirmed the weight loss and acknowledged the failure to implement the Registered Dietitian's recommendations.
The facility failed to submit an Initial Allegation Report within 2 hours for an abuse incident involving two residents. One resident, who was severely cognitively impaired, grabbed another resident's arm, causing bruising. The Administrator delayed the report submission, believing he had 24 hours unless there was significant bodily harm.
The facility failed to thoroughly investigate an allegation of resident-to-resident abuse involving two cognitively impaired residents. The investigation lacked proper documentation and did not include interviews with relevant staff and residents present during the incident.
Failure to Implement Abuse Reporting Policy Resulting in Delayed Investigation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse, neglect, and exploitation policy when an allegation of staff-to-resident abuse was made, resulting in delayed internal reporting, investigation, and protection of the resident. The facility’s policy dated 9/1/24 required that all alleged violations be reported immediately, but no later than two hours after the allegation, to the Administrator, State Agency, APS, and other required agencies when applicable, and that an immediate investigation and protective measures be initiated. Resident #1, who had dementia without behavioral disturbances, was allegedly subjected to physical abuse when Nurse Aide (NA) #1 observed NA #2 push Resident #1’s head to the side with an open hand placed above her ear and temple area sometime in September 2025. NA #1 believed that putting hands on a resident in this manner would be considered abuse but did not report the incident at the time and continued to observe NA #2 working on the floor, including providing care to Resident #1, after the incident. Months later, during the last week of January 2026, NA #1 informed an agency nurse (Nurse #1) that he had witnessed NA #2 hit Resident #1 on the side of the head in the past, and he demonstrated the motion, which Nurse #1 interpreted as NA #2 popping the resident’s head with an open hand. Nurse #1 believed the incident should have been reported but did not notify facility leadership, including the DON or Administrator, as required by policy; instead, after her shift she contacted APS directly. The Administrator later documented that APS came to the facility on 1/30/26 to investigate an allegation that NA #2 slapped Resident #1. Interviews with the DON and Administrator confirmed that staff were expected to report suspected or observed abuse immediately to a supervisor and that the supervisor must immediately notify the Administrator so the facility could promptly investigate and protect the resident. Both NA #1 and Nurse #1 failed to follow the facility’s abuse reporting policy, leading to delayed notification of the Administrator and delayed facility investigation and protective actions for Resident #1.
Failure to Report and Assess Resident Fall Resulting in Undiagnosed Fractures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was properly assessed by a nurse after a fall because a nurse aide did not appropriately report the fall. The resident had dementia with severe cognitive impairment and a history of two or more prior falls without injury. On the evening in question, the resident was in or near her room handling tray lids when she lost her balance and fell. NA #2 witnessed the fall, helped the resident up, and assisted her back to bed instead of leaving her in place and immediately notifying a nurse for assessment. In her written statement, NA #2 said she told the nurse that the resident had fallen, but in a later interview she admitted she did not report the fall correctly and acknowledged she should have reported it. Around the same time, Nurse #2 heard the resident scream and went to the room, finding the resident already in bed, tense and frightened but without obvious signs of pain, bruising, or swelling. Nurse #2 questioned NA #2 in the hallway; NA #2 appeared agitated and only described the resident taking tray lids off the cart, without mentioning a fall. NA #1, who was nearby, corroborated that he heard the scream, saw NA #2 coming out of the resident’s room, and heard NA #2 tell Nurse #2 only that the resident had been taking tray lids off the cart, with no report of a fall. As a result, Nurse #2 did not have information that a fall had occurred and did not perform a focused post-fall assessment at that time. Later that evening, during the night shift, NA #3 attempted to get the resident up for a scheduled shower and found she could not stand, appeared weak, and struggled to get up. NA #3 reported this to Nurse #3, who then assessed the resident and noted that she could only take one or two steps before yelling out and grabbing her right leg, and that her right elbow was swollen. Nurse #3, who had not received any report of a new fall on that date and only knew of a prior fall two days earlier, contacted the on-call provider and obtained orders for x-rays of the right elbow, hip, and leg. The x-rays, completed the following day, showed acute fractures of the right olecranon and right hip/femoral neck, leading to the resident’s transfer to the hospital for surgical repair. The facility’s DON, Administrator, NP, and Medical Director all stated that NAs should not move a resident after a fall and should notify a nurse so the nurse can assess for injury, and that the facility’s fall protocol required a nurse assessment before moving a resident, which did not occur immediately after this resident’s fall because the fall was not properly reported by NA #2.
Misappropriation of Controlled Narcotics and Inadequate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of controlled narcotic medications, contrary to its Abuse, Neglect and Exploitation policy that prohibits exploitation and misappropriation of resident property. An agency nurse (Nurse #1) worked a single 12‑hour night shift and signed out multiple doses of controlled substances for six residents on narcotic control sheets without corresponding documentation of administration on the Medication Administration Records (MARs). For one resident with scheduled Oxycodone 10 mg three times daily and PRN Oxycodone 5 mg, Nurse #1 signed out Oxycodone 10 mg at times that did not match the scheduled administration times and documented one scheduled dose as given on the MAR, while also signing out PRN Oxycodone 5 mg on separate narcotic sheets that were not documented as administered on the MAR. A third narcotic sheet for this resident showed an unexplained change in tablet count from 28 to 26 without dates or signatures. For five additional residents with PRN orders for Hydromorphone, Oxycodone, Tramadol, and Hydrocodone‑Acetaminophen, Nurse #1 signed out multiple doses on the narcotic records during the same night shift, but none of these doses were documented as administered on the MARs by Nurse #1 or any other nurse. In two cases, narcotic sheets for Oxycodone 10 mg included entries where Nurse #1 documented wasting of tablets at illegible times, with Nurse #2 signing as a witness. However, the MARs for these residents contained no corresponding entries indicating that the medications had been administered. One nurse later reported that a resident whose PRN narcotics had been signed out denied taking the pain medication, and the MAR showed no administration entries for those doses. The facility became aware of the issue when a staff nurse (Nurse #3) noticed an unusual number of PRN narcotics signed out for a resident who typically did not request pain medication and found missing PRN Oxycodone that the resident denied receiving. Subsequent review of narcotic sign‑out sheets revealed discrepancies attributed to Nurse #1, including multiple narcotic withdrawals without MAR documentation for six residents. An email from the DON and Nurse #2 confirmed that Nurse #2 had signed as a waste witness for narcotics for two residents at Nurse #1’s request without actually observing the disposal. The pharmacist recalled the misappropriation of resident narcotics and confirmed that the facility later replaced all unaccounted‑for narcotic medications at facility expense.
Failure to Properly Witness and Reconcile Wasted Narcotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective systems for accurate reconciliation and proper wasting of narcotic medications, specifically oxycodone, for two residents. One resident had a standing order for oxycodone 10 mg three times daily for pain, and review of the narcotic record showed that an agency nurse (Nurse #1) signed out oxycodone doses on a specific evening. The same record showed that another agency nurse (Nurse #2) signed as a witness to the disposal of an oxycodone 10 mg tablet at an illegible time. A second resident had an order for oxycodone 10 mg every three hours as needed for pain, and the narcotic record indicated that Nurse #1 signed out oxycodone doses for this resident on the same evening, with Nurse #2 again signing as a witness to the disposal of an oxycodone 10 mg tablet at an illegible time. The facility became aware of a possible misappropriation of residents’ property when a staff nurse (Nurse #3) reported concern to the DON that as-needed narcotics were being signed out for a resident who usually did not request pain medication, and that some as-needed oxycodone was missing for one of the residents. Nurse #3 also noted that the medications were not signed as administered on the MAR and that the resident denied taking the pain medication. Subsequent review of the narcotic sign-out sheets showed that Nurse #2 had signed as a witness to Nurse #1’s disposal of narcotics for both residents. In an email to the DON, Nurse #2 admitted signing the narcotic sheets as a waste witness at Nurse #1’s request without visually observing the disposal of the medications, contrary to the facility’s standard practice that nurses visually witness narcotic waste before signing as a witness.
Failure to Provide Timely and Effective Pain Management After Resident Fall
Penalty
Summary
A resident with a history of stroke and right-sided hemiplegia experienced a fall during an assisted transfer, resulting in acute pain and later confirmed fractures of the tibia and fibula. The resident, whose preferred language was Spanish and required an interpreter, reported severe pain immediately after the fall, rating it as 9 out of 10. Despite these reports, there was ineffective communication among staff, and a medical provider was not notified of the fall or the resident's pain until two days later. During this period, staff failed to use an interpreter to accurately assess the resident's pain level or the effectiveness of any interventions. Documentation and interviews revealed that the resident repeatedly expressed pain through both verbal and non-verbal cues, such as grimacing, crying, and grabbing her knee. Staff members, including nurse aides and nurses, were made aware of the resident's pain and the fall, but there was a lack of timely action to address her needs. Pain assessments were documented as zero on the medication administration record, despite clear evidence of pain, and the resident did not receive any pain medication until ibuprofen was ordered and administered two days after the incident. This initial pain management was ineffective, and there was no evidence that a provider was contacted for additional or alternative pain control until the nurse practitioner was notified of the x-ray results. The resident did not have a care plan in place for pain, and staff did not consistently use interpreters to communicate with her, resulting in inadequate assessment and delayed treatment. The nurse practitioner, upon finally being notified and using an interpreter, assessed the resident and ordered opioid pain medication, which was effective. The deficiency was identified through record review, interviews, and direct observation, showing a failure to provide safe and appropriate pain management for a resident with acute pain following a fall.
Failure to Notify Physician of Critical X-ray Results Following Resident Fall
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician of critical x-ray results for a resident who experienced acute pain following a fall. The resident reported falling in the bathroom, landing on her right knee, and experiencing immediate and ongoing severe pain. The day after the fall, the nursing supervisor contacted the on-call provider, who ordered a right leg x-ray. The x-ray was performed and results indicating acute, nondisplaced fractures of the proximal tibia and fibula were received by the facility later that day. Despite the x-ray results being available and acknowledged by multiple staff members, including the nursing supervisor and the DON, the results were not communicated to a medical provider until the following day. The nursing supervisor relayed the results to other nurses but did not instruct them to notify the physician, nor did she do so herself. The DON also reviewed the results and confirmed with the nursing supervisor that she had received them, but did not provide explicit instructions to notify the physician. The night shift nurse was informed of the fracture but was not asked to take further action. As a result, the physician and nurse practitioner were not made aware of the resident's acute fractures until the next day. This delay in communication led to a delay in medical intervention and evaluation in the emergency department. The resident ultimately required a two-day hospitalization, with orthopedics recommending a hinged knee brace and non-weight bearing status. Interviews with the nurse practitioner, medical director, and on-call physician confirmed that no notification of the x-ray results was received over the weekend, and that appropriate action would have been taken had they been informed in a timely manner.
Failure to Notify Physician of Resident Fall and Acute Pain
Penalty
Summary
A deficiency occurred when facility staff failed to notify a physician after a resident reported a fall and was experiencing acute pain. The resident, who had a history of stroke and right-sided hemiplegia, communicated in Spanish that she had fallen in the bathroom while being assisted by two staff members. Despite the resident's clear reports of significant pain and visible signs of injury, including bruising and swelling of the right knee and shin, staff did not immediately notify a physician or initiate appropriate medical interventions. Multiple staff members became aware of the resident's pain and the reported fall, but there was confusion and lack of clear communication regarding responsibility for notifying the physician and completing post-fall assessments. The day shift Nursing Supervisor was informed of the incident but did not contact the physician, instead instructing the day shift nurse to handle the situation. The day shift nurse, having already given report to the night shift nurse, assumed the night shift nurse would complete the necessary notifications and documentation. The night shift nurse, in turn, believed the day shift nurse had already addressed the issue. As a result, no physician was notified on the day of the fall, and no immediate medical evaluation or intervention was provided. It was not until the following day, after the resident's family member called the facility to inquire about the fall and pain management, that the Nursing Supervisor contacted the on-call provider. An x-ray was then ordered, revealing acute nondisplaced fractures of the proximal tibia and fibula. The delay in physician notification and medical intervention resulted in the resident experiencing prolonged pain and a delay in receiving appropriate care, including hospitalization and orthopedic management.
Failure to Protect Resident from Neglect and Delayed Medical Response After Fall
Penalty
Summary
A resident who primarily spoke Spanish experienced a fall during a staff-assisted transfer, resulting in immediate pain to her right knee. The nursing supervisor was informed of the fall and the resident's pain, but did not report the incident or the pain to a medical provider. There was no evidence that staff used an interpreter to accurately assess the resident's condition or pain level at the time. The lack of effective communication among staff led to a delay in notifying a medical provider about the fall and the resident's pain until the following day. When the medical provider was finally notified, orders were given for an x-ray and ibuprofen for pain management. The x-ray, which revealed acute fractures of the proximal tibia and fibula, was completed, but the results were not communicated to a medical provider until the next day. During this period, the resident continued to experience significant pain, which was not effectively managed, as the first administration of pain medication was delayed and proved ineffective. The resident reported, through an interpreter days later, that no one had asked her if she was hurt after the fall and that she was simply put back into bed. The deficiencies identified included failure to protect the resident from neglect, failure to notify the physician of the fall and subsequent pain, inadequate assessment and documentation following the fall, failure to provide a safe transfer, and ineffective pain management. The resident ultimately required hospitalization for her injuries, and orthopedic recommendations included a hinged knee brace and non-weight bearing status for the affected leg. Facility leadership declined to comment on whether the incident constituted neglect.
Failure to Recognize and Respond to Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with a history of stroke and right-sided hemiplegia, who was cognitively intact and required substantial assistance for transfers and personal care, experienced a fall during a staff-assisted transfer from the toilet. The nurse aides involved did not report the fall to a nurse, and the resident was not assessed by a nurse or medical provider before being moved and transferred back to bed. The resident immediately experienced pain in her right knee, but staff did not inquire about injury or pain, nor did they document the incident or perform a comprehensive assessment at the time. Communication failures among staff further contributed to the deficiency. The night shift nurse aide learned of the resident's pain and the fall from the resident's roommate and reported it to the nursing supervisor, who then assessed the resident but did not observe significant injury at that time. The nursing supervisor instructed the assigned nurse to follow fall protocol, including contacting the physician, but there was no evidence that these steps were taken. The assigned nurse did not document the incident, perform vital signs, or complete an incident report, citing time constraints and lack of specific instructions. The night shift nurse also did not take further action, assuming the day shift nurse was responsible. The lack of timely assessment and communication led to a delay in medical evaluation and intervention. The resident continued to experience pain, and it was not until the following day that the on-call provider was notified and an x-ray was ordered. The x-ray, which revealed acute proximal tibia and fibula fractures, was not communicated to a medical provider until the next day, further delaying appropriate treatment. The resident ultimately required hospitalization and orthopedic intervention. Throughout the incident, there was a lack of documentation, failure to follow established protocols, and ineffective communication among staff, resulting in delayed recognition and treatment of a significant injury.
Failure to Provide Safe Transfer and Adequate Supervision Resulting in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when staff failed to provide a safe transfer for a resident with right-sided hemiplegia and a history of stroke, resulting in a fall and acute fractures of the right tibia and fibula. The resident, who was dependent for transfers and required a total mechanical lift with two-person assistance according to her Kardex, was instead assisted by staff using a stand and pivot transfer. During a transfer from the toilet, one staff member left to retrieve the wheelchair, leaving the resident holding onto an assist rail with her non-functional right hand, while the other staff member was not paying attention. The resident lost her balance, fell onto her right knee, and immediately experienced significant pain. The care plan did not specify the transfer method, and staff did not follow the Kardex instructions for a mechanical lift. After the fall, the resident was returned to bed by staff without being asked if she was hurt, and no immediate assessment or documentation of the incident was completed. Multiple staff interviews revealed inconsistencies in the account of the transfer and the fall, with some staff denying any unusual events and others expressing concern about the resident's instability during toileting. The resident, who spoke only Spanish, was not provided with an interpreter during the incident, which contributed to communication barriers. The injury was not reported to nursing supervisors or documented in a timely manner, and there was a delay in notifying the physician and obtaining appropriate medical evaluation. The resident remained in pain for an extended period before the injury was properly assessed and diagnosed. The lack of adherence to the resident's transfer requirements, insufficient supervision during the transfer, and failure to promptly recognize and report the fall led to a delay in treatment. The resident ultimately required hospitalization for management of her fractures, and the incident was confirmed through interviews with the resident, her roommate, family, and facility staff.
Inaccurate MDS Assessments for Swallowing Disorders, Pressure Ulcers, Dental Status, and Restraints
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for multiple residents, resulting in deficiencies in the areas of swallowing disorders, pressure ulcers, dental status, and physical restraints. For one resident with protein-calorie malnutrition and dysphagia, both a speech therapy evaluation and a nutrition evaluation documented clear signs and symptoms of a swallowing disorder, including loss of food from the mouth, coughing, and complaints of pain when swallowing. However, the quarterly MDS assessment did not reflect these symptoms, and the Regional MDS Consultant acknowledged this was an oversight due to the absence of a dedicated MDS Coordinator. Another resident with dementia and malnutrition was found to have two unstageable pressure ulcers that developed after admission, as documented by the Wound Care Practitioner. Despite this, the discharge MDS assessment incorrectly coded the ulcers as present on admission. Additionally, the same resident was observed to be edentulous and receiving pureed food, but both the admission and significant change MDS assessments failed to indicate the absence of natural teeth, despite a speech therapy evaluation noting edentulism upon admission. The MDS assessments were completed remotely, and the Regional MDS Consultant confirmed the errors after reviewing the medical records. Further inaccuracies were identified in the coding of physical restraints. One resident with intact cognition was documented in the MDS as using bed rails as a physical restraint, although the resident used the rails for mobility and repositioning, and the facility was restraint free. Another resident with moderately impaired cognition was incorrectly coded as using a chair restraint, despite being able to self-transfer and having no device preventing rising from the chair. These errors were confirmed by the Regional MDS Consultant and the Administrator, who both stated that the MDS assessments did not accurately reflect the residents' conditions or the use of restraints.
Failure to Invite Resident to Participate in Care Planning
Penalty
Summary
A resident with intact cognition was readmitted to the facility and underwent several Minimum Data Set (MDS) assessments, including quarterly and annual reviews. Record review revealed there was no evidence that the resident was invited to participate in care plan meetings following these assessments. The resident reported having attended care plan meetings in the past but could not recall the last time one was held, and expressed a desire to participate in future meetings to provide input about his care. Interviews with the Social Worker (SW) and Administrator confirmed that the SW was responsible for tracking and inviting residents to care plan meetings, but had not consistently documented these meetings in the resident's medical record. The SW acknowledged that care plan meetings for this resident had not been held during the current year, and that the process had lapsed. The Administrator confirmed the expectation that care plan meetings should be scheduled and held with resident participation, as per regulatory guidance.
Failure to Ensure Resident Accessibility to Light Switch
Penalty
Summary
A dependent resident with severely impaired cognition and limited mobility was unable to access the light switch in his room due to a broken switch cord. The cord, which was only 2.5 inches long, was located 5 feet from the floor and 6 feet from the bed, making it unreachable for the resident, who required assistance to stand and walk. The resident reported that he had to rely on nursing staff to turn off the light, which was inconvenient and required repeated requests for assistance. He expressed a desire for the maintenance staff to repair the switch cord to better accommodate his needs. Nursing staff who regularly cared for the resident were unaware of the broken switch cord, as it was obscured by a tall table lamp. The maintenance director stated that he conducted weekly walkthroughs to identify repair needs and also relied on nursing staff to report issues, but acknowledged the need for immediate repair in this case. Both the DON and the facility administrator confirmed that residents should have full accessibility to their light fixtures at all times and that staff are expected to promptly report and address such repair needs.
Failure to Address ADL and Transfer Needs in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed all activities of daily living (ADL) needs for two residents. One resident with cerebral palsy, who was dependent on staff for mobility and transfers and required assistance with all ADL tasks except eating, did not have a care plan that addressed his needs for transfers, bathing, and personal and oral hygiene. Although his care plan addressed limited physical mobility, it omitted specific interventions for his ADL care needs. Interviews with the resident and staff confirmed that he required substantial assistance and the use of a mechanical lift for transfers, but these needs were not reflected in his care plan. The omission was attributed to the absence of a dedicated MDS Coordinator at the time. Another resident with a right below-knee amputation, who required substantial assistance for transfers, also had a care plan that did not reflect his need for transfer assistance. The Regional MDS Consultant acknowledged that the transfer status was overlooked due to a personal emergency affecting MDS staff during the care plan's initiation. Both the consultant and the administrator confirmed that the care plans should have included these essential details to guide staff in providing appropriate care.
Failure to Complete Bed Rail Assessments and Obtain Informed Consent
Penalty
Summary
The facility failed to assess the risks of entrapment and complete bed rail assessments, as well as failed to obtain informed consent prior to the installation of bed rails for two residents. For one resident with dementia and Parkinson's disease, there was no documentation of a bed rail assessment since admission, despite the resident having severely impaired cognition and being dependent on staff for bed mobility. Observations showed the resident using bilateral quarter-length bed rails with staff assistance, and interviews with staff confirmed that bed rail assessments and informed consent from the responsible party had not been completed. Another resident with a non-displaced fracture and osteoporosis, who was her own responsible party, also had no bed rail assessment documented since admission. This resident had moderately impaired cognition and required substantial assistance for bed mobility, but was observed to be ambulatory and able to stand without assistance. Staff interviews indicated that bed rail assessments were supposed to be completed upon admission and quarterly, and that consent was required for residents with impaired cognition, but these steps had not been followed. Interviews with the Rehab Therapy Director, DON, and Regional Clinical Director of Operations revealed a lack of a clear process and communication regarding responsibility for bed rail assessments. It was acknowledged by leadership that assessments should be completed prior to bed rail installation, upon admission, and quarterly, but this was not occurring in practice. Maintenance was also expected to ensure proper installation and fit of bed rails, but the required assessments and consents were not documented for the residents involved.
Failure to Provide Prescribed Nectar Thick Liquids to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with dementia and dysphagia, who was ordered to receive nectar thick liquids, was provided with a cup of tea of thin liquid consistency during a lunch meal service. The resident's care plan and diet card both indicated the need for nectar thick liquids, but the meal tray included thin tea. A nurse aide recognized the inconsistency and removed the tea from the resident's hand but did not remove it from the tray or out of the resident's reach. The resident subsequently picked up the cup and took a sip, resulting in a cough. The Business Office Manager, unaware of the resident's dietary restrictions, provided a straw for the tea, further enabling access to the thin liquid. Interviews revealed that the nurse aide relied on the diet card to verify the meal but did not anticipate the resident would reach for the tea. The Business Office Manager was not aware of the resident's thickened liquid order and assumed the tea was appropriate since it was on the tray. The Speech Therapist confirmed that the resident's diet order for nectar thick liquids was in place to prevent aspiration and that thin liquids should not have been served with meals. The administrator acknowledged that the resident was not provided with fluids of the prescribed consistency as ordered by the physician.
Failure to Administer Influenza Vaccine to Consenting Resident
Penalty
Summary
A deficiency occurred when a resident who was cognitively intact and had expressed a desire to receive the influenza vaccine did not receive it. The resident had a signed, though undated, informed consent form in her medical record indicating her wish to be vaccinated. Despite this, the medical record showed no documentation of the influenza vaccine being administered since October 2023. The resident recalled being offered the vaccine and completing the consent form, but stated she never received the vaccine, possibly because she was out of the facility at an appointment during the scheduled vaccination clinic. The DON confirmed the presence of the signed consent and the absence of documentation for vaccine administration. The facility had used an outside company to conduct a vaccination clinic, and residents not present or admitted after the clinic were to be placed on a list for the next clinic. However, the facility also had influenza vaccines available for administration outside of scheduled clinics. Due to changes in facility leadership and the new vaccination process, the resident's vaccination was missed.
Failure to Bill Managed Medicaid Results in Improper Discharge Notice
Penalty
Summary
The facility failed to ensure that the basis for a resident's discharge met the required criteria, specifically regarding the handling of payment and insurance claims. A resident with intact cognition was admitted with coverage through a Managed Medicaid plan, but the facility listed the payer source as private pay and did not submit a claim to the insurance for payment. As a result, the resident was issued a 30-day discharge notice for non-payment, despite having insurance coverage that should have been billed. The resident and their representative were not expecting the discharge and had planned for a longer stay to arrange for accessible housing. The representative also reported receiving ongoing billing statements totaling over $50,000, with no indication that insurance had been billed or had paid any portion of the charges. Interviews with facility staff revealed that approval for the resident's stay had been obtained from the Managed Medicaid plan, but due to the incorrect payer source designation, no claim was submitted. The Business Office Manager confirmed that the process to transition the resident to long-term traditional Medicaid was not initiated as required, and the Administrator was unaware that the insurance had not been billed. The discharge notice was issued based on non-payment of a presumed co-payment amount, but staff acknowledged that co-payment amounts are typically determined only after a claim is submitted. The former Business Office Manager, who may have had further information, was unavailable for interview.
Incomplete Discharge Summary Documentation for Discharged Resident
Penalty
Summary
The facility failed to complete a discharge summary that included a recapitulation of the resident's stay and a final summary of the resident's status for one resident who was discharged to the community. Record review showed that the discharge summary assessment for this resident was initiated but left incomplete, with only the Therapy section filled out and all other required sections, including Nursing, Dietary, Social Services, Activity, Reason for Discharge, Medical Summary, and Acknowledgement, left blank. The Social Worker, who was responsible for completing the Social Services section, confirmed during an interview that he did not consistently enter documentation into the resident's medical record and that the completion of the discharge summary was overlooked. The resident in question had intact cognition and no active discharge plan in place at the time of the quarterly MDS assessment. Although the Social Worker stated that a care plan meeting was held with the resident and their representative to discuss discharge plans and needs, there was no documented evidence of this in the medical record. The Administrator was unaware that the discharge summary had not been completed and stated that all sections should be completed by the respective departments according to regulatory guidelines.
Missed Antihypertensive Medication Doses Due to Untimely Refill Request
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received all scheduled doses of prazosin hydrochloride, a medication prescribed for hypertensive heart disease. The resident was admitted with a diagnosis of hypertensive heart disease without heart failure and had intact cognition. Physician orders indicated the resident was to receive prazosin hydrochloride 5 mg at bedtime and amlodipine 5 mg daily. While the resident consistently received amlodipine, the last dose of prazosin hydrochloride was administered on 06/07/25, after which three consecutive doses were missed. The missed doses resulted from a failure to request a timely refill from the pharmacy before the medication supply was depleted. Nurse #3 discovered the medication was unavailable on the cart and noted a refill request had been made, but did not follow up with the pharmacy or notify the DON. The MAR reflected that the medication was not administered and was held for three days. The pharmacy records showed the order was on hold pending clarification and receipt of a new prescription from the NP, which was not received until 06/11/25, at which point the medication was dispensed and administration resumed. During this period, the resident's blood pressure readings increased, and the resident reported not receiving the medication to both nursing staff and the NP. Interviews with staff confirmed that the expected protocol was to reorder medications 5-7 days before depletion and to notify the DON if a medication was unavailable. However, these steps were not followed, resulting in the resident missing three scheduled doses of prazosin hydrochloride.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide ongoing, consistent, and effective communication methods for a resident whose primary language was Spanish and who did not speak English. The resident, who was cognitively intact and had a history of cerebral infarction with right-sided hemiplegia, required an interpreter as documented in her care plan and Minimum Data Set (MDS) assessment. Despite this, staff interviews and observations revealed that there was no established or reliable system in place for staff to communicate with her in her preferred language. Staff members, including nurses and nurse aides, reported relying on the resident's roommate, who spoke both Spanish and English, to interpret the resident's needs. However, the roommate was noted to have a diagnosis of dementia and was not considered a reliable or appropriate interpreter. Some staff attempted to use gestures or translation apps on their personal phones, but there was no formal guidance or training provided by the facility on how to communicate with non-English speaking residents. Several staff members stated they had not been informed of any translation services available for use with the resident. The resident herself expressed frustration and distress over her inability to communicate her needs to staff, stating that only her roommate helped her and that staff did not attempt to use translation tools. The facility's social worker and other leadership acknowledged that there was no defined process or service in place for translation at the time of the survey, and that staff were unsure of what resources, if any, should be used to facilitate communication with non-English speaking residents.
Failure to Ensure Timely Refill and Administration of Scheduled Opioid Medication
Penalty
Summary
A deficiency occurred when the facility failed to maintain effective systems for acquiring and administering a scheduled opioid pain medication, tramadol, resulting in a resident missing three consecutive days of their prescribed pain management. The resident, who had osteoporosis and was receiving tramadol 50 mg once daily for generalized pain, did not receive the medication as ordered due to lapses in the medication refill process and lack of timely action by nursing staff. The Medication Administration Record showed that after the last dose was given, subsequent scheduled doses were not administered, and appropriate documentation was lacking for at least one of the missed doses. The breakdown began when the nurse who administered the last available tablet did not request a new prescription, and subsequent nurses also failed to initiate the refill process in a timely manner. One nurse attempted to start the refill but was delayed by the need for a nurse practitioner's signature and did not escalate the issue to the Director of Nursing. Additionally, attempts to access tramadol from the facility's Pyxis automated dispensing system were unsuccessful due to login issues, and the nurse did not notify supervisory staff about this barrier. Communication between shifts occurred, but the medication was still not obtained from the Pyxis or a local back-up pharmacy, despite these resources being available. Interviews with staff and the nurse practitioner revealed that the expectation was for nurses to begin the refill process 5-7 days before the medication ran out, especially for controlled substances. The failure to follow this protocol, combined with ineffective use of available pharmaceutical resources and lack of urgency among staff, led to the resident missing three days of scheduled pain medication.
Failure to Administer Prescribed Pain Medication for Three Consecutive Days
Penalty
Summary
Nursing staff failed to administer a prescribed opioid pain medication, tramadol, to a resident for three consecutive days, resulting in a significant medication error. The resident, who had severe cognitive impairment and was at risk for pain, had a physician's order for daily tramadol and as-needed acetaminophen for pain management. The medication administration record showed that the last dose of tramadol was given, after which the medication ran out and was not refilled in a timely manner. Nurses documented the absence of tramadol and initiated the refill process, but delays occurred due to the need for a nurse practitioner's signature and pharmacy delivery schedules. During the period when tramadol was unavailable, the resident received as-needed acetaminophen for mild pain, with pain assessments documented as low or absent. Despite the lack of tramadol, there were no documented progress notes on one of the days, and communication between nursing staff and the pharmacy was ongoing to resolve the medication shortage. The facility's emergency medication supply (Pyxis) contained tramadol, but it was not accessed for the resident during the lapse. Interviews with nursing staff and the nurse practitioner confirmed the medication error and acknowledged that the incident could have been avoided with earlier action. The Director of Nursing stated that refills for controlled medications should be initiated several days in advance to prevent such gaps. The administrator and DON both noted that the resident did not experience significant pain during the lapse, but the failure to administer tramadol as ordered constituted a significant medication error.
Failure to Document Resident Fall and Acute Pain
Penalty
Summary
A deficiency occurred when staff failed to document a reported fall and associated acute pain for a resident. The resident reported falling onto her right knee while being assisted in the bathroom by two staff members, resulting in immediate pain. Despite the resident's report and the nursing supervisor's assessment of pain, there was no documentation or assessment information in the medical record for the date of the incident. The last progress note was from the previous day, and no new documentation appeared until the following afternoon. Interviews revealed that the nursing supervisor assessed the resident and communicated the incident to both the outgoing and incoming nurses, instructing them on necessary actions. However, neither nurse completed the required documentation, assessment, or incident report. Each nurse assumed the other would handle the post-fall protocol, resulting in a lack of recorded assessment, notification, or follow-up in the resident's chart, as confirmed by facility leadership.
Survey Results Binder Not Accessible to Residents or Public
Penalty
Summary
The facility failed to post survey results in a location accessible to all residents and did not provide signage indicating the location of the survey results in areas accessible to the public. Observations over several days revealed that the survey results were kept in a binder on a side table in a waiting room located in the lobby. There was no signage in the lobby or resident hallways to indicate where the survey results binder could be found. All resident rooms were located behind a locked door that required a code to open, restricting resident access to the lobby area where the binder was kept. During a Resident Council Meeting, all residents present were unaware of the location of the survey results binder. After being informed, several residents stated they would need to ask staff to let them through the locked, coded door to access the lobby and the binder. The Administrator confirmed that the binder in the waiting room was the only copy available in the facility and acknowledged the lack of signage indicating its location. The Administrator also stated that residents could ask staff for access if they did not know the code themselves.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in two separate incidents involving a resident with a history of traumatic brain injury, bipolar disorder, and impulse control disorder. In the first incident, a moderately cognitively impaired resident physically assaulted a severely cognitively impaired resident by punching her in the face, causing her to fall backward and sustain a head injury. The injured resident was sent to the emergency room, where a CT scan revealed a small intraventricular hemorrhage and a scalp hematoma. The resident was evaluated by neurosurgery and returned to the facility after being deemed stable. In a separate incident, the same resident shoved another severely cognitively impaired resident, causing her to fall to the floor. Although this second resident was not injured, the event was witnessed by staff and confirmed through interviews and documentation. Both incidents occurred in common areas of the facility, with staff present in the vicinity. The resident responsible for the physical altercations had documented behavioral triggers related to personal space and belongings, and his care plan included interventions such as frequent observation and monitoring for behavioral triggers. However, these interventions did not prevent the physical abuse from occurring. The residents involved in these incidents had significant cognitive impairments and exhibited behaviors such as wandering and invading others' personal space, which contributed to the altercations. Staff interviews and video footage confirmed that the aggressive resident's behaviors were known and that staff had been educated on his triggers. Despite this, the facility did not effectively prevent the physical abuse, resulting in harm to at least one resident and the potential for fear, pain, and anxiety among those affected.
Failure to Implement Abuse Reporting and Resident Protection Policies
Penalty
Summary
The facility failed to implement its abuse prevention and reporting policies after a resident reported being attacked and cursed at by a male nurse aide. The resident, who had intact cognition and a history of anxiety and depression, informed a female nurse aide during the night shift that a male staff member had attacked and cursed at her. The nurse aide reported this to a medication aide, whom she considered her supervisor, but did not escalate the allegation to the nurse, DON, or Administrator as required by facility policy. The medication aide stated that the resident only expressed a preference not to have a male aide and did not mention abuse, while the male aide involved denied any inappropriate behavior and was not immediately removed from the facility, remaining on shift with access to other residents. The facility's abuse policy required immediate reporting of all alleged violations to the Administrator and Adult Protective Services (APS), and immediate action to protect the alleged victim, including removal or suspension of the accused employee. However, the allegation was not reported to the nurse or administration until the resident's responsible party informed the Administrator the following morning. The accused aide was only removed from the schedule after the morning report, and there was no immediate assessment of the resident for injury or further risk during the night shift. Staff interviews revealed confusion about reporting protocols and a lack of direct communication to the appropriate supervisory personnel. Additionally, the facility failed to report the alleged sexual abuse to Adult Protective Services in a timely manner. Although the Administrator and social worker eventually contacted the Department of Social Services, this did not occur until several days after the initial allegation was made known to facility leadership. The delay in reporting to APS was confirmed by both the previous DON and Administrator, who acknowledged the requirement to notify APS promptly but did not do so as stipulated by policy.
Misappropriation of Controlled Medications in LTC Facility
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of controlled medications, affecting three residents. Resident #29, with a diagnosis of acute respiratory distress, had an order for morphine sulfate as needed for pain. The facility discovered that Nurse #6 misappropriated Resident #29's morphine after a change in his behavior was noted. A drug screening confirmed Nurse #6 tested positive for morphine, and a police investigation found the missing medication in his possession. The facility's investigation substantiated the misappropriation, and the North Carolina Board of Nursing was notified. Resident #58, admitted with a right tibia fracture, had an order for oxycodone for pain management. Nurse #7 was found to have fraudulently signed out oxycodone under Nurse #3's name, which was confirmed by discrepancies in the controlled substance count sheets and Resident #58's statement. Additionally, Resident #113, who had passed away, had oxycodone signed out fraudulently by Nurse #7. The facility's investigation confirmed the misappropriation, and the local sheriff's office was notified. The incidents involved staff members who appeared impaired while on duty, leading to the misappropriation of controlled substances. Nurse #6 and Nurse #7 were both found to have taken medications without authorization, affecting the residents' medication management. The facility's failure to prevent these incidents resulted in the misappropriation of residents' property, violating their rights to be free from such actions.
Failure to Implement Nutritional Recommendations for Residents
Penalty
Summary
The facility failed to implement the recommended nutritional interventions for two residents, leading to deficiencies in their care. Resident #25, diagnosed with diabetes mellitus and severe protein-calorie malnutrition, was recommended to receive 30 ml of liquid protein twice daily. However, this order was not transcribed to the Medication Administration Record (MAR) and was not administered from the start date of 10/30/23 through 06/27/24. Despite being cognitively intact and independent with eating, Resident #25 experienced a gradual long-term weight loss, and the Registered Dietitian (RD) noted that the recommendation for liquid protein was not followed. Resident #51, with a history of cerebrovascular accident and dysphagia, was ordered to receive enteral feedings with a 1.5 calorie nutritional supplement of 270 ml when oral intake was less than 50%. However, during an observation, Nurse #5 administered only 237 ml of the supplement. The RD confirmed that the nutritional needs were still being met with the lesser amount, but the order was not followed as written. Resident #51's oral intake ranged from 0 to 25% for most meals, and the RD had noted that the current plan of care was adequate to meet nutritional needs. Interviews with the RD and the Regional Nurse Consultant revealed that the RD's recommendations were communicated to the facility staff, but there was a breakdown in following through with the physician's orders. The RD's recommendations were sent via email to the Director of Nursing, the Regional MDS Coordinator, and the Dietary Manager, but the orders were not consistently implemented, leading to the deficiencies noted in the care of Residents #25 and #51.
Failure to Ensure Timely Physician Visits for New Admissions
Penalty
Summary
The facility failed to ensure that physician visits were conducted every 30 days for the first 90 days of admission for several residents. This deficiency was identified through record reviews and staff interviews, revealing that six out of twelve sampled residents did not receive the required physician visits. For instance, Resident #2, admitted with conditions such as cerebrovascular disease and dementia, was not seen by the facility's Medical Doctor (MD) since admission, although visits by a Nurse Practitioner (NP) were documented. Similarly, Resident #16, with diagnoses including diabetes and cirrhosis of the liver, was only seen once by the MD after admission, despite multiple NP visits. The same pattern was observed for Resident #22, who had end-stage renal disease and other serious conditions, and was only seen once by the MD. The facility's failure to adhere to the regulatory requirement for monthly MD visits during the initial 90 days of admission was consistent across these cases. The issue was compounded by a lack of awareness among the Medical Records staff regarding the specific regulatory requirements for MD visits. The MD was reportedly managing his own schedule, and the Medical Records staff were only tracking the last visit by either the MD or NP, not specifically ensuring compliance with the monthly MD visit requirement. This oversight led to the deficiency being identified during an audit conducted by the Medical Records staff, following concerns raised by the MDS Coordinators.
RN Coverage Deficiency
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for at least 8 consecutive hours per day on six specific dates within the review period. The deficiency was identified through a review of daily nurse staffing sheets and time clock reports, which showed a lack of required RN coverage on the dates of 04/27/24, 04/28/24, 05/20/24, 05/21/24, 05/26/24, and 06/08/24. Interviews with the Scheduling Coordinator and the Regional Clinical Nurse Consultant revealed that the absence of RN coverage was primarily due to the resignation of the weekend RN supervisor and challenges in maintaining a stable nurse administration team, particularly the Director of Nursing position, following a change in corporate ownership in September 2023.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to properly secure and store medications, leading to several deficiencies. An opened bottle of Silvadene cream was found unattended in a resident's room, with the resident unaware of how it got there. Staff interviews revealed that the cream should have been stored in the treatment cart. Additionally, expired over-the-counter medications were found in the medication storage room and on a medication cart, with no designated staff assigned to regularly check for expired medications. This oversight resulted in expired medications remaining on the shelves, contrary to the manufacturer's guidelines. Further deficiencies were noted in the storage of insulin and eye drops. Insulin pens and bottles were found stored at room temperature for an unknown duration, contrary to the manufacturer's guidelines that require refrigeration. Staff interviews indicated a lack of awareness and time to check medication carts for proper storage and expiration. The Acting DON and Administrator acknowledged the issues, attributing them to a lack of leadership due to frequent turnover in the nursing department. They expected nursing staff to maintain proper medication storage and ensure the facility was free of expired or unattended medications.
Infection Control and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Observations revealed that staff did not use the required gowns and gloves during high-contact care activities for residents with central lines, feeding tubes, tracheostomy, and urinary catheters. For instance, a nurse was observed performing care on a resident with a PICC line without wearing a gown, and another nurse was unaware of the need for EBP when administering enteral feeds. The lack of EBP signage and personal protective equipment near residents' rooms further highlighted the facility's non-compliance. Interviews with staff, including nurses and nurse aides, indicated a lack of awareness and training regarding EBP. Several staff members, including a medication aide and a nurse, reported not receiving any education on EBP, and the acting Director of Nursing confirmed the absence of such training. The Regional Nurse Consultant and Infection Preventionist acknowledged that the information on EBP was provided to the former Director of Nursing, but it was not implemented or communicated to the staff. Additionally, the facility failed to follow its hand hygiene policy during incontinence care. An observation of a nurse aide providing care to a resident showed improper glove use and hand hygiene practices, such as not changing gloves between cleaning different body sites and not performing hand hygiene after removing soiled gloves. The acting Director of Nursing and the Regional Nurse Consultant both expressed expectations for proper hand hygiene practices, which were not met by the staff.
Failure to Include Resident in Care Planning
Penalty
Summary
The facility failed to invite a resident and/or their Resident Representative (RR) to participate in care planning, as evidenced by the case of a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia and dementia. The resident was admitted to the facility and had several Minimum Data Set (MDS) assessments completed, but there was no evidence that care plan meetings were held or that the resident or their RR were invited to provide input. The RR was unaware of the facility's process for conducting care plan meetings and recalled attending only one meeting at the time of admission. The deficiency was attributed to a breakdown in the process following a change in facility management. The responsibility for scheduling and facilitating care plan meetings was transferred to the Social Worker (SW) during the transition, leading to missed meetings. The SW acknowledged the oversight and was working on improving the process. The Regional Clinical Nurse Consultant confirmed the lack of care plan meetings and noted that a Performance Improvement Plan (PIP) was attempted but deemed insufficient. Both the Regional Clinical Nurse Consultant and the Administrator recognized the issue as a result of unclear responsibilities regarding care plan meeting schedules.
Failure to Protect Resident Health Information
Penalty
Summary
The facility failed to protect the private health information of two residents by leaving confidential medical information unattended and exposed in areas accessible to the public. During an observation, a medication cart was left unattended in the hallway with the Medication Administration Record (MAR) of a resident visible on the computer screen. This screen displayed the resident's name, picture, and current medications, making it accessible to anyone passing by. Nurse #1, responsible for the cart, admitted to being distracted and acknowledged the oversight, despite having completed HIPAA training. A similar incident occurred later when the same nurse left another resident's MAR visible on the unattended medication cart. The nurse was seen talking to a staff member away from the cart, leaving the screen accessible to unauthorized individuals. The Acting Director of Nursing and the Administrator both expressed that it was expected for all staff to follow HIPAA guidelines and safeguard residents' personal health information at all times. The facility provides HIPAA training during orientation and annually thereafter.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement effective interventions to prevent resident-to-resident physical abuse, resulting in an incident where a severely cognitively impaired resident with a known history of aggression hit another resident. Resident #23, who had a history of major neurocognitive disorder secondary to traumatic brain injury and chronic aggression, was admitted to the facility without specific interventions or increased supervision in place. On the day of the incident, Resident #23 hit Resident #11, who also had severe cognitive impairment and a history of physical behaviors, causing a small cut and bruising. The incident occurred when Resident #11 entered Resident #23's room, leading to Resident #23 striking Resident #11 multiple times. A visitor witnessed the event and informed the staff, who then separated the residents. The facility's investigation confirmed the abuse, noting that Resident #23 admitted to hitting Resident #11 because he was blocking the door. Despite being aware of Resident #23's aggressive history, the facility did not have adequate measures in place to prevent such incidents. The facility's investigation revealed that the staff was notified of the incident by a visitor, and both residents were assessed for injuries. The Administrator acknowledged awareness of Resident #23's aggressive behavior history but was not aware of any specific interventions implemented upon his admission. The facility substantiated the abuse allegation as it was a witnessed incident, but no specific precursor to the aggression was identified.
Failure to Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy and procedures, specifically in the areas of reporting and investigation. An allegation of abuse was reported by a resident, who claimed to have witnessed another resident being held down and provided care against her will by a male staff member. This allegation was communicated to the Medical Records Director, who then informed the Regional MDS Consultant and the Administrator. However, the Administrator dismissed the report, stating it did not count as abuse and did not need to be reported to the State Agency. The facility's policy requires immediate investigation and reporting of abuse allegations to the State Agency within specified timeframes. Despite this, the Administrator did not initiate an investigation or report the incident to the State Agency. The Medical Records Director provided a detailed account of the alleged incident, but the Administrator did not recall being informed of the specifics and did not take the necessary steps to address the allegation. The deficiency affected a resident with moderate cognitive impairment, who was allegedly involved in the incident. The failure to report and investigate the allegation promptly resulted in a delay in addressing the potential abuse. The Regional Clinical Nurse Consultant later confirmed that the initial report should have been submitted when the allegation was first reported, but it was overlooked, leading to a delayed response from the facility.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, comprehensive care plans for two residents, focusing on nutritional risk and indwelling catheter management. Resident #2, admitted with urinary retention and dementia, had a physician's diet order for a regular diet with pureed texture and regular/thin liquids, and a suprapubic catheter order. The admission MDS assessment indicated intact cognition and dependence on staff for self-care tasks, including eating, with an indwelling catheter and a mechanically altered diet. Despite these assessments, Resident #2's comprehensive care plan did not address nutrition or catheter management. The Regional MDS Consultant, who completed the MDS assessments remotely, acknowledged the oversight and confirmed that these areas should have been included in the care plan. Similarly, Resident #22, admitted with diabetes, end-stage renal disease, and dependence on renal dialysis, had a physician's diet order for regular texture and regular/thin liquids, with additional dietary instructions from dialysis. The admission MDS assessment showed intact cognition and required assistance with self-care tasks and mobility, receiving dialysis services and a therapeutic diet. However, the comprehensive care plan for Resident #22 lacked a plan addressing nutritional risk. The Regional MDS Consultant confirmed the absence of a nutritional care plan and stated it was the responsibility of the MDS staff to ensure comprehensive care plans were completed.
Failure to Obtain Physician's Order for Heparin Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of heparin used by a nurse to flush the peripherally inserted central catheter (PICC) for a resident. The resident was admitted with diagnoses including diabetes mellitus and pulmonary embolism and was at risk for complications related to anticoagulant therapy. The care plan included administering medications as ordered by the physician and monitoring for side effects. However, there was no current physician's order for flushing the PICC line with heparin, which was observed being done by a nurse without a written order. During an interview, the nurse confirmed the absence of a written physician's order for the use of heparin to flush the PICC line, stating it was the facility's policy to use this method. The Nurse Practitioner also confirmed that a physician's order specifying the dose of heparin was necessary, especially since the resident was already on anticoagulant medication, apixaban. The facility's policy for central catheter flushing was mentioned, but it was not followed in this instance, leading to the deficiency.
Failure to Secure Controlled Medications After Resident's Death
Penalty
Summary
The facility failed to properly manage controlled medications following the death of a resident, leading to drug diversion. Resident #113, who was admitted with thrombocytopenia, had an order for oxycodone to manage pain, which was discontinued after his death. However, the controlled medications were not removed from the medication cart and returned to the pharmacy as required. This oversight allowed the medications to remain accessible and ultimately led to their misappropriation. Nurse #7 was implicated in the diversion of controlled substances, as she was found to have signed out oxycodone tablets fraudulently under the names of other nurses. The discrepancies were discovered when Nurse #3, who took over the medication cart, noticed that her name was falsely used to sign out medication for another resident. Further investigation revealed that the signatures on the controlled substance count sheet for Resident #113 were also falsified, indicating that Nurse #7 had diverted the medications. Interviews with staff, including the Acting DON and the Administrator, highlighted a lack of adherence to the facility's protocol for handling medications of deceased residents. The Acting DON, who was responsible for Resident #113 at the time of his death, could not recall if she had removed the medications as required. The Administrator confirmed that the expectation was for controlled medications to be removed within 24 hours and returned to the pharmacy within 72 hours, a procedure that was not followed in this case.
Deficiency in Vaccine Documentation
Penalty
Summary
The facility failed to document the refusal or acceptance of influenza and pneumonia vaccinations for a resident reviewed for immunizations. The resident, who was cognitively intact, was admitted to the facility with no documentation regarding the receipt, offer, refusal, or education of the flu or pneumonia vaccinations. The resident mentioned usually refusing the flu shot but was uncertain about the pneumonia shot. Interviews with the Regional Nurse Consultant and Infection Preventionist, as well as the Administrator, revealed that the consent forms were lost during a company ownership transition, which led to the breakdown in maintaining proper documentation of vaccine consents.
Incomplete Nurse Staffing Sheets
Penalty
Summary
The facility failed to ensure that daily nurse staffing sheets were filled out completely for 27 out of 123 days reviewed during the period from October 1, 2023, through January 31, 2024. The daily nurse staffing sheets were supposed to include the date, current resident census, and the number of staff and hours worked for RNs, LPNs, and CNAs for each 12-hour shift. However, for the specified dates, the columns indicating the number of staff and hours worked for each shift were left blank, with only the total daily number of hours worked noted at the bottom of the sheets. The Scheduling Coordinator, who took over the scheduling responsibilities on March 18, 2024, reported that she was unable to locate the completed nurse staffing sheets for the missing dates. As a result, sheets were filled out retroactively with only the total hours worked. The Regional Clinical Nurse Consultant acknowledged that it was the Scheduler's responsibility to ensure the completion and accuracy of these sheets. The consultant also noted that since a new corporation took over in September 2023, the facility had difficulty maintaining a stable nurse administration team, particularly in the Director of Nursing position, which contributed to the oversight.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan addressing the immediate needs of residents within 48 hours of admission, affecting two residents reviewed for dialysis and nutrition. Resident #22, admitted with diagnoses including diabetes and end-stage renal disease, did not have a baseline care plan that included goals or interventions for dialysis services, nutrition, or discharge plans. The resident, who had intact cognition, stated he discussed discharge goals with staff but did not recall discussing or receiving a written baseline care plan. The Regional Clinical Nurse Consultant and Administrator identified a breakdown in the process, as nurses were unaware that the baseline care plan needed to be printed and reviewed with the resident or their Responsible Party (RP). Similarly, Resident #25, admitted with diabetes mellitus and severe protein-calorie malnutrition, did not have a baseline care plan completed within the first 48 hours of admission. Nurse #3, responsible for the admission evaluation, confirmed that the computer system did not trigger her to complete the baseline care plan for this resident. The Regional Nurse Consultant and Administrator reiterated that it was the admitting nurse's responsibility to complete and review the baseline care plan with the resident or their RP within the required timeframe. The absence of a baseline care plan for these residents highlights a systemic issue in ensuring timely and comprehensive care planning upon admission.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to obtain weekly weights as ordered by the physician and did not implement the recommendation for a nutritional supplement to promote weight stability for a resident with significant weight loss. The resident, who had diagnoses including dementia, chronic obstructive pulmonary disease, and cerebral vascular accident with hemiplegia, was supposed to receive weekly weights and various nutritional supplements. However, the facility did not follow through with these orders, leading to a significant weight loss that was not properly addressed or monitored. The resident's weight fluctuated significantly, with documented weights showing a drop from 124 pounds to 97 pounds over a short period, raising concerns about the accuracy of the weights and the effectiveness of the interventions in place. The Registered Dietitian's recommendation to add a health shake with breakfast was not implemented, and there was no physician's order to support this recommendation. The care plan indicated that the resident's nutritional status should be monitored, but the facility failed to report significant weight loss to the Medical Doctor as required. Interviews with staff revealed confusion and lack of follow-up on the resident's weights, with some weights being crossed out and marked as incorrect without proper reweighing. The Nurse Practitioner and Medical Doctor both expressed doubts about the accuracy of the documented weights and the significant weight loss reported. The Director of Nursing, who took over the position recently, was unaware of the Registered Dietitian's recommendation and confirmed that the weight of 97 pounds was accurate after reweighing. The resident's diet order was changed to a regular pureed diet with thin liquids, but the facility's failure to obtain weekly weights and implement nutritional interventions as ordered by the physician contributed to the resident's significant weight loss. Interviews with family members and staff highlighted the resident's poor appetite and need for encouragement during meals, further emphasizing the facility's shortcomings in addressing the resident's nutritional needs.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to complete and submit an Initial Allegation Report within 2 hours to the State Regulatory Agency for two residents involved in an abuse incident. Resident #2, who was severely cognitively impaired, was found in Resident #3's room and had grabbed Resident #3's arm, causing redness and bruising. The incident occurred on 03/09/24 at 5:15 PM, and the Administrator was notified immediately by Nurse #1. However, the Initial Allegation Report was not faxed to the State Agency until 03/10/24 at 3:06 PM, which was 21 hours and 51 minutes after the facility became aware of the allegation of abuse. The Administrator confirmed that he was notified of the incident on the evening of 03/09/24 and considered it an allegation of abuse. However, he did not initiate the Initial Allegation Report until the following day because he believed he had 24 hours to submit the report unless there was significant bodily harm. Since Resident #3 only sustained bruising, the Administrator did not consider it significant bodily harm and delayed the report submission. Nurse #1 also revealed that she had not received any education on how to report resident-to-resident altercations other than ensuring the residents' safety and notifying the Administrator.
Failure to Conduct Thorough Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of resident-to-resident abuse involving two residents. Resident #2, who was severely cognitively impaired, was found in Resident #3's room, grabbing Resident #3's left arm, which resulted in a small bruise. The incident was reported by Nurse #1, who separated the residents and notified the Administrator. The Administrator then informed Buncombe County Adult Protective Services and Asheville Police, who initiated their investigations. However, the facility's internal investigation was found lacking in several areas, including the failure to interview relevant staff and residents who were present during the incident and the lack of thorough documentation of the interviews conducted. The investigation file contained unsigned and undated questionnaires from staff and residents who were not present during the incident. Additionally, the residents interviewed resided in the Assisted Living unit rather than the skilled nursing unit where the incident occurred. The Administrator admitted to not specifying which units should be interviewed and relied on shower sheets to assess potential injuries among cognitively impaired residents. The Administrator also failed to provide documentation of interviews with the Nurse Aides assigned to the involved residents on the evening of the incident. This lack of thoroughness and proper documentation led to the deficiency in the facility's investigation process.
Latest citations in North Carolina
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
A resident with dementia, stroke, dysphagia, and severe cognitive impairment, who was edentulous and dependent for ADLs, was care planned and listed on the NA Kardex to receive assisted oral care at least twice daily. Over nearly a month, NA documentation showed denture care was provided only three times, and surveyors observed the resident’s upper and lower dentures with brown stains and debris buildup. One NA, assigned on several day shifts, believed the resident did not have dentures and only offered mouthwash and a basin, while another NA, aware the resident wore dentures, usually did not perform denture care because the resident was already in bed and did not want to remove them. The DON later confirmed the dentures had visible debris and staining and that the care plan required regular oral care and proper denture cleaning.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Date and Discard Opened Nutritional Supplements per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to properly date and discard opened containers of nutritional supplements stored in nourishment room refrigerators on the North and South Units. During observations of these refrigerators with the Dietary Manager, surveyors found a one-quart nutritional shake in the North Unit refrigerator with no date indicating when it was opened, despite the manufacturer’s label stating it must be used within four days after opening if refrigerated. In the South Unit refrigerator, surveyors observed two one-quart nutritional shakes dated 4/24 and 4/28, both beyond the manufacturer’s four-day use-by period, as well as an opened and undated 8-ounce diabetic nutritional shake whose label required use within 48 hours of opening. In interviews, the Dietary Manager stated that dietary staff did not stock the nutritional shakes in the nourishment refrigerators and that nurses were responsible for the nutritional shakes given to residents, including dating them when opened and discarding them when past the use-by date. The Dietary Manager also explained that dietary staff checked the nourishment refrigerators twice daily only for items provided by the kitchen, including restocking and checking expiration dates on those snacks and drinks. A nurse confirmed that a physician’s order was required for a resident to receive a nutritional shake and that nurses were responsible for dating the shakes when opened and ensuring they were used and discarded according to the manufacturer’s instructions. The Administrator stated that the person who opened a nutritional shake was responsible for writing the date opened on the container and noted that historically dietary staff checked dates on food and drinks stored in the nourishment refrigerators.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Failure to Provide Ordered Denture and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide ordered assistance with denture and oral care for a dependent resident with severe cognitive impairment, dementia, stroke, dysphagia, and edentulism. The resident’s admission MDS documented severely impaired cognition, a need for setup or clean-up assistance with oral hygiene, and no refusal of care or behaviors. The care plan and NA Kardex both directed staff to provide or assist with oral care at least twice daily using a soft toothbrush or foam swabs, and identified the resident as at risk for oral and dental health problems and dependent in ADL self-care. However, NA documentation showed denture care was recorded as provided only three times over nearly a month-long period. During observation, the resident reported wearing upper and lower dentures and displayed dentures with brown stains and debris buildup around the teeth and gums, stating he could brush his dentures if he had a toothbrush and toothpaste. One NA, assigned on multiple day shifts, stated she provided only mouthwash and a basin because the resident had difficulty brushing, believed the resident did not have dentures, and confirmed she had not provided denture care. Another NA on night shift acknowledged knowing the resident wore dentures, having seen them on the bed or nightstand, but stated she usually did not perform denture care because the resident was already in bed and did not want to remove them, and described denture care only as soaking them overnight. When the DON later observed the dentures, he confirmed visible debris and brown staining, and acknowledged that the care plan and Kardex required oral care at least twice daily and that dentures should be brushed and soaked overnight.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
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