Vero Health & Rehab Of Sylva
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylva, North Carolina.
- Location
- 417 Cloverdale Road, Sylva, North Carolina 28779
- CMS Provider Number
- 345302
- Inspections on file
- 29
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Vero Health & Rehab Of Sylva during CMS and state inspections, most recent first.
The facility submitted inaccurate PBJ staffing data to CMS, showing missing RN and licensed nurse coverage for multiple days, despite schedules and time clock reports confirming adequate coverage. The inaccuracy resulted from a transition between payroll systems and lack of data review prior to submission.
Two residents with moderate cognitive impairment and no upper extremity limitations were unable to reach the pull cords for their bedside lights, despite expressing a desire to use them. Observations showed the cords were positioned out of reach, and staff interviews confirmed the issue had not been addressed for both residents.
A resident's code status was inconsistently documented, with the care plan listing full code while the EHR, physician's order, and code status binder indicated DNR. Staff interviews revealed the Social Worker did not update the care plan due to not receiving the signed advance directive paperwork, resulting in conflicting information about the resident's wishes.
A resident was not offered, administered, or properly documented for the pneumococcal vaccine as required by facility policy. The resident, who was cognitively intact, reported not being offered the vaccine, and staff interviews confirmed there was no documentation of consent, administration, or refusal in the records. The DON and Corporate Nurse Consultant were unable to provide evidence that the vaccine process had been followed.
A resident's COVID-19 vaccination status was not determined or documented, with no evidence of informed consent, administration, or refusal found in the medical record. The resident, who was cognitively intact, reported not being offered the vaccine since admission and was unsure of his current status. Facility staff, including the DON and Corporate Nurse Consultant, were unable to locate any documentation regarding the resident's COVID-19 vaccine status.
A review of records and staff interviews revealed that the facility did not have a valid surety bond in place to cover the total balance of personal funds deposited by 55 residents in the trust fund account. The bond had expired, and key staff were unaware of its status until the survey.
Survey results were stored in a binder located in a first-floor lobby, placed about five feet high, making it inaccessible to residents whose rooms were on a secured second floor. Residents reported not knowing the binder's location and stated they would need staff assistance to access it, with one wheelchair user unable to reach it independently. Facility staff confirmed the binder was not accessible to residents without help.
A resident with a history of obstructing ureteral stones and UTIs was not followed up with a urologist as required after hospital discharge. The facility failed to schedule the necessary appointment, leading to multiple UTIs and antibiotic resistance. Communication and coordination issues among staff contributed to the deficiency.
The facility failed to provide adequate portable oxygen tanks, confining residents to their rooms for several days, and did not maintain dignity during meal assistance for a resident. Residents with respiratory conditions were unable to leave their rooms due to a reported shortage of portable oxygen tanks, leading to feelings of depression and boredom. Additionally, a resident requiring assistance with eating was fed by a staff member standing over her, which was identified as a dignity issue.
The facility failed to maintain a safe and sanitary environment, with mold observed at a nursing station, repeated flooding due to poor drainage, and unclean kitchen vents. Additionally, a resident's bed footboard and another resident's wheelchair armrests were in disrepair, with staff failing to report or address these issues in a timely manner.
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper hand hygiene protocols. A nurse did not wear a gown while caring for a resident with a feeding tube, and a nursing assistant did not change gloves or perform hand hygiene after catheter care. Additionally, a resident was not assisted with hand hygiene before meals, despite being dependent on staff for such care.
The facility's kitchen failed to maintain food safety and hygiene standards, with wet and dirty dishware, spoiled produce, and moldy bread observed. Staff interviews revealed a lack of routine checks for spoilage and cleanliness, with no specific staff assigned to these tasks. The Dietary Manager and Administrator acknowledged these oversights.
The facility did not involve two cognitively intact residents in their care planning process. Both residents had not attended care plan meetings since March, despite revisions to their care plans in May and June. The Social Worker cited staffing changes and a state survey as reasons for the delays.
A non-ambulatory resident with osteoarthritis was unable to access a light switch behind her bed due to a broken cord, requiring reliance on staff for assistance. Despite regular care from nursing staff and maintenance walkthroughs, the issue was not identified or reported, highlighting a lapse in communication and attention to resident needs.
A resident, assessed as a safe smoker, requested a fourth smoking session after dinner, which aligns with the facility's policy allowing up to four sessions daily. Despite the resident's cognitive intactness and clear communication of his preference, the facility only provides three sessions, citing staff availability issues. This failure to accommodate the resident's choice led to a deficiency.
A facility failed to report a neglect incident to the State Agency involving a resident who did not receive incontinence care from a Nurse Aide (NA). The NA had expressed discomfort in caring for the resident and requested reassignment, which was communicated to a nurse who agreed to provide care. The Administrator was unaware of the neglect until receiving the CMS-2567 and did not file an initial report, believing the issue was thoroughly investigated.
A facility failed to complete a PASRR application for a resident with new psychiatric diagnoses, including delusional disorder and dementia with behavioral disturbances. The resident was admitted with an outdated Level I PASRR, and despite being prescribed medications for these conditions, a new application was not completed. Interviews revealed that staff were unaware of the need for a new PASRR application, leading to the oversight.
A resident with severe cognitive impairment and physical limitations did not receive proper nail care or meal assistance. Observations showed the resident eating with unclean hands and struggling to open meal items without adequate staff support. Despite care plans requiring regular nail checks and meal assistance, staff failed to provide consistent help, leading to unhygienic conditions and inadequate meal support.
A resident with hemiplegia and a muscle contracture did not have a prescribed hand splint applied due to a lack of communication and documentation after discharge from occupational therapy. The splint, necessary for contracture management, was not transitioned to nursing staff, and the order was missing from the MAR and TAR.
A resident with hemiplegia and hemiparesis was unsafely transferred from bed to wheelchair using a mechanical lift without locking the wheels, causing instability. The nurse involved was inexperienced with the lift, leading to the oversight. The Rehabilitation Manager and DON confirmed the importance of locking the wheels for stability.
A resident with respiratory failure and severe cognitive impairment was observed using supplemental oxygen without a physician's order. Despite the resident's need for oxygen due to breathing issues, no order was found in the records. Interviews with the DON, a Nurse Practitioner, and the Administrator confirmed the oversight.
A travel nurse at an LTC facility, unfamiliar with the facility's mechanical lift, failed to lock the lift's wheels during a resident transfer, leading to an unstable and unsafe situation. The nurse had not received proper training, as the COTA responsible for lift training did not keep up with agency staff. The DON acknowledged the need for a more comprehensive orientation checklist to include lift training for all staff.
A resident with severely impaired cognition and diagnoses including Diabetes Mellitus and hypertension was not assessed for eligibility or offered the pneumococcal vaccine. The resident's vaccination status was not up to date, and the reason was coded as not offered. Interviews with the Infection Preventionist and DON revealed awareness of the oversight, with the DON citing insufficient time to complete a vaccine audit. The Administrator also acknowledged the oversight.
The facility failed to provide quarterly statements for residents' personal funds accounts, affecting several residents who were cognitively intact. The Business Office Manager did not issue statements unless requested, due to a misunderstanding of regulatory requirements. The facility's Administrator was unaware of this issue, which arose after the transition to an electronic fund management system.
The facility failed to notify a medical provider of a resident's significant condition changes, leading to the resident's death. Additionally, the facility did not inform a resident's Guardian after a positive THC test. Staff miscommunication and failure to follow protocols were evident.
A resident experiencing a medical emergency was neglected when staff failed to activate emergency medical services after administering Naloxone for a suspected drug overdose. The resident later died. Additionally, the resident did not receive necessary incontinence care, leading to a fall and severe injuries. The facility also failed to notify a medical provider of significant changes in the resident's condition and did not ensure nursing staff were trained in emergency response.
A resident with a complex medical history exhibited symptoms of a drug overdose, including being non-responsive with constricted pupils and impaired respirations. Despite administering Narcan, the staff failed to call 911 as required by the physician's order, leading to the resident's death. Interviews revealed a lack of familiarity with the facility's Narcan policy and inadequate training.
The facility failed to enforce their smoking policy, leading to a resident vaping while on oxygen, and did not prevent a cognitively impaired resident from exiting the facility unsupervised. Additionally, a resident was exposed to an illegal substance, resulting in altered mental status and impaired mobility.
The facility failed to ensure nursing staff were trained and competent in responding to medical emergencies, leading to the death of a resident who showed signs of opioid overdose. The involved nurses did not notify a medical provider or initiate emergency procedures, and the lack of proper orientation and training for agency nurses contributed to the mishandling of the situation.
A resident missed three doses of lorazepam due to the facility's failure to obtain the medication from the pharmacy. The resident experienced significant anxiety symptoms, and staff were unaware they could request an electronic prescription for immediate pickup from a local pharmacy.
A resident with an anxiety disorder missed three scheduled doses of lorazepam due to a failure in medication administration, leading to severe anxiety symptoms. Despite staff efforts to obtain the medication, it was not available, causing significant distress for the resident.
The facility failed to maintain clean and sanitary conditions in multiple resident rooms and bathrooms, with issues including stained floors, dirty privacy curtains, and baseboards in disrepair. Housekeeping and maintenance staff cited staffing shortages as a reason for incomplete cleaning and maintenance tasks.
The facility failed to report suspicious white powder and a pill splitter found in a resident's room to law enforcement after a suspected overdose and did not notify APS after another resident alleged abuse. The facility's investigation was incomplete, and key evidence was lost.
The facility failed to ensure that the Medical Director (MD) was aware of the Narcan policy, which had the potential to affect all residents with active orders for the medication. The MD, who started in February 2024, admitted to being unfamiliar with the policy, and the Administrator confirmed that the MD had only been notified of the updated policy after issues were identified during the survey.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in visitation rights, safe environment, notification of changes, quality of care, accident hazards, pharmacy services, and significant medication errors. Issues included restricted visitation, failure to notify medical providers of significant changes, unsupervised resident exits, exposure to illegal substances, and missed medication doses.
A facility restricted a resident's right to receive visitors by denying access to a former social worker who had continued to visit the resident after terminating her employment. The resident, who had severe cognitive impairment and required extensive assistance, became visibly upset when informed of the restriction. The administrator made this decision without consulting the resident or their family, citing concerns about setting a precedent for other former employees.
Inaccurate PBJ Staffing Data Submission Due to Payroll System Transition
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) for one reviewed federal fiscal quarter. Specifically, the PBJ report indicated there were no Registered Nurse (RN) hours reported for several dates and the entire month of March, as well as a lack of 24-hour licensed nursing coverage for multiple days. However, review of daily staff schedules and time clock reports showed that an RN was onsite for at least 8 hours each day and licensed nursing coverage was present 24 hours a day during the period in question. For one date, the Director of Nursing (DON), a salaried employee, was onsite but did not appear in the time clock records due to not clocking in or out. The Human Resources (HR) Director, responsible for PBJ submissions, confirmed that the data for the quarter was submitted without a thorough review for accuracy, citing a transition between two payroll systems as a contributing factor. The HR Director prioritized timely submission over data verification due to the payroll system change. The Corporate Nurse Consultant also confirmed that RN coverage was consistently provided, and attributed the inaccurate PBJ data to the payroll system transition, which resulted in missing or incorrect staffing information being reported to CMS.
Failure to Ensure Pull Cords for Bedside Lights Were Within Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents by not ensuring that the pull cords for the lights above their beds were within reach. Both residents had moderate cognitive impairment but no impairment of their upper extremities, and each expressed a desire to use the pull cord to control their lights. Observations revealed that the beds were positioned so that the pull cords hung against the wall and were not accessible to the residents while in bed. One resident stated she wanted to use the pull cord but could not reach it and was unsure when she last used it, while the other also reported being unable to reach her pull cord despite wanting to use it. Interviews with facility staff indicated that maintenance issues were tracked through a computer system, which the Maintenance Director reviewed daily. The Maintenance Director acknowledged that the pull cord for one resident was not within reach and was unaware of the issue for the other resident. The Corporate Nurse Consultant agreed that the pull cords should be accessible to residents who are able and wish to use them. The deficiency was identified through observations, record reviews, and interviews with residents and staff.
Failure to Ensure Consistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected throughout the medical record. Although the resident's advance directive care plan indicated a full code status, other documentation in the electronic health record (EHR), a physician's order, and the code status binder at the nurses' station all indicated a Do Not Resuscitate (DNR) status. The discrepancy was identified during a review of the resident's records and confirmed through staff interviews. Staff interviews revealed that the Social Worker (SW) and MDS Nurse were responsible for updating the advance directive care plan when a resident's code status changed. The SW acknowledged that the care plan was not updated to reflect the DNR status because the signed advance directives paperwork was not returned to her after being completed by the family. The Director of Nursing (DON) confirmed that the care plan should match the code status in the EHR and code status binder, and that the SW was responsible for updating the care plan when changes occurred.
Failure to Offer, Administer, or Document Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer, administer, or document the pneumococcal vaccine for one resident who was reviewed for immunizations. According to the facility's policy, residents are to be assessed for eligibility and offered the pneumococcal vaccine series within 30 days of admission unless medically contraindicated or previously vaccinated. The resident in question was admitted to the facility and was found to be cognitively intact. The Minimum Data Set indicated the vaccine was offered and declined, but there was no signed consent, administration record, or documentation of refusal in the resident's electronic health record. Interviews with the resident revealed that he had not been offered the pneumococcal vaccine since admission. The DON, who also served as the Infection Preventionist, was unable to confirm whether the vaccine had been offered or administered and could not locate any documentation in the paper or electronic records. The Corporate Nurse Consultant also confirmed there was no documentation available and acknowledged that there were areas for improvement in the immunization process, but no new process had been initiated at the time of the survey.
Failure to Determine and Document Resident COVID-19 Vaccination Status
Penalty
Summary
The facility failed to determine and document the COVID-19 vaccination status of a resident who was admitted and assessed as cognitively intact. Upon review of the resident's electronic health record, there was no signed informed consent, record of administration, or documentation of refusal for the COVID-19 vaccine. Additionally, there was no evidence in the medical record of any past COVID-19 vaccinations administered to the resident. The resident reported that he typically kept his immunizations up to date and had received prior COVID-19 vaccines, but stated he had not been offered the vaccine since admission and was unsure if he was up to date. Interviews with facility staff, including the DON and the Corporate Nurse Consultant, revealed that neither could locate documentation regarding the resident's COVID-19 vaccine status in any records. The DON, who also served as the Infection Preventionist, was new to the facility and unable to confirm if the resident had received or been offered the vaccine. The Corporate Nurse Consultant acknowledged there was no reason for the lack of documentation and recognized areas for improvement in the immunization process, but no new process had been initiated at the time of the survey.
Failure to Maintain Valid Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a valid surety bond to secure the personal funds of all residents deposited in the resident trust fund account. Record review showed that the total balance in the Resident Trust Fund Account was $63,647.25 for 55 residents. The Surety Bond Continuation Certificate provided indicated that the bond, which was for $90,000, had expired and was no longer in effect. Staff interviews revealed that the Business Office Manager was unaware of the bond's expiration and deferred responsibility to the corporate office, while the Corporate Nurse Consultant was also unaware that the bond had expired until it was brought to their attention during the survey. The Administrator was not available for interview during the survey.
Survey Results Not Accessible to Residents
Penalty
Summary
The facility failed to make survey results easily accessible to residents, as required. Observations over three days revealed that the survey results were kept in a binder placed in a wall file pocket in the first-floor lobby, approximately five feet high. All resident rooms were located on the second floor, which was only accessible by a secured elevator. The stairwell door on the second floor was also locked and required a code, further limiting resident access to the first floor and the survey results binder. During a Resident Council Meeting, all five residents present stated they did not know where the survey results binder was located. After being informed, they indicated that accessing the binder would require staff assistance to unlock the elevator and accompany them to the lobby. One resident using a wheelchair noted she would not be able to reach the binder independently due to its height. Interviews with the Social Services Director and the Corporate Nurse Consultant confirmed that the only survey results binder was in the first-floor lobby and was not accessible to residents without staff help.
Failure to Follow Up with Urologist Leads to Multiple UTIs
Penalty
Summary
The facility failed to follow up with a urologist for a resident who was hospitalized for obstructing ureteral stones, hydronephrosis, UTI, pyelonephritis, and sepsis. After being discharged from the hospital with a stent and a urinary catheter, the resident was supposed to have a follow-up appointment with a urologist the following week. However, the appointment was not scheduled, and the order for the follow-up was mistakenly discontinued by the Director of Nursing, who assumed it was an old order without verifying if the appointment had been completed. The resident experienced multiple UTIs and urinary pain while waiting for the urology follow-up, which was repeatedly rescheduled due to transportation issues and prioritization of other residents' appointments. The facility's Transportation Aide and Receptionist were responsible for scheduling appointments, but there was a lack of communication and oversight to ensure the resident's urgent medical needs were prioritized. The resident's condition was further complicated by antibiotic resistance, and the facility's failure to secure timely urology follow-up contributed to ongoing health issues. Interviews with facility staff, including the DON, Unit Managers, and medical providers, revealed a breakdown in communication and coordination regarding the resident's care plan and follow-up appointments. The facility's appointment scheduling process lacked a clear system for tracking and prioritizing urgent medical appointments, leading to delays in necessary medical evaluations and treatments for the resident. This deficiency affected the resident's health and increased the risk of further complications.
Oxygen Supply and Dignity Issues in Resident Care
Penalty
Summary
The facility failed to treat residents in a dignified manner by not providing adequate portable oxygen tanks, resulting in residents being confined to their rooms for several days. Resident #51, who has chronic respiratory failure and COPD, was unable to leave her room due to the lack of portable oxygen tanks, which made her feel depressed and anxious. Similarly, Resident #77, with acute and chronic respiratory failure and pulmonary fibrosis, and Resident #8, with COPD, were also confined to their rooms due to the shortage of portable oxygen tanks. These residents expressed feelings of boredom and upset due to their inability to perform daily activities. The issue arose when the facility reportedly ran out of portable oxygen tanks for a period of three days, as noted by Nurse #3, who confirmed the absence of tanks upon checking the storage room. Despite the central supply staff and the Director of Nursing stating that the facility did not completely run out of tanks, the residents' accounts and Nurse #3's observations indicate otherwise. The central supply staff maintained that deliveries were consistent, and the facility had a system in place to order more tanks if needed, yet the residents experienced a disruption in their daily routines due to the lack of portable oxygen. Additionally, the facility failed to maintain dignity during meal assistance for Resident #34, who required substantial assistance with eating due to cognitive impairment and physical limitations. NA #3 was observed standing over Resident #34 while feeding her, despite the availability of chairs in the dining room. This practice was identified as a dignity issue by both Nurse #3 and the Director of Nursing, who emphasized the importance of being at eye level with residents during feeding to ensure a respectful and effective dining experience.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by several deficiencies observed during the survey. At nursing station #1, a dark black substance, suspected to be mold, was found on the wall and ceiling, with a moist drip line extending down the wall. The Maintenance Director, who had been in his role for over three months, acknowledged the presence of the substance and identified it as mold due to the moisture and residue left on his fingers. Despite the Maintenance Director's awareness, the issue had not been addressed until after the surveyor's observation. The facility also failed to manage outside water drainage, resulting in flooding in one of the hallways, the dining room, and two resident rooms. The Maintenance Director admitted that the dining room had flooded multiple times due to an issue with the drain outside the building, which had not been resolved despite previous attempts. The flooding was exacerbated by rain, and the Maintenance Director suggested that the gravel and plastic outside the building needed to be removed and the ground graded to prevent further flooding. Additionally, the facility did not maintain the kitchen air vents in a sanitary condition, with three out of six vents over the food preparation area covered in a black substance. The Dietary Manager was aware of the issue since the last health department inspection in October 2023, but the vents had not been cleaned or replaced. Furthermore, the facility failed to repair a resident's bed footboard and another resident's wheelchair armrests, both of which had been in disrepair for an extended period. Staff members were either unaware of the issues or had not communicated them effectively to the Maintenance Director, resulting in prolonged neglect of necessary repairs.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and implement an infection control policy, specifically regarding Enhanced Barrier Precautions (EBP). Nurse #4 was observed providing care to a resident with a feeding tube without wearing a gown, which is required under EBP. The nurse acknowledged awareness of EBP but did not follow the protocol, and the Director of Nursing (DON) and Infection Preventionist admitted that the protocols had not been implemented due to a lack of staff training. Additionally, a nursing assistant (NA) failed to change gloves and perform hand hygiene after providing urinary catheter care and before handling clean bedding for another resident, which was against the facility's urinary catheter care policy. The facility also did not adhere to its hand hygiene policy for a resident who was dependent on staff for hand hygiene before meals. The resident was observed eating with unclean hands and long fingernails, which had a dark substance underneath. The assigned NA admitted to not assisting the resident with hand hygiene before meals, as it was not a practice previously done at the facility. Both the DON and the Administrator acknowledged that staff should have assisted the resident with hand hygiene and checked nail cleanliness before meals.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in the kitchen, as observed during a survey. Ready-for-use metal pans and cooking pots were found to be stacked while still wet, and some were dirty. Specifically, 4 out of 7 small square metal pans, 2 out of 5 large rectangle metal pans, 3 out of 3 deep small rectangle metal pans, and 2 out of 3 deep small square metal pans were wet-nested. Additionally, 2 out of 3 large deep cook pots, 3 out of 5 large rectangle metal pans, and 3 out of 3 small deep rectangle metal pans were dirty. The cold food storage contained spoiled cucumbers with white fuzzy growth, and a plastic storage container was improperly dated. In the dry storage area, 2 out of 6 loaves of bread had visible mold growth and were not dated. Interviews with staff revealed a lack of routine checks for spoilage and cleanliness. The Dietary Manager acknowledged that pots and pans should have been air-dried and checked for cleanliness before storage. She also stated that produce and cold storage items should be checked daily for spoilage and expiration, but no specific staff member was assigned to this task. The bread was supposed to be dated when removed from the delivery box, but this was missed. The Administrator confirmed that the kitchen should have been checking for expired and spoiled food, and ensuring that pots and pans were clean and dry before being put away.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to involve residents and/or their representatives in the development and implementation of their person-centered care plans for two residents. Resident #27, who was cognitively intact, had not been invited to a care plan meeting since March 14, 2024, despite her care plan being revised in May 2024. The Social Worker, responsible for scheduling these meetings, acknowledged that care plan meetings were delayed due to a previous staff member's departure and a state survey in May 2024, which led to rescheduling. Similarly, Resident #37, also cognitively intact, had not participated in a care plan meeting since March 26, 2024, although his care plan was revised in June 2024. The Social Worker confirmed that Resident #37's care plan meeting was overdue due to the same staffing and scheduling issues. The Administrator noted that a state survey in May 2024 contributed to the rescheduling of care plan meetings, further delaying the process.
Inaccessible Light Switch for Non-Ambulatory Resident
Penalty
Summary
The facility failed to accommodate the needs of a dependent resident, identified as Resident #60, by not ensuring accessibility to a light switch located behind her bed. Resident #60, who was admitted to the facility and moved to her current room in August 2023, was found to have intact cognition but was non-ambulatory due to osteoarthritis and impairment in both lower extremities. During an observation, it was noted that the light switch cord was broken and inaccessible from her bed, requiring her to rely on nursing staff to control the light fixture, which she found inconvenient. Despite the issue persisting since her room change, Resident #60 had not reported the problem to the staff. Interviews with nursing staff, including a nurse aide and a nurse who frequently cared for Resident #60, revealed that they were unaware of the broken switch cord and its inaccessibility. The Maintenance Director also acknowledged the oversight, despite conducting regular walkthroughs to identify repair needs, and depended on staff to report such issues. The Director of Nursing and the Administrator both expressed expectations for staff to be attentive to residents' living environments and report repair needs promptly, highlighting a lapse in communication and attention to resident needs within the facility.
Facility Fails to Accommodate Resident's Smoking Preferences
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating a request for a fourth smoking session, despite the resident being assessed as a safe smoker. The facility's smoking policy allows for up to four smoking times daily, but currently only three are scheduled. Resident #83, who is cognitively intact and uses a wheelchair, expressed a desire for an additional smoking session after dinner, aligning with his preference to smoke after each meal. This request was communicated during a resident council meeting, but the facility has not implemented the additional session. Interviews with staff, including the Activity Aide and the Director of Nursing, revealed awareness of the resident's request for a fourth smoking session. However, the facility has not made arrangements to accommodate this request, citing uncertainty about staff availability for supervision after dinner. The Administrator acknowledged the policy allows for four sessions but stated that the facility has not committed to providing them. This inaction led to the deficiency, as the facility did not fully support the resident's choice as outlined in their policy.
Failure to Report Neglect to State Agency
Penalty
Summary
The facility failed to submit an Initial Allegation Report to the State Agency for a resident reviewed for neglect. The facility's policy, dated 2017, requires that all reports of resident abuse, neglect, and injuries of unknown source be promptly and thoroughly investigated by facility management. Additionally, the policy mandates that the facility Administrator or designee promptly notify relevant persons or agencies, including law enforcement, of any suspected or substantiated incidents of mistreatment, neglect, or abuse. During a complaint investigation survey, the facility was cited for neglect when a Nurse Aide (NA) failed to provide incontinence care to a resident. The Administrator was not made aware of the neglect while surveyors were onsite and only learned of the issue upon receiving the CMS-2567. The NA had expressed discomfort in caring for the resident and requested reassignment, which was communicated to a nurse who agreed to provide personal care for the resident. Despite this, the Administrator did not file an initial report to the State Agency, believing the issue had been thoroughly investigated and unaware of the neglect. The Administrator was officially notified of the neglect when informed of immediate jeopardy during the survey.
Failure to Complete PASRR Application for Resident with New Psychiatric Diagnosis
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with a new psychiatric diagnosis. Resident #41 was admitted with a Level I PASRR dated nearly three years prior to his admission. Upon admission, the resident had diagnoses including delusional disorder, dementia with behavioral disturbances, and psychosis not due to a substance or known physiological condition. Despite being prescribed medications for these conditions, a new PASRR application was not completed to determine if a Level II PASRR referral was necessary. Interviews with facility staff revealed a lack of awareness and action regarding the need for a new PASRR application. The Social Worker, who was new to the facility, indicated that the previous Social Worker handled PASRR applications, and a new application had not been completed for Resident #41. The Administrative Assistant was unaware that the Level I PASRR was outdated and did not request a new application from the hospital. The Administrator acknowledged the need for a new PASRR application for new psychiatric diagnoses but was unaware of the resident's new diagnosis, leading to the oversight.
Failure to Provide Adequate Nail Care and Meal Assistance
Penalty
Summary
The facility failed to provide adequate nail care and meal assistance to a resident with severe cognitive impairment and physical limitations. The resident, who was admitted with diagnoses including dementia and stroke sequelae, required substantial assistance with eating and personal hygiene. Observations revealed that the resident was eating with his hands, which were noted to have long fingernails with a dark substance underneath, indicating a lack of proper nail care. Despite the care plan specifying that nails should be checked and cleaned regularly, this was not done, leading to unhygienic conditions. During a dining observation, the resident was seen struggling to open a milkshake carton and ice cream cup, and was not provided with the necessary assistance by the staff present. The resident attempted to eat using his hands, despite having silverware available, and was only intermittently cued by staff to use a spoon. The staff, including a nurse aide and a hospitality aide, failed to consistently assist the resident with meal setup or provide the necessary feeding assistance, as outlined in the care plan. Interviews with staff, including the nurse aide, nurse, occupational therapy assistant, Director of Nursing, and Administrator, confirmed the oversight in providing meal assistance and nail care. The staff acknowledged that the resident's nails should have been checked and cleaned regularly, especially since the resident ate with his hands. Additionally, the staff admitted that they should have provided more consistent meal assistance and cueing to ensure the resident used utensils properly, as he required supervision and encouragement to do so.
Failure to Apply Hand Splint for Contracture Management
Penalty
Summary
The facility failed to apply a hand splint to a resident, identified as Resident #43, for the management of a contracture. Resident #43 was readmitted to the facility with diagnoses including hemiplegia and hemiparesis following a stroke, affecting the right dominant side, and a muscle contracture. The care plan for Resident #43, last reviewed on 5/30/24, included an intervention for wearing a right hand-based splint for 4-6 hours daily to manage and prevent contracture. However, the order for the splint was not present on the resident's July 2024 medication administration record (MAR) or treatment administration record (TAR). Observations conducted on multiple occasions revealed that Resident #43 did not have the splint applied, and it was not visible in his room. Interviews with staff, including an Occupational Therapy Assistant (OTA) and nurses, indicated a lack of awareness and communication regarding the management of the splint after Resident #43 was discharged from occupational therapy services on 7/3/24. The OTA stated that the splint was kept in the therapy closet and was applied by therapy staff, but there was no documentation or communication to nursing staff about the need to continue applying the splint after discharge from therapy. Further interviews with the Nurse Practitioner and Director of Nursing confirmed that the splint should have been applied daily to prevent further contracture. However, the management of the splint was not transitioned to nursing, and nursing staff were not educated on its application. The Director of Nursing and the facility Administrator acknowledged that the splint was necessary for contracture management, but the order was not reflected in the MAR or TAR, leading to the deficiency.
Unsafe Transfer Using Mechanical Lift
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a total mechanical lift, as observed during a transfer from bed to wheelchair. The incident involved a resident with hemiplegia and hemiparesis following a stroke, who required extensive assistance with activities of daily living and was dependent on a total mechanical lift for transfers. During the transfer, Nurse #1 and Nurse Aide #1 did not lock the wheels of the lift, resulting in an unstable transfer as the lift moved while the resident was being lowered into the wheelchair. Nurse #1, who had never assisted with a total mechanical lift before, mistakenly believed the wheels were locked. The Rehabilitation Manager and the Director of Nursing both confirmed that the wheels should be locked to ensure stability and prevent the lift from rolling during transfers. This oversight in procedure had the potential to cause injury to the resident during the transfer process.
Failure to Obtain Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen for a resident with respiratory failure. The resident, who was admitted with a diagnosis of respiratory failure and had severe cognitive impairment, was observed wearing oxygen at 2 liters per minute on multiple occasions. Despite the resident's need for oxygen due to breathing problems, a review of the physician's orders revealed no order for oxygen. Interviews with the Director of Nursing and the Nurse Practitioner confirmed that the resident should have had an order for oxygen, and the Administrator acknowledged the oversight.
Inadequate Training on Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that staff was adequately trained in using a total mechanical lift, leading to a deficiency in the care provided to a resident. During an observation, a nurse and a nurse aide attempted to transfer a resident from bed to wheelchair using a mechanical lift. The nurse, who was a travel nurse and worked as a weekend supervisor, was unfamiliar with the facility's lift and had not received training on its use. The nurse did not lock the wheels of the lift, causing it to be unstable during the transfer, which could have compromised the resident's safety. The Certified Occupational Therapist Assistant (COTA) responsible for providing lift training admitted to not keeping up with agency staff training and had not trained the nurse in question. The Director of Nursing acknowledged the oversight and recognized the need for a more comprehensive orientation checklist that includes lift training for all staff, including agency personnel. The lack of proper training and oversight led to the unsafe transfer of the resident, highlighting a gap in the facility's training procedures.
Failure to Offer Pneumococcal Vaccine
Penalty
Summary
The facility failed to assess and offer the pneumococcal vaccine to a resident, identified as Resident #5, who was admitted with diagnoses including Diabetes Mellitus and hypertension. The resident's admission Minimum Data Set indicated severely impaired cognition and noted that the pneumococcal vaccination was not up to date, with the reason being that it was not offered. Interviews with the Infection Preventionist and the Director of Nursing (DON) revealed awareness of the oversight, with the DON stating that they had been employed for only a few weeks and had not yet completed a resident vaccine audit. The previous Infection Preventionist or DON had not offered or provided the vaccine to the resident. The Administrator acknowledged the oversight in not offering or administering the pneumococcal vaccine to Resident #5.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly statements for residents' personal funds accounts, affecting four residents who were reviewed. Each of these residents, identified as cognitively intact, reported not receiving statements about their personal funds balance. Interviews with the residents and their family members confirmed the absence of these statements, which are essential for residents to manage their finances effectively. The Business Office Manager (BOM) revealed that statements were not issued unless specifically requested by the residents. This practice was based on the BOM's understanding that there was no state-regulated requirement to provide regular statements. The BOM mentioned that the facility's Resident Fund Management Service (RFMS) had transitioned to an electronic system about a year ago, and since then, statements were only sent upon request, not quarterly as expected. The facility's Administrator was unaware of the issue until it was brought to her attention during the survey. The lack of awareness and the BOM's misunderstanding of the requirements led to the deficiency, as residents were not receiving the necessary information to manage their personal funds effectively. This oversight highlights a gap in communication and understanding of regulatory expectations within the facility's financial management practices.
Failure to Notify Medical Provider and Guardian
Penalty
Summary
The facility failed to notify a medical provider of significant changes in a resident's condition. Resident #8 was observed to be unresponsive to painful stimuli, had low oxygen saturation levels, and pupil constriction. Nurse #14 suspected a drug overdose and administered two doses of Narcan without notifying a medical provider. Although Resident #8 temporarily responded to the Narcan, he was later found with no heart rate or respiratory rate and was pronounced dead. The Medical Director confirmed that the resident should have been sent to the hospital and that the facility's policy for Narcan administration was not followed. Additionally, the facility failed to notify the Guardian of Resident #6 after the resident tested positive for THC. Resident #6 was found with slurred speech and impaired movements, and a urine drug screening confirmed the presence of THC. Nurse #2 did not notify the Guardian immediately, assuming that the Director of Nursing or Unit Manager would do so. The Guardian was not informed of the drug screening results in a timely manner, which was against the facility's expectations. Interviews with staff revealed a lack of communication and adherence to protocols. Nurse #14 and Nurse #20 both assumed the other had notified the medical provider regarding Resident #8's condition. Similarly, Nurse #2 and Unit Manager #2 assumed the other had notified Resident #6's Guardian. The Director of Nursing and the Medical Director both confirmed that the facility's policies were not followed, leading to significant lapses in care and communication.
Removal Plan
- Re-education to licensed nursing staff, including agency nurses on ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders by the Director of Nursing Services/Assistant Director of Nursing (designee). Licensed nursing staff that are not available will not be scheduled until the education has been completed.
- Facility wide audit completed by Nurse Consultant to determine if for any resident who received Narcan, the medical provider has been notified. The audit identified 3 residents who have a diagnosis of opioid dependence, one resident has scheduled pain management, and two residents have prn pain management per physician order.
- The actions the facility will take to ensure the nurses notify the medical provider of administration of Narcan by the DNS reviewing the 24-hour report on a daily basis for appropriate notification documentation in the Electronic Medical Record (EMR). Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the Director of Nursing Services and/or the Assistant Director of Nursing Services, Unit Managers, and Supervisors.
- If the Director of Nursing Services is unavailable the Assistant Director of Nursing will assume this responsibility of reviewing the 24-hour report.
- Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose prior to working their first shift by the DNS/Assistant Director of Nursing (designee).
Neglect and Failure to Provide Emergency Care
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when they did not provide appropriate care and services during a medical emergency. Resident #8 was found unresponsive with low oxygen saturation and constricted pupils, indicating a possible drug overdose. Nurse #14 administered two doses of Naloxone but did not activate emergency medical services. Later that day, Resident #8 was found without a heart rate or respiratory rate and was pronounced dead. Additionally, the facility neglected to provide incontinence care to Resident #8, who was cognitively intact but experiencing mental status changes, including hallucinations and confusion. Despite requiring increased assistance with toileting, Resident #8 was left unattended and fell while attempting to go to the bathroom, resulting in a left hip fracture and a laceration that required surgical repair. The facility also failed to notify a medical provider of significant changes in Resident #8's condition and did not ensure that nursing staff were trained and competent in responding to medical emergencies. This lack of proper care and communication contributed to the resident's deteriorating condition and eventual death.
Removal Plan
- The licensed nursing staff who neglected to activate emergency response were Nurse #14 and Nurse #20.
- The facility has filed a report of the neglect to the health care personnel registry.
- Education on the facility policy for Abuse and Neglect Prevention was presented to all facility staff by the Administrator, Director of Nursing and Assistant Director of Nursing. This educational in-service included the policy and implementation of procedures to prevent abuse and neglect.
- Included in this education was a review of staff training expectations on preventing, identifying, reporting abuse and neglect.
- The facility has filed a report of the neglect to the licensing agency.
- The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders.
- The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers.
- Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee).
- The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy.
Failure to Initiate Emergency Medical Services for Drug Overdose
Penalty
Summary
The facility failed to initiate emergency medical services for a resident who exhibited symptoms of a drug overdose. The resident was found slumped over, non-responsive, with constricted pupils and impaired respirations. Despite these critical signs, the staff did not call 911 as required by the physician's order for Narcan administration. The resident was later pronounced dead, and this deficiency affected one of the three residents reviewed for quality of care. The resident had a complex medical history, including chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, congestive heart failure (CHF), obstructive sleep apnea, anxiety disorder, and panic disorder. The resident's care plan included monitoring for respiratory depression and administering oxygen and pain medications as ordered. However, there was no mention of opioid or Narcan use in the care plans. On the day of the incident, the resident received multiple medications, including opioids and sedatives, which likely contributed to the overdose. Interviews with the staff revealed a lack of familiarity with the facility's policy for Narcan administration and the necessity to call 911. The nurse who administered Narcan did not call emergency services, believing that the resident's Do Not Resuscitate (DNR) status precluded further action. This misunderstanding was compounded by the fact that the nurse had not received training on Narcan administration. The facility's failure to activate emergency medical services as required by the physician's order directly contributed to the resident's death.
Removal Plan
- The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders.
- Licensed nursing staff that are not available will not be scheduled until the education has been completed.
- The DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response.
- Feedback will be provided by the DNS to the licensed nurse addressing any challenges or barriers in the use of Narcan and/or the activation of the emergency response.
- Re-education was provided to licensed nursing staff about the activation of the emergency response when Narcan is administered.
- Agency licensed nurses working at the facility will receive education on activating emergency response when administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee).
- The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders.
- The DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers.
- Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee).
- The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system, which is denoted in the revised Narcan Administration Policy.
Failure to Enforce Smoking Policy and Prevent Elopement
Penalty
Summary
The facility failed to enforce their smoking policy and monitor a resident with a history of non-compliance with the smoking policy. Resident #8, who was on oxygen, was found to have a vape pen in his possession on multiple occasions and was observed vaping while on oxygen. This placed both Resident #8 and his roommate at increased risk for fire and combustion. Despite repeated infractions, the facility did not revoke Resident #8's smoking privileges or issue a discharge notice, and staff were unable to determine how Resident #8 was obtaining the vape pens and cigarettes. The facility's smoking policy was not effectively enforced, and staff were unable to adequately supervise residents while smoking or vaping. The facility also failed to prevent a resident with moderate cognitive impairment and a history of wandering and exit-seeking behaviors from exiting the facility unsupervised. Resident #1 was found outside the facility in freezing temperatures, wearing inadequate clothing, and holding multiple pieces of mail. Staff disarmed the emergency exit door alarm without initiating the facility's elopement protocol, conducting a full resident head count, or thoroughly searching the area. This failure placed Resident #1 at high risk for serious injury from falls and hypothermia. Additionally, the facility failed to protect a resident from exposure to an illegal substance. Resident #6 experienced altered mental status, impaired physical mobility, and slurred speech after being exposed to tetrahydrocannabinol (THC). The drug screening test confirmed the presence of THC in Resident #6's system. These deficient practices affected multiple residents and posed a high likelihood of serious injury to all residents involved.
Removal Plan
- The list of resident smokers, including those who vape, was updated by social services. This updated smoking list included the current residents who also vape. The intent of this list is to provide a tool for the staff assigned to supervise the smokers to be able to be a check and balance for any changes.
- An audit was completed by the Nurse Consultant to ensure that the smokers' smoking assessments were completed. The audit denoted that 23 smoking assessments required updating. Assessments, which included the safe use of oxygen, were completed.
- The Administrator sent out to families/guardians a letter/text message via Cliniconex/Point Click Care (PCC) regarding the purchase of cigarettes, lighting materials, and vapes. Families/guardians are to give smoking items to the nurse or activities so they can be secured.
- The smoking policy was revised to include that if a resident who is on oxygen and there is suspicion of not complying with the smoking policy and refuses a room search, the facility (Administrator and/or DNS) will notify the police or fire safety of the unsafe situation.
- The staff were educated on the revised smoking policy which included that residents cannot have cigarettes, lighting material, and vape pens on their person, or in their rooms. Education was provided by the Director of Nursing/Assistant Director of Nursing/Unit Managers/Supervisors. All staff including contract staff, have been educated as to the policy expectations for following steps for ensuring enforcement of this policy. This information was provided by the Administrator and the Director of Nursing. The Administrator educated the Director of Human Resources of the updated policy and procedures addressing staff's conduct if and when they engage in any personal smoking procedures. This includes the disciplinary procedures that will occur in the event these policy expectations aren't followed. Staff smoking policy expectations was added to the employee onboarding checklist to document that this policy has been reviewed and understood.
- Residents who smoke and utilize oxygen were educated on removal of oxygen prior to going outside to smoke or vape by the Director of Nursing/Assistant Director of Nursing/Unit Managers/Supervisors. Reminders will be given upon each designated smoking time to all smoking and vaping residents by the assigned staff members providing supervision.
- Education was provided to the smokers by social service on the smoking policy and the policy and procedures of failure to abide by safety requirements.
Failure to Ensure Nursing Staff Competency in Medical Emergencies
Penalty
Summary
The facility failed to ensure that nursing staff were trained and competent in responding to medical emergencies, activating emergency procedures with emergency medical services (EMS), and notifying medical providers. This deficiency was observed in the case of a resident who was unresponsive to painful stimuli, had low oxygen saturation levels, and pupil constriction, indicative of a possible opioid overdose. Despite these critical signs, the nursing staff did not notify a medical provider or initiate emergency procedures with 911, leading to the resident's death. The involved staff members, Nurse #20 and Nurse #14, demonstrated a lack of competency in handling the emergency situation, including the administration of Narcan and the subsequent steps required for emergency response and medical provider notification. Nurse #20, who was an agency nurse on her first day at the facility, did not receive proper orientation or training on emergency procedures, including the administration of Narcan. She relied on Nurse #14, who also lacked training and familiarity with the facility's policies. Nurse #20 did not know that EMS should be notified when Narcan is administered and was not aware of how to contact the on-call provider. Nurse #14, who was the weekend supervisor, also did not follow through with the necessary emergency response steps, mistakenly believing that the resident's DNR status precluded further action. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that agency nurses typically did not receive a shift orientation before working on the floor. The facility's failure to provide adequate training and orientation to its nursing staff, particularly agency nurses, directly contributed to the mishandling of the medical emergency involving the resident. This lack of preparedness and competency among the nursing staff resulted in a critical delay in emergency response, ultimately leading to the resident's death.
Removal Plan
- An audit was completed by the Nurse Consultant on the number of residents who are prescribed opioid medication, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids.
- The Director of Nursing/Assistant Director of Nursing (designee) has re-educated the licensed nursing staff on medical emergencies and emergency activation response per physician orders.
- The actions the Director of Nursing/ Assistant Director of Nursing (designee) will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers, which can require re-education if needed.
- Agency licensed nurses working at the facility will receive education on medical emergencies and activation of the emergency response by the DNS/Assistant Director of Nursing (designee).
- Licensed nursing staff, including agency staff that are not available will not be scheduled until the education has been completed. The Director of Nursing/Assistant Director of Nursing (designee) will provide education on medical emergencies, medical provider notification, and activation of emergency response for the nursing staff unavailable before they start the shift.
- The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy.
- The facility will initiate Mock Medical Emergencies Drills on each shift weekly x 4 weeks, and then ongoing monthly upon completion of the licensed nursing education. The DNS and/or the ADNS will critique the drill denoting areas in need of improvement.
Failure to Administer Antianxiety Medication
Penalty
Summary
The facility failed to obtain an antianxiety medication from the pharmacy, resulting in a resident missing three doses of lorazepam. This deficiency affected a resident who was admitted with an anxiety disorder and had physician orders for lorazepam to be administered three times a day. On the day in question, the resident did not receive any doses of lorazepam, leading to significant anxiety symptoms including panic, sweating, crying, and shaking. The resident repeatedly requested the medication and sought assistance from family members to calm down. Nurse #17, who was assigned to care for the resident, was informed that the resident was out of lorazepam and attempted to contact the pharmacy to obtain the medication. Despite notifying the ADON and DON, the medication did not arrive before the end of her shift. The ADON and DON were new to their roles and were unaware that they could request an electronic prescription to be sent to a local pharmacy for immediate pickup. Instead, they waited for the scheduled nightly delivery from the facility pharmacy, which did not arrive in time. Interviews with the resident's mother, the Medical Director, and the Pharmacist confirmed the failure to obtain the medication in a timely manner. The Pharmacist had no record of a stat request for the medication on the day in question. The Administrator acknowledged the difficulty in getting the prescription refilled and confirmed that the resident missed three scheduled doses of lorazepam, which contributed to the resident's increased anxiety.
Failure to Administer Scheduled Lorazepam Doses
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors by not administering three scheduled doses of lorazepam, an antianxiety medication. Resident #7, who was admitted with an anxiety disorder, had a physician's order for lorazepam one milligram (mg) three times a day. On the day in question, the resident did not receive the scheduled doses at 8:00 AM, 2:00 PM, and 9:00 PM, as indicated in the Medication Administration Record (MAR). This resulted in the resident experiencing severe anxiety symptoms, including panic, sweating, crying, and shaking, and repeatedly asking for assistance from family members to calm down. Nurse #17, who was assigned to care for Resident #7 on the day of the incident, reported that the resident was out of lorazepam and that there was none available in the emergency back-up medication dispenser. Despite notifying the Assistant Director of Nursing (ADON) and Director of Nursing (DON) and contacting the pharmacy, the medication did not arrive before the end of her shift. Throughout the day, Resident #7 exhibited signs of distress and repeatedly requested his medication, which was not available. Interviews with the nursing staff, the resident's mother, and the Medical Director confirmed the medication error. The Medical Director stated that a temporary prescription should have been issued, and the ADON and DON acknowledged that in hindsight, they should have arranged for the medication to be picked up from a local pharmacy. The Administrator confirmed that the resident missed three scheduled doses of lorazepam on the day in question, leading to significant anxiety and distress for Resident #7.
Facility Fails to Maintain Clean and Sanitary Conditions
Penalty
Summary
The facility failed to maintain clean and sanitary conditions in multiple resident rooms and bathrooms, as observed by surveyors. Specifically, the shared bathroom floors in several rooms were found with dried yellow and brown stains, and food debris was scattered across the floors of other rooms. Housekeeping staff admitted to being unable to clean all assigned rooms due to staffing shortages, and the Housekeeping Director confirmed that routine cleaning was not always completed as expected. Additionally, privacy curtains in some rooms had large, dried stains that were not addressed despite daily checks by housekeeping staff. The baseboards in certain rooms were also found to be dirty and in disrepair. In one instance, a baseboard had a dried dark brown stain that was not cleaned over several days. The Housekeeping Director acknowledged that baseboards should be cleaned when visibly soiled and during deep cleaning sessions, but staffing shortages had hindered these efforts. Furthermore, the bathroom in one room had a strong odor of urine and visible yellow and brown stains around the base of the toilet, which were not addressed despite daily cleaning protocols. Maintenance issues were also identified, including baseboards pulling away from the walls in some bathrooms. The Maintenance Director stated that random room checks were conducted weekly, and management staff were responsible for reporting any concerns. However, the Maintenance Director was unaware of the specific issues with the baseboards in the identified rooms. The Administrator confirmed that while some environmental issues had been corrected, there were still ongoing projects to address, and she expected resident rooms and bathrooms to be clean and free of odors, with privacy curtains and baseboards in good repair.
Failure to Report and Investigate Suspected Abuse and Overdose
Penalty
Summary
The facility failed to report suspicious white powder and a pill splitter found in a resident's room to local law enforcement after the resident was suspected of a drug overdose and was given two doses of Naloxone with a positive response. The facility also failed to investigate and preserve potential evidence when they lost the white powder. Staff interviews revealed that the pill splitter and white powder were found and reported to the nursing leadership, but no further action was taken, and the items were lost. The Administrator claimed to be unaware of the incident despite being present at a meeting where it was discussed. Additionally, the facility failed to submit a complete investigation report and notify Adult Protective Services (APS) after another resident alleged abuse from a staff member. The resident reported being fed inappropriately and physically restrained by a nurse aide. The facility's investigation was incomplete, missing key evidence such as a text message from the resident detailing the abuse. The Administrator and other staff members were aware of the allegation but did not ensure that APS was notified. These deficiencies affected two residents, one of whom died after a suspected overdose, and the other who alleged abuse. The facility's policies on abuse investigations and reporting to state agencies were not followed, leading to a lack of proper investigation and notification to the appropriate authorities.
Medical Director Unaware of Narcan Policy
Penalty
Summary
The facility failed to ensure that the Medical Director (MD) was aware of resident care policies related to the administration of Naloxone or Narcan, a medication designed to rapidly reverse opioid overdose in an emergency situation. The MD, who started working at the facility in February 2024, was not familiar with the facility's Narcan policy. This deficiency was identified during a review of the Medical Director/Attending Physician job description and interviews with the MD and the Administrator. The job description included responsibilities such as attending quality assurance meetings, providing guidance to staff, and ensuring compliance with state and federal regulations. However, the MD admitted during an interview that he was unaware of the Narcan policy, which required staff to notify Emergency Medical Services when administering the medication. The Administrator also confirmed that the MD had attended some QA meetings but was not aware of the Narcan policy until it was discussed during the current survey. The deficiency had the potential to affect all residents with active orders for Narcan. The Administrator revealed that the MD had been notified of the updated Narcan policy only after the issues were identified during the survey. This lack of awareness and communication regarding critical resident care policies could have serious implications for the timely and effective administration of emergency medications like Narcan. The facility's failure to ensure that the MD was fully informed about essential care policies highlights a significant gap in the coordination and oversight of medical care within the facility.
Repeated Deficiencies in Quality of Care and Safety
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions following multiple recertification and complaint investigation surveys. This resulted in seven repeat deficiencies in areas such as visitation rights, safe and comfortable environment, notification of changes, quality of care, accident hazards, pharmacy services, and significant medication errors. For instance, the facility imposed a restricted visitation schedule that limited indoor and outdoor visitation of family and friends to 30 minutes per visit, affecting a resident's visitation rights. Additionally, the facility failed to notify a medical provider of significant changes in a resident's condition, leading to the resident's death after suspected drug overdose without timely medical intervention. The facility also failed to ensure a safe and comfortable environment. One resident with a history of wandering and exit-seeking behaviors was found outside the facility unsupervised, wearing inappropriate clothing for the cold weather, which posed a high likelihood of serious injury from falls and hypothermia. Another resident was exposed to an illegal substance, resulting in altered mental status and impaired physical mobility. The facility's failure to enforce their smoking policy and monitor a resident with a history of non-compliance led to the resident vaping while on oxygen, increasing the risk of fire and combustion. In terms of pharmacy services and significant medication errors, the facility failed to obtain and administer prescribed medications, leading to missed doses and adverse effects on residents. One resident missed three doses of antianxiety medication, resulting in panic, sweatiness, crying, and shaking. Another resident missed multiple doses of an anticonvulsant medication, and the facility failed to administer a short-acting insulin as ordered by the physician. These repeated deficiencies indicate the facility's inability to sustain an effective QAA program, despite the committee meeting regularly to discuss plans of correction and implement changes.
Facility Restricts Resident's Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing by restricting visitation for a resident with severe cognitive impairment. Resident #3, who required extensive assistance for most activities of daily living, expressed a strong preference for having family or a close friend involved in discussions about their care. Despite this, the facility's administrator denied visitation from a former social worker who had continued to visit the resident after terminating her employment. The resident became visibly upset when informed that the social worker would no longer be able to visit, indicating the importance of these visits to the resident's emotional well-being. The administrator left a voicemail for the former social worker, stating that she would no longer be allowed to visit the facility due to her status as a self-terminated employee. The administrator justified this decision by expressing concerns about setting a precedent for other former employees. Despite the resident's clear preference and emotional response, the administrator did not consult with the resident or their family before making this decision. The facility owner chose not to send a formal letter to the former social worker, leaving the situation unresolved and the resident without the desired visits.
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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