Autumn Care Of Marshville
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshville, North Carolina.
- Location
- 311 W Phifer Street, Marshville, North Carolina 28103
- CMS Provider Number
- 345268
- Inspections on file
- 24
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Autumn Care Of Marshville during CMS and state inspections, most recent first.
A resident with a history of stroke, epilepsy, slurred speech, and dysphagia had an order for Atorvastatin 40 mg to be given orally once daily, whole and not crushed, consistent with the manufacturer’s instructions. An agency nurse on her first shift crushed and administered the resident’s nighttime medications, including Atorvastatin, without checking the physician’s order or consulting the provider or pharmacy. The resident’s POA observed the nurse crushing the medications, informed her that the order required the tablet to be given whole, and was told the medications had already been crushed and would be withheld until the next scheduled dose if refused. The cognitively intact resident confirmed receiving the Atorvastatin in crushed form and being told it would not harm her and would not be given again until the next scheduled time if she refused it.
The facility failed to maintain effective systems for shift-change narcotic reconciliation and secure storage of discontinued controlled substances, resulting in 80 missing oxycodone-containing tablets for two residents. One resident with PRN oxycodone/acetaminophen had a full card of tablets present one afternoon, but the next morning the oncoming MA and off-going nurse skipped the required physical narcotic count on one cart, relying on verbal confirmation instead; later that morning, when the resident requested pain medication, the MA found that the oxycodone/acetaminophen blister pack was missing. For a second, recently deceased resident with PRN oxycodone via gastric tube, a nurse removed the narcotics from the locked drawer and placed them in a pharmacy return bag left in the medication room; the next day the MA carried this bag to a nurse manager, who then stored it in an unlocked cabinet at the nurse’s station. When two nurses later attempted to count and scan the medications for return, they discovered that the oxycodone tablets for this resident were missing, confirming that discontinued narcotics had not been kept under the required double-lock system.
A resident with dementia, anoxic brain damage, and significant transfer and ADL assistance needs did not receive necessary dental services despite ongoing concerns reported by the POA about mouth pain and difficulty chewing. The care plan and MDS did not identify dental problems, and there was no documented dental exam for many months after admission. The POA arranged an initial visit at an outside dental office, where a dentist identified periodontal disease and the need for multiple extractions and placed a referral to an oral surgery office in the resident’s communication binder, but the specialist office reported never being contacted. A subsequent visit to another dental office resulted only in a cleaning and X-ray, and that office later declined treatment because the resident could not independently transfer to the dental chair. Staff interviews revealed lack of an established process to follow up on outside dental appointments, uncertainty about who was responsible for scheduling and communication, missing documentation of any in-house dental visit, and no equipment or plan to safely transfer the non-ambulatory resident for dental procedures, leading to prolonged delays in obtaining needed dental care.
A cognitively intact resident with epilepsy and prior stroke was given multiple anticonvulsant medications in crushed form by an agency nurse, despite physician orders and manufacturer directions that at least some of the tablets, including extended-release Brivaracetam and Lamotrigine, be swallowed whole. The nurse, on her first shift, relied on another nurse’s statement and her own assumption based on the resident’s stroke history, crushed the nighttime doses, and told the resident and POA that if the medications were refused, they would not be offered again until the next night. After taking the crushed medications, the resident experienced nausea, increased slurred speech, sweating, feeling hot, and weakness, reported these symptoms to staff, and later missed PT due to weakness. A NA observed increased sweating but did not obtain VS, and nursing staff did not notify the NP or physician at the time of the error; later interviews with the pharmacist, NP, and physician linked the symptoms to the crushed administration of the anticonvulsants.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and failing to provide adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or staff involved.
A resident with severe cognitive impairment experienced an unwitnessed fall, after which the facility failed to conduct ongoing comprehensive assessments or effectively communicate changes in the resident's condition. Despite signs of pain and abnormal limb positioning observed by staff, no immediate physical assessment was conducted. The resident was later diagnosed with a hip fracture requiring surgery and a clavicle fracture after being sent to the hospital at the family's request.
A nurse failed to disinfect a resident's glucometer according to the manufacturer's instructions, using a bleach wipe for only 10 seconds instead of the required 4 minutes. Despite having received training, the nurse was unaware of the correct procedure. The DON and SDC confirmed the nurse should have known the protocol, and the Administrator expected adherence to guidelines.
The facility inaccurately posted nurse staffing information by counting CMAs as LPNs over four days. The Staffing Coordinator, due to incorrect training, misreported the staffing levels, which the Administrator was unaware of.
A resident with a history of diabetes, anxiety, CHF, and dysphagia experienced a significant change in condition, including audible congestion and difficulty swallowing. Despite concerning vital signs, staff failed to notify the physician or take appropriate action. The resident was found not breathing and was pronounced deceased. Interviews revealed a lack of awareness and action regarding the resident's condition, with the Medical Director and DON indicating that the staff should have been notified.
A resident experienced neglect when staff failed to provide necessary care during a significant change in condition, leading to the resident being found unresponsive and not receiving immediate CPR. The nurse did not recognize the seriousness of the situation, failed to notify the physician, and did not verify the resident's code status promptly. The resident was later pronounced deceased by EMS.
A resident was found unresponsive and not breathing, but CPR was not administered immediately due to a nurse's assumption of a DNR status. The resident, who was a full code, did not receive timely CPR, and the code blue protocol was not activated. The delay and lack of coordination led to the resident being pronounced deceased by EMS upon arrival.
A resident with a full code status experienced a change in condition, including difficulty swallowing and audible congestion. Despite abnormal vital signs, the nurse did not notify the physician or initiate timely interventions. The resident was later found unresponsive, and CPR was delayed due to a failure to verify code status promptly.
Crushing and Improper Administration of Atorvastatin Against Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice and physician orders for medication administration for one resident. The resident was admitted with diagnoses including cerebral infarction, epilepsy, slurred speech, and dysphagia, and had a physician’s order dated 02/07/2026 for Atorvastatin 40 mg to be administered orally once daily, with explicit instructions that the tablet was to be given whole and not crushed. The manufacturer’s prescribing information for Atorvastatin similarly stated that the tablets are to be swallowed whole and should not be crushed, chewed, or broken. The Medication Administration Record for 02/09/2026 at 9:00 PM showed that Atorvastatin 40 mg was administered and included instructions that it was not to be crushed, although it did not specify the form in which it was actually given. On the night of 02/09/2026, an agency nurse (Nurse #3), working her first shift at the facility and first time caring for this resident, crushed and administered the resident’s nighttime medications, including Atorvastatin 40 mg, without verifying the physician’s order. The resident’s POA, who stayed overnight, observed Nurse #3 crushing and administering the medications and informed her that the order specified the medication must be given whole, stating she had a copy of the order available. Nurse #3 responded that the medications had already been crushed and told the POA that if the resident refused the crushed medication, she would not receive it until the next scheduled dose. In a separate interview, the cognitively intact resident confirmed that Nurse #3 administered her nighttime medications, including Atorvastatin 40 mg, in crushed form and told her the medication would not harm her and that if she refused it, she would not receive it again until the next scheduled dose. Nurse #3 later acknowledged she crushed the medication based on her belief that it needed to be crushed due to the resident’s history of stroke and information from the previous shift nurse, and admitted she did not verify the physician’s order or contact the provider or pharmacy to clarify the order.
Failure to Reconcile and Secure Narcotics Resulting in Missing Oxycodone Tablets
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective systems for shift-change narcotic reconciliation and to keep discontinued narcotic medications secured under two locks, resulting in missing controlled substances for two residents. For one resident, there was a physician’s order for oxycodone/acetaminophen 10/325 mg, one tablet by mouth twice per day as needed for moderate pain. The medication administration record showed that this resident received a dose on one morning for severe pain rated 9/10, administered by a medication aide (MA) and documented as effective. The MA reported that on the prior afternoon narcotic count, she recalled seeing a full card of 30 tablets of oxycodone/acetaminophen in the locked narcotic drawer for this resident. On the following morning, the MA was scheduled to work the day shift and received report and the medication cart from a nurse who had worked the prior afternoon and night shifts. The MA and the nurse counted narcotics on one hall’s cart and found the count accurate. However, when they went to count the narcotics on the second cart, the nurse told the MA that the count was the same as the previous afternoon and that they did not need to perform the count. The MA acknowledged that she knew she should not skip the narcotic count but relied on the nurse’s verbal assurance and signed the narcotic count sheet without physically counting the narcotics on that cart. Later that morning, when the resident requested pain medication, the MA opened the locked narcotic drawer and discovered that the resident’s oxycodone/acetaminophen blister pack was missing, despite her knowledge that a full card had been present the previous day. The facility’s internal investigation and interviews confirmed that the narcotic count for that cart had not been properly completed at shift change, and that the missing oxycodone/acetaminophen for this resident could not be located. Pharmacy records confirmed that 60 tablets had been delivered, and the facility determined that 50 tablets of oxycodone/acetaminophen 10/325 mg for this resident were missing. The former DON and unit manager both stated that nurses and medication aides, including the involved staff, had been trained to complete narcotic counts at every shift change, but in this instance the process was not followed, and staff relied on verbal confirmation rather than a physical count. A second deficiency involved discontinued narcotic medications for another resident who had a physician’s order for oxycodone 5 mg via gastric tube every four hours as needed for pain and who had died a few days before the events described. A nurse removed this resident’s narcotic medications from the locked narcotic drawer, placed them in a clear pharmacy return bag, and left the bag in the medication room. The next morning, the same MA was informed by the nurse that there were medications on the counter in the medication room that needed to be returned to the pharmacy. The MA, aware that the resident had died and that medications needed to be returned, took the bag from the medication room to the unit manager at the main nurse’s station but did not look inside the bag or verify its contents. The unit manager, who was occupied with investigating the first resident’s missing narcotics, placed the bag in an unlocked cabinet behind the nurse’s station instead of securing it under double lock as required. Later that day, when the unit manager and another nurse prepared to return medications to the pharmacy, they followed the process requiring two nurses to count and scan medications for return. At that time, they discovered that the oxycodone 5 mg tablets prescribed for the deceased resident were missing from the return bag. The unit manager acknowledged that she should have locked the medications in a locked cabinet in the medication room but failed to do so. The former DON stated that the unit manager was aware that narcotic medications needed to be locked, and the regional clinical leader stated that discontinued narcotics were to be kept under two locks until pharmacy retrieval with two nurses signing them out. The investigation determined that 30 tablets of oxycodone 5 mg for this resident could not be accounted for and that the medications had not been continuously secured under a double-lock system. Overall, the events leading to the deficiency consisted of staff failing to complete required shift-change controlled substance counts by physically verifying narcotics, relying instead on verbal confirmation, and failing to maintain discontinued narcotics under required double-lock security. These actions and inactions resulted in a total of 80 missing oxycodone-containing tablets for two residents, with the facility unable to substantiate the misappropriation or determine what happened to the medications.
Failure to Coordinate and Secure Necessary Dental Services for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary assistance was provided to obtain routine and emergency dental services for a resident with significant cognitive and physical impairments. The resident was admitted with diagnoses including unspecified dementia, anoxic brain damage, unspecified intellectual disability, and hypertensive heart disease without heart failure, and required partial to substantial assistance with ADLs, including setup or clean-up assistance for oral hygiene and substantial assistance for transfers. The care plan dated 08/19/2025 did not identify any dental health problems, and the quarterly MDS documented no mouth or facial pain and no chewing discomfort, despite later reports from the POA that the resident complained of mouth pain and had difficulty chewing. Review of the EHR from 11/20/2024 through 07/09/2025 showed no evidence of a dental examination during that period. The sequence of events shows multiple missed opportunities and breakdowns in coordination to secure needed dental treatment. The POA reported raising concerns about the resident’s dental needs beginning in April 2025, including observed discomfort while eating and verbal complaints of mouth pain, and stated he repeatedly informed the Social Worker and other staff. The POA ultimately scheduled the first dental appointment himself at Dental Office #1 on 07/10/2025. A Unit Manager note for that date indicated the resident returned from Dental Office #1 and was not seen due to inability to ambulate, but the dentist at Dental Office #1 reported that the resident was in fact seen, was found to have periodontal disease, and needed multiple extractions due to tooth decay and cavities. The dentist stated the resident’s teeth appeared not to have been properly cared for and that, due to their condition, the resident would have experienced pain. The dentist further stated he referred the resident to an oral and maxillofacial specialist (Dental Office #2) and placed the referral and instructions in the communication binder for the facility to call and schedule the appointment, but Dental Office #2 reported having no record of any contact or treatment for the resident. Additional delays and failures occurred with subsequent dental arrangements. A Unit Manager note dated 07/29/2025 documented that the resident returned from Dental Office #3 with a diagnosis of gum disease and a need for multiple extractions, and a progress note dated 08/27/2025 indicated prior authorization was completed for Dental Office #3. However, the Chief Compliance Officer at Dental Office #3 stated the resident was only seen for a cleaning and X-ray at an initial appointment scheduled by the POA, and no treatment orders were communicated to the facility. The Social Worker stated she first learned of the dental concerns from the POA in July 2025, did not recall being told the resident was in pain, and believed dental services were being provided from August through September 2025 because she received no follow-up communication from nursing staff or the NP. She also stated there was no established process to follow up on outside dental appointments and could not provide documentation that the resident had ever been seen by the in-house dental provider, who visited quarterly and was present in October 2025. A Social Work note on 10/07/2025 documented that Dental Office #3 could not treat the resident unless he could transfer independently to the dental chair, and that an in-house dental appointment was scheduled for 10/17/2025, but the POA informed her of his intent to discharge the resident on 10/13/2025 due to delays in obtaining necessary dental services. Staff interviews further highlighted communication and process failures that contributed to the deficiency. Unit Manager #1 acknowledged family concerns about the resident’s teeth and stated the resident required assistance transferring to a dental chair, but the facility lacked appropriate resources to assist with transfers at dental offices. She indicated that nursing and Social Work attempted to locate dental offices that could accommodate the resident’s transfer needs and that the appointment scheduler handled communication with Dental Office #1, but she was unaware of any referral to Dental Office #2. NA #3, who transported the resident to some appointments, stated she did not transport the resident to Dental Office #1 because she was on leave, transported him to Dental Office #3 on 08/27/2025, did not stay for the appointment, and had no equipment to facilitate safe transfers, learning from the POA that Dental Office #3 declined treatment because the resident could not transfer to the dental chair. The NP stated she completed authorization in August 2025 and believed delays were related to finding a facility that could accommodate the resident’s physical needs and accept his managed insurance. The DON and Administrator, both hired after the resident’s discharge, reported that the referral to Dental Office #2 may have been lost in communication and that they were not aware of the resident’s dental concerns at the time, while the Administrator stated he expects nursing and Social Work to follow up on residents’ dental needs.
Crushing of Anticonvulsant Medications Contrary to Orders and Manufacturer Directions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple anticonvulsant medications ordered to be given whole were crushed and administered. The resident, who had diagnoses including cerebral infarction, epilepsy, slurred speech, and dysphagia, was cognitively intact and did not exhibit behavioral symptoms or rejection of care per a recent MDS. Physician orders specified that Brivaracetam 100 mg, Eslicarbazepine 800 mg, Lamotrigine 200 mg, and Xcopri 150 mg were to be administered orally and not crushed, with Brivaracetam explicitly ordered as “DO NOT CRUSH.” Manufacturer prescribing information for Brivaracetam and extended-release Lamotrigine stated that tablets should be swallowed whole and not chewed or crushed, while Eslicarbazepine and Xcopri could be administered whole. On the evening in question, an agency nurse (Nurse #3), working her first shift at the facility and first time with the resident, crushed and administered the resident’s nighttime doses of Brivaracetam, Eslicarbazepine, Lamotrigine, and Xcopri. The MAR reflected that the medications were given but did not specify whole versus crushed administration. According to the resident’s POA, she was present and informed Nurse #3 that the medications should not be crushed based on the physician’s orders she had in her possession. Nurse #3 responded that the medications had already been crushed and told the resident that if she did not take them, she would not receive them again until the next night. The resident reported that Nurse #3 told her the crushed medications would not hurt her, and she took them because they were important for seizure control and she was told she would otherwise miss the dose. Following administration of the crushed medications, the resident and her POA reported onset of symptoms including nausea, increased slurred speech beyond baseline, sweating, feeling extremely hot, and weakness within approximately 40 minutes to an hour. The POA stated she notified Nurse #3 of these symptoms and that Nurse #3 checked on the resident once during the night to obtain vital signs. NA #2, who cared for the resident that evening, reported the resident said she was scared when her medications were crushed and was noted to be sweating more than usual around the time of administration; NA #2 assisted with comfort measures but did not obtain vital signs. The pharmacist, NP, and facility physician each confirmed that crushing and administering these anticonvulsants together could alter their intended release and contribute to the symptoms described, and the NP stated the side effects the resident experienced were a direct result of the medications being crushed and administered all at once. Nursing staff did not notify the NP or physician at the time of the medication error, and the physician later reported he had been unaware of the incident.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential incidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or their conditions mentioned.
Failure to Assess and Communicate Changes in Condition After Fall
Penalty
Summary
The facility failed to complete and document ongoing comprehensive assessments for a resident after an unwitnessed fall and did not have effective systems in place for communicating changes in condition. The resident, who was severely cognitively impaired, experienced an unwitnessed fall from bed. Initially, a nurse assessed the resident and noted no pain or injury. However, this was the only documented nursing assessment following the fall. During subsequent shifts, staff observed signs of pain, such as wincing when the resident was turned, but these observations were not consistently reported to nursing staff or followed up with a physical assessment. On the day following the fall, the resident expressed pain in her lower right extremity to therapists, who observed that her right lower extremity was externally rotated and flexed. Despite these observations being reported to a nursing staff member, no immediate physical assessment was conducted. Later that day, a family member reported that the resident was in significant pain, leading to a physician being contacted and an x-ray being ordered. The family ultimately requested that the resident be sent to the hospital, where she was diagnosed with a closed right hip fracture requiring surgery and a non-operable right clavicle fracture. The deficiency occurred because the facility did not have effective communication and assessment protocols in place to identify and respond to changes in the resident's condition following the fall. The lack of timely and thorough assessments, as well as inadequate communication among staff, contributed to a delay in diagnosing the resident's injuries, which were only identified after the family intervened and requested hospital evaluation.
Improper Disinfection of Glucometer
Penalty
Summary
The facility failed to properly disinfect a resident's glucometer according to the manufacturer's instructions, as observed during a survey. Nurse #1 was seen removing a glucometer from an unsealed plastic bag, using it to check a resident's blood glucose level, and then placing it on the medication cart without following the correct disinfection procedure. The nurse used a germicidal disposable bleach wipe to clean the glucometer for approximately 10 seconds, contrary to the manufacturer's instructions that required the surface to remain visibly wet for 4 minutes and to air dry. Nurse #1 was unaware of the correct procedure and expressed uncertainty about how to keep the glucometer wet for the required time. Interviews with the Director of Nursing (DON) and the Staff Development Coordinator (SDC) revealed that Nurse #1 had received training and competency reviews on the disinfection procedure. Despite this, she did not follow the correct protocol during the observation. The DON and SDC confirmed that Nurse #1 should have known the proper procedure, and the Administrator expected all staff to adhere to the manufacturer's guidelines. The SDC noted that Nurse #1 felt nervous during the observation, which may have contributed to the oversight.
Inaccurate Nurse Staffing Information Posted
Penalty
Summary
The facility failed to post accurate nurse staffing information for four consecutive days. The discrepancies were identified during a review of the Daily Posted Nurse Staffing forms and the nursing schedule. On each of the days reviewed, the posted staffing information inaccurately listed the number of Licensed Practical Nurses (LPNs) and included Certified Medication Aides (CMAs) as LPNs. Specifically, on three of the days, the forms indicated three LPNs were staffed, while the schedule showed a combination of LPNs and CMAs. On the fourth day, the form inaccurately listed two LPNs instead of one LPN and one CMA. The Staffing Coordinator, responsible for updating the forms, admitted to counting CMAs as LPNs due to incorrect training received when she assumed her role four months prior. The Administrator was unaware of the inaccuracies and confirmed that CMAs should not have been recorded as LPNs.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the physician for a resident who experienced a significant change in condition. The resident, who had a medical history including type 2 diabetes mellitus, anxiety, chronic congestive heart failure, and dysphagia, was observed with audible congestion, difficulty swallowing, and was trying to cough up phlegm. Despite these symptoms, neither the Medical Director nor the Nurse Practitioner was notified. The resident's vital signs were concerning, with a low pulse, low oxygen saturation, and clammy skin, yet no medical intervention was sought. Throughout the evening and night shifts, various staff members interacted with the resident but failed to recognize the severity of the situation or take appropriate action. A nurse noted the resident's symptoms and even crushed medications due to the resident's difficulty swallowing, but did not notify a physician or take further steps to address the resident's declining condition. The resident was found not breathing in the early morning hours and was pronounced deceased shortly thereafter. Interviews with staff revealed a lack of awareness and action regarding the resident's change in condition. The Medical Director expressed that the staff should have contacted him or the Nurse Practitioner when the symptoms were first observed. The Director of Nursing also stated that the nurse should have applied oxygen and notified the physician due to the resident's low oxygen levels. The failure to act upon the resident's change in condition and notify the appropriate medical personnel led to a critical oversight in care.
Neglect and Failure to Administer CPR in a Timely Manner
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect, as evidenced by the lack of necessary care and services provided to a resident who experienced a significant change in condition. The resident exhibited symptoms such as audible congestion, difficulty swallowing, and attempts to cough up phlegm, yet the nurse did not recognize the seriousness of the situation, failed to notify the physician, and did not conduct thorough and ongoing assessments. This neglect resulted in the resident being found not breathing and without a pulse, and subsequently pronounced deceased by emergency medical services. The facility also failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately and did not have an effective system in place for staff to respond to emergency situations. When the resident was found unresponsive, the nurse did not verify the resident's code status and resumed other duties. It was only after being informed of the resident's full code status that the nurse initiated CPR, but without following the code blue protocol. The nurse ceased CPR when fatigued, and the resident was later pronounced deceased. Additionally, the facility did not provide complete, thorough, and ongoing assessments, nor did it intervene when the nurse failed to recognize the seriousness of the resident's condition. Despite the resident's vital signs indicating a critical state, the nurse did not obtain another set of vital signs or initiate lifesaving resuscitative efforts. The Director of Nursing acknowledged the nurse's lack of competency in handling the situation, which included not notifying the physician, not monitoring the resident, and failing to verify the resident's code status immediately.
Failure to Administer Immediate CPR to Full Code Resident
Penalty
Summary
The facility failed to ensure that Cardiopulmonary Resuscitation (CPR) was administered immediately to a resident who was unresponsive, not breathing, and had no pulse. Nurse #1 was notified of the resident's condition but did not verify the resident's code status and assumed the resident was a Do Not Resuscitate (DNR). As a result, Nurse #1 did not initiate CPR immediately and resumed her duties elsewhere. It was only after being informed by another nursing assistant that the resident was a full code that Nurse #1 began CPR, but she did not activate the code blue protocol. The resident, who had been readmitted to the facility with diagnoses including type 2 diabetes mellitus, anxiety, chronic congestive heart failure, and dysphagia, was found unresponsive by a nursing assistant. Despite the resident's care plan indicating a full code status, Nurse #1 failed to act promptly. The delay in initiating CPR and the lack of a coordinated emergency response contributed to the resident being pronounced deceased by emergency medical services (EMS) upon their arrival. Interviews with staff revealed that Nurse #1 did not seek assistance from other staff members nor did she utilize the crash cart effectively. The crash cart was found to lack essential equipment such as an automated external defibrillator (AED), oxygen, tubing, or a suction machine. The emergency medical services report confirmed that CPR was not in progress upon their arrival, and the resident was found to be in asystole with no pulse or respiration.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to provide complete, thorough, and ongoing assessments for a resident experiencing a change in condition. The resident, who was a full code, exhibited symptoms of difficulty swallowing, audible congestion, and attempts to cough up phlegm. Despite these symptoms, Nurse #1 did not obtain vital signs or implement interventions to relieve the congestion. The resident's vital signs showed concerning levels, including a low pulse and oxygen saturation, but Nurse #1 did not take further action or notify the physician or Nurse Practitioner. On the morning of the incident, the resident was found with no pulse, and Nurse #1 did not verify the resident's full code status or initiate resuscitative efforts immediately. It was not until later that Nurse #1 became aware of the resident's full code status and began CPR, but by then, emergency medical services pronounced the resident deceased. Interviews with staff and record reviews indicated that there was a lack of timely response and communication regarding the resident's change in condition. The Medical Director and Nurse Practitioner both stated that they would have expected staff to obtain vital signs and notify them of the resident's symptoms. The Director of Nursing also indicated that Nurse #1 should have applied oxygen and notified the physician. The failure to act upon the resident's change in condition and the delay in initiating CPR contributed to the deficiency identified in the facility's care practices.
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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