Autumn Care Of Saluda
Inspection history, citations, penalties and survey trends for this long-term care facility in Saluda, North Carolina.
- Location
- 501 Esseola Circle, Saluda, North Carolina 28773
- CMS Provider Number
- 345351
- Inspections on file
- 26
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Autumn Care Of Saluda during CMS and state inspections, most recent first.
A resident was admitted with a documented sacral pressure-related skin condition, including nursing notes describing reddened areas on the inner/top buttocks treated with foam dressings and physician-ordered wound care. However, the admission MDS was coded as if the resident had no unhealed stage I pressure ulcer during the look-back period. In interviews, the MDS coordinator, DON, and Administrator all acknowledged that the admission MDS should have been coded to reflect a stage I pressure ulcer present on admission.
A resident with mood disorder, nicotine dependence, and muscle weakness, who was cognitively intact and largely independent in ADLs, had documented smoking risk assessments showing safe smoking scores until a later assessment recorded the resident as a non-smoker. The facility’s policy required smoking risk assessments on admission, quarterly, and with changes in condition. After the resident’s smoking privileges were revoked due to escalating behavior and later reinstated by the Administrator, the Social Worker updated the care plan to reflect supervised smoking but did not complete a new smoking risk assessment, despite this change in smoking status and the expectation from the DON and Administrator that such an assessment be done.
A cognitively impaired resident with dementia, bipolar disorder, and documented elopement risk exited the building unsupervised after exhibiting increased exit-seeking behavior. The resident’s care plan and elopement assessment identified exit-seeking, verbalizations about going home, and independence with ambulation, with interventions focused on redirection and 1:1 approach during elopement attempts. On the day of the incident, the DON and Administrator discussed the resident’s escalated behaviors in morning clinical meeting and instructed staff to increase observation, but the resident was intermittently monitored while staff also cared for other residents. During a period of frequent vendor and staff traffic through a keypad-locked side common area door, the resident was able to follow or be let out with a vendor or staff member and was later found outside in the driveway, away from the building, without staff knowledge of his exit.
A nurse in an LTC facility misappropriated controlled narcotic medications prescribed to three residents. The nurse signed off on the removal and wasting of medications without a second nurse's witness signature, violating facility policy. The discrepancies were discovered when staff noticed double signatures and unknown witness signatures on narcotic medication records. An investigation confirmed the diversion of five narcotic medications, leading to criminal charges against the nurse.
The facility was found deficient in food storage and handling practices. Spoiled cucumbers and bell peppers were discovered in the walk-in refrigerator, and undated sandwiches were found in the kitchen refrigerator. Additionally, a dented can of catsup was improperly stored on the canned goods rack. The Certified Dietary Manager acknowledged these oversights, and the Administrator confirmed expectations for proper food storage and dating.
The facility failed to notify the physician of a fall and a delay in a STAT x-ray order for a severely cognitively impaired resident on blood thinner. The resident experienced a fall during a transfer, which was not reported by the CNAs involved. The resident later showed signs of pain and decreased mobility, leading to a delayed STAT x-ray that revealed a hip fracture. The lack of communication and proper notification procedures contributed to the resident's prolonged pain and delayed treatment.
A resident was injured after staff failed to follow the care plan requiring a total mechanical lift and two-person assistance for transfers. The resident was transferred using a sit-to-stand lift, resulting in a fall and a fractured left hip. The resident underwent surgery and was later discharged to hospice care, where she expired shortly after.
A resident was not assessed by a nurse after a fall and was moved without proper evaluation. The following day, a STAT x-ray order was delayed, and the facility did not inform the NP. The x-ray revealed a hip fracture, leading to delayed hospital transfer.
A resident with severe cognitive impairment fell and fractured their hip after a nurse aide used an incorrect mechanical lift for transfer. The incident was not reported, leading to a delay in medical assessment and treatment. The resident later underwent surgery and was discharged to hospice care, where they expired.
The facility failed to ensure that all nursing staff, including agency staff, received proper orientation and competency verification before providing care to residents. An agency NA improperly transferred a resident using a sit-to-stand mechanical lift instead of the required total mechanical lift with two-person assistance, resulting in the resident suffering an acute hip fracture. The incident revealed significant lapses in staff training and awareness of resident care plans.
Inaccurate MDS Coding for Pressure Ulcer on Admission
Penalty
Summary
The deficiency involves the facility’s failure to accurately code the Minimum Data Set (MDS) assessment for a resident with a pressure ulcer. The resident was admitted with a documented pressure ulcer on the sacrum per the admission skin assessment, although the stage of the ulcer was not specified in that assessment. Subsequent nursing documentation, including a progress note, identified a reddened area on the bilateral inner/top buttocks covered with foam dressing, and the Medication Administration Record showed a physician’s order to cleanse the bilateral inner buttock area with normal saline and apply a foam border dressing, which was carried out. Another nurse’s progress note documented that the sacral dressing was changed the following day. Despite this documentation of a pressure-related skin condition present at admission, the admission MDS assessment indicated that the resident did not have an unhealed stage I pressure ulcer during the look-back period. In interviews, the MDS Coordinator stated that the admission MDS should have been coded to reflect a stage I pressure ulcer present on admission, and the DON stated that MDS assessments should be coded correctly and that she expected the admission MDS to show a stage I pressure ulcer present on admission. The Administrator also confirmed that the admission MDS should have been correctly coded to reflect a stage I pressure ulcer present on admission.
Failure to Complete Required Smoking Risk Assessment After Change in Smoking Status
Penalty
Summary
The facility failed to complete required quarterly smoking risk assessments for a resident who smoked. The resident was admitted with diagnoses including mood disorder, nicotine dependence, and muscle weakness. The facility’s smoking policy required a smoking risk assessment on admission, quarterly, and upon changes in condition. The resident’s MDS assessments showed that he was cognitively intact, independent in most ADLs, and coded for tobacco use. Smoking risk assessments were documented on 06/05/25 with a score of 7, on 08/28/25 with a score of 8, and on 02/26/26 indicating the resident was not a current smoker. The resident’s care plan, updated on 04/10/26, identified him as a supervised smoker with interventions to explain the smoking policy as needed and monitor for unsafe smoking signs. The resident was observed smoking under supervision on 04/21/26 with no issues noted. The Social Worker stated she was responsible for quarterly smoking assessments and relied on computer notifications, confirming she last assessed the resident on 02/26/26 as a non-smoker. She reported that the resident’s smoking privileges were revoked in January 2026 due to escalating behavior toward other residents during smoking times and that the Administrator reinstated these privileges on 04/10/26. Although the Social Worker updated the care plan to include smoking at that time, she did not complete a new smoking risk assessment despite acknowledging she should have done so due to the change in smoking status. The DON and Administrator both confirmed that a new smoking risk assessment should have been completed when smoking privileges were reinstated, in accordance with the facility’s policy.
Failure to Supervise Elopement-Risk Resident During Vendor Traffic
Penalty
Summary
The deficiency involves the facility’s failure to effectively supervise a cognitively impaired resident who was assessed as being at risk for elopement and who exited the building unsupervised and without staff knowledge. The resident had diagnoses including dementia, bipolar disorder, panic disorder, and anxiety disorder, and an MDS documented severe cognitive impairment with a need for supervision for mobility and transfers. The resident’s care plan, initiated and updated prior to the incident, identified risk of elopement with behaviors such as standing by exit doors, verbalizing intent to walk out, and attempting to follow staff as they exited. Interventions on the care plan included 1:1 approach during elopement attempts, redirection from the front door area with offers of coffee, snacks, walks in the courtyard, or return to the room, and maintaining a calm environment. An elopement assessment completed prior to the incident documented that the resident was independent with ambulation and exhibited exit-seeking behaviors, including verbalizing a desire to go home or go on a trip, and not accepting the current residence. Despite this, the immediate intervention listed was to continue the current plan of care. On the morning of the elopement, the DON and Administrator reported that the resident had shown increased exit-seeking behavior, including asking about leaving and standing near common area doors that were locked with a keypad. This escalation was discussed in the morning interdisciplinary team meeting, and staff were informed they needed to increase observation and redirection of the resident due to the heightened behaviors. On the day of the incident, Nurse #1 reported that around 10:10 a.m. the resident was inquiring about leaving the facility; she told him he needed to talk to the physician and that it was almost time to go smoke. The resident then left the nurse’s station and went to his room, where he lay on his bed. NA #1 stated that at approximately 10:30 a.m. the resident was in his room sitting on his bed after she had redirected him with an offer of coffee when he asked how he could get home. NA #1 acknowledged she was aware of his exit-seeking behavior and the need to keep an eye on him but stated she had other residents to care for and could not continuously watch him. At 10:42 a.m., Nurse #1 saw the resident outside, midway down the facility driveway, approximately 150 feet from the building and about 50 feet from the road, and immediately brought him back inside. The facility’s investigation concluded that, on a day when multiple vendors and staff were entering and exiting through a side common area door, the resident was able to leave the building by following or being let out by a vendor or staff member through that door, resulting in an unsupervised exit despite his known elopement risk and recent increase in exit-seeking behavior. Interviews with the NP indicated that during prior visits the resident had always been observed sitting on his bed and had not shown exit-seeking behavior to her. However, staff interviews and documentation on the Kardex and elopement assessment confirmed that exit-seeking behaviors were known and that the resident was identified as at risk for elopement. The side common area doors used by vendors were locked with a keypad, and only certain management staff had the code, but on the day of the incident vendors and staff were going in and out through those doors, and the resident was able to leave undetected. The combination of known elopement risk, documented increased exit-seeking behavior that morning, reliance on intermittent observation rather than continuous supervision, and active vendor traffic through a secured exit led to the resident’s unsupervised departure from the facility.
Misappropriation of Controlled Narcotics by Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled narcotic pain medications, affecting three residents. Nurse #1 was involved in the misappropriation of medications, as evidenced by discrepancies in the controlled narcotic medication declining records. Nurse #1 signed off on the removal and wasting of medications without a second nurse's witness signature, which is against the facility's policy. This was observed in the records of three residents who were prescribed opioid medications for pain management. Resident #46, who had intact cognition, was prescribed hydrocodone-acetaminophen for hip pain. On a specific date, Nurse #1 signed for the removal of one tablet and claimed it was wasted without a witness, and later removed two more tablets, claiming both were administered. Similarly, Resident #1, with severely impaired cognition, was prescribed oxycodone-acetaminophen for chronic pain. Nurse #1 signed for the removal of two tablets on two occasions, claiming one was wasted each time, with one instance lacking a witness signature. Resident #18, with intact cognition and chronic pain, was prescribed oxycodone extended release. Nurse #1 signed for the removal of two tablets, claiming one was wasted with an unknown witness signature. The facility became aware of the alleged drug diversion when staff noticed double signatures and unknown witness signatures on the narcotic medication records. An investigation revealed that Nurse #1 admitted to signing as a witness without another nurse present and could not account for the wasted medications. The facility reported the incident to law enforcement and the state agency, and Nurse #1 faced criminal charges. The investigation confirmed that five narcotic medications were diverted, and the facility took steps to address the issue, including notifying relevant authorities and conducting audits.
Deficiency in Food Storage and Handling
Penalty
Summary
The facility failed to properly manage food storage and handling, as observed during a survey. In the walk-in refrigerator, cucumbers and green bell peppers were found with signs of spoilage, having been received on dates far exceeding the recommended storage period. The cucumbers were shriveled with white on the surface, and the bell peppers were shriveled with black on the surface. Additionally, in the kitchen refrigerator, a ham and cheese sandwich and a peanut butter and jelly sandwich were found without any date labels, indicating a lapse in the facility's protocol for dating food items. Furthermore, the canned goods rack contained an unopened can of catsup with a significant dent, which should have been placed in the damaged goods return area. Interviews with the Certified Dietary Manager (CDM) and the Administrator revealed that the vegetables should have been discarded after seven days, and the sandwiches should have been dated when made. The CDM acknowledged the oversight and indicated that the dented can of catsup was improperly returned to the shelf instead of being set aside for return. The Administrator confirmed that the expectation was for food to be stored and dated according to regulatory standards, and spoiled vegetables should be discarded.
Failure to Notify Physician of Fall and Delay in STAT X-ray Order
Penalty
Summary
The facility failed to notify the physician of a fall and a delay in a STAT x-ray order for a severely cognitively impaired resident on blood thinner. The resident experienced a fall while being transferred to the toilet using a sit-to-stand mechanical lift. The CNAs involved did not report the incident to a nurse or physician, and the resident was moved without a proper assessment. The resident later displayed signs of pain and decreased range of motion in her left hip, leading to a STAT x-ray order that was delayed without notifying the physician of the delay. The x-ray eventually revealed an acute fracture of the left hip, and the resident was transferred to the ER for further evaluation and treatment. The resident underwent surgery and was later discharged to hospice care, where she expired. The incident began when an agency CNA was lowering the resident to the toilet, and the resident's foot slipped, causing her to be lowered to the floor. The CNA did not report the incident to a nurse, believing it was not a fall. Another CNA assisted in moving the resident back to her chair without notifying a nurse for an assessment. The following day, the resident's decreased mobility and pain were noticed, and a STAT x-ray was ordered. However, the x-ray was delayed, and the physician was not informed of the delay. Interviews with the involved staff revealed a lack of communication and understanding of the facility's protocols for reporting falls and changes in condition. The CNAs did not recognize the incident as a fall and failed to notify the appropriate medical personnel. The delay in the STAT x-ray order was not communicated to the physician, resulting in a delay in the resident's diagnosis and treatment. The facility's failure to follow proper notification procedures contributed to the resident's prolonged pain and delayed medical intervention.
Removal Plan
- The facility failed to notify the MD/NP and RP when Resident #1 fell and failed to notify the NP when there was a delay in a stat x-ray order. C.N.A. #1 and C.N.A #2 failed to notify a Nurse/MD or NP when Resident #1 fell and failed to notify before moving Resident #1 off the floor. C.N.A. #2 informed the NP that Resident #1 was having issues with her foot dragging. C.N.A #2 did not notify the NP of the fall. NP performed an assessment on Resident #1, no bruising or swelling was noted. NP ordered stat x-ray and changed scheduled Tylenol to three times daily for pain. Radiology contacted facility and notified the floor nurse that they would not be able to obtain the stat x-ray. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on proper notification of MD for any delay in stat orders. X-ray results revealed acute fracture of left hip. Facility notified Nurse Practitioner and received orders to send resident to the hospital for evaluation and treatment.
- Director of Nursing and/or designee completed education with all licensed nurses and CNA's including agency staff on notification to MD/NP and RP of all incidents or falls and accidents.
- Director of Nursing and/or designee completed education with all licensed nurses including agency staff on notification to MD/NP on delay of stat x-rays orders. Interviews were conducted with communicative residents. These interviews were conducted to determine if any issues regarding care and services would be identified. No other issues were identified. Unit managers completed skin checks on all residents. Skin checks were completed to ensure there were no signs of injury from an unreported fall, no negative findings were noted. Director of Nursing checked for any other stat x-ray orders and there were none.
- The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses including agency staff on reporting of incidents and accidents and reporting protocols and change in condition to physician or nurse practitioner. New hires to the facility are educated with the onboarding procedures. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff including agency staff on reporting of accidents and incidents. The Director of Nursing and/or their designee educated all licensed nurses including agency nurses on stat orders and procedures. This education included notification to physician or NP on a delay of stat orders or other changes of condition for the residents.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders from NP. Director of Nursing and/or their designee will audit results daily for 12 weeks to ensure order for x-rays are completed as ordered. NP was notified of this process. Director of Nursing and/or their designee will audit change of condition and incident reports daily for 12 weeks to ensure physician notification of incidents/accidents and falls has been completed. Director of Nursing and/or designee will have daily huddles with licensed nurses and C.N.A.'s at beginning and end of shift to discuss any change in condition or incidents that may have occurred throughout the shift in order to ensure proper notifications have been made. This is to ensure that MD/NP have been notified of any incidents. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed for three months.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when staff disregarded the resident's plan of care and transferred the resident without the use of a total mechanical lift and two-person assistance. During the first transfer, the resident was assisted to the floor. The following day, the Nurse Practitioner was asked to assess the resident due to her left foot dragging on the floor, and x-ray results revealed an acute fracture of the left hip. The resident underwent surgery to repair the left hip fracture and was later discharged to hospice care, where she expired shortly after. The incident began when a Nurse Aide transferred the resident independently using a sit-to-stand mechanical lift instead of the required total mechanical lift with two-person assistance. During the transfer from the toilet to the sit-to-stand mechanical lift, the resident's foot slipped, and the Nurse Aide had to lower the resident to the floor. Another Nurse Aide was called to assist, and they both helped the resident off the floor without using the proper mechanical lift. Transfers continued without using the total mechanical lift and assistance from two people. The following day, a Nurse Aide reported to the Nurse Practitioner that the resident's left foot was dragging on the floor when in a wheelchair but did not inform the Nurse Practitioner of the fall. The Nurse Practitioner assessed the resident and ordered immediate x-rays, which revealed an acute fracture of the left hip. The Director of Nursing was notified, and the resident was sent to the hospital for further evaluation and treatment. The resident underwent surgery and was later discharged to hospice care, where she expired shortly after.
Removal Plan
- The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift.
- X-ray was obtained which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. The Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room, and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at the facility, CNA #2 has been terminated.
- The Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from the therapy department. Unit managers cross-referenced the lift status to the Kardex and Care Plans.
- The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents and reporting protocols. Agency staff will be educated prior to the first shift working on proper lifts, facility policies, and reporting all incidents and changes in condition. New hires to the facility are educated with the onboarding procedures. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers and proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s, reporting of accidents and incidents, following the Kardex for proper transfers and change in condition. The Director of Nursing and/or their designee educated all facility staff on abuse and neglect, definition of abuse/neglect and facility policy for reporting. Staff educated that facility has no tolerance for abuse/neglect and will result in immediate termination. Director of Nursing and/or their designee educated agency staff on abuse/neglect policy, reporting and consequences of abuse/neglect. New staff will be educated upon hire by the Director of Nursing and/or their designee.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice.
- To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week to ensure residents requiring assist utilizing lifts are receiving the proper transfer. Unit Mangers will select 5 residents weekly that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy.
- Administrator and/or their designee will audit five (5) random staff members weekly to ensure that they understand the definition abuse/neglect and the reporting requirements for abuse/neglect.
- The Social Services Director and/or their designee will interview 5 alert residents and 5 responsible parties per week to ensure that no abuse/neglect is occurring.
- Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed.
Failure to Assess Resident After Fall and Delay in STAT X-ray Order
Penalty
Summary
The facility failed to assess a resident by a nurse after a fall and prior to getting her off the floor. On the day of the incident, a nurse aide transferred the resident from her bed to a sit-to-stand lift and then to the shower room. During a transfer in the shower room, the resident's foot slipped, and the nurse aide had to lower the resident to the floor. The nurse aide called for assistance from another nurse aide, but neither of them notified a nurse about the fall. Consequently, an assessment for injury was not completed by a nurse before the resident was moved back to her wheelchair. The following day, the nurse practitioner placed a STAT order for a left hip x-ray due to the resident's decreased range of motion and pain. However, there was a delay in executing the STAT x-ray order, and the facility did not inform the nurse practitioner about the delay. The x-ray results, which revealed a fracture of the resident's left hip, were not available until the next day. The delay in obtaining the x-ray results led to a delay in sending the resident to the hospital for further evaluation and treatment. Interviews with the involved staff revealed that they did not consider the incident as a fall and therefore did not follow the proper protocol of notifying a nurse and having the resident assessed before moving her. The nurse aides involved admitted to not reporting the incident to the nurse or the nurse practitioner, which contributed to the delay in care. The facility's failure to ensure timely assessment and execution of the STAT x-ray order resulted in delayed care for the resident, who suffered a hip fracture.
Removal Plan
- The facility failed to have resident assessed by a nurse after the fall and prior to getting her off the floor. The facility failed to report the fall and improper transfer when CNA #2 reported the resident having issues with her foot dragging. Nurse Practitioner was notified by C.N.A. #2 that resident could not move her left foot. Nurse Practitioner performed an assessment on resident, no bruising or swelling was noted. Nurse Practitioner ordered stat x-ray and changed Tylenol order to three times daily for pain. Radiology contacted facility and notified the floor nurse that they would not be able to obtain the stat x-ray. Floor nurse did not notify NP of delay in stat x-ray. Director of Nursing and/or designee re-educated floor nurse on proper notification to MD for any delay in stat orders. X-ray results revealed acute fracture of left hip. Facility notified Nurse Practitioner and received orders to send resident to the hospital for evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. Director of Nursing conducted an interview with C.N.A. #2 which revealed the incident and a conclusion on how the fracture occurred. C.N.A. #2 confirmed that resident was on the floor in the shower room and C.N.A #2 assisted C.N.A #1 in returning resident to chair. C.N.A #1 cannot return to the facility, CNA #2 has been terminated from the facility.
- Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any unreported incidents or other injury of unknown origin. No other issues were identified by residents. Head to toe skin assessments were completed on all residents by Unit Managers. This was done to ensure there were no signs or symptoms of injuries related to incidents not being reported. No negative findings were noted from residents. The Director of Nursing checked for any other stat x-ray orders and there were none.
- The Director of Nursing and/or their designee completed education of 100% C.N.A.'s and licensed nurses which included, safe transfers, reporting of incidents and accidents, and reporting protocols and change in condition. This includes having a licensed nurse assess a resident after all falls and/or incidents. Agency staff will be educated prior to first shift working on proper lifts, facility policies, and reporting all incidents and change in condition. New hires to the facility are educated with the onboarding procedures. The Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on reporting of incidents and accidents and the definition of a fall. Agency staff were educated prior to taking an assignment. The Director of Nursing and/or their designee completed 100% education of all licensed nurses on stat orders. This education included notification to MD/NP if stat order has been delayed. Agency nurses are educated on STAT orders prior to first shift working.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice. Director of Nursing and/or their designee will obtain copies of new and stat x-ray orders daily from NP. Director of Nursing and/or their designee will audit results daily to ensure orders for x-rays are completed as ordered. NP was notified of this process. Director of Nursing and/or their designee will randomly audit five (5) staff members weekly to monitor knowledge of reporting of incidents, falls and what is considered a fall. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed.
Failure to Safely Transfer Resident Resulting in Injury
Penalty
Summary
The facility failed to safely transfer a resident from the toilet to the shower chair, resulting in the resident falling to the floor. A nurse aide used a sit-to-stand mechanical lift instead of the total mechanical lift as indicated in the resident's care plan, which required two-person assistance. During the transfer, the resident's foot slipped, and the nurse aide had to lower the resident to the floor. Another nurse aide assisted in manually lifting the resident off the floor without using a mechanical lift, and the incident was not reported to a nurse for assessment. The resident, who had severe cognitive impairment and required total dependence on staff for mobility, was later found to have an acute fracture of the left hip. The injury was discovered after a nurse aide noticed the resident's foot dragging while in a wheelchair and reported it to the nurse practitioner. The resident was sent for an x-ray, which confirmed the fracture, and was subsequently transferred to the hospital for surgery. The resident was later discharged to hospice care and expired. Interviews with staff revealed that the nurse aide who performed the transfer had not received proper orientation or education on resident transfers or lift equipment from the facility. Additionally, the nurse aides involved did not follow the care plan or report the incident, leading to a delay in the resident receiving appropriate medical attention. The facility's failure to ensure proper use of mechanical lifts and adequate supervision during transfers directly contributed to the resident's injury and subsequent decline in health.
Removal Plan
- The facility failed to transfer resident #1 in a safe manner which resulted in a left hip fracture. Resident #1 was supposed to be transferred using a total lift and was transferred by C.N.A #1 with a sit to stand when the fall occurred. C.N.A. # 1 requested help from C.N.A. # 2. Both C.N.A.'s transferred the resident from the floor to her chair without the use of the proper lift. X-ray was obtained which revealed fracture of left hip, facility notified Nurse Practitioner and orders were obtained to transfer resident to the hospital for further evaluation and treatment. Immediate investigation for Injury of Unknown Origin was initiated. Director of Nursing conducted an interview with C.N.A. #2 which confirmed that resident was on the floor in the shower room and she assisted C.N.A #1 in returning resident to chair. CNA #1 is no longer permitted to work at facility, CNA #2 has been terminated.
- Director of Nursing and/or designee completed interviews with communicative residents regarding care and services provided to identify any other injury of unknown origin. No other issues were identified. Unit managers completed skin check on all residents to ensure there were no signs or symptoms of injury noted, no negative findings were noted. Current lift status was obtained from therapy department. Unit managers cross referenced the lift status to the Kardex and Care Plans.
- The Director of Nursing and/or their designee educated 100% C.N.A.'s and licensed nurses on safe transfers, reporting of incidents and accidents, reporting protocols, and what constitutes a fall, which is a change of plane. Director of Nursing and/or their designee educated agency staff on proper lifts, facility policies, reporting all incidents and accidents, change in condition and what constitutes a fall, which is a change of plane. New hires to the facility are educated with the onboarding procedures by the Director of Nursing and/or their designee. Director of Nursing and/or their designee educated all C.N.A.s and licensed staff on lift competencies and transfers. Education also included proper use of the lift, with return demonstration by the licensed staff and C.N.A.'s. Staff were educated on how to report accidents and incidents, how to understand the Kardex for proper transfers, and how to report change of condition with residents. Director of Nursing and/or designee educated Agency staff prior to taking an assignment on the units and completed return demonstration to ensure understanding and compliance with education.
- The facility made the decision to have an ad hoc QAPI committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice. To monitor ongoing compliance the Director of Nursing and/or their designee will complete observations of five (5) residents per week to ensure residents utilizing a lift are receiving the proper transfer. Unit Mangers will select 5 residents weekly that currently use a lift and compare therapy lift status to the current care plan and Kardex to ensure accuracy. Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and/or their designee for review/revision as needed. Corrective action will be completed. The facility alleged a IJ removal date.
Failure to Ensure Staff Competency and Proper Resident Transfers
Penalty
Summary
The facility failed to ensure that all nursing staff, including agency staff, received proper orientation and competency verification before providing care to residents. Specifically, Nurse Aide (NA) #1 transferred a resident using a sit-to-stand mechanical lift, contrary to the resident's care plan, which required a total mechanical lift with two-person assistance. This improper transfer resulted in the resident's foot slipping, causing the resident to be lowered to the floor and subsequently lifted manually by NA #1 and NA #2 without using the appropriate mechanical lift. The resident later suffered an acute fracture of the left hip, underwent surgery, and was eventually discharged to hospice care, where they expired shortly after. The incident highlights a significant lapse in ensuring that staff were adequately trained and aware of the resident's specific care requirements as outlined in their care plan and Kardex system. The competency checklist for NA #1 from the agency indicated previous training and experience in patient transfers but lacked specific information on using mechanical lifts. NA #1 admitted to not receiving orientation or education on resident transfers or lift equipment from the facility and was unaware of how to access resident care plans or the Kardex system. NA #2, who assisted NA #1, also did not provide proper guidance on the required transfer method for the resident. The Director of Nursing (DON) and the Scheduler failed to verify NA #1's competency in using mechanical lifts before allowing her to provide care, relying instead on a general skills checklist from the staffing agency. Interviews with various staff members, including the DON, Scheduler, and other nurses, revealed a lack of consistent orientation and competency verification for agency staff. The DON acknowledged that agency staff were given only basic resident care information and were expected to seek guidance from nursing staff if needed. The Administrator admitted that the incident was avoidable if the staff had followed the care plan, indicating a systemic issue in ensuring that all staff, including agency staff, were adequately trained and aware of the specific care needs of residents. This deficiency in staff training and competency verification directly led to the resident's fall and subsequent injury.
Removal Plan
- Director of Nursing and/or their designee completed education with facility licensed nurses and C.N.A.'s on lift competency with return demonstration. Licensed agency nurses and C.N.A.'s were educated on proper lift competency with return demonstration. Education was also provided on where licensed nurses and C.N.A.'s can locate current lift status.
- Director of Nursing and/or their designee educated all licensed nurses and C.N.A.'s, including agency staff on location of resident care guides.
- All new facility licensed nurses and C.N.A.'s will receive education from the unit managers on the location of the resident care guides during their orientation. Unit Managers were notified of this responsibility.
- All licensed nurses and C.N.A.'s from an agency are required to come in prior to their first shift to receive lift training and review facility policies. This training is completed by the Director of Nursing and/or their designee. The nursing scheduler is responsible for scheduling agency staff for this orientation. The nursing scheduler notified the agencies of this requirement. Each agency staff is now required to read through facility policies and procedures related to resident care which are located at each nurse's station in the Agency Orientation book. They are to acknowledge understanding of these policies by signing the Policy Acknowledgement Sheet. Agency staff are required to complete lift competency prior to working, this is completed by the Director of Nursing and/or their designee. The facility is requiring the agency to provide the skills checklist of each agency staff member for review prior to working. The Director of Nursing and/or their designee will review the skills check list to ensure that they have the skills to meet the needs of our residents.
- The Director of Nursing and/or their designee completed lift competencies with return demonstration for all licensed nurses and C.N.A.'s and agency staff.
- New hires will be educated Director of Nursing and/or designee on facility policies and lift competencies upon hire.
- The facility made the decision to have an ad hoc QAPI (Quality Assurance and Process Improvement) committee meeting as a result of our investigation into the incident. It was the decision of the QAPI committee to begin monitoring of this deficient practice for a period of 12 weeks.
- The Director of Nursing and/or their designee will audit five (5) agency staff, licensed staff and C.N.A.'s, to the location of the care guides for the residents.
- The Director of Nursing and/or their designee will audit five (5) facility and agency C.N.A.'s weekly for 12 weeks observing lift transfers. Any negative observations will be corrected immediately.
- Results of the audits will be presented monthly to the QAPI committee meeting by the Director of Nursing and or their designee for review and/or revision as needed for three (3) months.
Latest citations in North Carolina
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
A resident with dementia, stroke, dysphagia, and severe cognitive impairment, who was edentulous and dependent for ADLs, was care planned and listed on the NA Kardex to receive assisted oral care at least twice daily. Over nearly a month, NA documentation showed denture care was provided only three times, and surveyors observed the resident’s upper and lower dentures with brown stains and debris buildup. One NA, assigned on several day shifts, believed the resident did not have dentures and only offered mouthwash and a basin, while another NA, aware the resident wore dentures, usually did not perform denture care because the resident was already in bed and did not want to remove them. The DON later confirmed the dentures had visible debris and staining and that the care plan required regular oral care and proper denture cleaning.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Date and Discard Opened Nutritional Supplements per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to properly date and discard opened containers of nutritional supplements stored in nourishment room refrigerators on the North and South Units. During observations of these refrigerators with the Dietary Manager, surveyors found a one-quart nutritional shake in the North Unit refrigerator with no date indicating when it was opened, despite the manufacturer’s label stating it must be used within four days after opening if refrigerated. In the South Unit refrigerator, surveyors observed two one-quart nutritional shakes dated 4/24 and 4/28, both beyond the manufacturer’s four-day use-by period, as well as an opened and undated 8-ounce diabetic nutritional shake whose label required use within 48 hours of opening. In interviews, the Dietary Manager stated that dietary staff did not stock the nutritional shakes in the nourishment refrigerators and that nurses were responsible for the nutritional shakes given to residents, including dating them when opened and discarding them when past the use-by date. The Dietary Manager also explained that dietary staff checked the nourishment refrigerators twice daily only for items provided by the kitchen, including restocking and checking expiration dates on those snacks and drinks. A nurse confirmed that a physician’s order was required for a resident to receive a nutritional shake and that nurses were responsible for dating the shakes when opened and ensuring they were used and discarded according to the manufacturer’s instructions. The Administrator stated that the person who opened a nutritional shake was responsible for writing the date opened on the container and noted that historically dietary staff checked dates on food and drinks stored in the nourishment refrigerators.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Failure to Provide Ordered Denture and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide ordered assistance with denture and oral care for a dependent resident with severe cognitive impairment, dementia, stroke, dysphagia, and edentulism. The resident’s admission MDS documented severely impaired cognition, a need for setup or clean-up assistance with oral hygiene, and no refusal of care or behaviors. The care plan and NA Kardex both directed staff to provide or assist with oral care at least twice daily using a soft toothbrush or foam swabs, and identified the resident as at risk for oral and dental health problems and dependent in ADL self-care. However, NA documentation showed denture care was recorded as provided only three times over nearly a month-long period. During observation, the resident reported wearing upper and lower dentures and displayed dentures with brown stains and debris buildup around the teeth and gums, stating he could brush his dentures if he had a toothbrush and toothpaste. One NA, assigned on multiple day shifts, stated she provided only mouthwash and a basin because the resident had difficulty brushing, believed the resident did not have dentures, and confirmed she had not provided denture care. Another NA on night shift acknowledged knowing the resident wore dentures, having seen them on the bed or nightstand, but stated she usually did not perform denture care because the resident was already in bed and did not want to remove them, and described denture care only as soaking them overnight. When the DON later observed the dentures, he confirmed visible debris and brown staining, and acknowledged that the care plan and Kardex required oral care at least twice daily and that dentures should be brushed and soaked overnight.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
