Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ayden Court Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with respiratory failure, tracheostomy, and a Passy-Muir speaking valve, who was a full code, was found unresponsive and not breathing by CNAs. The assigned RN briefly assessed the resident, left to verify code status and call a Code Blue, and then initiated CPR with staff using a backboard and AED. During the code, staff provided ventilations with a bag-valve mask over the resident’s mouth and nose, did not remove the Passy-Muir Valve, and did not assess or suction the tracheostomy, contrary to the facility’s trach/CPR policy and the valve manufacturer’s instructions. When EMS arrived, they removed the Passy-Muir Valve, found it and the trach tube filled with secretions and a mucus plug, performed deep suctioning, and then ventilated via the tracheostomy, ultimately obtaining a pulse before transporting the resident to the hospital, where she was later pronounced deceased.
The facility failed to accurately complete MDS assessments for two residents, leading to deficiencies in coding cognition, mood, and discharge destination. One resident's cognition and mood assessments were incomplete due to staff unawareness of requirements, while another resident's discharge destination was incorrectly coded. The facility's staff acknowledged these errors.
A resident with hemiplegia and contracture in the left hand did not consistently have a prescribed palm guard applied, as observed during a survey. Despite instructions from physical therapy, the palm guard was often found in a basket rather than in the resident's hand. Staff interviews revealed that the resident was sometimes resistive to care, but there was no documentation of refusals. The DON was unaware of the issue, indicating a lapse in communication and documentation.
A facility failed to maintain a clean and homelike environment in a resident's room, as observed by a family member and staff. The ceiling vent was in disrepair, with a black substance and signs of water damage. The Maintenance Director admitted the issue was overlooked, and no work order was found for the vent. The Administrator expected maintenance staff to inspect and repair as needed.
A resident's medications, including Oxycodone, were mishandled in an LTC facility, leading to the misappropriation of a card containing 30 tablets. The Unit Manager and ADON failed to ensure the medications were returned to the pharmacy as required, and the control bag number on the Return of Drug form was altered. The discrepancy was discovered when the medications were found in the cart, but the DON was not immediately notified. The facility's policy for returning controlled substances was not followed.
A resident with chronic osteomyelitis was prescribed Oxycodone HCL 10 mg every 4 hours but received only 5 mg on two occasions due to confusion by medication aides. The facility's records showed inconsistencies, and the DON and Administrator expected correct dosages to be administered.
A facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. The resident, who had acute respiratory failure and COPD, was observed using a nasal cannula for oxygen, but no signage was present. Staff interviews confirmed that signage should have been placed upon admission or change in condition, highlighting a lapse in protocol.
A medication cart at an LTC facility was found unlocked and unattended in the hallway, contrary to protocol. Nurse #7 admitted to leaving it unlocked and later secured it upon noticing a surveyor. The DON confirmed that medication carts should always be locked when unattended.
A resident with osteomyelitis of the vertebra had discrepancies in their medical records regarding Oxycodone HCL administration. The narcotic count record showed 5 mg doses were signed out, while the MAR documented 10 mg doses. Staff interviews revealed inconsistencies, with one medication aide confirming a 5 mg administration, contrary to the MAR. The DON and Administrator expected accurate medical records, indicating a failure in maintaining them.
Failure to Provide Proper CPR and Airway Management for Tracheostomy Patient with Passy-Muir Valve
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate basic life support, including CPR and airway management, to a tracheostomy-dependent resident who was a full code. The resident had multiple respiratory-related diagnoses, including respiratory failure with hypoxia, tracheostomy status, COPD, tracheomalacia, stridor, and a history of recurrent airway concerns. She used a Passy-Muir one-way speaking valve and had physician orders for full code status, routine tracheostomy care with suctioning every shift and as needed, and scheduled nebulized bronchodilator treatments. The manufacturer’s instructions for the Passy-Muir Valve specified that the valve should be removed if the patient exhibited signs of respiratory distress and that it was contraindicated when the patient was unconscious. The facility’s tracheostomy/CPR policy required staff to assess consciousness, call 911, check breathing and pulse, assess the tracheostomy for plugging or dislodgement, suction as needed, and provide rescue breaths via a resuscitation bag to the tracheostomy. On the night of the event, the assigned nurse documented that around midnight she performed tracheostomy care, removed the Passy-Muir Valve, and did not need to suction at that time. Later, around 5:00–5:15 a.m., she again provided medications, tracheostomy care, a nebulizer treatment, and light suctioning of a small amount of clear secretions, then replaced the Passy-Muir Valve. Vital signs at that time included a respiratory rate of 18 and oxygen saturation of 96% on 2 L via trach collar, and the resident was described as alert, oriented, and talkative with no complaints. Around 6:00–6:15 a.m., two nurse aides entered the resident’s room to provide incontinence care and found her unresponsive and not breathing; one aide reported finding no pulse, while the nurse later stated she initially found the resident warm with a faint pulse. The aides left the resident and went to the nurses’ station to notify the nurse, and the nurse went to the room, briefly assessed the resident, then returned to the nurses’ station to verify code status and figure out how to call a Code Blue overhead. After the Code Blue was called, staff brought the emergency cart and backboard to the room and initiated CPR. Multiple staff interviews consistently indicated that chest compressions were started and that a nurse aide was instructed by the nurse to use the resuscitation bag over the resident’s mouth and nose, not over the tracheostomy. Staff also reported that the nurse did not assess the tracheostomy, did not remove the Passy-Muir Valve, and did not suction the tracheostomy during the code, despite the resident having a tracheostomy and a Passy-Muir Valve in place. The nurse later confirmed she did not check the tracheostomy airway or remove the Passy-Muir Valve at any point and clarified that the resuscitation bag was kept over the resident’s mouth for all respirations. When EMS arrived, they found staff performing CPR with an AED attached and a resuscitation bag being used over the mouth without oxygen. EMS removed the Passy-Muir Valve, noted it was filled with secretions and buildup, and found the tracheostomy tube plugged, requiring multiple rounds of deep suctioning before effective ventilation through the tracheostomy could be achieved. The Medical Director and the Passy-Muir company’s clinical representative both stated that respirations during CPR for a tracheostomy patient must be provided at the tracheostomy site and that the Passy-Muir Valve should be removed when the patient is in respiratory distress or unconscious. The resident was transported to the hospital, where records documented a large mucus plug in the tracheostomy and listed acute on chronic respiratory failure with anoxic brain injury, mucus plug, and tracheal stenosis status post tracheostomy as causes on the death certificate.
Inaccurate MDS Assessments for Cognition, Mood, and Discharge
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in coding cognition, mood, and discharge destination. Resident #58, who was admitted with chronic kidney disease, had an MDS assessment indicating he was rarely/never understood, yet the staff assessments for cognition and mood were not completed. The facility's Social Worker, responsible for these sections, was unaware of the requirement to complete a staff assessment if the resident could not be understood, despite having received some training from the corporate MDS consultant. The Administrator acknowledged that the assessment should have been completed accurately. For Resident #70, the discharge MDS was incorrectly coded as discharged to an acute hospital, while a progress note indicated the resident was transported home. The MDS Coordinator admitted the error in coding the discharge destination, and the Director of Nursing confirmed that the discharge MDS should accurately reflect the resident's discharge status. The Administrator also indicated that the MDS should be completed accurately, highlighting the facility's failure to ensure accurate documentation of resident assessments.
Failure to Apply Palm Guard for Resident with Hemiplegia
Penalty
Summary
The facility failed to apply a left-hand palm guard for a resident with hemiplegia and hemiparesis following cerebrovascular disease, contracture in the left hand, and dementia. The resident was moderately cognitively impaired and had impairments on one side of her upper and lower extremities. Observations revealed that the resident's left hand was often without the prescribed carrot palm guard, which was intended to protect the skin from moisture, pressure, and nail puncture injuries. Despite a physical therapy note instructing staff to keep the carrot in the resident's left hand except during bathing, the carrot was frequently found in a basket on the bedside table instead of in the resident's hand. Interviews with staff indicated that the resident was sometimes resistive to care, and there was no documentation of the resident's refusal to have the carrot placed in her hand. The Physical Therapy Director confirmed that the resident was to have the carrot placed in her left hand and that the nursing staff had been in-serviced on this procedure. However, the Director of Nursing was unaware of the situation and stated that the nursing staff should have documented any refusals. The lack of consistent application of the palm guard and failure to document refusals contributed to the deficiency in care for the resident.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment in one of the resident rooms, as observed and reported by a family member and staff. During an interview, a family member expressed concerns about the condition of the ceiling vent in the resident's room. An observation revealed that the area around the ceiling vent was in disrepair, with a black substance on one side and signs of possible water damage repaired with a white spackle-like substance. The Maintenance Director confirmed that vent inspections were conducted once or twice a month, but no work order was found for the ceiling vent in question. Upon visual inspection, the Maintenance Director acknowledged that the damage, likely due to condensation, had been overlooked. The Administrator stated that it was expected for maintenance staff to conduct inspections and make necessary repairs.
Misappropriation of Controlled Substances in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of property, specifically involving the mishandling of controlled substances. A resident was admitted to the facility and later expired, during which time their medications, including Oxycodone HCL, Lorazepam, Ultram, and Morphine Sulfate, were supposed to be returned to the pharmacy. However, the process was not followed correctly, leading to the misappropriation of a card containing 30 Oxycodone HCL 5 mg tablets. The Unit Manager (UM) and Assistant Director of Nursing (ADON) initially completed a Return of Drug form and placed the medications in a sealed bag. The UM attempted to fax the form to the pharmacy but did not verify its receipt. The medications were left in the locked narcotic drawer of the medication cart, and the control bag number on the Return of Drug form was later found to be altered. The UM discovered the discrepancy when a nurse informed her of the medications still being in the cart, but she did not immediately notify the Director of Nursing (DON). Upon further investigation, it was found that the medications had been transferred to a new sealed bag with a different control number, and the Return of Drug form was altered to match this new number. The DON and UM confirmed the missing Oxycodone tablets after opening the bag. The facility's policy required immediate return of controlled substances upon discontinuation, discharge, or death of a resident, which was not adhered to in this case.
Medication Administration Error Due to Dosage Confusion
Penalty
Summary
The facility failed to administer medications to a resident as ordered, resulting in the resident receiving an incorrect dose of Oxycodone Hydrochloride (HCL) on two separate occasions. The resident, who was admitted with diagnoses including osteomyelitis of the vertebra, left elbow pain, and trigeminal neuralgia, was prescribed Oxycodone HCL 10 mg to be administered every 4 hours for chronic osteomyelitis. However, on May 17 and May 18, the resident received only 5 mg of Oxycodone HCL instead of the prescribed 10 mg. This discrepancy was due to confusion about the dosage by the medication aides responsible for administering the medication. The narcotic controlled substance count record and the Medication Administration Record (MAR) showed inconsistencies in the dosage administered. Medication Aide #1 admitted to administering only 5 mg on May 17 due to confusion, while attempts to interview Medication Aide #4 were unsuccessful. The Director of Nursing and the Administrator both expressed that their expectation was for residents to receive the correct dosage of medications, highlighting a failure in meeting professional standards of quality in medication administration.
Failure to Post Oxygen Signage for Resident on Supplemental Oxygen
Penalty
Summary
The facility failed to post cautionary signage outside a resident's room to indicate the use of supplemental oxygen. This deficiency was identified for a resident who was admitted with acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. The resident had a physician's order for oxygen supplementation at 2 liters via nasal cannula or mask if oxygen saturation was less than 90%. Observations on multiple occasions revealed that the resident was using a nasal cannula for supplemental oxygen, but there was no signage outside the room indicating the use of supplemental oxygen. Interviews with facility staff, including a nurse, the unit manager, and the Director of Nursing, confirmed that it was standard procedure to place an oxygen sign on the door of any resident receiving oxygen therapy upon admission or when there was a change in condition requiring new oxygen therapy. Despite this protocol, the required signage was not placed on the resident's door, indicating a lapse in following established procedures for respiratory care safety measures.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to secure residents' medications in a locked medication cart, as observed with the Station 1 medication cart. During a continuous observation, the medication cart was found unlocked and unattended in the hallway outside the nurse's station. There were no medications on top of the cart, and no nurse was present at the station or in the nursing station. Staff were observed in the adjacent hallway, but no residents were present. Nurse #7 later approached the cart, observed the surveyor, and locked the cart. During an interview, Nurse #7 admitted to leaving the cart unlocked and stated that it should be locked when unattended. The Director of Nursing confirmed that the medication cart should be locked at all times when not attended by a nurse.
Inaccurate Medication Record Keeping for Oxycodone Administration
Penalty
Summary
The facility failed to ensure the accuracy of medical records concerning the administration of Oxycodone Hydrochloride (HCL) for a resident. The resident, who was admitted with conditions including osteomyelitis of the vertebra, had a physician's order for Oxycodone HCL 10 mg to be administered every 4 hours. However, discrepancies were found in the narcotic controlled substance count record and the Medication Administration Record (MAR). Specifically, the narcotic count record showed that only 5 mg doses were signed out on two occasions, while the MAR documented that 10 mg doses were administered. Interviews with staff revealed further inconsistencies. Medication Aide #1 confirmed administering only 5 mg of Oxycodone HCL on one occasion, contradicting the MAR entry. Attempts to interview Medication Aide #4 were unsuccessful. Both the Director of Nursing and the Administrator expressed expectations that medical records should accurately reflect the correct dosage of medications administered to residents, highlighting a failure in maintaining accurate medical records for the resident in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ayden
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Macgregor Downs Health Center By Harborview | 10.1 mi | — | 2 | 0 |
| Greenville Health And Rehabilitation Center | 10.6 mi | — | 0 | 0 |
| East Carolina Health And Rehabilitation Center | 10.7 mi | — | 10 | 0 |
| Cypress Glen Retirement Community | 10.8 mi | — | 0 | 0 |
| Pruitthealth-farmville | 11.8 mi | — | 0 | 0 |
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