Brunswick Cove Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Winnabow, North Carolina.
- Location
- 1478 River Road, Winnabow, North Carolina 28479
- CMS Provider Number
- 345318
- Inspections on file
- 22
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Brunswick Cove Nursing Center during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, failure to thrive, severe malnutrition, and psychosis exhibited escalating aggression despite non-pharmacological interventions. An NP gave a verbal order for Haldol 2 mg IM for agitation, but a unit manager nurse did not repeat back or verify the dose and instead retrieved four 5 mg/mL vials from the emergency supply and administered a total of 20 mg IM. The nurse initially reported the 20 mg dose to colleagues without it being questioned, only recognizing the tenfold error later while entering the written order into the record. The DON later identified the lack of read-back of the verbal order as a key process failure contributing to this significant medication error.
A resident receiving IV antibiotics via a PICC line did not have physician orders for required saline and heparin flushes, despite nursing staff administering these flushes according to protocol and pharmacy supply. Nursing staff relied on experience and available supplies but did not clarify or document orders in the eMAR, resulting in a deficiency related to the lack of proper physician authorization and documentation for catheter maintenance.
Two residents did not receive wound care and offloading interventions as ordered. One resident with a surgical hip wound did not have the Aquacel dressing changed per hospital discharge instructions, and staff failed to clarify or implement the correct protocol. Another resident with a neck/shoulder contracture did not consistently receive offloading or moisture-wicking interventions as ordered, with missed treatments documented and staff unable to confirm if care was provided.
A resident with quadriplegia and multiple pressure ulcers did not receive wound care as ordered by the physician. A nurse applied a petroleum gauze dressing to the right ankle, which was not prescribed, and failed to notify the wound care team that the wound had reopened. The Wound Treatment Nurse and DON confirmed that proper communication and adherence to orders were not followed, resulting in improper wound management.
A resident with COPD and chronic respiratory failure was observed receiving oxygen at 3 liters per minute via nasal cannula, despite a physician order for 2 liters per minute. Nursing staff did not verify the oxygen setting as required, and facility leadership confirmed that staff are expected to ensure oxygen is administered at the ordered rate.
A Wound Treatment Nurse provided wound care to a resident with a pressure ulcer without wearing the required protective gown, as mandated by the facility's Enhanced Barrier Precautions policy. The nurse only wore gloves and later admitted forgetting the gown, citing the absence of visible signage and accessible PPE in the room. Staff interviews confirmed that signage and PPE should have been present and that gowns and gloves are required for such care.
A resident with a history of subdural hemorrhage, syncope, and narcolepsy was not properly supervised while smoking, despite a care plan requiring supervision and a smoking apron after an incident where her clothing caught fire. Staff observations and interviews revealed the resident continued to smoke independently without the apron, and there was inconsistent awareness among staff about her supervision needs due to communication lapses.
The facility inaccurately coded MDS assessments for four residents, affecting areas such as medication, dental, and continence. A resident on antipsychotic medication was incorrectly recorded as not receiving it, while another with broken teeth was noted as having no dental issues. Additionally, a resident's continence status was misrepresented. These errors were attributed to human error, as confirmed by interviews with the MDS Coordinator and DON.
A resident with visual disturbances and a history of brain injury and Parkinson's Disease experienced delays in receiving ophthalmology and retinol specialist appointments. Despite multiple orders and requests, the resident was not seen by an ophthalmologist for several months, and the retinol specialist appointment was not obtained. Interviews revealed a breakdown in the facility's process for scheduling appointments, with staff unaware of orders and unable to provide documentation for the delays.
A facility failed to review and document pharmacy recommendations for a resident on antipsychotic medication. Despite multiple recommendations for an AIMS assessment by the Consultant Pharmacist, no documentation or response was recorded. Interviews confirmed that the assessment should have been conducted due to the resident's medication use.
A resident receiving olanzapine for delusions did not have an AIMS assessment completed, despite recommendations from the Consultant Pharmacist. The resident had severe cognitive impairment and was on antipsychotic and antianxiety medications. The Quality Assurance Nurse and DON acknowledged the oversight, citing a lack of automatic triggers in the computer system.
The facility failed to provide a CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents after their Medicare Part A skilled services ended. Both residents, one with moderate and the other with severe cognitive impairment, remained in the facility without receiving the necessary SNF ABN, despite signing a Notice of Medicare Non-Coverage (NOMNC). The Social Worker and Administrator were unaware of the requirement to issue the SNF ABN when residents stayed in the facility post-Medicare services.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. One resident's care plan did not include antidepressant or antiplatelet medication use, another's omitted bowel incontinence and antiplatelet medications, and a third's failed to mention an indwelling catheter. Interviews with the MDS Coordinator and DON confirmed that the care plans should have accurately reflected the residents' conditions and medication use.
The facility failed to display required oxygen use signage for two residents prescribed continuous oxygen therapy. One resident with asthma and another with chronic respiratory conditions were observed without signage outside their rooms and not wearing their oxygen as prescribed. Staff interviews confirmed the oversight, and the DON acknowledged the responsibility to place signage when oxygen orders were issued. Physicians noted no adverse outcomes as saturation rates were normal.
A resident in hospice care fell and sustained a head injury, but the facility failed to promptly notify the responsible party and the physician. The hospice nurse informed the responsible party, who opted for comfort measures. The facility's nurse practitioner and physician were not informed until the following day.
Significant Medication Error: Tenfold Haldol Overdose Due to Verbal Order Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error when a nurse administered an incorrect dose of Haldol IM to a resident. The resident had recently been discharged from a hospital stay for hip pain following a fall and was admitted to the facility with diagnoses including Parkinson’s disease, adult failure to thrive, severe protein-calorie malnutrition, benign paroxysmal vertigo, history of falling, depression, and cognitive communication deficit. At hospital discharge, and on admission to the facility, the resident was prescribed multiple psychotropic medications, including clozapine for psychosis related to Parkinson’s disease, clonazepam as needed for anxiety, and Remeron for depression. The resident’s medical history also included recurrent falls, severe malnutrition, and a history of delirium and significant hallucinations. On the day after admission, the resident exhibited escalating aggressive behaviors toward staff, including punching and head-butting nurses and slapping a nurse on the buttocks. Staff attempted non-pharmacological interventions such as redirection, providing activities, offering food and drink, and toileting, but these measures did not reduce the behaviors. Nurse practitioners and nursing staff observed the resident kicking, punching, scratching, and grabbing at staff, and the NP decided to order Haldol 2 mg IM for agitation, fighting, and restlessness. The NP reported that she clearly gave a verbal order for Haldol 2 mg IM to a unit manager nurse and then wrote the order, leaving it at the nurse’s computer for later entry into the medical record. The medication error occurred when the unit manager nurse obtained Haldol from the emergency medication supply and administered 20 mg IM instead of the ordered 2 mg. The nurse stated she could not recall whether the NP had specified the dose and admitted she did not repeat the verbal order back to the NP. She reported that “20 mg” stuck in her mind, took four vials of Haldol 5 mg/mL from the emergency supply, and administered the full 20 mg dose to the resident. After giving the injection, she informed another nurse and the NP that she had administered 20 mg, and no one questioned the dose at that time. The nurse later realized the error while entering the written order into the medical record, recognizing that the ordered dose was 2 mg, not 20 mg. The facility’s DON identified the failure to repeat back the verbal order as a breakdown in the process that contributed to the medication error. The consultant pharmacist and medical director confirmed that the intended dose of 2 mg IM was appropriate for the resident’s acute behaviors and that the resident instead received a significantly higher single dose than ordered.
Failure to Obtain Orders for PICC Line Flushes During IV Antibiotic Therapy
Penalty
Summary
The facility failed to obtain physician orders for flushing a percutaneous intravenous central catheter (PICC) with normal saline and heparin for a resident receiving intravenous (IV) antibiotics. The resident, who had diagnoses including diabetic foot ulcer, osteomyelitis, and lower extremity impairment, was admitted with a PICC line for administration of IV antibiotics such as Meropenem and Vancomycin. While there were physician orders for the antibiotics and for monitoring and changing the PICC dressing, there were no documented orders for the administration of saline or heparin flushes to maintain catheter patency. Despite the absence of orders, nursing staff routinely used prefilled saline and heparin flushes labeled for the resident, following the SASH (saline, antibiotic, saline, heparin) protocol before and after administering IV antibiotics. Multiple nurses confirmed during interviews that they administered the flushes based on their training and experience, and because the pharmacy provided the flushes. However, they acknowledged that they should have clarified and obtained specific orders for these flushes from the physician and entered them into the electronic medical record (eMAR). The pharmacy technician stated that flushes were automatically sent when IV antibiotics were ordered, but it was the facility's responsibility to ensure orders for flushes were entered into the eMAR. Both the nurse practitioner and the physician confirmed that explicit orders for saline and heparin flushes should have been in place to ensure proper documentation and administration. The Director of Nursing also acknowledged that, although best practices were followed in administering the flushes, the lack of documented orders constituted a deficiency.
Failure to Provide Ordered Wound Care and Offloading Interventions
Penalty
Summary
The facility failed to provide wound care and offloading as ordered for two residents reviewed for skin integrity. For one resident who was admitted after a left total hip replacement, the hospital discharge summary included an order for Aquacel dressing to be changed every 5-7 days or as needed. However, this order was not transcribed into the facility's physician orders, and instead, a daily cleansing and dry dressing order was implemented. Multiple nurses observed the Aquacel dressing in place but did not clarify the discrepancy between the observed dressing and the written orders. Documentation in the Treatment Administration Record (TAR) and nursing notes reflected confusion and lack of action to clarify or implement the correct wound care protocol. The Aquacel dressing was not changed within the specified timeframe, and the correct order was only identified after review by the Wound Treatment Nurse several days later. Another resident with a left neck/shoulder contracture and a history of rheumatoid arthritis, diabetes, and cellulitis had a physician order to offload the contracture and keep the neck fold clean and dry every 8 hours. Observations and interviews revealed that the offloading and moisture-wicking interventions were not consistently implemented as ordered. Nursing staff failed to ensure that offloading devices or moisture-wicking fabric were in place, and documentation in the TAR showed missed treatments. Nurses interviewed could not recall if the interventions were performed and acknowledged missing the order. Both deficiencies were confirmed through record review, staff interviews, and direct observation. The failures included not following hospital discharge orders for wound care and not implementing or documenting offloading and moisture management for a contracture as ordered. These lapses were not questioned or clarified by nursing staff, leading to a lack of appropriate treatment and care as specified in the residents' care plans and physician orders.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to follow a physician's order for wound treatment for a resident with quadriplegia, a history of vertebral fracture, and chronic pain. The resident had a stage 3 pressure ulcer and an unstageable deep tissue injury, both not present on admission. The care plan required monitoring, documentation, and specific wound care interventions, including weekly measurements and reporting abnormalities. Physician orders specified the type of dressing and frequency for each wound site. During an observation, it was found that a nurse applied a petroleum gauze dressing to the resident's right ankle, which was not in accordance with any current physician order. The correct treatment for the right ankle, which had previously resolved, was not in place, and the nurse had mistakenly applied the dressing intended for a different wound site. The Wound Treatment Nurse was unaware that the right ankle wound had reopened and had not been notified by the nurse who performed the dressing change. The nurse who applied the dressing admitted to putting the wrong dressing on the wrong area, believing there was an order for the right ankle. The Director of Nursing confirmed that staff are expected to notify the physician and Wound Treatment Nurse of new wounds and to follow prescribed orders. The Wound Physician also stated that new wounds should be reported so appropriate treatment can be implemented. The lack of communication and failure to follow physician orders led to improper wound care for the resident.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure was not administered oxygen at the physician-ordered rate. The resident had a documented order for continuous oxygen via nasal cannula at 2 liters per minute, and the care plan reflected this intervention. However, during two separate observations, the oxygen concentrator was set at 3 liters per minute instead of the prescribed 2 liters per minute. This discrepancy was confirmed by a nurse who was responsible for the resident's care during the observed shifts, who admitted she had not checked the oxygen setting earlier that morning. Interviews with facility staff, including the nurse practitioner and the Director of Nursing, confirmed that the expectation was for nurses to ensure oxygen was set at the ordered rate and to contact the provider if adjustments were needed. The Director of Nursing stated that nurses should verify oxygen rates when assuming care and throughout their shift. The administrator also confirmed the expectation that nurses monitor oxygen settings to ensure compliance with provider orders. The failure to administer oxygen at the prescribed rate was identified through record review, direct observation, and staff interviews.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to follow its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a pressure ulcer wound. During an observation of wound care, the Wound Treatment Nurse performed a dressing change for the resident without wearing the required protective gown, as stipulated by the facility's EBP policy. The nurse only wore gloves and did not don a gown at any point during the procedure, despite the resident having an open wound that required dressing. The nurse later acknowledged forgetting to put on the gown and indicated that the absence of visible signage in the resident's room contributed to this oversight. Further observations revealed that there was no visible personal protective equipment (PPE) such as gowns or gloves in the resident's room, nor was there appropriate signage posted to indicate the required PPE for high contact care activities. The only indicator present was a small magnetic banner on the door frame, which did not specify the PPE requirements. Interviews with staff, including the Wound Treatment Nurse and the DON, confirmed that signage and PPE should have been present and accessible, and that staff were expected to wear gowns and gloves for wound care under EBP. The lack of signage and accessible PPE contributed to the failure to adhere to infection control protocols during the observed care.
Failure to Supervise Resident Requiring Smoking Precautions
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and ensure the use of a smoking apron for a resident identified as requiring supervision while smoking. The resident, who had a history of nontraumatic subdural hemorrhage, syncope, collapse, and narcolepsy, was initially assessed as safe to smoke independently. However, following an incident where the resident's clothing caught fire from a cigarette, a reassessment determined that supervision and the use of a smoking apron were necessary due to burn marks on her clothing. Despite the updated care plan and smoking assessment indicating the need for supervision and a smoking apron, the resident continued to smoke independently without staff supervision and did not wear the provided apron. Observations confirmed that the resident was able to access smoking materials, smoke outside without supervision, and did not use the smoking apron, which was found stored in her dresser drawer. Interviews with staff revealed inconsistent awareness of the resident's supervision status, with some staff considering her an independent smoker and others acknowledging the need for supervision after the incident. The Director of Nursing and Administrator acknowledged lapses in communication regarding the resident's supervision status, particularly following changes in key nursing personnel. The lack of consistent implementation of the updated care plan and supervision requirements resulted in the resident continuing to smoke unsupervised and without the required protective equipment, despite her medical history and recent incident involving fire.
Inaccurate MDS Coding for Medications, Dental, and Continence
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in areas including medication, dental, and continence. Resident #283, who was admitted with major depressive disorder, was prescribed Aripiprazole, an antipsychotic medication. However, the MDS assessment incorrectly indicated that no antipsychotic medication was received since admission. Similarly, Resident #115, who received olanzapine for delusions, had an MDS assessment that failed to reflect the receipt of antipsychotic medication during the lookback period, particularly in the section regarding gradual dosage reduction. Resident #99, admitted with conditions including diabetes and stroke, was observed to have multiple broken upper teeth, contrary to the MDS assessment which indicated no dental issues. Additionally, Resident #76, who was noted to be continent of bowel and bladder in a progress note, was incorrectly coded as occasionally incontinent of bowel in the MDS assessment. Interviews with the MDS Coordinator and the Director of Nursing revealed these errors were due to human error, and there was an expectation for MDS assessments to be completed accurately.
Failure to Schedule Timely Vision Care Appointments
Penalty
Summary
The facility failed to ensure that a resident received timely ophthalmology and retinol specialist appointments as ordered. The resident, who had a history of post-traumatic brain injury and Parkinson's Disease, experienced visual disturbances and was recommended for an ophthalmology consult on multiple occasions. Despite orders being entered by nurses and requests made by the physician and nurse practitioner, the resident was not seen by an ophthalmologist until several months later, and the recommended retinol specialist appointment was not obtained. Interviews with facility staff revealed a breakdown in the process for scheduling appointments. The Medical Records Specialist, responsible for coordinating ophthalmology visits, indicated that the facility's usual provider was unavailable, and the Director of Nursing was informed of this issue. The Transportation Specialist, tasked with scheduling appointments, was unable to provide documentation or recall why there was a delay in obtaining the ophthalmology appointment and was unaware of the retinol specialist order. The Director of Nursing acknowledged a system process failure in handling referrals and appointments. The process required nurses to complete an appointment tracker form and submit it to the Transportation Specialist, but this was not consistently followed. Additionally, the consult note from the ophthalmologist was not reviewed by the nurse practitioner or physician, further contributing to the delay in obtaining necessary specialist care for the resident.
Failure to Document Pharmacy Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were reviewed and documented for a resident receiving antipsychotic medication. Resident #115, who was admitted with diagnoses including depression, dementia, and agitation, was prescribed olanzapine for psychotic disturbance and anxiety. Despite the Consultant Pharmacist recommending an AIMS assessment on multiple occasions, there was no documentation of the assessment being completed or any response to the recommendations. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed that an AIMS assessment should have been conducted due to the resident's antipsychotic medication use.
Failure to Complete AIMS Assessment for Resident on Psychotropic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was receiving psychotropic medications. The resident, who was admitted with diagnoses including psychotic disturbance with mood disturbance and anxiety, had been receiving olanzapine, an antipsychotic medication, since March 11, 2024, for delusions. Despite the resident's severe cognitive impairment and the use of antipsychotic and antianxiety medications, there was no record of an AIMS assessment being completed in the electronic medical record. The Consultant Pharmacist had recommended an AIMS assessment on multiple occasions, specifically on March 20, April 16, May 22, and June 17, 2024. Interviews with the Consultant Pharmacist, Quality Assurance Nurse, and Director of Nursing revealed that the assessment was overlooked. The Quality Assurance Nurse acknowledged responsibility for completing the AIMS when recommended, and the Director of Nursing confirmed that the assessment had never been completed, attributing the oversight to the computer system not automatically triggering the need for the assessment.
Failure to Provide SNF ABN to Residents Post-Medicare Part A
Penalty
Summary
The facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents prior to the termination of their Medicare Part A skilled services. Resident #112, who had moderate cognitive impairment, was admitted to the facility and received Medicare Part A services until the end of April 2024. Although a Notice of Medicare Non-Coverage (NOMNC) was signed, there was no record of an SNF ABN being provided. During an interview, Resident #112 could not recall receiving any forms related to the end of Medicare Part A services. The facility's Social Worker admitted to not completing the SNF ABN form, citing a lack of awareness that it was necessary when a resident remained in the facility after Medicare Part A services ended. Similarly, Resident #115, who had severe cognitive impairment, was admitted to the facility and received Medicare Part A services until early February 2024. A NOMNC was signed, but no SNF ABN was provided. The Social Worker again acknowledged not completing the SNF ABN form due to unawareness of its necessity. The facility Administrator also stated a lack of awareness regarding the requirement for the SNF ABN form when residents remain in the facility post-Medicare Part A services. These oversights resulted in the facility's failure to properly inform residents of their potential financial liability for services not covered by Medicare.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical needs. Resident #76, who was admitted with depression, anxiety, and insomnia, was found to have a care plan that did not include focus areas for antidepressant or antiplatelet medication use, despite receiving these medications. The care plan also inaccurately reflected the resident's continence status, as the resident was able to take herself to the bathroom and was continent of bowel and bladder. Interviews with the MDS Coordinator and the DON confirmed that the care plan should have included these medications and accurately reflected the resident's condition. Resident #99, admitted with a history of stroke and peripheral vascular disease, had a care plan that failed to address bowel incontinence and the use of antiplatelet medications. The resident was frequently incontinent of bladder and always incontinent of bowel, yet the care plan only included bladder incontinence. Additionally, the care plan did not mention medications for constipation, which the resident was receiving. Interviews with the MDS Coordinator and the DON indicated that the care plan should have included bowel incontinence and the medications the resident was receiving. Resident #283, admitted with urinary retention, had a care plan that did not include the use of an indwelling catheter, despite having a physician's order for it. The care plan focused on bowel and bladder incontinence but omitted the catheter, which was a significant aspect of the resident's care. The MDS Coordinator and the DON acknowledged that the care plan should have included the indwelling catheter to accurately reflect the resident's condition.
Failure to Display Oxygen Use Signage for Residents
Penalty
Summary
The facility failed to apply appropriate signage indicating the use of oxygen outside the rooms of two residents who were prescribed continuous oxygen therapy. Resident #11, diagnosed with asthma, was admitted with an order for continuous oxygen at 2 LPM via nasal cannula. Observations on multiple occasions revealed that there was no signage outside her room indicating oxygen use, and she was not wearing her oxygen as prescribed. Interviews with staff, including a medication aide and a nurse, confirmed the absence of the required signage and the oversight in ensuring the resident was using her oxygen. The Director of Nursing acknowledged that the signage should have been placed when the oxygen order was written or when the concentrator was placed in the room. Similarly, Resident #112, with diagnoses including congestive heart failure and chronic respiratory failure, was also prescribed continuous oxygen at 2 LPM. Observations showed no signage outside his room, and he was seen without his oxygen while in the dining room. Interviews with the resident and nursing staff revealed that he would remove his oxygen when leaving his room, and the staff had not placed the necessary signage. The Director of Nursing confirmed the responsibility of the nursing staff to place the signage when the oxygen order was issued. Both residents' physicians noted that there were no adverse outcomes from the residents not wearing their oxygen, as their saturation rates remained within normal limits.
Failure to Notify Responsible Party and Physician of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party and the facility physician of a resident's fall and change in condition. Resident #89, who was in hospice care and had a do not resuscitate order, fell out of bed and sustained a laceration over her left eyebrow. Despite the presence of local family members, the facility did not inform the resident's designated responsible party, her daughter living in North Dakota, or the facility physician about the fall and subsequent change in condition until the following day. Interviews with staff and family members revealed that the hospice nurse was the first to inform the responsible party about the fall and the resident's unresponsive state. The hospice nurse arrived at the facility after being notified by the staff and found the resident unresponsive with fixed pupils. The responsible party was contacted by the hospice nurse, not the facility, and was informed of the resident's condition and the options for care. The responsible party decided against transferring the resident to a hospital, opting for comfort measures instead. The facility's nurse practitioner and physician were not informed of the resident's fall and change in condition until the day after the incident. The nurse practitioner learned of the situation during rounds, and the physician noted that there were no records of any calls from the facility regarding the incident. This lack of timely communication with both the responsible party and medical providers constitutes a deficiency in the facility's protocol for handling changes in a resident's condition.
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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