Camellia Gardens Center For Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Henderson, North Carolina.
- Location
- 280 South Beckford Drive, Henderson, North Carolina 27536
- CMS Provider Number
- 345344
- Inspections on file
- 25
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Camellia Gardens Center For Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to submit accurate RN staffing data to CMS through PBJ over three consecutive quarters. On multiple dates, PBJ reports showed zero RN hours even though daily schedules documented an RN scheduled for at least 8 hours, often covered by salaried RNs such as a regional nurse consultant and an MDS nurse who did not clock in or out. Because these salaried hours required manual entry by the corporate office, and this process was inconsistently performed, the PBJ submissions did not accurately reflect actual RN coverage.
The facility failed to follow its own COVID-19 vaccination policy by not consistently assessing eligibility, educating, offering, or documenting COVID-19 vaccination for multiple residents and staff. Several residents with conditions such as diabetes, CKD, COPD, hypertension, vascular dementia, and OSA were coded on the MDS as not up to date on COVID-19 vaccination, yet their immunization records lacked evidence of recent offers, administrations, or refusals of the vaccine. Some cognitively intact residents could not recall being offered the vaccine, and the Unit Manager could not provide documentation of their vaccination status. The IP reported having offered vaccines but had no records or declination forms, while the DON acknowledged not focusing on COVID-19 vaccinations and confirmed vaccines had not been offered during her tenure. For staff, the facility could not produce any documentation of COVID-19 vaccination status, and leadership interviews revealed confusion over who was responsible for tracking and maintaining these records.
Surveyors found an opened multi-dose vial of Tuberculin Purified Diluted solution in a medication room refrigerator that was not dated when opened, despite manufacturer instructions requiring discard 30 days after opening. The DON stated the Unit Manager is responsible for checking for expired or undated medications and acknowledged the vial should have been discarded or returned to the pharmacy. The Unit Manager reported that she and staff nurses check for expired and undated medications but could not explain why the vial was not dated and could not recall when she last checked the medication room and refrigerator. The Administrator stated that all multi-dose vials are expected to be dated when opened.
The facility failed to provide and document required written transfer/discharge notices and bed-hold policy information for multiple residents sent to the hospital. A cognitively intact resident who was her own RR had two hospital transfers without documented written notice of the reason for transfer, and for one transfer there was no documented bed-hold policy; she reported not receiving either written notice or the policy. Another resident with moderately impaired cognition was transferred without documented written notice or bed-hold policy, and the RR confirmed not receiving them. A third cognitively intact resident was transferred for planned surgery; the RR reported receiving written transfer notice but not the bed-hold policy, and the DON acknowledged emailing about the surgery but not the policy. Staff interviews revealed confusion between the Social Worker, Business Office Manager, and Administrator regarding who was responsible for issuing written transfer/discharge notices and mailing the bed-hold policy, and the facility could not explain the missing notices and documentation.
A resident with chronic respiratory failure and COPD, requiring continuous oxygen therapy, repeatedly smoked in undesignated areas while using a portable oxygen tank, despite being assessed as unsafe to smoke without supervision. Staff observed and reported these incidents, but no effective interventions or increased monitoring were implemented, and the resident's care plan did not address his ongoing non-compliance. The resident eventually sustained a flash burn after his shirt caught fire while smoking with oxygen in use, highlighting failures in supervision, communication, and enforcement of the facility's smoking policy.
A resident with end-stage COPD, who was on oxygen therapy, sustained burns after smoking while on oxygen and required EMS transfer to the hospital. The incident and subsequent change in condition were not documented in the medical record, as confirmed by the nurse on duty and the facility administrator.
A resident assessed as safe to smoke independently and known to use tobacco did not have a care plan addressing smoking, despite being observed smoking in non-designated areas on multiple occasions. Staff interviews confirmed the absence of a smoking care plan until after direct observation by the MDS Coordinator, resulting in a deficiency for not developing a comprehensive, person-centered care plan.
A resident with severe cognitive impairment was subjected to inappropriate behavior by a nurse aide, who exposed herself and passed gas on the resident while other staff laughed. Another resident witnessed the incident and reported it. The facility's Administrator confirmed the incident, leading to the aide's termination, but expressed a desire to remove the resident due to his behavior.
The facility placed an industrial-sized heater in the hallway and space heaters in several resident rooms, creating tripping hazards and violating life safety codes. Residents had to navigate around unsecured cords, and the heaters were unapproved for safety. The heating system had been out for weeks, leading to these temporary measures.
The facility exceeded the acceptable medication error rate, reaching 16% during an observation. A resident did not receive prescribed eye drops due to their absence in the medication cart. Another resident received incorrect dosages of Sodium Bicarbonate, Calcium Acetate, and Hydroxyzine Pamoate due to a nurse's failure to verify medication orders against available medications. The DON confirmed the need for accurate medication administration.
The facility failed to follow infection control policies, including not donning gowns for wound care on a resident with MRSA, neglecting hand hygiene during medication administration, and handling medications with bare hands. These actions were observed among staff members, leading to deficiencies in infection prevention and control.
A resident experienced discomfort due to inadequate room heating, as the facility's heating system was broken and space heaters caused circuit breakers to trip. The resident reported being cold at night and faced privacy issues during self-catheterization. The facility's temperature log lacked specific details, and the Administrator was unaware of the nighttime issues with resetting the circuit breaker.
A resident with quadriplegia and mental health issues was involved in a verbal and physical altercation with the DON during a smoking break. The resident accused the DON of hitting her, supported by a bruise photo. Conflicting accounts from witnesses and staff, including the DON's admission to hitting the resident, complicated the investigation. The facility deemed the abuse unsubstantiated, but concerns about the investigation's thoroughness and potential retaliation were raised.
The facility failed to implement effective anti-retaliation policies, leading to staff fear of reporting abuse allegations. A resident reported being struck by the DON, but staff were reluctant to come forward due to fear of job loss. Despite assurances from the Administrator and Nurse Consultant, the investigation could not confirm the allegations due to staff's fear of retaliation.
A facility failed to conduct a thorough investigation after a resident alleged being struck by the DON. The resident claimed no assessment was done, and a photo showed a bruise on her face. The facility's report indicated the resident struck the DON, and the abuse was deemed unsubstantiated. No documentation of a skin assessment was found.
A resident with osteomyelitis did not receive scheduled doses of Vancomycin and Cefepime due to an error in entering orders into the electronic medical record. The orders were incorrectly categorized, preventing the pharmacy from receiving them, resulting in missed doses. Nursing staff confirmed the antibiotics were unavailable, and the issue was not resolved until after the scheduled administration times.
A resident admitted with diabetes and osteomyelitis did not receive prescribed antibiotics and insulin due to errors in medication orders and communication. The facility had the medications available, but staff failed to administer them due to misunderstandings and lack of coordination.
The facility did not ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, for 48 out of 180 days reviewed. This was identified through a review of staffing schedules, and attempts to contact the prior DON and Scheduler were unsuccessful. The Administrator acknowledged the responsibility of the DON and Scheduler in ensuring compliance with RN coverage requirements.
The facility failed to resolve and communicate efforts to address resident concerns from Resident Council meetings in late 2023 and early 2024. Issues included delayed responses to requests, problems with obtaining ice, lost clothing, and meal-related complaints. Staff interviews revealed a breakdown in the grievance resolution process, with department heads not returning resolutions to the Social Worker, who was responsible for logging and resolving grievances.
The facility failed to provide written advance directive information and opportunities to formulate advance directives for five residents with various medical conditions. Despite having physician orders for code status, there was no documentation of education or offers to formulate advance directives. Interviews revealed that the only resource available was the MOST form, and the Administrator acknowledged the lack of documentation.
The facility failed to notify the responsible parties and the Ombudsman in writing about the transfer of two residents to the hospital. The DON, Administrator, and Social Worker were unaware of their responsibilities regarding these notifications, leading to a lack of documentation and communication with the Ombudsman, who had previously requested such notifications.
Two residents in the facility experienced significant medication administration deficiencies. One resident, with breast cancer and vascular dementia, had inconsistent administration of letrozole, a cancer medication, due to confusion and lack of communication among staff. Another resident, admitted with osteomyelitis and a stump infection, missed several doses of an antibiotic due to unclear delivery and administration processes. The facility's staff, including the DON and Unit Manager, were unaware of these issues until later, highlighting lapses in communication and oversight.
The facility failed to maintain proper documentation for influenza and pneumococcal vaccinations for several residents. There were no signed consent or declination forms, nor records of education provided to residents or their responsible parties. Interviews with new staff members revealed they were unable to locate the required documentation, and the Administrator could not explain the absence of records.
The facility failed to notify physicians about missed medication doses for two residents. One resident did not receive letrozole for breast cancer on multiple occasions, and another missed doses of an antibiotic for a wound infection. Despite being aware of the unavailability of medications, staff did not inform the necessary medical personnel promptly.
A resident admitted with a PICC line for intravenous antibiotic therapy did not have physician orders for its management due to oversight by the Unit Manager. Despite the care plan addressing monitoring needs, the necessary orders were not entered, and nursing staff were unaware of the omission. The DON and Regional Nurse Consultant confirmed the orders should have been in place upon admission.
A resident with severe cognitive impairment was left unsupervised while smoking, contrary to the facility's policy requiring supervision and a smoking apron. The resident was observed smoking without staff present, and another resident provided and lit the cigarette. The responsible nurse aide admitted to leaving the resident unsupervised to retrieve smoking materials, acknowledging the error.
A newly admitted resident with osteomyelitis and a stump infection did not receive a scheduled dose of IV antibiotic due to a delay in medication delivery. The resident's medication orders were entered upon arrival, but the pharmacy's delivery schedule resulted in the antibiotic not being available for the 10:00 pm dose. The DON confirmed the medication was delivered later that night.
A facility failed to address recommendations from a Consultant Pharmacist regarding a resident's use of haloperidol, an antipsychotic medication. The resident, diagnosed with vascular dementia and schizophrenia, was prescribed haloperidol without an allowable diagnosis. Despite receiving the Consultant Pharmacist's report, the DON did not verify the correction of the physician order, leading to a deficiency in medication management.
The facility failed to maintain proper documentation for COVID-19 vaccinations for two residents, leading to a deficiency. A resident received a vaccine without a signed consent form or documented education, while another had no records of subsequent doses. Interviews with new staff revealed they were unaware of the missing documentation due to recent appointments.
A facility failed to document a thorough investigation into an abuse allegation by a resident with cognitive impairment. The resident accused a nurse aide of physical abuse, leading to the aide's suspension. The investigation report lacked evidence of completed resident interviews and assessments, and the files could not be found, indicating inadequate documentation.
The facility failed to deliver mail to residents on Saturdays, affecting all 65 residents. Interviews revealed that mail was only delivered Monday through Friday by the Activities Director, or on Saturdays if she was present. Staff members, including the Manager on Duty, were unaware of their responsibilities for mail delivery on Saturdays, leading to inconsistencies and confusion in the process.
Inaccurate PBJ Submission of RN Staffing Hours
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS via the Payroll Based Journal (PBJ) system, specifically related to RN hours for three consecutive quarters of Federal Fiscal Year 2025. For Quarter 2, the PBJ report showed no RN hours on several specific dates, while the daily staff schedules for those same dates showed an RN scheduled for at least 8 hours per day. Similar discrepancies were identified in Quarter 3 and Quarter 4, where the PBJ reports reflected no RN hours on multiple dates, yet the facility’s daily staffing schedules documented that an RN was scheduled for at least 8 hours on each of those dates. During interviews, the Regional Nurse Consultant stated that on each of the dates with zero RN hours reported in PBJ, the facility did in fact have RN coverage for a minimum of 8 consecutive hours, often provided by herself and the MDS nurse, both of whom are salaried RNs who do not clock in or out, resulting in no timecard record of their worked hours. She explained that the corporate office was responsible for manually adjusting and entering hours for salaried nursing staff who covered shifts. The Administrator reported that the corporate office was not always consistent in manually entering these hours, which led to multiple dates with inaccurate RN staffing data in the PBJ submissions for the three reviewed quarters. Attempts by surveyors to contact the Regional Business Office Manager by telephone were unsuccessful, and no return call was received.
Failure to Offer and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The deficiency involves the facility’s failure to assess residents for eligibility, educate them on COVID-19 vaccination, offer the vaccine, and document vaccination status as required by its own policies. The facility’s Infection Prevention and Control Program policy assigned oversight of infection prevention to the Infection Preventionist (IP), and the COVID-19 Vaccination policy required the facility to educate and offer the vaccine to residents, resident representatives, and staff, and to maintain documentation. Despite these policies, surveyors found that residents’ records lacked evidence that COVID-19 vaccines or additional doses had been offered, administered, or refused, and that staff vaccination status was not documented. For five residents reviewed for immunizations, records and interviews showed missing or incomplete COVID-19 vaccination documentation. One resident with diabetes, chronic kidney disease, and COPD had received a COVID-19 vaccine dose in the facility, but there was no documentation of any subsequent offer, administration, or refusal of additional doses, and the MDS coded the resident as not up to date. Another cognitively intact resident with diabetes and COPD had last refused the vaccine in 2023, with no documentation of any further offers or refusals. A resident with severe cognitive impairment and vascular dementia had last refused the vaccine in 2023, again with no record of additional offers or refusals. Two cognitively intact residents with COPD, hypertension, diabetes, chronic kidney disease, and obstructive sleep apnea had no documentation at all that the COVID-19 vaccine had been offered, given, or refused, and both reported they were unsure if the vaccine had been offered in the past year. The Unit Manager confirmed she could not provide any documentation of COVID-19 vaccination status for these residents. Interviews with facility leadership and staff further demonstrated a lack of clear responsibility and tracking for COVID-19 vaccination activities. The IP, in the role for about one and a half years, stated she had offered the COVID-19 vaccine to residents and believed none wanted it, but she was unable to locate any documentation of offers or signed declination forms. The DON, in the position for about four months, stated she had not focused on resident COVID-19 vaccinations and confirmed the facility had not offered the vaccine to residents during her tenure, with no documentation that residents were offered the vaccine in the prior year. Regarding staff, the facility was unable to provide any documentation of staff COVID-19 vaccination status. The IP stated she was not responsible for maintaining staff vaccination records and did not know who was; the DON similarly did not manage staff vaccination logs and was unsure who did. The Administrator stated that she and the nursing management team, including the IP, Unit Manager, and DON, were working together to track staff vaccinations and that information was sent to corporate, but she was unable to provide any documentation of staff COVID-19 vaccination status.
Undated Multi-Dose Tuberculin Vial Found in Medication Refrigerator
Penalty
Summary
Surveyors identified a deficiency in medication labeling and storage when, during an observation of Nurse's Station #1 medication room, they found an opened multi-dose vial of Tuberculin Purified Diluted solution stored in the medication refrigerator without a date indicating when it had been opened. The manufacturer's instructions on the vial specified that the medication should be discarded 30 days after opening, but there was no way to determine the open date from the vial. During interviews, the DON stated it was the Unit Manager's responsibility to check the medication room for expired or undated opened medications and acknowledged that the undated medication should have been discarded or returned to the pharmacy. The Unit Manager reported that she and the staff nurses are responsible for checking the medication room for expired and undated opened medications, but she could not explain why the vial had not been dated when opened and was unable to recall when she last checked the medication room and refrigerator for expired or undated medications. The Administrator stated that all multi-dose vials should be dated when opened. No residents or specific patient conditions were mentioned in relation to this deficiency, and the report focuses solely on the improper labeling and oversight of the multi-dose vial of Tuberculin solution in the medication storage area.
Failure to Provide Written Transfer/Discharge Notices and Bed-Hold Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notifications of transfer/discharge to the hospital and to provide or document provision of the bed-hold policy to residents and/or their Resident Representatives (RRs). For Resident #1, who was cognitively intact and her own RR, the medical record showed two hospital transfers. For the first transfer, there was no documentation that she received written notification of the reason for transfer/discharge or a copy of the bed-hold policy. For the second transfer, the record again lacked documentation of written notification of the reason for transfer/discharge, although the bed-hold policy was provided. In an interview, Resident #1 stated she had not received written notification of the bed-hold policy or the transfer/discharge notice when she was transferred to the hospital. For Resident #60, who had moderately impaired cognitive skills and could not complete the BIMS, the record showed a hospital transfer with no documentation that the resident or RR received written notification of the reason for transfer/discharge or a copy of the bed-hold policy. In an interview, the RR confirmed not receiving written notification of the transfer/discharge or the bed-hold policy. The Social Worker reported that the Business Office Manager was responsible for providing the bed-hold policy when a resident was transferred, and also stated she was not aware she was responsible for written transfer/discharge notifications. The Business Office Manager stated she typically followed up within 24 hours and sent a handwritten bed-hold policy the next day after transfer, but could not locate evidence that the bed-hold policy had been provided for this resident. For Resident #34, who was cognitively intact, the record showed a hospital transfer with no documentation that the resident or RR received a copy of the bed-hold policy. The RR stated she did not receive the bed-hold policy but did receive written notification of the transfer, and she had coordinated the surgery date with the DON, knowing the resident would return to the same bed. The DON stated that during the week of this transfer the Business Office Manager was out of the office, and the DON communicated with the RR by email about the upcoming surgery but did not email the bed-hold policy and was not aware it needed to be mailed. Throughout interviews, the Administrator stated that the Social Worker was responsible for written transfer/discharge notifications and the Business Office Manager was responsible for ensuring the bed-hold policy was completed and mailed, but was unable to explain why the required notices and policies were not sent or documented for these residents.
Failure to Supervise Unsafe Smoking Practices for Resident on Oxygen
Penalty
Summary
The facility failed to provide effective supervision and implement adequate interventions for a resident who was assessed as unsafe to smoke without supervision and had a known history of non-compliance with the facility's smoking policy. Despite being on continuous supplemental oxygen therapy for chronic respiratory failure and COPD, the resident was repeatedly observed by staff smoking in undesignated areas while using a portable oxygen tank via nasal cannula. These incidents were reported to facility leadership, but no new interventions or increased monitoring were implemented to prevent recurrence, and the resident's care plan did not document his non-compliance or address the ongoing risk. On multiple occasions, the resident exited the facility independently and smoked with his oxygen in use, both alone and in the presence of another resident. Staff removed the oxygen tank when they discovered these incidents, but no harm occurred until a later event when the resident's shirt caught fire while smoking with oxygen in use. The resident sustained a flash burn to his face and upper lip, requiring evaluation in the emergency department. Interviews with staff revealed inconsistent awareness of the resident's supervision requirements, lack of communication regarding his non-compliance, and failure to ensure that staff responsible for supervision were informed of which residents required monitoring during smoking times. The facility's smoking policy prohibited smoking in all but designated areas and specifically forbade oxygen use in those areas. However, the resident was able to obtain cigarettes from visitors and access exit doors with codes known to residents and visitors. Staff and leadership acknowledged breakdowns in the smoking supervision process, including lack of effective monitoring, failure to update care plans with non-compliance information, and inadequate enforcement of the smoking policy. The deficiency affected multiple residents reviewed for smoking, and immediate jeopardy was identified due to the facility's failure to implement effective interventions after repeated incidents.
Failure to Document Change in Condition and Hospital Transfer
Penalty
Summary
The facility failed to maintain a complete and accurate medical record by not documenting a resident's change in condition that required Emergency Medical Services (EMS) intervention and subsequent hospitalization. The resident, who had chronic respiratory failure with hypoxia and end-stage COPD, was admitted to the facility on oxygen therapy. On the day of the incident, the resident was smoking a cigarette while receiving oxygen, resulting in a flash burn. The resident sustained burns to the upper left lip, singed nose hair, and a burn mark on the forehead, but did not report pain or breathing difficulties at the time. Despite the severity of the incident and the need for EMS transfer to a hospital, there was no documentation in the resident's electronic medical record regarding the change in condition or the events leading to the transfer. The nurse on duty confirmed that she did not document the incident, and the facility administrator verified that there were no nurse progress notes for the relevant shift. This lack of documentation constitutes a failure to maintain a complete and accurate medical record as required.
Failure to Develop Comprehensive Smoking Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan to address smoking for one resident. The resident was admitted with a Safe Smoking screen indicating they were safe to smoke independently and was noted as cognitively intact, using tobacco, and able to ambulate and transfer independently. Despite these findings, there was no care plan in place related to smoking as of a specific observation date. The resident was observed smoking in areas outside the designated smoking area, including the employee parking lot and another location approximately 100 feet from the designated area. Staff interviews revealed that the resident had been seen smoking on multiple occasions prior to the initiation of a care plan, but this was not documented or addressed until after a direct observation by the MDS Coordinator. The MDS Coordinator and DON confirmed that a smoking care plan was not initiated until after the resident was observed smoking, despite prior assessments and staff observations indicating the resident's tobacco use. The DON stated that the resident had denied smoking when the smoking policy was reviewed with all residents who had Safe Smoking Screening Assessments. The lack of a timely and comprehensive care plan addressing the resident's smoking behavior constituted the deficiency identified during the survey.
Inappropriate Behavior and Lack of Dignity in Resident Care
Penalty
Summary
The facility failed to provide services with dignity and respect for two residents, leading to a deficiency in resident rights. Resident #3, who had severe cognitive impairment and a history of verbal aggression, was subjected to inappropriate behavior by a nurse aide. The aide exposed herself and passed gas on Resident #3 while other staff members laughed, failing to intervene or stop the behavior. This incident occurred despite Resident #3's repeated requests to be left alone and his refusal of care. Resident #1, who was cognitively intact, witnessed the incident and reported it during a therapy session the following day. The Rehabilitation Director confirmed the report and took steps to inform the Director of Nursing and other relevant personnel. Multiple staff members, including nurse aides, confirmed the inappropriate actions of the nurse aide and the laughter from the staff, although some were reluctant to intervene due to fear of workplace repercussions. The facility's Administrator acknowledged the incident, stating that the nurse aide involved was suspended and terminated. However, the Administrator also mentioned that there were no cameras in the facility to capture the event, contradicting a staff member's claim that the incident was recorded. The Administrator expressed a desire to remove Resident #3 from the facility due to his behavior, which included racial slurs and vulgar language towards staff.
Heaters Create Safety Hazards in Facility
Penalty
Summary
The facility failed to maintain an environment free from accident hazards by placing an industrial-sized heater in the hallway and space heaters in several resident rooms, creating tripping hazards. During an initial tour, it was observed that the industrial heater's cord was not secured, causing residents in wheelchairs to navigate around it. Additionally, space heaters in rooms 102, 103, 104, 105, and 106 had cords that were not taped down, posing further tripping risks. Residents expressed concerns about the heaters, with one resident noting the inconvenience of navigating around them. The facility's heating system had been out for three weeks, prompting the use of these temporary heating solutions. Interviews with residents and staff revealed that the space heaters were unapproved for safety in the facility, and their use violated life safety codes due to fire risks. The Administrator explained that the heating system required a part that needed to be manufactured, leading to the temporary use of heaters. The Director of Plant Operations confirmed that the facility had been on fire watch since the heaters were installed. Despite these measures, the presence of the heaters and their cords in resident areas constituted a significant safety hazard, as confirmed by the Life Safety Engineering Supervisor.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 16% error rate during a medication administration observation. This deficiency was identified through observations, staff interviews, and record reviews involving two residents. For Resident #11, a medication aide did not administer prescribed eye drops due to their absence in the medication cart, despite the resident having a current order for Carboxymethylcellulose sodium PF ophthalmic solution for dry eyes. For Resident #12, a nurse administered incorrect dosages of three medications. The nurse gave a 325 mg tablet of Sodium Bicarbonate instead of the ordered 650 mg, only one 667 mg capsule of Calcium Acetate instead of two, and a 25 mg capsule of Hydroxyzine Pamoate instead of the ordered 50 mg. The nurse acknowledged the discrepancies upon review and admitted to not verifying the medication orders against the available medications. The Director of Nursing confirmed that medications should be administered as ordered and that the medication carts should match the orders.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during wound care for a resident with MRSA. Nurse #1 and a nurse aide entered the room of a resident on contact precautions without donning gowns, despite a sign indicating the requirement. Nurse #1 provided wound care to the resident's feet, which had tested positive for MRSA, without wearing a gown. The nurse later stated that the required PPE was not available outside the resident's door and expressed uncertainty about the necessity of wearing a gown for wound care. During a medication pass observation, Medication Aide #1 did not perform hand hygiene between residents, despite the facility's policy requiring hand hygiene before and after medication administration. The aide was observed administering medications to multiple residents, including those on contact precautions, without sanitizing her hands. When interviewed, the aide attributed her lapse in hand hygiene to nervousness, although she acknowledged the importance of hand hygiene, especially for residents on contact precautions. Nurse #3 was observed handling medications with bare hands during medication administration, contrary to the facility's policy that requires using gloves or avoiding direct contact with medications. The nurse admitted to using her hands to prevent losing or dropping pills. The Director of Nursing later clarified that medications should be handled with a gloved hand to prevent contamination and ensure safe administration practices.
Failure to Maintain Comfortable Room Temperature
Penalty
Summary
The facility failed to provide a comfortable room temperature for a resident, identified as Resident #16, who was cognitively intact. The resident reported that the facility had been without heat in certain rooms for three weeks, and space heaters were used as a temporary solution. However, when multiple space heaters were used simultaneously, the circuit breaker would trip, leaving the resident without heat. The resident expressed discomfort due to the cold temperatures at night, requiring multiple blankets and a thick hoodie to stay warm. The resident also faced privacy issues during self-catheterization due to the need to keep the door open for heat, which was not feasible. The facility's Administrator and Maintenance Director confirmed the heating issues, stating that a part needed to be manufactured to fix the heating unit. The Maintenance Director, who was new to the facility, used a digital thermometer to measure the room temperature, which read 73 degrees Fahrenheit, although it did not feel that warm. The facility maintained a temperature log, but it lacked specific details such as the time of day and who recorded the temperatures. The Administrator was unaware of the staff's inability to reset the circuit breaker at night, which contributed to the resident's discomfort.
Failure to Prevent Abuse and Conflicting Accounts of Incident
Penalty
Summary
The facility failed to prevent physical and verbal abuse involving a resident with a history of quadriplegia and mental health disorders. The incident occurred when the Director of Nursing (DON) and a Nurse Aide (NA) escorted three residents, including the involved resident, outside to smoke. An argument ensued between two residents, during which the DON allegedly told the resident to be quiet, leading to a verbal altercation. The resident accused the DON of hitting her, which was corroborated by a photograph showing a bruise on the resident's face. Multiple interviews provided conflicting accounts of the incident. The resident claimed the DON hit her, while the DON stated she only made contact to prevent herself from falling after being hit by the resident's wheelchair. Witnesses, including another resident and confidential sources, provided varying testimonies, with some indicating the DON pushed the resident and others denying any physical contact. The police report listed both the DON and the resident as suspects in a simple assault case, but no injuries were documented. The facility's investigation concluded that the abuse was unsubstantiated, with the Administrator stating that the resident had run her wheelchair into the DON. However, confidential sources reported that the DON admitted to hitting the resident, and there were concerns about potential retaliation against those who came forward. The lack of video evidence and the facility's decision to return the DON to work shortly after the incident raised further questions about the thoroughness of the investigation.
Failure to Implement Anti-Retaliation Policies in Abuse Reporting
Penalty
Summary
The facility failed to implement policies and procedures that promote a culture of safety and open communication, as well as prohibit potential retaliation for staff who report abuse allegations. This deficiency was highlighted by the case involving a resident who reported being struck by the Director of Nursing (DON). Despite the facility's policy stating that staff should be able to report concerns without fear of retribution, multiple confidential sources expressed fear of losing their jobs if they came forward with information about the incident. These sources included staff members who either witnessed the altercation or heard a confession from the DON admitting to hitting the resident. The incident in question involved a resident who allegedly struck the DON with an electric scooter and attempted to hit the DON with her arms and legs. The DON reportedly raised her arms to deflect the resident's attempts. However, confidential sources reported that the DON admitted to hitting the resident twice. The facility's investigation, led by the Administrator and a Nurse Consultant, was unable to confirm the allegations due to the reluctance of staff to come forward, despite assurances that they would not face retaliation. The Administrator acknowledged the challenge of convincing staff that they could report incidents without fear of losing their jobs.
Failure to Conduct Thorough Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an abuse allegation involving a resident and the Director of Nursing (DON). The incident occurred when the resident claimed to have been struck by the DON, who was subsequently suspended. However, the facility's investigation report indicated that the resident had struck the DON with her electric scooter and attempted to hit the DON, who then raised her arms to deflect the strikes. Despite the altercation, there was no documentation of a skin assessment or any assessment of the resident's injuries immediately following the incident. The resident later confirmed that no assessment was conducted, and a photograph taken by the resident showed a bruise on her face, which she claimed to have shown to the Administrator and the Social Worker. However, there was no documentation or statements from the Administrator or Social Worker regarding the photograph. The Administrator concluded that the abuse allegation was unsubstantiated, and the investigation results were submitted to the state agency. Despite interviews with the Administrator and a Nurse Consultant, it remained unclear whether a skin assessment was completed on the day of the incident.
Failure to Administer Antibiotics Due to Order Entry Error
Penalty
Summary
The facility failed to have an effective system in place for entering new admission orders into the electronic medical record, which resulted in missed doses of antibiotics for a resident. Resident #7, who was admitted from the hospital with a diagnosis of osteomyelitis, required intravenous Vancomycin and Cefepime. However, due to an error in entering the orders into the electronic system, the pharmacy did not receive the prescriptions, leading to missed doses. Upon admission, the orders for Vancomycin were incorrectly entered as 'Other Orders' instead of 'AHR Medication Orders,' which prevented the pharmacy from receiving the order. Additionally, there was no evidence that an order for Cefepime was entered at all. As a result, Resident #7 did not receive the scheduled doses of Cefepime and Vancomycin on the specified dates. The nursing staff, including Nurse #5 and Nurse #7, confirmed that the antibiotics were not available from the pharmacy, and attempts to rectify the situation were delayed. Interviews with the nursing staff and the pharmacist revealed that the pharmacy only received the orders for the antibiotics on a later date, with a start date that was after the resident's admission. The Director of Nursing acknowledged the issue and attempted to contact the hospital to send the antibiotics with the resident, but the resident was already en route. The Medical Doctor for the resident also acknowledged that the antibiotics should have been administered upon admission, but the facility was not prepared to do so due to the order entry error.
Failure to Administer Antibiotics and Insulin Upon Admission
Penalty
Summary
The facility failed to administer four doses of antibiotics and one dose of insulin to a resident upon admission, leading to significant medication errors. The resident, who was admitted from the hospital with diagnoses of diabetes and osteomyelitis, was prescribed intravenous Vancomycin and Cefepime for a six-week course to treat the infection, as well as Glargine insulin for diabetes management. However, due to a series of oversights and miscommunications, the resident did not receive the initial doses of these medications. Upon admission, Nurse #4 entered an order for Vancomycin into the electronic medical record but failed to enter the order for Cefepime. This omission, coupled with the lack of communication and verification of medication availability in the automated medication dispensing system, resulted in the resident missing doses of both antibiotics. Despite the facility having the antibiotics in stock, the staff did not access them due to a misunderstanding of the system's requirements and a lack of coordination among the nursing staff. Additionally, the order for Glargine insulin was discontinued prematurely by Nurse #4, leading to the resident missing a scheduled dose. The Director of Nursing and other staff members were unaware of the insulin's availability in the backup fridge kit, and there was no communication with the physician to address the discontinuation. These lapses in medication administration and communication highlight the facility's failure to ensure the resident received the necessary treatments upon admission.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to maintain compliance with the requirement of having a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, for 48 out of 180 days reviewed. This deficiency was identified through a review of the Nursing Staff Schedule and the Daily Staffing Form, which showed that an RN was not scheduled for the required hours on multiple specific dates between August 2023 and March 2024. Attempts to contact the prior Director of Nursing (DON) and Scheduler for clarification were unsuccessful, as calls and messages were not returned. During an interview, the Administrator acknowledged that it was the responsibility of the DON and the Scheduler to ensure compliance with the RN coverage requirement, and noted that staffing changes had occurred, suggesting improvements were made.
Failure to Resolve and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to effectively resolve and communicate efforts to address resident concerns voiced during Resident Council meetings held in October 2023, January 2024, and June 2024. During a Resident Council group interview, residents expressed ongoing issues with the resolution of concerns raised in these meetings. The review of Resident Council minutes revealed that there was no documentation of the facility's response to concerns raised in previous meetings, such as a resident not receiving requested money for three weeks, issues with obtaining ice, lost clothing, delays in being put to bed, cold food, lack of meal variety, and laundry being returned to the wrong residents. Interviews with facility staff, including the Activities Director, Administrator, and Social Worker (SW), highlighted a breakdown in the grievance resolution process. The Activities Director reported complaints to the Administrator, who delegated them to department heads. However, the SW, who was responsible for logging and resolving grievances, indicated that department heads often did not return resolutions, preventing her from creating resolution letters. The Administrator acknowledged that department heads were not returning grievance resolutions to the SW, and there was no thorough process in place to log grievances and check their status. The SW was not formally notified of her role as the Grievance Official, contributing to the lack of resolution and communication of resident concerns.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written advance directive information and an opportunity to formulate an advance directive for five residents. These residents were either admitted or readmitted with various medical conditions such as heart failure, diabetes, chronic obstructive pulmonary disorder, and seizures. Despite having physician orders for code status, there was no documentation in their medical records indicating that they were educated about or offered the opportunity to formulate advance directives. For instance, Resident #1, who was readmitted with heart failure and other conditions, had no record of advance directive education. Similarly, Resident #5's medical orders were signed by a Nurse Practitioner without the resident or their responsible party's signature, and the responsible party could not recall any discussion about advance directives during the admission process. Interviews with facility staff, including the Regional Nurse Consultant and the Administrator, revealed that the only available resource for advance directives was the Medical Orders for Scope of Treatment (MOST) form, which was stored in binders at the nurses' stations. The Administrator acknowledged that discussions and education about advance directives should have been documented for each resident and stated that residents should be reassessed for advance directives every three months or when there is a significant change in condition. However, this was not reflected in the documentation for the residents reviewed.
Failure to Notify Responsible Parties and Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely written notification to the resident's responsible party and the Ombudsman regarding the transfer of residents to the hospital. Specifically, for one resident, there was no documentation that the resident, their responsible party, or the Ombudsman were notified of the reason for the transfer to the hospital. The Director of Nursing (DON) and the facility Administrator were unaware of the requirement to send written notifications, and the Social Worker was unaware of her responsibility to notify the Ombudsman. Additionally, for another resident, the facility did not notify the Ombudsman of the resident's transfer to the hospital. The DON and the facility Administrator confirmed the lack of notification, and the Social Worker stated she was unaware of her responsibility to notify the Ombudsman. The Ombudsman confirmed that she had not been notified of resident discharges and had previously requested such notifications from the facility Administrator.
Medication Administration Deficiencies for Two Residents
Penalty
Summary
The facility failed to administer significant medications as ordered for two residents, leading to deficiencies in medication management. Resident #24, diagnosed with malignant neoplasm of the female breast and vascular dementia, had an active physician order for letrozole, a medication used to treat breast cancer. Despite the medication being delivered to the facility, it was inconsistently administered throughout August 2024. Several staff members, including medication aides and nurses, documented the medication as either administered or on order, indicating a lack of availability. Interviews with staff revealed confusion and lack of communication regarding the medication's whereabouts, and the Unit Manager and Director of Nursing were unaware of the missed doses until later notified. Resident #269, admitted with osteomyelitis and complications of a stump infection, had an active order for piperacillin sodium-tazobactam, an antibiotic to be administered intravenously every eight hours. The medication was not administered as scheduled on multiple occasions shortly after admission, with documentation indicating it was not available or not delivered. Interviews with nursing staff revealed a lack of clarity on the medication's delivery and administration, and the Nurse Practitioner was not informed of the missed doses. The Director of Nursing was also unaware of the issue until later, despite the medication being available at the facility for the scheduled administrations. The deficiencies in medication administration for both residents highlight significant lapses in communication, documentation, and oversight within the facility. The failure to ensure medications were administered as ordered, coupled with the lack of timely notification to medical providers, contributed to the deficiencies observed by surveyors. These issues underscore the need for improved processes and accountability in medication management to prevent similar occurrences in the future.
Deficiency in Vaccination Documentation
Penalty
Summary
The facility failed to maintain proper documentation for influenza and pneumococcal vaccinations for four out of five residents reviewed. Specifically, the facility did not have signed consent or declination forms, nor did it have records of education provided to the residents or their responsible parties regarding the vaccines. Resident #28 declined the pneumococcal vaccine, but the date of declination was not recorded, and there was no documentation of consent or education for the influenza vaccine administered. Resident #16 received the influenza vaccine, but there was no documentation of consent or education. Resident #29 declined the pneumococcal vaccine, but the date was unknown, and there was no documentation of consent or education for the influenza vaccine administered. Resident #10 received the influenza vaccine, but there was no documentation of consent or education. Interviews with the facility's staff, including the Regional Nurse Consultant, Infection Preventionist, and Director of Nursing, revealed that they were unable to locate the required documentation. The staff members were new to their positions and could not explain why the documentation was missing. The Administrator indicated that the Director of Nursing and the Infection Preventionist were responsible for maintaining the immunization documentation but could not provide an explanation for the absence of the records, as the administrative team was new to the facility.
Failure to Notify Physicians of Missed Medication Doses
Penalty
Summary
The facility failed to notify the physician about the non-administration of prescribed medications for two residents. Resident #24, diagnosed with malignant neoplasm of the female breast and vascular dementia, had a physician order for letrozole, a medication for breast cancer, which was not administered on multiple dates in August 2024. The Medication Administration Record (MAR) indicated the medication was on order, but there was no documentation that the Nurse Practitioner (NP) or Medical Director was informed of the missed doses. Interviews revealed that the medication was unavailable, and although the medication aide and nurse were aware, they did not notify the necessary medical personnel until much later. Similarly, Resident #269, with diagnoses including osteomyelitis and complications of stump infection, had an order for an antibiotic, piperacillin sodium-tazobactam, which was not administered on several occasions due to non-delivery. The MAR noted the missed doses, but there was no documentation of physician notification. Interviews with nursing staff and the NP confirmed that the missed doses were not communicated to the physician or the Director of Nursing (DON), highlighting a lapse in the facility's protocol for medication administration and notification.
Failure to Obtain Physician Orders for PICC Line Management
Penalty
Summary
The facility failed to obtain a physician order for the management of a peripherally inserted central catheter (PICC) for a resident who was admitted with osteomyelitis and complications of a stump infection. Upon admission, the resident had a PICC line in the right upper arm for intravenous antibiotic therapy. Although the care plan included monitoring for redness or drainage around the PICC and wound site, there were no physician orders for the PICC line's use and management. The Unit Manager, responsible for entering the physician orders, acknowledged forgetting to generate the required orders for the PICC line, despite being aware of its necessity for antibiotic therapy. Interviews with the nursing staff revealed a lack of awareness and oversight regarding the missing orders. Nurse #4, who completed the admission assessment, did not enter the physician orders, assuming the Unit Manager would do so. Nurse #2, responsible for administering the antibiotics, did not notice the absence of PICC line orders but followed facility policy by flushing the line before and after medication administration. The Director of Nursing and the Regional Nurse Consultant confirmed that the orders should have been entered upon admission, highlighting a lapse in the facility's process for ensuring all necessary physician orders are in place for new admissions.
Failure to Supervise Resident During Smoking
Penalty
Summary
The facility failed to provide adequate supervision and safety measures for a resident identified as a supervised smoker. Resident #9, who had severe cognitive impairment and was a tobacco user, was observed smoking unsupervised at the facility's smoking area. The resident was not wearing the required smoking apron, and there were no staff members present to supervise him. Another resident, who was a non-supervised smoker, provided Resident #9 with a cigarette and lit it for him. This incident occurred despite the facility's smoking policy and care plan, which required Resident #9 to be supervised and to wear a smoking apron while smoking. Nurse Aide #1, who was responsible for supervising Resident #9 during designated smoking times, admitted to leaving the resident unsupervised to retrieve his cigarettes and lighter. Upon returning, the aide found Resident #9 already smoking. The facility's administrator confirmed that staff were aware of the smoking protocol, which included obtaining cigarettes and smoking aprons for supervised smokers before they exited the building. The deficiency highlights a lapse in following established protocols for resident safety and supervision during smoking activities.
Failure to Administer Timely IV Antibiotic to New Admission
Penalty
Summary
The facility failed to ensure that intravenous antibiotic medication was available as ordered for a newly admitted resident with osteomyelitis and complications of a stump infection. The resident had a physician's order for piperacillin sodium-tazobactam to be administered every 8 hours, but the 10:00 pm dose was not given because the medication was not delivered on time. Nurse #5, who was responsible for the 3:00 pm to 11:00 pm shift, documented that the medication was not administered due to its unavailability, as the pharmacy typically delivered new admission medications around 2:00 am. The deficiency occurred despite the discharge summary, which included the resident's medication list, being provided to the Unit Manager before the resident's arrival. The Unit Manager entered the medication orders into the system upon the resident's admission. The Director of Nursing confirmed that medication orders were received before admission but were not entered until the resident arrived, leading to a delay in the delivery of the medication. The Consultant Pharmacist indicated that medication orders become active once the resident is admitted, and the orders are reviewed for contraindications before being sent to the facility.
Failure to Address Pharmacist Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to address recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Review (MRR) for a resident who was reviewed for unnecessary medications. The resident, who was admitted with diagnoses including vascular dementia and schizophrenia, was prescribed haloperidol, an antipsychotic medication, without an allowable diagnosis to support its use. Although the Consultant Pharmacist's report provided schizophrenia as an allowable diagnosis, the facility did not update the physician order accordingly. The Consultant Pharmacist completed the MRR and sent the reports to the Director of Nursing (DON), who was responsible for ensuring the recommendations were completed. However, the DON did not verify that the physician order was corrected, despite receiving the completed and signed recommendation report. The Administrator confirmed that the DON was responsible for ensuring the resident's diagnosis was updated for the haloperidol medication.
Deficiency in COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain proper documentation for COVID-19 vaccinations for two residents, leading to a deficiency in their immunization process. Resident #16 was administered the COVID-19 vaccine at the facility, but there was no documentation of a signed immunization consent form or evidence that vaccination education was provided to the resident or their Responsible Party (RP). The Regional Nurse Consultant confirmed the absence of these documents during an interview. Similarly, for Resident #29, the facility's records showed administration of the first dose of the COVID-19 vaccine, but there was no documentation of any subsequent doses being offered, administered, or declined. Interviews with the facility's new Infection Preventionist (IP) and Director of Nursing (DON) revealed that they were unable to provide information regarding the immunization records for Residents #16 and #29 due to their recent appointments. The Administrator also confirmed that the new administrative team was unaware of the reasons behind the missing documentation, as the previous DON could not be reached for clarification. This lack of documentation and continuity in the immunization process led to the identified deficiency.
Failure to Document Abuse Investigation
Penalty
Summary
The facility failed to maintain documented evidence of a thorough investigation into an allegation of staff-to-resident abuse involving a resident with a history of stroke and mild cognitive impairment. The resident accused a nurse aide of physical abuse, prompting the immediate suspension of the aide. The investigation report, completed by the previous Administrator, outlined plans to interview and assess all residents under the care of the accused aide. However, there was no evidence that these interviews and assessments were completed, and the allegation was ultimately not substantiated. Interviews with the President of Operations and the previous Administrator revealed that the investigation files could not be located, indicating a lack of proper documentation and follow-through on the investigation process.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to provide mail delivery to residents on Saturdays, affecting all 65 residents. Interviews with the Resident Council revealed that mail was only delivered Monday through Friday by the Activities Director, or on Saturdays if she was present. The Activities Director confirmed that she was responsible for mail delivery during weekdays, and the Manager on Duty was supposed to handle it on Saturdays. However, interviews with staff members, including Medical Records/Central Supply and the Dietary Manager, indicated that they had never distributed mail on Saturdays when serving as Manager on Duty. Further interviews revealed confusion and inconsistency in mail delivery procedures. The Receptionist stated that she collected mail and placed it in the Activities Director's mailbox, as instructed by the Regional Business Office Manager (BOM). The Receptionist had never distributed mail to residents. The Regional BOM confirmed that the Receptionist was supposed to give the mail to the Activities Director, who worked most Saturdays. The Administrator acknowledged that prior to a specific date, mail was not delivered on Saturdays unless the Activities Director was present. Despite new instructions for Managers on Duty and the Receptionist to distribute mail on Saturdays, these procedures were not being followed.
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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