Carolina Rehab Center Of Cumberland
Inspection history, citations, penalties and survey trends for this long-term care facility in Fayetteville, North Carolina.
- Location
- 4600 Cumberland Road, Fayetteville, North Carolina 28306
- CMS Provider Number
- 345505
- Inspections on file
- 31
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Carolina Rehab Center Of Cumberland during CMS and state inspections, most recent first.
Surveyors identified that the facility’s medication error rate exceeded 5% when an RN administered the wrong stool softener to a resident and an incorrect form of calcium supplement to another resident. In the first case, the RN gave docusate sodium capsules from stock instead of the ordered sennosides-docusate sodium combination. In the second case, the RN administered a Calcium 600 mg with Vitamin D tablet from stock instead of the ordered calcium citrate 950 mg (200) tablet, explaining that only one calcium product was stocked. The DON later confirmed the calcium citrate order had been continued from the hospital without prior verification against the facility’s available stock.
Expired food items, including chicken breast strips, green beans, prepacked sandwiches, and nutritional shakes, were found stored in three nourishment room refrigerators. The Dietary Manager, DON, and Administrator all confirmed that staff were expected to remove expired food, but these items were not discarded as required.
A resident with a surgical incision on the right heel was admitted to a facility without proper wound care orders. The facility failed to coordinate with the resident's podiatrist, resulting in delayed treatment and significant maceration of the wound. The resident's condition worsened, requiring hospitalization and additional surgeries. Interviews revealed a lack of communication and coordination in managing the resident's wound care.
A resident fell from a transport van due to the van driver's failure to level the lift platform with the van. The resident, who required assistance for mobility, was being transported to a physician's visit when the driver mistakenly lowered the lift to the ground. Despite encountering resistance, the driver continued to push the resident's wheelchair, resulting in both the resident and the driver falling out of the van. The resident was evaluated at the ER and found to have no acute injuries.
A resident's privacy was compromised when a Nurse Aide used a cell phone for a video call in the shower room while the resident was unclothed. The resident, who was dependent on staff for bathing, felt exposed as the phone was angled towards her. The incident occurred when the Nurse Aide received an emergency call and chose to remain in the room, despite the privacy curtain initially being in place.
A resident with a stage 4 pressure sore and osteomyelitis did not receive scheduled doses of the antibiotic Ertapenem on two consecutive days. The nurse responsible did not administer the medication, citing an inability to find it and a perceived pharmacy issue. However, the pharmacy confirmed delivery, and the DON later discovered the medication was in the facility. The resident's physician extended the treatment to account for the missed doses.
A resident with a left below-knee amputation was unable to use his prosthesis due to a missing liner, hindering his gait training. Despite notifying the DOR, the facility delayed ordering a replacement until after the resident called 911. The prosthetic company required a prescription, and further delays occurred due to payment issues, resulting in the liner being delivered only after payment was made.
A resident's medical record was inaccurately documented at a facility, leading to a misrepresentation of their condition. The resident, with a history of MRSA pneumonia, was incorrectly noted as having pneumonia again due to a nurse's error in associating an antibiotic order with the wrong ICD code. This resulted in an inaccurate care plan update, causing confusion for the resident's responsible party. The physician confirmed no pneumonia diagnosis was made during the resident's stay.
A resident with severe cognitive impairment and osteoporosis was not transferred according to her care plan, which required a mechanical lift and two staff members. Instead, a Nurse Aide manually lifted the resident, leading to a deficiency. The resident later showed signs of a fracture, though the exact cause was uncertain. Staff interviews confirmed the care plan was not followed.
A resident with severe cognitive impairment and dependency on staff for all ADLs sustained a facial fracture after hitting a bed side rail during care. The facility failed to remove the bed rails and did not assess the resident's need for them, leading to the injury.
The facility failed to complete bedrail assessments and maintain bedrails securely, resulting in a facial fracture for one resident and ongoing safety concerns for another. The residents' complaints and issues with bedrails were not adequately addressed, leading to significant safety risks.
The facility's QAA committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in Supervision to Prevent Accidents (F689) and other areas. Incidents included a resident smoking with oxygen in use, a resident rolling off the bed during care, and a resident sustaining a leg fracture during an unsafe transfer. The facility also failed to post accurate RN staffing information and the resident census.
A resident was not administered prednisone as per the hospital discharge summary for 23 days due to a medication reconciliation error. The issue was discovered when the resident's family inquired about the medication, leading to the physician being notified and the medication being restarted. The physician confirmed that the missed doses did not cause harm, and the Director of Nursing acknowledged the oversight.
The facility failed to document that Pneumococcal and Influenza vaccines were offered and declined, and did not provide proof of education on the benefits and side effects of the vaccines for five residents. Interviews revealed inconsistencies and gaps in the documentation process.
The facility failed to ensure proper urinary catheter care for two residents, leading to deficiencies in maintaining the urine collection bag below the level of the bladder and preventing the urinary drainage bag from coming into contact with the floor. One resident was left with a leg bag for several days due to a reported shortage of drainage bags, while another resident's drainage bag frequently touched the floor due to improper securing and the need for a low bed. These lapses in care increased the risk of UTIs and other complications.
The facility failed to involve a resident's designated representatives in the Medicaid application process, despite the resident's cognitive impairment and inability to make decisions independently. The Business Office Manager misunderstood the resident's BIMS score and had the resident sign the forms without consulting the representatives, causing distress when they later discovered the application had been submitted without their consent.
The facility failed to obtain the responsible party's permission before opening a Resident Trust Fund account for a severely cognitively impaired resident, leading to unauthorized direct deposits of the resident's benefits. The Business Office Manager misunderstood the resident's cognitive abilities and did not involve the family in the decision-making process.
The facility failed to notify law enforcement and APS regarding an allegation of staff-to-resident abuse. The Administrator mistakenly believed she had five days to report and did not notify authorities because the resident retracted the allegation on the fifth day.
A nurse aide failed to follow proper peri-care procedures by using the same washcloth to clean both dirty and cleaner areas of a severely cognitively impaired resident, spreading feces in the process. The DON confirmed the correct procedure was not followed.
A cognitively impaired resident with a history of paranoia and aggression assaulted another resident, causing injuries and fear. Despite known behavioral issues, the facility's interventions were insufficient, and staff were occupied with other residents during the incident, highlighting a significant lapse in supervision and safety measures.
A resident with paraplegia and incomplete quadriplegia sustained a fractured leg when two nursing staff members used a sliding board for transfer, despite therapy's recommendation for a mechanical lift. The staff were not fully aware of the care plan instructions, and the resident's insistence on using the sliding board contributed to the unsafe transfer.
A facility failed to obtain a psychiatric referral for a resident with dementia who exhibited severe psychosis and aggressive behavior. Despite multiple physician recommendations and documented episodes of agitation and paranoia, the necessary psychiatric evaluation was not completed, leading to the resident's hospitalization after an altercation with another resident.
The facility's QAPI Committee failed to maintain procedures and monitor interventions, leading to repeated deficiencies in supervision and accident prevention. Incidents included a resident sustaining a fractured leg during an unsafe transfer, a resident found smoking with oxygen via nasal cannula, and another resident rolling off the bed during care, resulting in injuries and hospitalization.
Medication Error Rate Above 5% Due to Incorrect Medication Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 38 medication administration opportunities, resulting in a 5.26% error rate. During a medication pass observation, a nurse prepared and administered two 100 mg capsules of docusate sodium from a stock bottle to a resident. Record review showed that this resident did not have an order for docusate sodium 100 mg, but instead had an active order, dated 5/29/25, for two tablets daily of a combination product containing sennosides and docusate sodium 8.6-50 mg. The nurse later stated she had not realized she had administered the wrong type of stool softener. In a separate observation with another resident, the same nurse removed and administered one tablet of Calcium 600 mg with Vitamin D 5 mcg from a stock bottle. Record review revealed that this resident had an order, dated 1/8/26, for calcium citrate 950 mg (200) one tablet daily, with the 200 indicating the amount of elemental calcium. The nurse reported that the facility had only one dosage of calcium stocked and that she administered what was available in stock rather than the specifically ordered calcium citrate. The DON later confirmed that the calcium citrate order originated from the hospital and was continued on admission, and that there had been no prior verification with the physician regarding the discrepancy between the ordered calcium supplement and what the facility had in stock.
Expired Food Items Found in Nourishment Room Refrigerators
Penalty
Summary
Surveyors observed that expired food items were stored in three out of four nourishment room refrigerators, specifically in Units 1, 2, and 3. During inspections with the Dietary Manager, an unopened pack of chicken breast strips and green beans with a use by date of 5/13/25 was found in Unit 1, a half-full box of prepacked sandwiches with a best if used by date of 4/27/25 was found in Unit 3, and two bottles of nutritional shake with an expiration date of 5/6/25 were found in Unit 2. The Dietary Manager discarded all expired items upon discovery. Interviews with the Dietary Manager, DON, and Administrator confirmed that both dietary and nursing staff were expected to routinely inspect and remove expired food from nourishment refrigerators, but this was not done, resulting in the presence of expired food items.
Failure to Coordinate Wound Care Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to obtain necessary orders to coordinate care with a resident's podiatrist, resulting in inadequate treatment of a surgical incision site on the resident's right heel. Upon admission, the resident had no orders regarding the care of the surgical incision or the soft cast, despite being discharged from the hospital with a severe heel fracture and subsequent surgery. The facility's wound care nurse practitioner did not remove the soft cast to inspect the incision, citing a lack of supplies and direction to do so, and defaulted to not removing it until the resident was seen by the podiatrist. This led to a significant delay in addressing the resident's wound care needs. The resident's condition deteriorated as the surgical dressing was not removed, and no treatment was provided until the resident's podiatrist visit, where significant maceration was noted. The podiatrist initiated treatment with oral antibiotics and dressing changes, but the resident's condition worsened, requiring further intervention. The facility's failure to communicate with the podiatrist and clarify wound care orders upon the resident's admission contributed to the delay in treatment and the subsequent infection that necessitated hospitalization and additional surgeries. Interviews with facility staff, including the wound care nurse practitioner, nurse, director of nursing, and medical director, revealed a lack of communication and coordination in managing the resident's wound care. The facility relied on the wound care nurse practitioner's orders, which did not include removing the soft cast or initiating dressing changes, and did not question the absence of specific treatment orders. The delay in the resident's podiatrist appointment, due to insurance issues, further exacerbated the situation, as the facility did not proactively seek clarification or orders for wound care, ultimately leading to the resident's hospitalization for infection management.
Resident Falls During Transport Due to Improper Lift Use
Penalty
Summary
The facility failed to ensure the safe transportation of a resident to a physician's visit, resulting in an accident. The incident involved a contracted transportation company's van driver who did not ensure the lift platform was level with the van before rolling the resident out. As a result, the resident fell backwards out of the transport van onto a lift platform that was approximately 3 feet below the level of the van. The resident, who was cognitively intact and used a wheelchair, required substantial to maximum assistance for mobility. The incident was captured on video, which showed the van driver lowering the lift platform all the way to the ground instead of keeping it level with the van. The driver then attempted to roll the resident backwards out of the van, encountering resistance due to the safety mechanisms. Despite this, the driver continued to push, resulting in both the resident and the driver falling out of the van. The resident landed on her back inside her wheelchair, and the driver fell on top of her. The resident was transported to the emergency room for evaluation, where no acute injuries were found. Interviews with the resident, staff, and the van transportation company confirmed the sequence of events. The van company's director acknowledged the driver's mistake and noted that there were no mechanical issues with the van or lift. The driver admitted in a statement that she had mistakenly lowered the lift platform to the ground and did not realize it until the accident occurred. The facility had previously used the transportation company without incident, and the driver had been trained on safety procedures, but failed to apply them correctly in this instance.
Removal Plan
- The Driver was suspended. The lift gate was damaged during the incident and therefore the van was removed from service until repaired.
- The driver was drug and alcohol tested with no findings.
- The driver was interviewed by the contract transport company and maintained that a flap on the van used to keep patients in place failed to drop as expected therefore causing her to trip.
- The transportation contract company owners came to the facility and brought the van that was part of the incident. The administrator, assistant administrator and owners discussed their findings. The owners stated the van was equipped with video camera that was on the dash and pointed toward the back. They reviewed the video footage however stated it was difficult to fully understand what was happening with the lift gate due to resident #7 and her chair being in the center. They stated they also reviewed footage of her earlier transportations for the day and noticed that the sides of the lift gate were not in visible sight as they had been on her earlier transports for the day. The owners maintain that those flaps only stay up if the lift gate is not level. The driver had received certification upon hire on safety as it relates to ensuring the lift gate is even with the van bumper prior to unrestraining a patient and proceeding with unloading.
- The owners had implemented a remediation plan of their own after reviewing the tapes. All transports that have a single driver must call dispatch prior to removing the patient from the van to confirm all safety techniques including having the lift gate level are in place prior to unloading a patient.
- The facility failed to ensure resident #7 was safe during the unloading process of transport resulting in fall from the van.
- Any residents receiving transports are affected by this practice. The transport company implemented that when working alone all drivers will be required to confirm the lift is floor level by walking on the lift and notifying their administration, prior to unloading all residents, that lift is level and safe.
- All drivers received education by the transport company owners on Passenger Assistance Safety which includes lift operating procedures and safety harnesses. This was supplied to the facility by the transport company. Any new driver will receive education by the transport company in orientation and will be sent to administrator as needed. The center contracts with no other transportation company and therefore no further education was required from other companies.
- The Quality Assurance Committee (Regional Director of Clinical Services, administrator, Director of Nursing, Assistant Director of Nursing) met to review the findings and initiated a plan.
- Unit secretary or designee will ride on transport for an audit of 2 transports weekly x 4 weeks, weekly x 8 weeks to ensure the lift gate is level prior to wheeling patient off the van and driver has made all safety checks prior to unloading a patient.
- The audits will be reported to Quality Assurance for further review quarterly x 2.
Privacy Breach During Resident Shower
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's personal and medical records when a Nurse Aide used a cell phone by video chat in the vicinity of an unclothed resident receiving a shower. The incident involved a resident who was cognitively intact but totally dependent on staff for bathing and showering. The resident reported that while being showered by one Nurse Aide, another Nurse Aide, who was supposed to be present as a precaution against false accusations, used her cell phone for a video call within the shower room. The resident felt exposed and believed that the individuals on the call could see her naked. The incident occurred when the Nurse Aide received an emergency call about a sick child and chose to remain in the shower room to take the call, rather than stepping out to maintain the resident's privacy. The privacy curtain was initially in place, but the Nurse Aide moved to a position where the phone was angled towards the resident, causing the resident to feel her privacy was compromised. The resident yelled at the Nurse Aide, who then left the room. The facility's investigation confirmed the incident, noting that the Nurse Aide was present as a second staff member due to the resident's history of making false accusations. The Director of Nursing and the Administrator acknowledged the Nurse Aide's actions were inappropriate, despite the emergency nature of the call, and recognized the need for privacy to be maintained at all times during resident care.
Failure to Administer Scheduled Antibiotic
Penalty
Summary
The facility failed to administer a daily intravenous antibiotic, Ertapenem, to a resident on two consecutive days. The resident, who was admitted with a stage 4 pressure sore and osteomyelitis, was scheduled to receive the antibiotic as part of a six-week treatment plan. The medication was not documented as administered on the resident's Medication Administration Record (MAR) for two days. Nurse #1 confirmed that she did not administer the antibiotic, citing an inability to locate it and a perceived issue with the pharmacy. However, the pharmacy confirmed that the medication had been delivered to the facility, and there were no processing issues reported. The Director of Nursing (DON) initially believed the missed doses were due to a pharmacy issue but later discovered the antibiotic was present in the facility. The pharmacist confirmed the delivery of the medication and reported no record of a call from the facility regarding the missing doses. The resident's physician was informed of the missed doses after the weekend and extended the treatment to compensate for the missed doses. The physician did not believe the missed doses adversely affected the resident.
Failure to Replace Lost Prosthetic Liner
Penalty
Summary
The facility failed to facilitate the replacement of a lost prosthetic liner for a resident with a left below-knee amputation, which hindered the resident's ability to use his prosthesis and walk. The resident, who was cognitively intact but had moderate vision impairment, was unable to continue gait training due to the missing liner. Physical therapy documentation indicated that the resident was unable to perform static standing or ambulate for several days because the gel sleeve for the prosthesis could not be located. Despite notifying the Director of Rehab (DOR) and requesting a replacement, the issue persisted, and the resident was discharged from therapy without meeting his ambulation goals. The resident reported the missing prosthetic liner to 911, prompting a facility service concern report. The report noted that the resident claimed the liner had been missing for 30 days, and the DOR contacted a prosthetic company to check the availability of a replacement. However, the facility did not place the order until after the resident's 911 call, and the prosthetic company required a prescription to proceed. The prescription was sent, but the liner was not in stock, causing further delays. The prosthetic company notified the facility when the liner arrived, but payment was not made until a month later, delaying delivery. Interviews with staff revealed that the DOR was aware of the missing liner after the resident's 911 call, but the Director of Nursing (DON) was not informed until the clinical meeting following the incident. The prosthetic company confirmed that the facility's first request for the liner was made the day after the 911 call, and the liner was delivered only after payment was received. The resident expressed frustration over the lack of assistance in obtaining a new liner, which prevented him from using his prosthesis and continuing therapy.
Inaccurate Medical Record Documentation for Resident Diagnosis
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident regarding their diagnoses. The resident, who had a history of MRSA pneumonia while hospitalized, was inaccurately documented as having pneumonia again while residing at the facility. This error occurred when Nurse #1 entered a verbal order for Ciprofloxacin, an antibiotic, to treat the resident's yellow/green tracheal secretions. Instead of documenting the order for the discolored sputum alone, Nurse #1 incorrectly associated the order with the ICD code for MRSA pneumonia, which was part of the resident's history upon admission. This mistake led to the resident's care plan being updated inaccurately to reflect that the resident had developed pneumonia and was receiving antibiotics for it, despite no diagnosis of pneumonia being made. The resident's responsible party expressed concern about the conflicting information regarding the resident's condition, as they were told both that the resident had and did not have pneumonia. The physician confirmed that the resident had not been diagnosed with pneumonia while at the facility, and the antibiotics were prescribed due to concerns about the color of the resident's mucous.
Failure to Follow Transfer Care Plan Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a Nurse Aide followed a resident's plan of care during a transfer, which resulted in a deficiency. Resident #2, who was severely cognitively impaired and totally dependent on staff for transfers, was supposed to be transferred using a mechanical lift with the assistance of two staff members, as per her care plan. However, on the evening of August 6, 2024, the assigned Nurse Aide, unable to find assistance, manually lifted the resident into bed without using the mechanical lift, contrary to the care plan instructions. Resident #2, who had Alzheimer's disease, contractures, and osteoporosis, was found to have a bluish, swollen foot on July 18, 2024, and later, on August 7, 2024, an x-ray revealed a mildly displaced fracture of the tibia and fibula. The Nurse Aide reported that she had previously lifted the resident manually due to her small size and weight, and other aides had done the same. The Nurse Aide did not believe that her actions caused the fracture, as she was careful during the transfer and the resident did not show signs of pain. Interviews with the facility's staff, including the Unit Manager and the rehabilitation director, confirmed that the Nurse Aide should have used the mechanical lift as per the care plan. The facility's medical director noted that due to the resident's osteoporosis, the fracture could have occurred from minimal trauma or even spontaneously. Despite the uncertainty about the exact cause of the fracture, the failure to follow the care plan was identified as a deficiency.
Failure to Ensure Safe Care Resulting in Resident Injury
Penalty
Summary
The facility failed to provide safe care to a dependent resident, resulting in a facial fracture. Resident #216, who had severe cognitive impairment and was dependent on staff for all activities of daily living, sustained a facial injury when her face hit the bed side rail during care. The incident occurred when Nursing Assistant #3 found the resident with her face against the bed side rail and later noticed blood coming from her mouth. The resident developed bruising on her chin and around her left eye, and a subsequent x-ray revealed a right zygomatic arch fracture. The resident was later hospitalized for shortness of breath, and the hospital confirmed the facial fracture. Interviews with staff and the physician indicated that the resident was nonverbal and could not turn or reposition herself independently, suggesting that the injury was likely caused by the bed side rail during care. The investigation revealed that the resident's bed had side rails that were not supposed to be in use. The Director of Nursing and Corporate Nurse Consultant confirmed that the bed rails were not removed when the resident was moved to a new room, which was a process breakdown. The Administrator acknowledged that the resident had not been assessed for bed rails, which contributed to the accident. The facility's failure to ensure the bed rails were removed and to assess the resident's need for them led to the resident's injury.
Failure to Complete Bedrail Assessments and Maintain Bedrails Securely
Penalty
Summary
The facility failed to ensure a bedrail device assessment was completed prior to the use of bedrails for two residents and failed to ensure bedrails were maintained securely for one resident. Resident #216, who had severe cognitive impairment and was dependent on staff for all activities of daily living, sustained a facial fracture after hitting her face on the bedrail during care. The facility's investigation revealed that no bedrail device assessment was completed for Resident #216, and the resident was not supposed to have bedrails on her bed. The incident occurred when the resident coughed and hit the bedrail with her face, leading to bruising and a subsequent facial fracture identified during a hospital visit for an unrelated condition. Interviews with staff confirmed that the resident was nonverbal and could not turn or reposition herself independently, and the bedrails were not assessed or intended for her use. Resident #66, who was cognitively intact and required partial assistance for mobility, had issues with a loose left siderail that was not securely maintained. Despite the resident's complaints and makeshift solution of bracing the siderail with a dresser, the facility failed to address the issue promptly. The resident's left siderail was observed to be loose and lacking a necessary latch, which prevented it from being securely locked in place. The Maintenance Director attempted to fix the siderail but did not succeed, and the issue persisted. Interviews with staff revealed that the resident had reported the problem to multiple staff members, but no effective action was taken to resolve it. The facility's failure to complete proper bedrail assessments and maintain bedrails securely resulted in significant safety risks for the residents. The lack of assessment and improper maintenance of bedrails led to injuries and ongoing safety concerns. The facility's processes for bedrail assessment and maintenance were found to be inadequate, contributing to the deficiencies observed during the survey.
Repeated Deficiencies in Supervision to Prevent Accidents and Staffing Information
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions, resulting in repeated deficiencies in the area of Supervision to Prevent Accidents (F689). During multiple surveys, including recertification and complaint investigations, the facility was cited for failing to prevent accidents that resulted in significant harm to residents. Specific incidents included a resident found smoking in their room with oxygen in use on three occasions, a resident rolling off the bed during care resulting in a right frontal hematoma and laceration, and a resident sustaining a leg fracture during an unsafe transfer. The facility also failed to ensure peri-care was postponed until the last phase of bathing for a resident and did not shave two dependent male residents as required. Additionally, the facility was cited for failing to post accurate Registered Nurse (RN) staffing information and the resident census on the daily nursing staffing sheets. Despite the QAA committee meeting monthly and attempting to identify areas of concern, the facility continued to show a pattern of inability to sustain an effective Quality Assurance Program. The Administrator revealed that the root cause of the repeat accidents was determined to be the lack of Nursing Assistant competency due to insufficient hands-on training during the Covid pandemic.
Failure to Administer Prednisone as Ordered
Penalty
Summary
The facility failed to administer prednisone as per the resident's hospital discharge summary for 23 days. Resident #166, who was admitted with multiple diagnoses including orthopedic aftercare following surgical amputation, peripheral vascular disease, asthma, pulmonary fibrosis, and interstitial pulmonary disease, was supposed to continue taking prednisone 5 milligrams daily. However, this medication was not ordered until 7/2/23, despite being listed on the discharge summary from the hospital dated 6/9/23. The error was discovered when the resident's family inquired about the medication, leading to the physician being notified and the medication being restarted. Interviews with the physician and the Director of Nursing revealed that the prednisone order was missed during the medication reconciliation process upon admission. The physician confirmed that the resident should have been on prednisone since admission and noted that the missed doses did not cause any harm or deterioration to the resident. The Director of Nursing acknowledged that the medication should have been continued as per the hospital's discharge summary but was not aware of the error until it was brought to their attention by the family in July 2023. The admitting nurse responsible for the oversight was unavailable for an interview.
Failure to Document Vaccine Consent and Education
Penalty
Summary
The facility failed to document that the Pneumococcal and Influenza vaccines were offered and declined, and the reasons for the refusals. Additionally, the facility did not document that residents or their representatives were provided education regarding the benefits and potential side effects of the vaccines. This deficiency was observed in five residents, all of whom had no documented proof of vaccine consent or refusal, nor any evidence of education provided about the vaccines. For instance, Resident #14, who was not cognitively intact, had no consent forms on file, and there was no documented proof of refusal or education provided. Similarly, Resident #55, who was cognitively intact, stated he was never offered the vaccines by the facility, despite his immunization record indicating refusals without documented proof or reasons for refusal and education provided. Other residents, including Resident #59, Resident #92, and Resident #96, also had similar issues with missing documentation and lack of proof of education regarding the vaccines. Interviews with the Infection Preventionist, Nurse Consultant, Director of Nursing, and the facility Administrator revealed inconsistencies and gaps in the documentation process for vaccine consent and refusal. The Infection Preventionist admitted to not having signed VIS consent/declination forms for the residents in question. The Nurse Consultant and Director of Nursing acknowledged that the facility's process for documenting vaccine refusals and education was not followed correctly. The facility Administrator stated that while the facility was not required to get a signed declination or consent, it should have been documented in the electronic medical record or elsewhere. The Nurse Practitioner emphasized the importance of offering vaccinations and educating residents on the risks and benefits, and that refusals should be documented in the medical record along with the reasons for refusal.
Improper Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper urinary catheter care for two residents, leading to deficiencies in maintaining the urine collection bag below the level of the bladder and preventing the urinary drainage bag from coming into contact with the floor. Resident #267, who was admitted with a diagnosis of overactive bladder and had an indwelling urinary catheter, was observed with a leg bag attached to her catheter while lying in bed. Despite the availability of drainage bags, the resident was left with a leg bag for several days, including overnight, due to a reported shortage of drainage bags. This situation was confirmed by multiple staff members, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), who acknowledged the risk of urinary tract infection (UTI) due to the improper use of the leg bag at night. Resident #98, who had obstructive and reflux uropathy and required an indwelling urinary catheter, was observed multiple times with his urinary catheter drainage bag touching or partially lying on the floor. Despite the facility's policy and manufacturer's guidelines stating that the drainage bag should not touch the floor, observations revealed that the bag was not properly secured and often came into contact with the floor. Interviews with the Infection Preventionist (IP) Nurse and other staff members confirmed that the improper positioning of the drainage bag increased the risk of UTIs. The IP Nurse and other staff members attempted to address the issue by adjusting the bed height and securing the bag, but the problem persisted due to the resident's need for a low bed to prevent falls. The facility's failure to maintain proper urinary catheter care for these residents was further highlighted by the lack of communication and coordination among staff members. The Central Supply Clerk and the ADON were aware of the drainage bag shortage but did not effectively resolve the issue in a timely manner. Additionally, the staff's inconsistent adherence to the facility's policies and procedures for catheter care contributed to the deficiencies observed. These lapses in care and oversight put the residents at increased risk for UTIs and other complications related to improper catheter management.
Failure to Involve Resident's Representatives in Medicaid Application
Penalty
Summary
The facility failed to allow a resident's designated representative to decide whether an application for Medicaid would be completed for the resident. This deficiency involved a resident who was admitted with a diagnosis of cerebral infarction and was cognitively impaired, as indicated by a BIMS score of 99. Despite the resident's inability to communicate effectively and the presence of designated representatives (RR#1 and RR#2) responsible for making decisions on his behalf, the Business Office Manager (BOM) proceeded to have the resident sign forms authorizing the facility to apply for Medicaid without consulting the representatives. The BOM, misunderstanding the significance of the BIMS score, believed that a score of 99 indicated the resident could understand and sign the paperwork. The BOM attempted to explain the Medicaid application process to the resident, who nodded but did not verbally respond, and then signed the forms. The BOM did not contact the resident's representatives before obtaining the resident's signature, despite their established role in managing his financial and healthcare decisions. This action caused distress to the resident's representatives when they later discovered the application had been submitted without their consent. Interviews with various staff members, including social workers, nurses, and the Assistant BOM, confirmed that the resident was not capable of making such decisions independently. The staff consistently reported that the resident's cognitive impairment prevented him from understanding complex financial matters. The facility's failure to involve the resident's designated representatives in the Medicaid application process constituted a significant oversight and breach of protocol, leading to the identified deficiency.
Unauthorized Opening of Resident Trust Fund Account
Penalty
Summary
The facility failed to obtain the permission of the responsible party (RP) before opening a Resident Trust Fund account for a resident who was severely cognitively impaired. The resident, who had a diagnosis of cerebral infarction and was unable to communicate, was admitted to the facility with the understanding that his RP and another family member would make decisions for him. Despite this, the Business Office Manager (BOM) had the resident sign the Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form without involving the RP or obtaining their consent. The form was signed by the resident, who had a BIMS score of 99, indicating severe cognitive impairment, and lacked witness signatures as required for an illegible signature or mark (X). The BOM misunderstood the BIMS score and believed the resident could understand and sign the forms, leading to the unauthorized opening of the trust account and the direct deposit of the resident's benefits into it. Interviews with various staff members, including the Social Worker (SW), nurses, and the BOM, revealed that the resident was not capable of making financial decisions for himself. The BOM admitted to explaining the form to the resident and taking his nodding as an indication of understanding, despite his severe cognitive impairment. The BOM also acknowledged that she did not involve the RP or other family members in the process because she could not get them to come in and sign the forms. The resident's family members confirmed that they were not aware of the trust account and had not given permission for its creation. They only became aware of the direct deposit changes through an automated text message and were not informed by the facility. The facility's failure to involve the RP in the financial decision-making process for the resident, who was severely cognitively impaired, led to the unauthorized opening of a Resident Trust Fund account. The account was eventually closed when the resident's family decided to transfer him to a Veteran's Administration (VA) facility and privately pay for his care. The incident highlights a significant lapse in the facility's adherence to protocols for managing residents' financial affairs, particularly for those who are unable to make decisions for themselves.
Failure to Notify Authorities of Abuse Allegation
Penalty
Summary
The facility failed to notify law enforcement and Adult Protective Services (APS) regarding an allegation of staff-to-resident abuse involving one resident. The facility became aware of the abuse allegation on January 30, 2024, at 10:52 AM, when the resident reported that a nurse aide was rough with his legs during care. However, the Administrator did not contact law enforcement or APS, mistakenly believing she had five days to notify them and because the resident retracted his allegation on the fifth day. This failure to report was identified during a review of the initial report sent to the state regulatory agency and confirmed through an interview with the Administrator on May 1, 2024.
Improper Peri-Care Procedure
Penalty
Summary
The facility failed to ensure peri-care was postponed until the last phase of bathing for a resident who was severely cognitively impaired and required maximal assistance with bathing and toileting hygiene. During an observation, a nurse aide was seen using the same washcloth to clean both dirty and cleaner areas of the resident's body, spreading feces in the process. The nurse aide did not notice the feces on the washcloth and continued to clean the resident's back, buttocks, and hamstrings with it. The Director of Nursing confirmed that the nurse aide should have discarded the washcloth after cleaning the dirty area to prevent the spread of feces. The resident's care plan included specific instructions for toileting hygiene and brief changes, which were not followed correctly during the observed incident.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a cognitively impaired and dependent resident from abuse by another cognitively impaired resident. Resident #2, who had a history of paranoia, delusions, and aggression, entered Resident #3's room and assaulted him while staff were attending to other residents during an evening meal. Resident #3 sustained a laceration near his eye, multiple areas of bruising, and expressed fear that the incident would occur again. This incident was observed and reported by multiple staff members and residents, highlighting a significant lapse in supervision and safety measures for vulnerable residents. Resident #2 had a documented history of severe cognitive impairment and behavioral issues, including paranoia, delusions, and aggression. Despite these known issues, the facility's interventions, such as medication adjustments and attempts at psychiatric referrals, were insufficient to prevent the assault. Staff interviews revealed that Resident #2 had exhibited aggressive and paranoid behaviors on multiple occasions, yet he was often easily redirected and had not previously harmed other residents. However, the facility failed to ensure that a psychiatric consult was completed, which may have provided additional insights and interventions to manage Resident #2's behaviors. On the evening of the incident, staff were occupied with other residents, leaving Resident #3 vulnerable to the attack. Multiple staff members, including nurses and nurse aides, responded to the scene after hearing screams and found Resident #3 on the floor with injuries. The facility's investigation revealed that Resident #2 had a history of confusion and agitation, often expressing paranoid delusions about being attacked. Despite these warning signs, the facility did not implement adequate safety measures to protect other residents from potential harm, resulting in the severe assault on Resident #3.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a resident was transferred safely, resulting in Resident #1 sustaining a fractured leg. Resident #1, who had a diagnosis of paraplegia and incomplete quadriplegia, was documented by physical therapy as having impaired strength in all extremities and was totally dependent on staff for transfers. Despite therapy's determination that a sliding board was not appropriate for Resident #1 due to her limited mobility, two nursing staff members used a sliding board to transfer her, leading to the injury. The physical therapy evaluation and progress notes clearly indicated that Resident #1 required a mechanical lift for safe transfers, and this was documented in her care plan and Kardex. However, on the evening of the incident, a nurse and a nurse aide used a sliding board to transfer Resident #1, resulting in her right leg getting caught and subsequently fracturing her femur. The staff involved were not fully aware of the care plan instructions, and Resident #1's insistence on using the sliding board contributed to the unsafe transfer. Interviews with the staff revealed that they were trying to accommodate Resident #1's preferences, despite the established safety protocols. The incident highlights a significant lapse in following the prescribed care plan and ensuring resident safety during transfers.
Failure to Obtain Psychiatric Referral for Dementia Resident
Penalty
Summary
The facility failed to obtain a psychiatric referral as ordered for a resident diagnosed with dementia who exhibited signs of psychosis. The resident, who had a history of severe cognitive impairment and behavioral disturbances, was admitted to the facility following a hospitalization where he had been physically restrained and started on antipsychotic medication. Despite multiple instances of severe agitation, paranoia, and hallucinations, the facility did not ensure that the resident received the necessary psychiatric evaluation and services as ordered by the physician. The resident's medical records and physician notes indicated ongoing issues with agitation, paranoia, and psychotic episodes, including suicidal ideations and aggressive behavior towards staff and other residents. The facility's Director of Nursing noted the need for a psychiatric referral, but the referral was not completed due to the resident's initial refusal. Subsequent physician notes continued to document the resident's severe agitation and psychosis, yet no psychiatric consult was obtained. The resident's condition escalated, leading to multiple incidents of aggressive behavior, including an altercation with another resident. Despite the physician's repeated recommendations for a psychiatric referral, the facility failed to follow through, resulting in the resident being hospitalized after a severe episode of aggression. The facility's Social Services Director later confirmed that the psychiatric referral had been missed, and the resident was only referred for psychiatric services after the altercation occurred.
Repeated Deficiencies in Supervision and Accident Prevention
Penalty
Summary
The facility's Quality Assurance/Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put into place following previous surveys. This resulted in a repeat deficiency related to the failure to provide supervision to prevent accidents. During a complaint survey, it was found that two nursing staff members transferred a resident using a sliding board, despite therapy determining that the resident did not have the functional ability to use it safely. This led to the resident sustaining a fractured leg. Additionally, during a recertification and complaint survey, the facility failed to supervise a resident who was non-compliant with the smoking policy, resulting in the resident being found smoking in their room with oxygen via nasal cannula on three occasions. There were no systems or interventions in place to prevent recurrent noncompliance with the smoking policy by residents. In another incident during a complaint investigation, the facility failed to prevent a resident from rolling off the bed during care, which resulted in a right frontal hematoma, laceration, and right periorbital swelling, leading to hospitalization. These repeated deficiencies over three federal surveys indicate a pattern of the facility's inability to sustain an effective Quality Assurance/Performance Improvement program. Despite the administrator's belief that the QAPI program was effective and had prevented specific incidents from being repeated, the continued occurrence of accidents suggests otherwise.
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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