Cedar Hills Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Clemmons, North Carolina.
- Location
- 3905 Clemmons Road, Clemmons, North Carolina 27012
- CMS Provider Number
- 345131
- Inspections on file
- 30
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Cedar Hills Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
A cognitively intact resident with mobility limitations and a care plan requiring one-person assistance for toileting requested urgent help to the bathroom after receiving a bowel-stimulating medication. One NA responded, turned off the call light, and reported the need to other staff but did not assist the resident. Another NA later entered only to deliver a meal tray, acknowledged the resident’s need for incontinence care, then left to pass trays and assist other residents with eating, citing a supposed rule against providing incontinence care while trays were in the hallway. The resident remained soiled for an extended period, repeatedly used the call light, and ultimately received incontinence care only after a rehab staff member escalated the situation, delaying the resident’s ability to eat and compromising dignity.
A resident with severe cognitive impairment and bowel/bladder incontinence, who required extensive assistance with toilet hygiene, had their call light intentionally disconnected by a NA during an overnight shift to stop repeated call light use. The NA removed the call cord from the wall and inserted a plastic fork into the socket, later providing incontinence care but failing to reconnect the call light. On the next shift, another NA heard the resident yelling, found the fork in the call light socket, and discovered the resident soiled with urine and feces, confirming the resident had been left without the ability to summon assistance.
A resident with bowel and bladder incontinence, joint contractures, and COPD, who required one-person assistance for toileting and transfers, requested help to the bathroom after receiving a bowel stimulant. One CNA responded to the call light, was told of the urgent toileting need, turned off the light, and relayed the request to the nurse and another CNA but did not provide care. The second CNA, citing a long-standing rule against providing incontinence care while meal trays were in the hallway, delayed assisting the resident until after trays were passed and other residents were helped with eating, by which time the resident had soiled herself and required incontinence care instead of toileting. The resident reported repeatedly using the call light and waiting over an hour before a rehab staff member answered and alerted nursing staff, after which incontinence care was finally provided.
The deficiency involves the facility’s failure to provide physician-ordered wound treatments to two residents on weekend day shifts when the wound care nurse was not present. One resident with a recent below-the-knee amputation had orders and a care plan for daily dressing changes and monitoring, but the Treatment Administration Record showed no documentation for two consecutive weekend days; the assigned agency nurse stated she was not informed she was responsible for wound care, and a family member reported bleeding on the sheets and an inability to get the dressing replaced. Another resident with bilateral lower extremity lymphedema and a care plan for pressure ulcer risk had daily orders for Xeroform, abdominal pads, Kerlix, and ace wraps to both legs, but the Treatment Administration Record showed a missed treatment on a weekend day; the assigned nurse, who reported being new and not skilled at wrapping legs, confirmed the treatment was not completed, and the resident verified the treatment was not received. The DON stated that nurses assigned to the hall are expected to complete ordered treatments on weekends.
Surveyors identified a medication error rate above 5% when a nurse, unable to locate a prescribed polysaccharide iron complex capsule for a resident with iron deficiency and other conditions, substituted and administered an acidophilus probiotic tablet that had no corresponding physician order. The nurse stated she believed the two could be interchanged because they were both probiotics. Subsequent interviews with nursing leadership and the NP confirmed that the two medications are different, should not be substituted by staff, and that the provider should have been notified when the ordered medication was unavailable, resulting in the resident not receiving the prescribed iron supplement.
Surveyors observed that medications were not properly stored or labeled on a medication cart. When Vitamin D3 and acetaminophen were missing from one cart, a nurse obtained tablets from another cart, had them poured into open medicine cups (one labeled only as "Vit D3" and one left unlabeled), and then stored these cups in the top drawer of the cart for continued use instead of in original covered, labeled containers. Later, an open cup of tablets labeled only as magnesium, with an unknown number of tablets, was also found in the same cart drawer. The DON confirmed that medications were not supposed to be stored open in medicine cups in the cart.
Surveyors found that the dish machine was operating below the required 120°F wash temperature, with readings between 90°F and 100°F, while dietary staff continued to process dishware. The dietary staff member using the machine was unsure whether it was a high- or low-temperature unit, even though posted instructions specified the correct parameters, and reported that temperatures had been fluctuating for about a week. The DM incorrectly believed the unit was a high-temperature machine, claimed to have submitted a work order that maintenance never received, and could not provide documentation. A regional food service consultant later confirmed the unit was a low-temperature machine and had not been informed of the malfunction, while the Maintenance Director stated he only became aware of the issue after the surveyors’ tour and then discovered hot water was not reaching the machine.
Surveyors found that garbage and refuse were not properly contained or managed in the dumpster area. A large, open construction-type container was overflowing with trash bags, some of which were on the ground, and there was no covering over the container. Two shared dumpsters were observed with doors left open, trash visible inside, and the surrounding gated area littered with cardboard, used gloves, cup lids, paper, an office chair, and a large planter, along with a strong odor. Staff interviews showed uncertainty about who was responsible for keeping the dumpster doors closed and the area clean, and the report notes these conditions had the potential to attract pests and rodents.
The facility did not implement its antibiotic stewardship program as required by its own policy, despite pharmacy tracking sheets showing that multiple residents were on antibiotics over several consecutive months. The policy called for an Infection Preventionist to track antibiotic starts, monitor adherence to evidence-based criteria, and review resistance patterns, but the current DON, responsible for Infection Prevention and Control, could not locate prior infection monitoring or tracking information. The previous DON reported that no antibiotic stewardship program was in place during her tenure and that she received no guidance, while the Administrator stated she expected the program to be in place and that infections were discussed in QAPI meetings, without evidence of a formal stewardship process.
The facility failed to complete baseline care plans within 48 hours of admission for multiple newly admitted residents with complex conditions such as paraplegia, dementia, fractures, CHF, COPD, pneumonia, diabetes, malnutrition, chronic wounds, and chronic pain. Record reviews showed that baseline care plans were missing from the charts, and staff interviews revealed that UMs, the DON, and the Administrator were often unaware that these plans had not been completed. Nurses and UMs gave conflicting statements about who was responsible for the baseline care plans, with some nurses believing UMs would complete them, some UMs stating the admitting nurse was responsible, and one UM reporting she had not been trained. In at least one case, a nurse reported that the baseline care plan was not included on the list of required admission assessments, contributing to the omission.
Surveyors found that the facility failed to maintain documentation of influenza and pneumococcal vaccine consents or declinations and failed to document education on benefits and potential side effects for multiple residents. Several cognitively impaired residents had MDS assessments indicating vaccines were not offered, and their medical records lacked any evidence that vaccines were administered, offered, accepted, or declined, or that education was provided. One cognitively intact resident had a recorded declination of a pneumococcal vaccine without a date and no record of an influenza vaccine for the current season. Another resident had documentation of vaccines given outside the facility in prior periods but no record of being offered the current season influenza vaccine or receiving related education. Interviews with the DONs and the Administrator showed that immunization processes and documentation had not been established or monitored, and staff were unaware whether immunizations were being completed.
A cognitively intact resident was admitted without being informed in writing of the right to accept or refuse medical/surgical treatment or to formulate an advance directive, and no code status or advance directive was documented in the medical record. The resident reported not receiving any paperwork or education on advance directives and expressed a wish to be resuscitated. The SW acknowledged that information on advance directives was only given if residents requested it, and a nurse confirmed there was no code status order in the EMR or code status book. The DON and Administrator each described expectations that admitting nursing staff obtain code status orders and that the SW or other staff explain advance directive choices, but there was no clear process or documentation showing this occurred for the resident.
Surveyors found that the facility did not provide the required CMS SNF-ABN (form 10555) to two residents whose Medicare Part A skilled services were ending while they remained in the facility. Record review showed no documentation that either resident or their representatives received the correct Part A liability notice before skilled coverage ended. The Social Worker, who stated it was her responsibility to issue these notices, instead used an Advance Beneficiary Notice of Non-Coverage form intended for Medicare Part B items and services, and the Administrator reported being unaware that the wrong form was being used.
Surveyors identified that the facility did not develop complete, measurable care plans for two residents in key areas. One resident with cognitive impairment and dependence on staff for ADLs, who expressed that group activities were somewhat important, had no care plan addressing ADLs or activities, which staff attributed to MDS non-triggering and lack of care plan training. Another cognitively intact resident with polyarthritis and metabolic encephalopathy, who participated in discharge planning and had a goal to return to the community, had no discharge planning goals or interventions in the care plan, which the responsible Social Worker and leadership described as an oversight.
A resident with neurogenic bladder, paraplegia, and an indwelling catheter did not receive consistent catheter output monitoring and documentation as ordered, with multiple shifts lacking recorded output and reports from the resident that the catheter bag was sometimes not emptied unless she requested it. Staff and a PA reported seeing full catheter bags with urine backflow. The resident was also observed with dry stool on the buttocks and catheter near the meatus, and an NA applied a brief without cleaning the area despite an order for routine cleansing with soap and water. In addition, ordered daily UA and C&S specimens over three days were not obtained or documented, and a later specimen showed E. coli, while the PA described repeated problems with obtaining ordered urine specimens and needing to reorder tests.
Surveyors found multiple loose, unlabeled pills of various shapes, sizes, and colors in two medication carts on the same hall, stored directly in cart drawers rather than in properly labeled packaging. A nurse and a medication aide each confirmed the presence of these loose medications but could not explain why they lacked required identifying information such as resident name or prescribing details. The Unit Manager reported that staff are expected to audit carts during shift changes and notify her of loose medications, and the DON stated that carts are audited by Unit Managers and the pharmacist and that loose pills should be disposed of, yet neither could explain why loose tablets remained in the carts at the time of the survey.
A cognitively intact resident with fractures, muscle weakness, and anxiety, who required staff assistance with toileting and mobility and used a wheelchair, reported that CNAs delayed more than 30 minutes in responding to her call light for incontinence care and told her not to ring out, which made her upset and mad. A grievance documented that night-shift aides were not changing her in a timely manner and told her not to call for help. The DON and Administrator confirmed that two NAs on the night shift were delayed in providing care and admitted they told the resident not to call out, even if they claimed it was said jokingly, resulting in a failure to treat the resident with dignity and respect.
Two residents who were cognitively impaired and dependent for ADLs did not receive needed nail and facial hair care despite clear care needs and expressed or observed need for grooming. One resident with dementia had long, jagged fingernails with debris under them on repeated observations, even after a NA acknowledged the issue and stated care would be provided. Another resident with a stroke and a hand contracture was observed with long, unshaven facial hair, mild body odor, and long, jagged nails, including a very long thumb nail, after a bath in which the NA had not offered nail care; a family member confirmed the resident appeared unkempt and that nails and facial hair had not been addressed, and there were no documented refusals of care.
A resident with spina bifida, paraplegia, and a stage 4 sacral pressure ulcer did not consistently receive ordered Dakin’s solution and collagen-based wound treatments, as multiple dates on the TAR lacked documentation of completion. Nurses assigned to provide care could not explain missed treatments, and one RN acknowledged that weekend treatments were sometimes not done and simply left unsigned. The wound nurse reported the resident’s concerns about missed weekend care and found that some treatments she provided were not signed off. The cognitively intact resident, dependent on staff for toileting and repositioning, reported that wound care was sometimes not done on weekends and described a specific missed treatment. Wound notes showed periods of deterioration with increased undermining, and the PA and wound NP stated that ordered treatments are necessary and that failure to perform dressing changes can impede or worsen wound healing, while facility leadership was unaware that treatments were being missed.
A resident with a history of C. diff infection and multiple comorbidities developed abdominal tenderness and loose stools, prompting a provider to order stool testing for C. diff on three separate occasions. Despite documented loose stools on multiple days and the provider’s notes that testing was still pending, nursing staff did not obtain a stool specimen for C. diff until several days after the initial and subsequent orders. Laboratory records showed no C. diff result for extended periods following the first two orders, and the specimen was only collected after the third order, at which point the test returned positive. Interviews with the PA, nursing staff, DON, and Administrator confirmed that the facility’s expectation was for ordered C. diff stool samples to be collected promptly, which did not occur in this case.
Surveyors found that the facility failed to follow its enhanced barrier precautions policy for a resident with a sacral wound. The resident’s door lacked required signage and PPE was not available outside the room. An NA began incontinence care wearing only gloves and without a gown, and only donned full PPE after the surveyor intervened upon observing the sacral wound and dressing. In interviews, the NA reported she relied on door signage to know when to use PPE, while the ADON and Administrator confirmed the resident should have been on enhanced barrier precautions with appropriate signage and PPE in place before care.
Survey results were kept in an unlabeled binder mounted high on a lobby wall without any posted notice of its location, making it inaccessible to residents in wheelchairs and unclear to visitors. Reception staff working different shifts had not been educated on what the survey results were or where they were kept, with one believing they were in a wall rack and another thinking they were in a desk drawer. Several residents at a Resident Council meeting reported they did not know what survey results were or where to find them, and the Activity Director confirmed she had not discussed survey results or their location during council meetings and was unsure of their exact placement, while the Administrator knew the general area but was unaware of the lack of labeling, signage, and staff education.
A resident with Alzheimer's and other conditions fell from a waist-height bed during incontinence care, sustaining a head laceration requiring staples. The resident became combative, and the NA, attempting to calm her, inadvertently allowed her to roll off the bed. Staff acknowledged the resident's known behaviors and the need for careful supervision during care.
The facility failed to resolve grievances raised during Resident Council Meetings over several months, including issues with coffee service and laundry. Interviews with residents confirmed ongoing concerns, and the Activity Director and Administrator were unaware of the lack of resolution and documentation.
A resident's monthly weights were not documented as ordered by the physician, with no weights recorded from February to October except for one in October. Interviews revealed a lack of awareness and a system to ensure weights were consistently documented, leading to the deficiency.
A resident was improperly discharged from an LTC facility after returning late from a leave of absence due to car trouble. The facility failed to provide documentation for the discharge, which was directed by the Regional Office Manager, despite the facility being able to meet the resident's needs. The Interim Administrator acknowledged the miscommunication and confirmed the resident should have been allowed to stay.
A resident was discharged from an LTC facility without proper discharge planning after being delayed due to transportation issues. The resident, who was cognitively intact and independent, was not given discharge instructions or prescriptions, leading her to seek medication refills at a hospital. Facility staff were misdirected to discharge the resident due to her absence exceeding 24 hours, which was later acknowledged as an error.
A facility failed to consistently monitor a resident's weight as required by physician orders, leading to incomplete nutritional assessments. The resident's MDS assessments lacked weight data, and the care plan's goals for weight management were not supported by regular evaluations. Staff interviews revealed systemic issues in weight documentation and oversight, contributing to the deficiency.
A resident with hemiplegia and hemiparesis did not receive the recommended restorative range of motion program and splinting devices as advised by the occupational therapist. Observations showed the resident without the necessary splints, and staff interviews revealed a lack of documentation and awareness regarding the application of these devices. The Regional Nurse Consultant confirmed the absence of a physician's order for the splinting devices and exercise program.
A resident with end-stage renal disease did not have a documented physician's order for dialysis services or a specific care plan in place. The facility failed to monitor the resident's condition after dialysis treatments, as vital signs were not taken and the permacath site was not checked for bleeding. Interviews and observations revealed a lack of awareness and oversight in the facility's processes, leading to inadequate dialysis care.
The facility failed to monitor nurse aide registry expirations, allowing a nurse aide to work with an expired listing. The lapse occurred due to the absence of a Staff Development Coordinator and a tracking system, resulting in the aide performing resident care tasks without a valid registry listing.
Two residents in an LTC facility were not provided with adequate privacy, as they lacked privacy curtains and one had an uncovered catheter bag. Despite being reported, the absence of curtains persisted, leaving residents exposed during care. The facility's administration was unaware of these issues until the survey.
Two residents in a facility's 200-hall lacked privacy curtains, affecting their privacy during care. One resident, cognitively intact, had requested a curtain since admission, while the other, cognitively impaired, had been without one for months. Despite reports to the previous housekeeping director, the issue remained unresolved. The new Director of Housekeeping and the Administrator were unaware of the missing curtains.
The facility did not post required contact information for State agencies and advocacy groups, including the State Survey Agency and the Ombudsman program, during a four-day survey. Observations showed no signage in common areas or nursing units, and the Administrator was unsure why postings were missing.
Two residents in the facility did not receive critical medications upon admission, leading to significant medication errors. One resident, with a history of seizures, did not receive antiseizure medications due to delayed pharmacy delivery and lack of stat ordering by the nurse. Another resident, admitted after knee replacement surgery, did not receive prescribed pain medication as it was not available in the emergency backup supply and was not ordered stat. The facility's Administrator was unaware of these issues, and the Pharmacist noted that the lack of antiseizure medication contributed to seizures.
A resident with a urinary catheter experienced abdominal pain and catheter flushing issues, which were not reported to the NP. Additionally, a urinalysis was delayed in being sent to the lab, and the results indicating an infection were not communicated until the resident was hospitalized. Staff interviews revealed a lack of communication and procedure adherence.
A facility failed to report an alleged abuse incident involving a severely cognitively impaired resident with hemiplegia and epilepsy to Adult Protective Services within the required 24-hour timeframe. The resident's family member reported that a male nurse allegedly slapped the resident. The facility's Administrator was informed of the allegation but delayed reporting it to Adult Protective Services. The facility conducted an investigation, suspended the accused nurse, and notified the police, but the allegation was unsubstantiated.
A resident with a suprapubic catheter experienced a delay in urinalysis testing after reporting purple urine, indicating a potential infection. The sample was not sent to the lab promptly, and when tested, it was contaminated. Despite symptoms of pain and distention, the facility did not act on the lab's suggestion for a new sample. The resident was hospitalized with a urinary tract infection due to a clogged catheter.
A resident admitted with a knee replacement did not receive prescribed pain medication due to delays in processing orders and lack of communication. The resident reported a pain level of 6, but the medication was not available, and the emergency backup supply was not utilized. Staff interviews revealed a lack of awareness and action, leading to inadequate pain management.
A resident admitted with a knee replacement did not receive prescribed Oxycodone/Acetaminophen for pain management due to unavailability. The admitting nurse faxed the prescription to the pharmacy but did not receive the medication. The resident was given Acetaminophen instead, and the nurse lacked access to emergency backup medications. The DON and Administrator were not informed, and the prescribed pain management was not provided, resulting in a deficiency.
Failure to Provide Timely Toileting and Incontinence Care, Compromising Resident Dignity
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and timely assistance with toileting and incontinence care. The resident was cognitively intact and had diagnoses including non-progressive congenital joint contractures and COPD, with a care plan indicating a self-care performance deficit and the need for one-person assistance for toileting and transfers. On the day of the incident, the resident had received medication to stimulate a bowel movement and, feeling the medication begin to work, activated her call light at approximately 12:15 PM to request help to the bathroom so she could avoid soiling herself in bed. A nurse aide who was not assigned to the resident (NA #1) responded to the call light within several minutes, was informed of the urgent toileting need, turned off the call light, and told the resident she would return, but did not provide assistance. NA #1 reported that she informed a nurse (Nurse #2) and another nurse aide (NA #2) at the nurses’ station that the resident needed help to the bathroom. Subsequently, NA #2 entered the room to deliver the resident’s lunch tray; by that time, the resident had already had a bowel movement and requested incontinence care. NA #2 turned off the call light and stated she would return, but instead prioritized passing trays and assisting other residents with eating, citing a long-standing rule that residents could not receive incontinence care or toileting assistance while meal trays were in the hallway. The resident reported repeatedly activating her call light and stated she waited over an hour, until approximately 1:22 PM, before a staff member from rehabilitation (the Director of Rehabilitation Services) answered the call light. The resident told this staff member she had been waiting and needed to be changed, and incontinence care was provided only after this was communicated to nursing staff. During this period, the resident remained soiled and delayed eating her lunch until after she received incontinence care. The resident expressed anger, frustration, and dislike of sitting in her feces, noting that at home she had been able to reach the bathroom independently and did not soil herself in an incontinence brief. Facility leadership later confirmed that there was no facility rule prohibiting incontinence care while meal trays were in the hallway and characterized the incident as a dignity issue.
Call Light Disconnected, Leaving Dependent Resident Soiled and Without Access to Assistance
Penalty
Summary
A resident with chronic kidney disease, hypertension, severe cognitive impairment, and bowel and bladder incontinence required substantial to maximum assistance with toilet hygiene. During an overnight shift, the assigned nursing assistant reported that the resident repeatedly pressed the call light, sometimes without needing assistance, and continued to hold the call light in his hand. Around 5:15 a.m., the nursing assistant removed the resident’s call light cord from the wall socket and inserted a plastic fork into the socket to prevent the call light from ringing while she completed her last round. She stated she informed the nurse on duty, who told her she could not do that and instructed her to reconnect the call light. The nursing assistant later returned to the resident’s room between approximately 5:30 a.m. and 5:45 a.m. to provide incontinence care but forgot to reinsert the call light cord. On the following day shift, another nursing assistant assigned to the resident heard yelling from the resident’s room upon arrival to the unit. When she entered, she observed a plastic fork in the call light socket and the resident reported that someone had removed his call light, though he could not identify who. The resident was found soiled with urine and feces and was taken for a shower. The day-shift nursing assistant reported the situation to the nurse, who then observed the fork in the socket, removed it, and reconnected the call light cord. The facility’s review of records and staff interviews determined that the resident’s call light had been intentionally disconnected by staff, leaving the resident unable to access assistance and resulting in the resident being found soiled with urine and feces on the next shift.
Failure to Provide Timely Toileting and Incontinence Care When Requested
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with toileting and incontinence care to a resident who was unable to perform these activities independently. The resident had non-progressive congenital joint contractures and COPD, was assessed as incontinent of bowel and bladder, and was care planned to require one-person assistance for toileting and transfers. Therapy documentation showed the resident could transfer with assistance using a walker and wheelchair to reach the commode. On the day of the incident, the resident reported receiving medication to stimulate a bowel movement and, when she felt it begin to work, she activated her call light requesting help to the bathroom because she believed she could get there with assistance and wanted to avoid having a bowel movement in bed. According to the resident, a nurse aide responded to the first call light within several minutes, was informed of the urgent toileting need, turned off the call light, and said she would return, but no one came. The resident then activated the call light again, at which time another nurse aide entered to deliver a lunch tray. The resident reported that she informed this aide that she now required incontinence care because she had not been assisted to the bathroom and had soiled herself; this aide also turned off the call light and stated she would return. The resident stated she waited, became angry, and again activated her call light, which was eventually answered by the Director of Rehabilitation Services, to whom she reported that she had been waiting for over an hour and needed to be changed. Staff interviews confirmed that the first nurse aide, who was not assigned to the resident and was unfamiliar with her needs, responded to the call light, turned it off, and relayed the toileting request to the nurse and the second nurse aide at the nurses’ station. The second nurse aide acknowledged being informed that the resident needed assistance to the bathroom but stated that there was a long-standing rule that residents could not receive incontinence care or toileting assistance while meal trays were in the hallway, and she waited until after trays were passed and she had assisted other residents with eating before providing incontinence care and reheating the resident’s lunch. The nurse on duty stated that the resident’s call light may have been on about ten minutes before the first aide answered it and confirmed that the toileting request occurred as meal trays were being delivered. The Director of Rehabilitation Services reported answering the call light later, finding that the resident needed to be changed and had been waiting, and then notifying nursing leadership of the resident’s needs.
Failure to Provide Physician-Ordered Wound Treatments on Weekends
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatments as ordered by physicians and as outlined in residents’ care plans. Resident #5, who had a right below-the-knee amputation, had a physician’s order dated 3/3/2026 to wrap the amputation site with an abdominal pad and Kerlix daily and as needed, and to monitor the site for signs and symptoms of infection. The care plan for Resident #5 included a focus area for a surgical wound to the right lower extremity with an intervention to follow facility protocols for treatment. The Treatment Administration Record showed blank documentation for the ordered wound treatment on 3/7/2026 and 3/8/2026. Nurse #1, an agency nurse assigned to the resident on those dates, stated she had not been informed she was responsible for completing wound treatments over the weekend and confirmed that if the treatment was not checked off, she did not complete it. A family member reported that wound care was not provided that weekend, that the area was bleeding on the sheets, and that she could not get the nurse to replace the dressing, leading her to attempt to put the dressing on herself. Resident #16, admitted with bilateral lower extremity lymphedema, had a care plan focus area initiated on 4/14/2026 for risk of pressure ulcer development related to lymphedema, with an intervention to administer treatments as ordered and monitor for effectiveness. A physician’s order dated 4/15/2026 directed staff to apply Xeroform gauze to both legs, cover with abdominal pads and Kerlix from behind the toes to below the knees, and apply an ace wrap in the same manner every day shift. The Treatment Administration Record for Resident #16 showed a blank documentation space for the ordered treatment on 4/19/2026. Nurse #3, who was assigned to the resident that day, stated she did not remember whether she administered the treatment, acknowledged she was a new nurse and not very skilled at wrapping legs, and confirmed that if the treatment was not checked off, she did not complete it. Resident #16 confirmed she did not receive her leg treatment on that date. The Director of Nursing stated that nurses assigned to the hall are responsible for completing treatment orders on weekends when the wound care nurse is not in the building and that both nurses should have completed the ordered treatments.
Medication Error Due to Unordered Substitution of Probiotic for Prescribed Iron Supplement
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 2 errors out of 33 opportunities, resulting in a 6.06% error rate during a medication pass for one resident. The resident involved had diagnoses including anemia, iron deficiency, and hyperlipidemia and a physician’s order for polysaccharide iron complex 150 mg by mouth once daily for deficiency. During a continuous observation of medication administration, the nurse assigned to the resident’s medication pass was unable to locate the ordered polysaccharide iron complex on her medication cart or in the medication storage room. Despite the absence of a corresponding physician order, the nurse poured an acidophilus 500 million tablet into the resident’s medication cup and stated that, since both medications were probiotics, one could be substituted for the other, then administered the acidophilus along with the resident’s other medications. Interviews with the nurse and multiple supervisory staff revealed differing descriptions of the process to follow when a medication is not available, including checking other carts, overstock, medication rooms, Pyxis, and contacting Central Supply, the provider, or family, depending on whether the medication was house stock, over-the-counter, or prescription. The DON later confirmed that polysaccharide iron complex and acidophilus are different medications and should not be substituted. The nurse practitioner stated that if a medication is not available, staff should notify him so he can place the medication on hold until it is received, and that acidophilus probiotic is not the same as polysaccharide iron complex and staff should not make such substitutions. He also stated that staff should have notified him of the administration of acidophilus in place of the ordered iron supplement, and that while no harm occurred, the resident did not receive the intended benefits of the prescribed polysaccharide iron complex.
Improper Storage and Labeling of Stock Medications on Medication Cart
Penalty
Summary
The deficiency involves failure to properly label and securely store medications in accordance with professional standards on one of two medication carts reviewed (300-hall medication cart #1). During a continuous medication administration observation for Resident #12, the assigned nurse did not have a bottle of Vitamin D3 (cholecalciferol) 25 mcg/1000 units in her cart or in the medication storage room. She obtained the medication from another cart on the same hall, where the unit manager poured 8 tablets of Vitamin D3 into a medicine cup, labeled the cup "Vit D3," and handed it to her. The nurse then placed this open medicine cup into the top drawer of her medication cart for continued use instead of storing the medication in its original covered and labeled bottle. In a subsequent continuous observation for Resident #10, the same nurse did not have Acetaminophen 500 mg in her cart and again obtained the medication from the unit manager’s cart. The unit manager poured 12 tablets of Acetaminophen 500 mg into an unlabeled medicine cup and gave it to the nurse, who placed the open, unlabeled cup in the top drawer of her cart for ongoing use, stating she did not have a pen to label it. Later observation of the same cart, with the DON present, revealed that although the previously observed cups of Vitamin D3 and Acetaminophen had been discarded, there was an open medicine cup of white tablets labeled “Magnesium” in the top drawer, about half full, with an unknown number of tablets. The DON stated medications were not supposed to be stored open in medicine cups in the medication cart.
Failure to Maintain Required Dishwashing Temperatures and Communication Breakdowns
Penalty
Summary
The facility failed to ensure its low-temperature dishwasher maintained the required wash temperature of 120°F, as observed during a kitchen tour when three checks of the dish machine showed water temperatures ranging from 90°F to 100°F. During this time, dietary staff continued to send dishware through the machine despite the substandard temperatures. The dietary staff member operating the machine was unsure whether it was a high- or low-temperature unit and relied on the manufacturer’s instructions posted on the machine, which specified a 120°F wash temperature and 50 ppm chlorine during the rinse cycle. He reported that the machine’s water temperature had been fluctuating for approximately one week and stated he had informed the Dietary Manager when the temperature decreased, but he did not explain why he continued to wash dishware in the malfunctioning machine. The Dietary Manager stated in an interview that the dishwasher was a high-temperature machine and acknowledged awareness of the fluctuating water temperatures, claiming to have submitted an electronic work order to maintenance, though she did not provide a copy when requested. A Regional Food Service Consultant later confirmed that the dishwasher was in fact a low-temperature machine and reported she had not been aware that it was not operating correctly. The Maintenance Director stated he first learned of the temperature issue after the initial kitchen tour and reported that he had not received any verbal or electronic work order from dietary. Upon inspection, he found that hot water was not reaching the dish machine, and both hot water tanks were subsequently replaced. These events demonstrate that the dishwashing process did not meet required temperature standards for proper operation over at least several days prior to the surveyors’ observation.
Improper Trash Disposal and Unsanitary Dumpster Area
Penalty
Summary
Surveyors observed that the facility failed to properly dispose of garbage and refuse in the dumpster area. On multiple observations, a large, open-to-air construction-type container was found overflowing with bags of trash, with additional bags on the ground next to the building. There was no covering or tarp over this container or the trash bags. Over several days of observation, the condition of this construction-type container did not change, and it continued to be used as an uncovered trash receptacle. In addition, two trash dumpsters located in a gated, fenced area at the back of the parking lot were found with their side doors open and trash visible inside. The surrounding area was littered with cardboard pieces, used plastic gloves, plastic cup lids, paper, an office chair lying on its side, and an upside-down large planter on the ground. A pungent odor was noted within the gated dumpster area. Staff interviews revealed that the dumpsters were shared with a neighboring facility, and the Dietary Manager was unsure who was responsible for keeping the dumpster doors closed and the enclosed area clean. The report states these practices had the potential to attract pests and rodents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its antibiotic stewardship program as required by its own policy, which had the potential to affect all 87 residents. The written policy, effective 12/2025, stated that the Antibiotic Stewardship Program was intended to optimize the infection prevention program by guiding treatment of infections and reducing adverse events associated with antibiotic use. The policy specified that the Infection Preventionist would use expertise and data to track antibiotic starts, monitor adherence to evidence-based criteria for evaluation and management of infections, and review antibiotic resistance patterns in the facility. Pharmacy services produced antibiotic use tracking sheets showing that 25 residents were on antibiotics in November 2025, 37 in December 2025, and 40 in January 2026, but there was no evidence that these data were being used within a functioning stewardship program. During interviews, the current DON, who had been in the role since the end of December 2025 and was responsible for the Infection Prevention and Control program, stated she was in the process of getting the Antibiotic Stewardship Program in place but was unable to locate any information from prior months. When asked about monitoring and tracking infections, she reported she could not find any information for the prior months. The previous DON, who served from 9/2025 to 12/2025, confirmed by telephone that she did not have an antibiotic stewardship program in place and that no one had provided her with guidance or instructions. The Administrator stated she expected the antibiotic stewardship program to be in place per protocol and reported that infections were discussed during QAPI meetings, but there was no indication that a formal antibiotic stewardship program, as described in the facility policy, had been implemented.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop baseline care plans within 48 hours of admission for multiple residents. For nine of thirty sampled residents, there was no documented evidence that a baseline care plan had been completed, despite diagnoses and conditions that required coordinated care. These residents included individuals with paraplegia and neuromuscular bladder dysfunction, closed fracture, dementia, type 2 diabetes, hypothyroidism, hypertension, dementia with a history of falls, protein calorie malnutrition, chronic wounds, acute on chronic systolic congestive heart failure, acute respiratory failure, displaced femur fracture, chronic obstructive pulmonary disease (COPD), influenza, pneumonia, fractures of the hand and pelvis, diabetes, chronic pain syndrome, and other serious conditions. In each case, record review showed that the baseline care plan was either missing or had not been developed by the time of the surveyor’s review. Staff interviews revealed a lack of awareness and inconsistent understanding of responsibility for completing baseline care plans. Unit managers repeatedly stated they were not aware that baseline care plans had not been completed for specific residents and confirmed, after attempting to locate them, that they did not exist. The DON consistently stated that the admitting nurse was responsible for completing the baseline care plan, with the expectation that if the admitting nurse did not complete it, the oncoming nurse or unit manager would do so within the required timeframe. However, the DON also acknowledged not knowing why the baseline care plans had not been completed for several residents. In some interviews, unit managers stated that the baseline care plan was part of the admission process and should be completed at the time of admission, while in other interviews, staff indicated that the baseline care plan was not included in the list of required admission assessments. Additional interviews highlighted confusion and lack of training among nursing staff regarding who was responsible for baseline care plan completion. One nurse who admitted a resident with influenza, pneumonia, and COPD stated that the baseline care plan was not on the list of assessments to be completed for new admissions and believed the unit manager would complete it, even though she was aware of the 48-hour requirement. Another nurse assigned to a resident with multiple pelvic fractures and COPD did not complete the baseline care plan, believing the unit manager was responsible. The unit manager who assisted with that admission stated she did not complete the baseline care plan because she had not yet been trained and thought the admission nurse was responsible. Administrators interviewed were not aware that baseline care plans had not been completed for the affected residents, though they stated they expected baseline care plans to be completed within the regulatory timeframe. Across all nine residents cited, the common factors leading to the deficiency were the absence of completed baseline care plans in the medical records within 48 hours of admission and inconsistent or incorrect assumptions among staff about who was responsible for completing them. The surveyors’ findings were based on record reviews that failed to show any baseline care plans and on staff interviews that confirmed the plans had not been developed, despite staff acknowledging that such plans should be completed within 24–48 hours of admission to address residents’ immediate needs.
Failure to Document Flu and Pneumonia Vaccine Consents, Declinations, and Education
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of influenza and pneumococcal vaccination consents or declinations, as well as failure to document education on the benefits and potential side effects of these vaccines, for all five residents reviewed. For a cognitively intact resident admitted on a specified date, the MDS showed she was not offered the influenza vaccine and had declined the pneumococcal vaccine, but her medical record did not contain the date of declination, any documentation of an influenza vaccine for the current season, or any record that the vaccines were offered, accepted, or declined, or that education was provided. During interview, this resident could not recall whether she had been offered either vaccine, and the facility could not produce supporting documentation. For a severely cognitively impaired resident, the MDS indicated the resident was not offered influenza or pneumococcal vaccines, while the medical record stated the resident declined both vaccines without including dates of declination. The facility was unable to provide documentation that either vaccine was offered, that the resident or responsible party had the opportunity to accept or decline, or that education on benefits and potential side effects was provided. Another severely cognitively impaired resident had no documentation in the medical record for either influenza or pneumococcal vaccination, and the MDS also indicated the resident was not offered these vaccines. The facility again could not provide evidence that the vaccines were offered, that a decision was made by the resident or responsible party, or that any vaccine education occurred. A further severely cognitively impaired resident had documentation that a pneumococcal vaccine and a prior season influenza vaccine were administered outside the facility, but there was no documentation of an influenza vaccine for the current season. The MDS indicated this resident was not offered the influenza vaccine, and the facility could not provide documentation that the current season influenza vaccine was offered, that the resident or responsible party had the opportunity to accept or decline, or that education was provided. Another resident with moderate cognitive impairment had no documentation in the medical record for either influenza or pneumococcal vaccines, and the MDS indicated these vaccines were not offered. Interviews with the current DON, the previous DON, and the Administrator revealed that the current DON had not yet started gathering immunization information, the previous DON had not received guidance on resident immunizations and did not know if they were being done, and the Administrator was unaware that immunizations had not been completed or offered, despite expecting that residents would receive education and consent per protocol.
Failure to Inform Resident of Treatment Rights and Advance Directive Options
Penalty
Summary
The facility failed to inform and provide written information to a cognitively intact resident regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. The resident was admitted on a specified date, and the nursing admission assessment documented that the resident was cognitively intact. However, there was no documentation in the medical record that the resident had been informed of the right to accept or decline medical or surgical treatment prior to making an advance directive decision, nor was there any advance directive or code status documented. During interview, the resident reported not receiving any paperwork or education on advance directives and stated a desire to be resuscitated if the heart stopped. Staff interviews confirmed the lack of required information and documentation. The Social Worker acknowledged that the facility had not informed the resident of the right to accept or decline treatment or to formulate an advance directive and explained that her practice was to provide advance directive information only if residents requested it. A nurse verified there was no code status order in the physician orders or in the code status book and was unsure why an order was missing. The DON stated she expected the admitting nurse to obtain code status and a physician order, and the Social Worker to provide advance directive education, while the Administrator stated an expectation that staff explain advance directive choices and that a code status order be in place, but was unaware that written documentation needed to be provided or who was responsible for providing it.
Failure to Provide Required SNF-ABN Notice for Ending Medicare Part A Coverage
Penalty
Summary
The facility failed to provide the required CMS Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) form 10555 to residents whose Medicare Part A skilled services were ending while they remained in the facility. For one resident admitted to Medicare Part A skilled services on 11/6/25, Part A coverage ended on 11/28/25, but record review showed no documentation that the resident or responsible party received the SNF-ABN prior to discharge from Part A services. Instead, the Social Worker reported that on 11/26/25 she issued an Advance Beneficiary Notice of Non-Coverage form intended for Medicare Part B items and services, meaning the resident did not receive the correct Part A liability notice required by CMS. A second resident was admitted to Medicare Part A skilled services on 11/28/25, with Part A coverage ending on 12/17/25, and this resident also remained in the facility after skilled services ended. Record review again showed no documentation that the resident or responsible party received the SNF-ABN form 10555 prior to discharge from Part A services. The Social Worker stated it was her responsibility to issue the SNF-ABN and acknowledged that on 12/15/25 she provided the same incorrect Advance Beneficiary Notice of Non-Coverage form used for Medicare Part B instead of the required SNF-ABN. In an interview, the Administrator stated she was not aware that the Social Worker had been using the wrong form and confirmed that both residents should have received the CMS SNF-ABN form 10555 as required by federal guidelines.
Failure to Develop Comprehensive Care Plans for ADLs, Activities, and Discharge Goals
Penalty
Summary
Surveyors found that the facility failed to develop comprehensive care plans for activities of daily living (ADLs) and activities for one resident, and for discharge planning for another resident. One resident with neurocognitive disorder with Lewy bodies and muscle weakness had a significant change MDS assessment indicating cognitive impairment and dependence on staff for personal hygiene, bathing, and toileting, and that it was somewhat important to participate in group activities. However, review of the comprehensive care plan showed no care plan for ADLs or activities. The MDS Coordinator stated that the resident was dependent on staff for ADLs per the MDS but was not care planned because the care area did not trigger on the MDS. The Assistant Activities Director, who completed the significant change MDS and coded the resident as finding group activities somewhat important, acknowledged that she did not create an activities care plan because she had not yet been trained on how to complete a care plan and agreed one should have been developed. The Administrator confirmed that care plans for ADLs and activities should have been developed and was unsure why these areas were omitted. For another resident admitted with polyarthritis and metabolic encephalopathy who later discharged home, the admission MDS showed the resident was cognitively intact, participated in discharge planning, and had a goal to return to the community. Despite this, the comprehensive care plan contained no goals or interventions related to discharge planning. The Social Worker, who reported being responsible for discharge planning and related care plans, stated she was aware of the resident's goal to return to the community but had not developed a discharge care plan and characterized this as an oversight. The DON and Administrator both indicated that the Social Worker should have created a discharge care plan and also described the omission as an oversight.
Failure to Provide Ordered Catheter Care, Output Monitoring, and Timely Urine Testing
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered catheter care, monitoring, and timely diagnostic testing for a resident with complex urologic conditions. The resident had spina bifida with hydrocephalus, paraplegia, neuromuscular dysfunction of the bladder, and a history of UTI, and was admitted with an indwelling urinary catheter related to neurogenic bladder. The care plan and physician orders required monitoring and documenting catheter output on day and night shifts, and monitoring for signs and symptoms of UTI. Review of the Treatment Administration Records showed multiple days across December, January, and February when catheter output was not documented on both day and night shifts. The resident reported that on some days the catheter bag was not emptied at all and that she had to ask staff to empty it. Staff interviews revealed that NAs sometimes emptied catheter bags and reported amounts to nurses, while a nurse and the PA both stated they had observed full catheter bags with urine backflow toward the resident. The facility also failed to provide appropriate catheter hygiene and perineal care as ordered. A physician order directed cleansing with soap and water every day and night shift. During an observation, dry brown stool was seen on the resident’s lower buttocks and on the urinary catheter from the meatus to the middle of the catheter. An NA was observed applying an adult brief over the area without cleaning the stool from the catheter. In a subsequent interview, the NA acknowledged that the stool had been present before she applied the brief and stated it should have been removed before the brief was applied, noting that the resident was not on her assignment. The PA stated that if stool remained on a urinary catheter and was not cleaned properly, it could cause a UTI. The DON and ADON both stated they would expect catheter care to be provided when needed, regardless of staff assignment. Additionally, the facility failed to obtain ordered urine analysis and culture and sensitivity specimens within the ordered timeframe. A physician ordered a UA and C&S once daily for three days, but the TAR showed no documentation that these specimens were obtained on the ordered dates. A later UA and C&S obtained on a subsequent date showed the resident was positive for E. coli. The PA reported there had been ongoing issues with specimens not being obtained, requiring him to reorder UAs multiple times and sometimes change antibiotics after results were finally received. Nursing leadership stated they expected licensed staff to collect specimens when ordered and to notify the provider if a specimen could not be obtained, and the Administrator stated that if a specimen could not be obtained, the PA should be called and the specimen should be obtained within 24 hours.
Loose, Unlabeled Medications Found in Two Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling and storage of medications when multiple loose, unlabeled pills were found in two of four medication carts observed on Hall 300. During an observation of Medication Cart #2 with a nurse present, surveyors noted several loose tablets of various shapes, sizes, and colors in multiple drawers of the cart, including pink, yellow, brown, white, and orange tablets, some marked and some unmarked. These pills were not in original packaging and lacked required identifying information such as the resident’s name or prescribing information. When questioned, the nurse confirmed the presence of the loose tablets and was unable to explain why medications were stored without the minimum required labeling information. A similar observation of Medication Cart #1 on the same hall, conducted with a medication aide present, revealed additional loose, unlabeled tablets and a capsule of various colors and sizes in several drawers of that cart. The medication aide confirmed the presence of these loose medications and likewise could not explain why they were stored without required identifying information. In subsequent interviews, the Unit Manager stated that staff were expected to audit medication carts during shift change and report any loose medications, but could not explain why loose pills were present in both carts. The DON reported that medication carts were audited by Unit Managers and the pharmacist and stated that all loose pills should be disposed of, but was also unable to explain why loose tablets were found in the two medication carts during the survey.
Delayed Call-Light Response and Disrespectful Communication Undermine Resident Dignity
Penalty
Summary
The facility failed to honor a resident's right to be treated with dignity and respect when staff delayed responding to her call light and told her not to call for help. The resident, who had been admitted with fractures of the left hand and left radius, muscle weakness, and anxiety, was cognitively intact and required staff assistance with toileting, bed mobility, and transfers, and used a wheelchair for mobility. According to a grievance initiated by the Social Worker, the resident reported that CNAs were not changing her in a timely manner and that night-shift aides were not coming in promptly; when they did respond, they told her not to ring out. In an interview, the resident stated that nursing assistants made her wait over 30 minutes for incontinence care after she used her call light and told her not to call for help, which made her upset and mad. She could not recall the exact date of the incident but confirmed that a grievance had been submitted. The DON and Administrator later indicated that their investigation showed that two nurse aides assigned to the resident’s hall during the night shift were delayed in providing care and admitted to telling the resident not to call out for assistance, stating they did so in a joking manner. The DON acknowledged that these staff did not treat the resident with respect.
Failure to Provide Dependent Residents with Nail and Facial Hair Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically nail care and facial hair care, to dependent residents. One resident with non-Alzheimer’s dementia, moderate cognitive impairment, and dependence for bathing, dressing, and personal care had a care plan identifying a self-care deficit and the need for assistance with clean and trimmed nails. On observation, this resident’s ten fingernails were approximately half an inch long, jagged, and had brown debris underneath. The resident expressed a desire for nail care and held up her hands. The assigned nurse aide acknowledged the nails were long and stated she would provide care, but a subsequent observation days later showed the nails remained untrimmed with debris still present, and the resident again held up her hands while the assigned aide admitted nail care had not been offered that morning. Another resident with a history of stroke, severely impaired cognition, a right-hand contracture, and dependence for all ADLs had care plans and physician/psychiatry notes indicating stability, no reported refusals, and a need for assistance with bathing, dressing, and nail care on bath days. Facial hair care was not addressed in the care plan. On observation, this resident had mild body odor, long facial hair on the upper lip, chin, and lower cheeks, and long nails, including a right thumb nail about an inch long and jagged. The resident indicated wanting a shave. The assigned nurse aide reported not having offered nail care during the bath and stated she would provide nail and facial hair care, but a later observation showed the resident’s nails and facial hair unchanged. A family member visiting at the time confirmed the facial hair was the longest he had seen, described the resident as looking ragged and needing a shave, and noted dirty nails needing trimming, particularly the sharp right thumb nail, and stated he had not been informed of any refusals of care.
Failure to Consistently Provide and Document Ordered Stage 4 Pressure Ulcer Treatments
Penalty
Summary
Failure to provide ordered pressure ulcer care occurred when nursing staff did not consistently complete or document prescribed sacral wound treatments for a resident with a stage 4 pressure ulcer. The resident, who had spina bifida with hydrocephalus, paraplegia, and impaired mobility, was care planned for a stage 4 sacral pressure ulcer with goals for healing and prevention of infection. Physician orders included Dakin’s solution dressings and later collagen powder with Dakin’s-moistened rolled gauze packing and a silicone super absorbent dressing, to be applied daily and as needed. The Treatment Administration Records (TARs) for December, January, and February showed multiple dates on which these treatments were not documented as administered. Record review identified missing treatment documentation on several specific dates in December, January, and February. Nurses assigned to provide the wound care on some of those dates, including Nurse #4 and Nurse #1, were unable to explain why the treatments were not completed, with Nurse #1 acknowledging that on weekends she could not always administer treatments and would simply not sign the TAR. The wound care nurse reported that the resident had voiced concerns that wound treatments were not being done on some weekends and confirmed that, although she had provided wound care on certain dates, those treatments were not signed off on the TAR. Attempts to interview another nurse responsible for a missed treatment date were unsuccessful. The resident, who was cognitively intact and dependent on staff for toileting, personal hygiene, and rolling, reported that wound treatments were sometimes not administered on weekends and specifically identified a recent date when treatment was not done. Nurse aides stated that when residents asked about wound care, they would notify the nurse and then inform the resident that the nurse was aware. Wound progress notes documented that the stage 4 sacral ulcer initially showed granulation tissue and later periods of deterioration with increased undermining. The physician assistant and wound nurse practitioner both stated that wound treatments are ordered for a reason and that failure to provide dressing changes as ordered could cause the wound to not progress or worsen. The DON and Administrator were not aware that wound treatments were not being administered on some weekend days and stated their expectation that treatments be provided according to physician orders.
Failure to Timely Obtain Ordered C. diff Stool Testing
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely ordered Clostridium difficile (C. diff) stool test for a resident with a history of C. diff infection who was experiencing abdominal tenderness and loose stools. The resident was admitted from a hospital with multiple diagnoses including declining functional status, pulmonary embolism, prior vaginal and rectal bleeding secondary to anticoagulant use, past C. diff infection, right hip osteoarthritis, depression, anxiety, obstructive sleep apnea, and generalized weakness. On 12/29/25, a provider documented abdominal tenderness on exam and ordered stool testing for C. diff. Bowel and bladder records showed a loose stool on 12/31/25, but there was no documented collection or result of a C. diff stool test following this order. In early January, the resident continued to have loose stools. A 1/2/26 provider note referenced multiple recent loose stools and indicated that the resident’s abdominal pain had resolved, with notation that stool testing for C. diff was still pending. Bowel and bladder records documented loose stools on 1/4/26 and 1/6/26, on days when Nurse #4 was assigned to the resident; however, Nurse #4 later reported being unable to recall the resident or why a stool sample was not collected on those dates. Laboratory records from 12/31/25 through 1/7/26 showed no C. diff stool result. A second order for C. diff stool testing was placed on 1/7/26, but again, no stool result was documented between 1/7/26 and 1/14/26. A third order for C. diff stool testing was placed on 1/11/26. On 1/8/26, the provider documented occasional loose stools, a history of diarrhea controlled with loperamide, and noted that the ordered C. diff stool had not yet been collected, despite having spoken with nursing staff and verbally requested collection. On 1/15/26, the provider documented that the resident appeared uncomfortable, reported stomach pain prior to bowel movements that was sometimes relieved afterward, and continued to have loose stools, with physical exam showing dull, nonspecific abdominal tenderness and active bowel sounds. The stool specimen was finally collected on 1/15/26, and on 1/16/26 the result was positive for C. diff. Interviews with nursing staff, the Physician Assistant, the DON, the Regional Nurse Consultant, and the Administrator confirmed that the expectation was for stool samples ordered for C. diff testing to be collected as soon as possible, but in this case the ordered testing was not obtained until after multiple orders and ongoing loose stools.
Failure to Implement Enhanced Barrier Precautions for Resident With Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policies for enhanced barrier precautions for a resident with a sacral wound. The facility’s policy, last revised in December 2025, required enhanced barrier precautions to prevent transmission of multidrug-resistant organisms. On two separate observations of the resident’s room and the hallway outside, there was no enhanced barrier precaution signage on the door and no PPE available outside the room, despite the resident having a sacral wound. During an observation of incontinence care, the nurse aide initially entered the room and began care wearing only gloves, without a gown, and turned the resident before the surveyor intervened upon noticing the sacral wound and foam dressing. After being stopped, the nurse aide removed her gloves, performed hand hygiene, exited the room, and then reentered wearing a surgical mask and gown and donned gloves before continuing care. In an interview, the nurse aide stated she would have donned PPE before providing care if enhanced barrier precaution signage had been posted, explaining she had been trained to put on PPE when a sign was present. The ADON confirmed that the resident had a wound, should have had an enhanced barrier precautions sign on the door, and that the nurse aide should have donned PPE prior to providing care. The Administrator also stated that her expectation was that residents requiring enhanced barrier precautions would have signage and accessible PPE prior to care.
Failure to Provide Accessible and Clearly Identified Survey Results
Penalty
Summary
The facility failed to make survey results readily accessible and known to residents and visitors. On one survey day, the survey results binder was observed in the lobby in an unlabeled binder placed about five feet off the ground in a wall-mounted wire rack, with no posting or indication of what it was or where survey results were located. This placement made it impossible for residents in wheelchairs to reach the binder without assistance. A facility-wide observation also revealed there was no posted notice anywhere in the building indicating the location of the survey results. Interviews with staff and residents showed a lack of awareness and education regarding survey results and their location. One receptionist, who worked weekdays, did not know where the survey results were, had not been educated about them, and only guessed that an unlabeled binder might contain them. Another receptionist, who worked afternoons and evenings, believed the survey results were in a drawer at the front desk and also reported no education on what they were or where they were kept. Multiple residents attending a Resident Council meeting stated they did not know what survey results were or where they were located, and the Activity Director acknowledged she had not reviewed this information during Resident Council meetings and was unsure of the exact location of the survey results. The Administrator reported knowing the binder was in the lobby near the front door but was unaware there was no posted notice, that the binder was not labeled, and that the receptionists had not been educated on the survey results’ location.
Resident Falls from Bed During Care, Sustains Head Injury
Penalty
Summary
The facility failed to provide care in a safe manner when a resident rolled off a bed raised to waist height, resulting in a laceration to the left side of her head that required five staples. The incident involved a resident with Alzheimer's dementia, osteoarthritis, and other conditions such as severe protein-calorie malnutrition and cognitive communication deficit. The resident was known to have repeated falls and required extensive assistance with bed mobility and other activities of daily living. Despite these needs, the care plan only included reporting falls to a physician and referring to physical therapy as needed. On the day of the incident, the resident became combative during incontinence care provided by a nursing assistant (NA). The NA, aware of the resident's behaviors during care, attempted to calm the resident by moving her hand off the resident, which led to the resident rolling off the bed and hitting her head on the wall. The bed was elevated to waist height, and the resident's behavior during care was known to include hitting and yelling. The nursing assistant did not maintain control of the resident during the care process, which contributed to the fall. Interviews with staff revealed that the resident was known to be calm when not touched and had behaviors related to her dementia. The staff, including the nurse assigned to the resident, acknowledged that the resident could not roll herself out of bed and that the accident could have been avoided by not letting go of the resident while on her side. The corporate nurse later suggested that the resident's pain might have contributed to her behavior during care, which was not initially considered by the facility's administration.
Failure to Resolve Resident Council Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised during Resident Council Meetings over a period of five months. Concerns were consistently raised about coffee not being served before breakfast and clothes not being returned from the laundry. These issues were documented in the Resident Council Meeting Minutes for the months of May, June, July, August, and September 2024. However, the Resident Council Follow-Up forms attached to these minutes did not demonstrate any response or resolution from the facility regarding these grievances. Interviews with several residents during a Resident Council Meeting in November 2024 confirmed that the issues remained unresolved. The Activity Director, who assumed the role in May 2024, was unaware that grievances needed to be documented and resolved. She mentioned addressing concerns in meetings with department heads but lacked documentation to show resolution. The facility's Administrator was also unaware that grievances from Resident Council meetings were not being completed and resolved, although he expected concerns to be addressed and documented.
Failure to Document Monthly Weights as Ordered
Penalty
Summary
The facility failed to follow physician orders to obtain a monthly weight for a resident who was admitted with diagnoses including hypertension, depression, and fractures. The physician's order specified that the resident's weight should be monitored every Monday. However, the resident's quarterly Minimum Data Set (MDS) assessments left the weight section blank, and there was no assessment of weight loss or gain. A review of the resident's electronic weight record showed no monthly weights were documented from February 2024 through October 2024, except for a single weight recorded in October. Interviews with facility staff revealed a lack of awareness and a system to ensure weights were consistently documented. The Corporate Nurse Consultant acknowledged the absence of a system for obtaining weights, and the Director of Nursing was unaware that the weights were not being taken as ordered. The Medical Director confirmed that weights should be documented monthly as per the physician's order, and the Interim Administrator stated that any issues with obtaining weights should be reported to the clinician and physician. The deficiency was identified when the facility realized weights were not being obtained, prompting the documentation of weights in October.
Improper Discharge Due to Miscommunication
Penalty
Summary
The facility failed to allow a resident to remain in the facility and initiated her discharge after she returned later than expected from a leave of absence. The resident, who was cognitively intact and independent with activities of daily living, had been away from the facility for over 24 hours due to car trouble. Upon her return, she was informed by staff that she could not stay because her absence exceeded 24 hours, which allegedly ended her insurance coverage. The facility did not provide written documentation stating the reason they could not meet her needs, and no discharge planning or notice of transfer was issued. Interviews with facility staff revealed that the directive to discharge the resident came from the Regional Office Manager, despite the facility being able to meet her needs. The Interim Administrator later confirmed that the staff received incorrect guidance regarding the discharge and acknowledged that the resident should have been allowed to stay. Attempts to interview the resident, her physician, emergency contact, and the Regional Office Manager were unsuccessful.
Failure to Provide Safe and Orderly Discharge
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was reviewed for discharge. The resident, who was cognitively intact and independent with activities of daily living, signed out of the facility on a leave of absence with an expected return time. However, due to transportation issues, the resident was unable to return as planned and was informed upon arrival that she had been discharged and could not remain in the facility. The resident was not provided with discharge instructions or prescriptions, and the discharge location was not verified, leading her to seek medication refills at a hospital. The facility's social worker and office manager indicated that they were instructed by the regional office manager to discharge the resident due to her absence exceeding 24 hours, which allegedly ended her insurance coverage. The social worker did not conduct any discharge planning, believing the discharge was against medical advice. The resident explained her delay was due to car trouble and attempted to contact the facility without success. The facility's interim administrator later acknowledged that the internal staff received misdirection regarding the discharge, and the resident should have been allowed to remain in the facility.
Failure to Monitor Resident's Weight Consistently
Penalty
Summary
The facility failed to comprehensively assess a resident's weight as part of their nutritional monitoring. The resident, who was cognitively intact, had a physician's order for monthly weight monitoring, but the facility did not consistently record these weights from February 2024 through September 2024. The resident's quarterly Minimum Data Set (MDS) assessments left the weight section blank, and there was no assessment of weight loss or gain. The care plan indicated a goal for gradual weight loss and maintaining adequate nutritional status, but the interventions, including dietician evaluations, were not effectively implemented due to missing weight records. Interviews with facility staff revealed systemic issues in obtaining and documenting weights. The Corporate Nurse Consultant acknowledged the lack of a system for consistent weight monitoring, and the MDS Coordinator noted that the absence of documented weights affected the MDS assessments. The Dietician had not completed a dietary assessment since the resident's admission because the resident had not been flagged for weight loss, and the Director of Nursing was unaware of the failure to take monthly weights. This lack of coordination and oversight led to the deficiency in monitoring the resident's nutritional status.
Failure to Provide Restorative ROM and Splinting for Resident
Penalty
Summary
The facility failed to provide restorative range of motion and the application of splinting devices as recommended by the occupational therapist for a resident with limited range of motion. The resident, who was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic subarachnoid hemorrhage, had impairments in the range of motion on one side of her body. The occupational therapy discharge summary recommended a restorative ROM program and the use of a T-splint for up to 6-7 hours a day to prevent further contracture. However, observations and interviews revealed that the resident did not receive follow-up exercises and was unable to apply the splints herself. During observations, the resident was seen without the recommended splinting devices, and interviews with staff indicated a lack of awareness and documentation regarding the application of these devices. The Regional Nurse Consultant confirmed the absence of a physician's order for the splinting devices and exercise program, which should have been completed based on the therapist's recommendations. The occupational therapist noted that if the resident remained in the facility, it was the nursing staff's responsibility to obtain the necessary physician's order and ensure the application of the splints and exercises.
Failure to Provide Adequate Dialysis Care
Penalty
Summary
The facility failed to provide adequate dialysis care for a resident with end-stage renal disease who required dialysis services. The resident, who was admitted with a permacath for dialysis, did not have a physician's order for dialysis services documented in their medical record. Additionally, the resident's care plan lacked specific information regarding dialysis care, and there was no documentation of monitoring the resident's condition after dialysis treatments. Interviews with the resident and nursing staff revealed that vital signs were not taken when the resident returned from dialysis, and the permacath site was not checked for bleeding. The nursing staff was observed assisting the resident back to bed and restarting tube feeding without performing necessary post-dialysis assessments. The MDS nurse and Unit Manager confirmed the absence of a dialysis care plan and physician's order, indicating a lack of awareness and oversight in the facility's processes. The Director of Nursing and Medical Director acknowledged the facility's policies and procedures for dialysis care, which were not followed in this case. The admitting nurse was responsible for obtaining dialysis orders from the hospital discharge summary, and the MDS nurse was to create a care plan. However, these steps were not completed, resulting in inadequate monitoring and documentation of the resident's dialysis care.
Failure to Monitor Nurse Aide Registry Expirations
Penalty
Summary
The facility administration failed to maintain effective systems to monitor the expiration of nurse aide registry listings, resulting in a deficiency. Specifically, a nurse aide, identified as NA #4, continued to work at the facility for three days after her registry listing with the North Carolina Nurse Aide Registry had expired. NA #4 was responsible for various resident care tasks, including passing breakfast trays, providing bed baths, incontinence care, assisting with meals, and grooming. The lapse in monitoring allowed NA #4 to work on multiple days with an expired registry listing, as confirmed by the NC Nurse Aide Registry representative. Interviews with facility staff revealed that the previous Staff Development Coordinator (SDC) was responsible for verifying registry listings during pre-employment screening, but the position was currently vacant. The Director of Nursing (DON) and the Administrator acknowledged the absence of a tracking system to monitor registry expirations. The Administrator noted that a tickler file or tracking system should be in place to alert staff about upcoming expirations, and the DON should communicate with employees about their license status. However, due to the vacant SDC position, this function was not being effectively managed, leading to the oversight with NA #4's expired registry listing.
Failure to Provide Privacy for Residents
Penalty
Summary
The facility failed to provide personal privacy for two residents, leading to a deficiency in maintaining the dignity and confidentiality of their care. Resident #14, who was cognitively intact and dependent on toilet use, was observed without a privacy curtain in his room, allowing his catheter to be visible from the hallway. Despite expressing his desire for a privacy curtain to the nursing staff, none was provided since his admission. Staff interviews revealed that the absence of privacy curtains had been reported multiple times to the previous housekeeping director, but no action was taken. Additionally, Resident #14's catheter bag lacked a privacy cover, which was known to the staff but not addressed. Resident #55, who was severely cognitively impaired and incontinent, also lacked a privacy curtain in a shared room, compromising privacy during care. The absence of a curtain had persisted for two to three months, and staff had reported this issue to the previous housekeeping director without resolution. The new Director of Housekeeping and the Administrator were unaware of the missing curtains until the survey, indicating a lapse in communication and oversight. Both residents were left without adequate privacy, which was expected by the facility's administration.
Privacy Curtain Deficiency in Two Resident Rooms
Penalty
Summary
The facility failed to provide privacy curtains for two rooms on the 200-hall, affecting two residents. Resident #14, who was cognitively intact, did not have a privacy curtain since admission, which prevented him from having privacy from the hallway during care. Despite expressing his need for a curtain to the nursing staff, the issue remained unresolved. Nurse Aide #8 confirmed the absence of the curtain and reported the issue multiple times to the previous housekeeping director, but no action was taken. The housekeeping aide, who regularly worked on the 200 Hall, was unaware of the missing curtain and indicated that the prior housekeeping director was responsible for handling and hanging curtains. Resident #55, who was cognitively impaired, also lacked a privacy curtain for two to three months. Similar to Resident #14, Nurse Aide #8 reported the missing curtain to the previous housekeeping director without resolution. The housekeeping aide admitted to missing the absence of the curtain during routine checks. Interviews with the Administrator and the new Director of Housekeeping revealed that they were unaware of the missing curtains and expected all residents to have them. The new Director of Housekeeping had just started in the role, and the previous director was unavailable for comment.
Failure to Post Required Contact Information for State Agencies and Advocacy Groups
Penalty
Summary
The facility failed to post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups, including the State Survey Agency, adult protective services, the Office of the State Long-Term Care Ombudsman program, and the protection and advocacy network. This deficiency was observed during a four-day onsite recertification survey. Observations conducted on multiple days revealed that there was no signage or posting in the facility's common areas, upper and lower nursing units that included the required contact information. During a walking tour of the facility with the Administrator, it was confirmed that the required postings were absent, except for the local Ombudsman posting. In an interview, the Administrator expressed uncertainty about why the postings were not in place and acknowledged their importance, indicating an oversight in maintaining compliance with posting requirements.
Medication Administration Failures for Two Residents
Penalty
Summary
The facility failed to administer necessary medications to two residents, leading to significant medication errors. Resident #8, who was admitted with a diagnosis of malignant neoplasm to the brain resulting in seizures, did not receive her prescribed antiseizure medications, Lamotrigine and Levetiracetam, on the evening of her admission and the following morning. The medications were not delivered to the facility until the day after her admission. Nurse #1, who was responsible for Resident #8 during the night shift, did not call the pharmacy for a stat order or notify the Nurse Practitioner about the unavailability of the medications. The Director of Nursing (DON) confirmed that the medications should have been ordered stat to prevent missed doses. Resident #9, admitted with a left knee replacement, kidney disease, and heart disease, did not receive his prescribed pain medication, Oxycodone/Acetaminophen, upon admission. The medication was not available in the facility's emergency backup supply and was not delivered until the day after his admission. Nurse #7, who was on duty during Resident #9's admission, did not report the unavailability of the medication to the DON or order it stat from the pharmacy. The DON stated that the nurse should have checked the emergency backup and notified the physician if the medication was unavailable. Interviews with the facility's Administrator revealed that she was not informed about the medication issues for both residents. The Administrator acknowledged that the medications should have been ordered immediately upon admission to ensure timely delivery. The Pharmacist confirmed that the lack of antiseizure medication contributed to Resident #8 experiencing seizures, highlighting the critical nature of timely medication administration.
Failure to Report Urinary Catheter and Urinalysis Issues
Penalty
Summary
The facility failed to promptly report critical medical information regarding a resident's urinary catheter care and urinalysis results to the appropriate medical personnel. The resident, who was cognitively intact and had a urinary catheter due to conditions such as end-stage renal disease and neuropathic bladder, experienced issues with catheter flushing on a specific date. Despite the resident's report of abdominal pain and distention, and the failure of the catheter flush to return fluid, this information was not communicated to the Nurse Practitioner (NP) on the same day. Additionally, a urinalysis ordered due to discolored urine was not sent to the laboratory until three days later, and the results indicating a urinary infection were not reported to the NP until the resident was sent to the hospital several days after the test was conducted. Interviews with facility staff revealed a breakdown in communication and procedure adherence. Nurse #2, who was responsible for the resident during the day shift, did not report the catheter flushing issue or the delay in sending the urinalysis to the NP. Furthermore, the laboratory results were not followed up on or communicated to the NP in a timely manner, leading to a delay in addressing the resident's infection. The Director of Nursing and the Administrator were also not informed of these lapses, indicating a systemic issue in the facility's reporting and communication processes.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to Adult Protective Services within the required timeframe for a resident who was severely cognitively impaired and required total assistance with bed mobility and transfers. The resident, diagnosed with hemiplegia and epilepsy, was allegedly slapped in the face by a male nurse, as reported by a family member. The incident occurred on 7/25/2024 and was reported to the facility's Administrator on 7/26/2024. However, the Administrator did not notify Adult Protective Services until 8/1/2024, which was beyond the 24-hour reporting requirement stated in the facility's Abuse, Neglect and Exploitation Policy. The facility conducted an investigation, suspended the accused staff member, and notified the police, but ultimately unsubstantiated the allegation.
Delayed Urinalysis and Inadequate Catheter Care
Penalty
Summary
The facility failed to ensure timely and appropriate testing of a urinalysis with culture for a resident with a suprapubic catheter. The resident, who had a history of end-stage renal disease, neurogenic bladder, and Parkinson's disease, reported purple urine to a nurse practitioner on August 5, 2024. A urinalysis with culture was ordered to rule out infection. However, the sample was not sent to the laboratory on the same day as ordered, and the results were delayed until August 8, 2024. The laboratory indicated the sample was contaminated and suggested a new sample, but the facility did not follow through with this recommendation. The resident experienced symptoms such as lower abdominal pain and distention, which were reported by the resident and a family member. Despite these symptoms, the facility did not act promptly to address the potential blockage of the catheter or the possibility of infection. The resident was eventually sent to the hospital on August 12, 2024, after experiencing decreased urine output and pain. The hospital admission note confirmed a urinary tract infection due to a clogged catheter, and the resident was treated with intravenous antibiotics. Interviews with facility staff revealed a lack of communication and follow-up regarding the urinalysis with culture. Nurse #2 admitted to placing the urine sample in the refrigerator but failed to ensure it was picked up by the laboratory in a timely manner. The Director of Nursing and the Administrator were not aware of the delays in testing and reporting the results. The nurse practitioner was also not informed of the results until the resident was hospitalized, indicating a breakdown in the facility's processes for managing and communicating critical health information.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered for a resident who was admitted with a left knee replacement. The resident was supposed to receive Oxycodone/Acetaminophen for pain rated at 4 or more on a scale of 1 to 10. However, the medication was not available when the resident reported a pain level of 6. The resident's pain medication was delivered to the facility after a delay, and the emergency backup supply was not utilized in a timely manner. Nurse #6 admitted the resident and did not fax the admission orders to the pharmacy until later in the evening, resulting in the medication not being available when needed. The resident's pain was not adequately managed due to a series of communication and procedural failures. Nurse #7 documented the resident's pain but did not ensure the medication was administered. The Director of Nursing and the Administrator were not informed of the issue, and the necessary steps to obtain the medication from the emergency backup or through a stat order were not taken. Interviews with staff revealed a lack of awareness and action regarding the resident's pain management needs, contributing to the deficiency.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to provide pain medication as ordered for a resident who was admitted with a left knee replacement. The resident was prescribed Oxycodone/Acetaminophen for pain rated at 4 or more on a scale of 1 to 10. However, the medication was not available on the night of admission. Nurse #6, who admitted the resident, faxed the prescription to the pharmacy but did not receive the medication that night. Instead, the resident was given Acetaminophen per standing orders, and Nurse #6 did not have access to the electronic emergency backup medications. Nurse #7, who worked later, noted the unavailability of the pain medication but did not document notifying the Nurse Practitioner about the issue. The Director of Nursing (DON) #2 and the Administrator were not informed of the medication unavailability at the time. DON #2 stated that the emergency backup should have been checked, and if the medication was not available, the physician or nurse practitioner should have been contacted for an alternative. The Administrator confirmed that the pain medication should have been provided from the emergency backup supply, and a stat order should have been sent to the pharmacy if necessary. The failure to provide the prescribed pain medication was not addressed promptly, leading to a deficiency in pain management for the resident.
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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