Cleveland Pines
Inspection history, citations, penalties and survey trends for this long-term care facility in Shelby, North Carolina.
- Location
- 1404 N Lafayette Street, Shelby, North Carolina 28150
- CMS Provider Number
- 345282
- Inspections on file
- 17
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Cleveland Pines during CMS and state inspections, most recent first.
Three residents with significant physical and cognitive impairments did not receive appropriate toenail care, as their long, thick, and curling toenails were not addressed through regular nursing assessments or timely podiatry referrals. Staff interviews revealed lapses in communication and follow-up, resulting in these residents not being scheduled for podiatry services despite clear need.
Several severely cognitively impaired residents with significant physical limitations were found with bed rails in use without individualized assessment, documentation of risks and benefits, or informed consent. Staff routinely installed bed rails on all beds as standard practice, often copying previous assessments rather than evaluating current resident needs. Leadership confirmed the absence of physician orders, care plan documentation, and staff training regarding proper bed rail assessment and consent procedures.
A cognitively impaired, nonverbal resident dependent on staff for all ADLs was kicked multiple times by another resident with a history of aggression. The incident occurred in a hallway and was witnessed by a NA, who intervened and reported the event. Staff interviews confirmed the aggressive behavior and the vulnerable status of the resident who was kicked, highlighting a failure to protect residents from abuse.
A facility failed to thoroughly investigate an incident where one resident was observed kicking another nonverbal, cognitively impaired resident. Staff separated the residents and performed an initial assessment, but did not conduct further physical or psychological evaluations, nor did they resolve conflicting staff accounts or document a comprehensive investigation as required by policy.
The facility did not complete required PASRR Level II reviews for three residents who received new mental health diagnoses after admission, despite initial PASRR Level I screenings indicating this was necessary if new diagnoses or significant changes occurred. Staff interviews revealed gaps in awareness and communication regarding the need for timely PASRR Level II completion when residents were newly diagnosed with mental health conditions.
Nursing staff failed to follow infection control protocols during tracheostomy care for two residents with respiratory failure, including not sanitizing hands or changing gloves after handling soiled materials and before performing subsequent steps of care. The Infection Preventionist was present but did not intervene, and both residents were severely cognitively impaired and required tracheostomy care as part of their care plans.
A facility failed to maintain accurate records and reconciliation for a controlled medication when a resident's Ativan inventory sheet and 10 tablets were found missing. Staff interviews confirmed the required documentation could not be located, and the DON acknowledged the records were not retained as per policy. The resident did not report missing any medication, but the administrator expected proper recordkeeping for controlled substances.
Residents expressed feelings of dependence and sadness due to the lack of group outings outside the facility, which had not occurred for almost two years. Despite requests during Resident Council Meetings, outings were not possible due to transportation limitations. The facility's van could only accommodate a few residents at a time and was primarily used for medical appointments, preventing recreational outings.
A facility failed to update a resident's advance directive records, resulting in conflicting code status information between the paper chart and electronic medical record. The resident's family requested a DNAR status due to the resident's poor prognosis, but the paper chart still indicated full resuscitation. Staff interviews revealed a lack of communication and proper documentation procedures, leading to the discrepancy.
A resident with hemiplegia and hemiparesis did not receive a prescribed left-hand splint to prevent further contracture. Despite an order placed by the occupational therapist, the splint was not received, and the resident was observed without it. Interviews revealed a lack of communication and follow-up among staff, including the OT, business office manager, and nurse practitioner, leading to the resident not receiving necessary treatment.
A Treatment Nurse in an LTC facility failed to follow the infection control policy for hand hygiene during a wound care procedure. The nurse did not sanitize her hands after doffing gloves and before donning new ones, contrary to the facility's policy. Interviews revealed a misunderstanding of the policy, and the Infection Preventionist had not audited the nurse during dressing changes.
Failure to Provide Timely Foot Care and Podiatry Services
Penalty
Summary
The facility failed to ensure appropriate foot care for three residents, resulting in untrimmed, thick, and curling toenails, and a lack of timely podiatry services. For each of the three residents, weekly nursing assessments did not document the need for toenail care, and there was no evidence in the electronic medical records that referrals to podiatry had been made or that the residents had been seen by a podiatrist. Observations revealed that all three residents had long, thick toenails, with some nails curling inward or appearing blackened, and staff interviews confirmed that these issues had not been reported or addressed. One resident with a traumatic brain injury and contractures was completely dependent on staff for all activities of daily living and was severely cognitively impaired. Despite this, her toenails were observed to be thick, long, and in poor condition, with no record of podiatry referral or care since admission. Another resident with a left above-the-knee amputation and peripheral vascular disease was also dependent on staff for personal care. His toenails were found to be thick and curling, and although staff recognized the need for podiatry intervention, no referral had been made, and he had not been scheduled for podiatry clinic visits. A third resident with peripheral artery disease and a below-the-knee amputation was similarly dependent on staff and unable to care for her own toenails. Her toenails were observed to be long and curling, and although she had previously refused podiatry care, there was no documentation of follow-up or rescheduling for podiatry services. Interviews with nursing staff, the nurse practitioner, the DON, and the social worker revealed a lack of communication and follow-up regarding residents' toenail care needs. Staff members often could not recall if they had reported the need for podiatry services, and the process for adding residents to the podiatry list was inconsistently followed. The DON and social worker acknowledged that sometimes follow-up did not occur as it should, resulting in residents not receiving necessary foot care.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess, document, and obtain informed consent for the use of bed rails for several severely cognitively impaired residents. In multiple cases, residents with significant physical and cognitive impairments, such as bilateral above-knee amputations, contractures, quadriplegia, and severe dementia, were found with bed rails in use without evidence of individualized assessment, documentation of risks and benefits, or informed consent from the resident or their representative. Staff interviews revealed that bed rails were routinely installed on all beds as a standard practice, regardless of individual resident need or ability to use the rails, and that assessments were often completed by copying information from previous assessments rather than through direct evaluation of the resident's current condition. Medical record reviews for the affected residents showed a lack of physician orders for bed rails, absence of care plans addressing bed rail use, and no documentation of discussions regarding the risks and benefits of bed rail use with residents or their representatives. In several instances, the Minimum Data Set (MDS) assessments did not indicate the use of bed rails, and care plans did not address their use, despite their presence on the residents' beds. Staff, including nurses and nurse aides, reported that residents were unable to use the bed rails due to their physical and cognitive limitations, and that the rails were primarily used to assist staff during care or to prevent residents from rolling out of bed, rather than for resident mobility or safety as intended. Interviews with facility leadership, including the DON, NP, and Administrator, confirmed that there was no process in place for obtaining informed consent or physician orders for bed rails, and that staff were not adequately trained on proper assessment procedures. The Administrator acknowledged that the issue was only recognized during the survey and that the facility's practices regarding bed rail assessments and use were not being executed correctly. Observations of the residents confirmed that bed rails were in use for residents who were nonverbal, unable to participate in their care, and physically incapable of using the rails for mobility or safety.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse, specifically resident-to-resident abuse. During the incident, a nurse aide (NA) heard yelling and, upon investigation, observed one resident kicking another in a hallway. The resident being kicked was severely cognitively impaired, nonverbal, and dependent on staff for all activities of daily living, with a history of wandering and grabbing objects or other residents' wheelchairs to propel herself. The resident who was kicking was alert, oriented, and had a documented history of being combative and physically aggressive with staff. Multiple staff interviews confirmed that the cognitively impaired resident was attempting to back away but was slow moving and nonverbal, only occasionally singing. The NA immediately separated the residents and notified the unit manager, who assessed the resident and found no visible injuries. The unit manager and other staff noted that the resident being kicked would likely have experienced pain or fear but was unable to communicate her feelings. The aggressive resident admitted to kicking the other resident several times, stating she was defending herself because the other resident would not move away. Documentation and interviews revealed inconsistent accounts among staff regarding whether physical contact occurred, but at least one staff member witnessed repeated contact with the lower legs. The incident was reported to the social worker and nurse practitioner, both of whom were informed that the aggressive resident had a history of such behavior. The facility's failure to adequately supervise and protect the vulnerable resident from abuse by another resident constituted a deficiency in ensuring resident safety and upholding residents' rights.
Failure to Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of resident-to-resident abuse involving two residents, one of whom had significant cognitive and physical impairments, including dementia, Parkinson's disease, and nonverbal status. The incident occurred when a nurse aide overheard yelling, entered the hallway, and observed one resident kicking another, who was attempting to back away but was slow moving and nonverbal. The nurse aide immediately separated the residents and notified the unit manager, who performed an initial assessment and found no visible injuries. However, no further assessments were conducted to evaluate for delayed physical injuries or mental anguish, despite the nonverbal resident's grimacing during the incident. Documentation and staff interviews revealed inconsistencies in the accounts of the incident, with some staff stating that physical contact occurred and others stating it did not. The facility's policy required a thorough investigation of all abuse allegations, including interviews with all involved parties and assessments for both physical and psychological harm. Despite this, the investigation folder lacked statements from all potential witnesses, did not address conflicting accounts, and did not include follow-up assessments for injuries that may have appeared later or for possible mental distress. Key staff, including the social workers and the administrator, did not initiate a formal investigation, citing the absence of injury as the reason. The administrator and social workers did not amend their statements to resolve discrepancies or document further inquiry, even after one resident admitted to kicking the other. The director of nursing was not directly informed, and there was no evidence that the incident was reported to required authorities as per facility policy. The lack of a comprehensive investigation and documentation failed to meet regulatory requirements for abuse prevention and response.
Failure to Complete PASRR Level II for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was completed for residents who received new mental health diagnoses, as required. For three residents, medical record reviews showed that although PASRR Level I screenings were completed prior to admission, subsequent new diagnoses of mental health conditions such as anxiety disorder, mood affective disorder, schizophrenia, post-traumatic stress disorder (PTSD), bipolar disorder, and major depressive disorder were documented in the electronic medical records. Despite these new diagnoses, no PASRR Level II reviews were completed for these residents, contrary to the recommendations noted in their initial PASRR Level I screenings, which specified that a Level II should be resubmitted if a new mental health diagnosis was suspected or if there was a significant change in condition. Staff interviews revealed a lack of awareness and understanding regarding the requirement to complete PASRR Level II reviews upon admission, readmission, or when a new mental health diagnosis was made. The social worker responsible for PASRR paperwork indicated she typically only completed Level II reviews for residents with limited Level II status or when there were changes in behaviors, and was not always informed of new mental health diagnoses. The administrator confirmed her understanding that PASRR Level II should be completed in a timely manner under these circumstances, but this was not consistently implemented for the residents in question.
Failure to Follow Infection Control During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to infection control standards during tracheostomy care for two residents with respiratory failure and tracheostomy status. In both cases, nursing staff did not sanitize their hands or change gloves at critical points during the procedure, despite handling visibly soiled materials and moving between different steps of care. Specifically, one nurse removed soiled tracheostomy ties and neck collar, handled the inner cannula, and inserted a new cannula without changing gloves or sanitizing hands. The same gloves were used to handle clean supplies after touching contaminated items, and the nurse only sanitized hands after completing the entire procedure and doffing gloves and gown. A second nurse also failed to change gloves or sanitize hands after inserting a new inner cannula and before cleaning around the stoma, removing soiled dressings, and replacing the neck strap and ties. This nurse continued to perform multiple steps of tracheostomy care, including handling soiled and clean items, without changing gloves or sanitizing hands. In both cases, the Infection Preventionist assisted but did not intervene to correct the infection control breaches during the procedures. Both residents involved were severely cognitively impaired and required ongoing tracheostomy care as part of their care plans. The observations were corroborated by staff interviews, where the nurses acknowledged the lapses in infection control and the Infection Preventionist confirmed awareness of the required procedures. The Director of Nursing stated an expectation that all infection control procedures be followed during tracheostomy care.
Failure to Maintain Accurate Controlled Substance Records and Reconciliation
Penalty
Summary
The facility failed to maintain effective systems for the accurate reconciliation and recordkeeping of controlled medications for one resident. Specifically, the controlled declining inventory sheet for a resident's Ativan 0.5mg tablets, received on a specified date, was missing and could not be located by the facility. The facility's policy required a separate, accurately maintained declining inventory record for each controlled substance, to be reconciled at each shift change by two licensed nurses and retained for at least three years. However, the required documentation for the resident's Ativan was not available for review, and the facility was unable to produce the sheet when requested. Interviews with staff revealed that a nurse discovered the resident's card containing 10 Ativan tablets was missing from the locked controlled substance drawer, while the inventory sheet remained in the nurse's book. The incident was reported to the DON, who confirmed the inventory sheet for the dispensed Ativan could not be found and acknowledged the requirement to retain such records. The missing medication was never recovered, and the resident did not recall missing any doses or having concerns about her medication. The administrator stated an expectation for accurate maintenance of controlled medication records in accordance with facility policy.
Lack of Group Outings for Residents
Penalty
Summary
The facility failed to provide group activities outside of the facility for residents who expressed the importance of such activities. This deficiency was identified through record reviews, activity calendars, and interviews with residents and staff. The facility's activity calendars from January 2024 to July 2024 showed no scheduled outings outside the facility, despite residents' requests during Resident Council Meetings from April 2023 to June 2024. Residents expressed feelings of dependence, sadness, and depression due to the lack of outings, which they had not experienced for almost two years. Several residents, including those identified as Residents #58, #8, #53, #20, #63, and #16, were interviewed and reported that they had repeatedly requested group outings during resident council meetings. They were informed that outings were not possible due to the lack of a suitable van for group transportation. These residents emphasized the importance of outings for their independence and socialization, expressing a desire to shop and dine outside the facility. The absence of these activities contributed to their feelings of sadness and dependence. Interviews with the Activities Director and the Administrator revealed that the facility's current van could only accommodate two to three residents at a time, and there was only one van driver available. The van was primarily used for medical appointments, and logistical challenges prevented its use for recreational outings. Although the facility had initiated a Make a Wish program for individual resident requests, no group outings had been organized. The Administrator acknowledged the residents' requests and the limitations faced in fulfilling them.
Failure to Update Advance Directive Records
Penalty
Summary
The facility failed to update and clarify the medical records to reflect the desired advance directive for a resident reviewed for code status. The resident was admitted to the facility with a Medical Orders for Scope of Treatment (MOST) form indicating full resuscitation, signed by both the resident and a Nurse Practitioner. However, a subsequent physician's order in the electronic medical record indicated a Do Not Attempt Resuscitation (DNAR) status, following discussions with the resident's family who were aware of the resident's decline and poor long-term prognosis. Interviews with facility staff revealed discrepancies between the paper chart and electronic medical record regarding the resident's code status. Nurse #1 was initially unaware of the DNAR order in the electronic record and relied on the paper chart, which still indicated full code status. Unit Coordinators acknowledged the conflicting directives and noted that the process for updating code status was not followed, as a new MOST form was not completed when the DNAR order was made. The Director of Nursing confirmed that the physician did not communicate the change in code status to the nursing staff, and the necessary documentation was not updated to reflect the family's wishes.
Failure to Provide Prescribed Hand Splint for Resident
Penalty
Summary
The facility failed to follow a physician's order to provide and apply a left resting hand splint for a resident with limited range of motion due to hemiplegia and hemiparesis. The resident, who was cognitively intact and had no refusals of care, was observed without the necessary splint on multiple occasions. The occupational therapist had evaluated the resident and determined the need for a new left-hand splint, as the current one did not fit properly. Despite placing an order for the splint with the business manager, the splint had not been received, and the resident had not begun occupational therapy services to address the contracture. Interviews with facility staff revealed a lack of communication and follow-up regarding the missing splint. The occupational therapist admitted to not checking on the order status, while the business office manager was unaware that the splint had not been received. The nurse practitioner, upon realizing the resident did not have the splint, suggested a temporary solution but noted that the resident should have been receiving treatment for the contracture. The Director of Nursing and the Administrator were also unaware of the situation, indicating a failure in ensuring the resident received the prescribed care.
Infection Control Policy Violation During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policy regarding hand hygiene during a wound care procedure for a resident. The Treatment Nurse did not perform hand hygiene as required by the facility's policy after doffing gloves and before donning a new pair. Specifically, after preparing the dressing with antimicrobial skin and wound gel, the nurse removed her gloves but did not sanitize her hands before putting on a new pair of gloves to remove the old dressing from the resident's wound. This lapse in protocol was observed during a wound treatment session. Interviews conducted with the Treatment Nurse, the Infection Preventionist (IP), and the Director of Nursing (DON) revealed a misunderstanding and lack of compliance with the hand hygiene policy. The Treatment Nurse believed it was acceptable to change gloves without sanitizing her hands if she had not yet touched the resident. The IP confirmed that handwashing audits are conducted, but the Treatment Nurse had not been specifically audited during dressing changes. The DON expressed that it was expected for all staff to follow the handwashing policy, emphasizing the importance of sanitizing hands after glove removal.
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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