Eden Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Eden, North Carolina.
- Location
- 226 N Oakland Avenue, Eden, North Carolina 27288
- CMS Provider Number
- 345241
- Inspections on file
- 21
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Eden Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, recent stroke, diabetes requiring insulin, and dependence in ADLs was discharged home after rehab despite documented need for 24‑hour care, home health, and DME. Facility staff relied on two friends as contacts, even though they repeatedly stated they could not provide 24‑hour care or assume legal/financial responsibility, and a family member listed as a contact was not included in discharge planning. The care plan lacked a person‑centered discharge component identifying responsible caregivers and coordinated services. When insurance coverage ended, the SW obtained a NOMNC by verbal consent from a friend who later reported feeling pressured and unclear about appeal options. The resident was discharged to an apartment alone, on a holiday, without confirmed 24‑hour support, with home health not yet in place and only a wheelchair delivered. In the days following discharge, home health and APS staff found the resident bedbound, soiled with incontinence, unable to answer the door or evacuate, and not consistently receiving prescribed medications, leading to hospital admission with a UTI. Surveyors determined this constituted immediate jeopardy beginning at the time of discharge.
A resident with severe cognitive impairment, anxiety, depression, communication deficit, and dementia was admitted without an identified legal decision maker or responsible party and with only limited Medicare Part A managed care coverage. The care plan did not address the absence of a legal representative or the need for assistance with a Medicaid application, and when the resident’s Medicare skilled days were exhausted, no additional payor source was identified. Facility staff, including the Admission Director and SW, acknowledged they knew the resident lacked a legal representative and financial coverage beyond Medicare and had discussed the need for guardianship and Medicaid application assistance, but no guardianship referral was made and no Medicaid application was initiated before the resident was discharged home/community with severe cognitive impairment still documented.
Surveyors found that food stored in two nourishment refrigerators was not consistently labeled or dated according to facility policy. Multiple items, including sandwiches, homemade food, beverages, and takeout containers, lacked resident names and dates, and some items were marked only with unclear date ranges. The Dietary Manager, DON, and Administrator all reported that nursing staff are responsible for labeling and dating food brought in by families, that food should be discarded within seven days, and that dietary staff are responsible for checking the refrigerators and discarding expired items, but these practices were not followed as observed.
Surveyors found that a medication cart contained two open, undated Lantus insulin pen injectors and several opened insulin pens (Lispro, Aspart Flex, and Glargine) that were marked as expired but had not been removed. A nurse reported that nurses assigned to the carts are responsible for dating multi-dose medications upon opening and discarding undated or expired vials, but acknowledged she had not checked the opening or expiration dates at the start of her shift. The DON stated that nurses are expected to verify opening and expiration dates on cart medications at the beginning of each shift and ensure no expired items remain.
A resident with a court-appointed Legal Guardian experienced abdominal pain and initially agreed, then refused, to go to the hospital. Nursing staff, believing the resident was alert and oriented, did not notify the Legal Guardian of the refusal or the change in condition, instead proceeding with in-house labs and x-rays. The Legal Guardian was only informed after the resident's condition worsened and a hospital transfer was required, preventing the representative from exercising the resident's rights.
A resident with neuromuscular dysfunction of the bladder had an unsecured indwelling urinary catheter, contrary to physician orders and care plan instructions. Observations showed the catheter was not attached to the leg, and the urine appeared dark with sediment. Staff interviews revealed a lack of knowledge and consistency in securing the catheter, with the DON confirming the need for securement devices to be checked every shift.
The facility failed to manage medications properly, with expired drugs and loose pills found in multiple medication carts. Nurses were unaware of these issues, and an open vial of lidocaine lacked a documented open date. The ADON stated that both third shift and assigned nurses were responsible for these tasks, but deficiencies persisted.
A resident with multiple sclerosis and muscle weakness did not receive the prescribed lightweight utensils with a rubber grip, as required for her condition. During a meal, she was given heavy weighted utensils, which she could not use, and no staff checked on her to correct the mistake. The Dietary Manager acknowledged the error but did not provide the correct utensils or offer to reheat the meal, leaving the resident unable to eat.
A facility failed to implement Enhanced Barrier Precautions during catheter care for a resident with an indwelling catheter. A nurse aide was observed performing the care without wearing a gown, despite the facility's policy requiring gowns and gloves for such procedures. The resident had a physician order for enhanced barrier precautions due to neuromuscular dysfunction of the bladder. The nurse aide admitted to forgetting the gown, and interviews with the DON and Administrator confirmed the requirement for gowns and gloves.
The facility failed to accurately document RN staffing for 51 out of 103 days, as revealed by a review of daily staffing sheets. Interviews with staff indicated a misunderstanding about including salaried RNs on the sheets, despite their presence in the building. The DON and Administrator confirmed the presence of an RN daily but did not ensure accurate documentation, leading to the deficiency.
Unsafe Discharge of Dependent, Cognitively Impaired Resident Without 24‑Hour Support
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a cognitively impaired resident with multiple comorbidities and dependence in ADLs. The resident had a history of stroke, dementia, diabetes, hypertension, hypothyroidism, hyperlipidemia, osteoarthritis, anemia, anxiety, and depression, and had been admitted after being found on the floor at home with weeks of medication non‑compliance. On admission, the resident required substantial to maximum assistance with bathing, dressing, toileting, transfers, and bed mobility, was frequently incontinent of bowel and bladder, and received insulin injections. The admission MDS documented severe cognitive impairment, and therapy and care plan documentation showed the resident needed extensive assistance and 24‑hour care and medication monitoring. From admission forward, the facility relied primarily on two friends as contacts, even though they repeatedly stated they could not provide 24‑hour care or assume legal or financial responsibility. The face sheet listed two friends as first and second emergency contacts and a family member as third contact, with no responsible party identified. The admissions Director and SW discussed guardianship and Medicaid with the friends, who declined, and the SW did not reach out to the family member at admission for input on care or discharge planning, despite his being listed as a contact and having been involved with the hospital and PCP. The care plan dated 3/20/26 addressed ADL and diabetes needs but did not include a person‑centered discharge plan with goals and interventions for identifying responsible caregivers, coordinating services for ADLs, psychosocial support, or financial needs. As the resident’s Medicare or insurance coverage neared exhaustion, the SW obtained a NOMNC by verbal consent from one friend, documented that the last covered day would be 4/2/26, and recorded that the representative did not wish to appeal and requested discharge. The friend later reported feeling pressured, not understanding the appeal process, and not knowing she could refuse to take the resident home, and both friends continued to tell staff they could not provide 24‑hour care or stay overnight. Despite therapy and NP documentation that the resident required 24‑hour care, home health, in‑home aide services, and DME such as an elevated toilet seat, 3‑in‑1 commode, grab bars, and assistive devices, the discharge proceeded without confirmation that 24‑hour support, services, or necessary DME were in place. Home health was contacted only shortly before discharge, with an anticipated 24–48 hour delay before a visit, and the only DME present at home at the time of the first home health visit was a wheelchair. The resident was discharged home on a holiday, to an apartment where she lived alone, without verified 24‑hour caregivers and without arrangements for continuous assistance with ADLs, incontinence care, mobility, or medication administration. Friends were only able to intermittently visit, provide meals, change the resident, and put her to bed, and they did not administer medications, including insulin. Over the days immediately following discharge, both a home health nurse and an APS worker found the resident in bed, soiled with urine and feces, unable to get out of bed even with assistance, unable to answer the door or vacate in an emergency, and not consistently receiving prescribed medications. The resident was also unable to use her medical alert necklace or call 911. Based on the APS assessment, an emergency order was obtained for transfer to the hospital, where the resident was admitted with a urinary tract infection. Surveyors determined that immediate jeopardy began when the resident was discharged home without the necessary 24‑hour support and services required to ensure her well‑being and safety.
Failure to Assist Cognitively Impaired Resident With Guardianship and Medicaid Application
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services to assist a severely cognitively impaired resident without a legal decision maker or payor source in obtaining guardianship and Medicaid coverage. The resident was admitted with diagnoses including anxiety, depression, communication deficit, and dementia, and the admission MDS documented severe cognitive impairment with no responsible party, guardian, or power of attorney identified. The care plan initiated on 3/20/26 did not include any interventions addressing the lack of a legal decision maker or assistance with completion of a Medicaid application. The resident’s payor source at admission was a Medicare managed care plan with limited Part A skilled days, which were exhausted on 4/3/26, and there was no additional payor source documented. Record review showed no evidence that the facility assisted the resident with a Medicaid application or made any referral for guardianship or other means of establishing a legal decision maker, despite awareness of the resident’s severe cognitive impairment and lack of a representative. The discharge MDS, coded as a return not anticipated to home/community, continued to show severe cognitive impairment. Interviews with the Admission Director and Social Worker confirmed that both were aware the resident had no legal representative and no additional financial coverage beyond Medicare, and that guardianship and Medicaid needs had been discussed but not acted upon. The Social Worker stated that no guardianship referral or Medicaid application assistance was provided and attributed this to running out of time before the resident’s discharge. The Administrator reported there was a breakdown in communication and that existing policies did not clearly define the roles and responsibilities of the Admission Director and Social Worker regarding initiation of guardianship and financial applications for such residents.
Improper Labeling and Dating of Resident Food in Nourishment Refrigerators
Penalty
Summary
Surveyors identified a deficiency in food storage practices in two nourishment refrigerators on the 400 and 500 hallways. During observation of the 400 hallway nourishment refrigerator, they found multiple food items without resident names or dates, including a gallon-size clear plastic bag containing a sandwich, a 4-ounce juice carton, and a snack bag; a peanut butter and jelly sandwich in a plastic bag; food wrapped in aluminum foil; an opened 16-ounce soda bottle; and a takeout 20-ounce coffee cup. They also observed a takeout box with pinto beans and seasoned rice labeled with a date range written as the 13th–15th, rather than a clear single date. In the 500 hallway nourishment refrigerator, surveyors observed a small plastic container with homemade food with no label for resident name or date, a gallon-size plastic container with homemade food labeled only with a date range of 2/5–2/9 and no resident name, and a grocery bag containing a box of fried chicken with no name or date. In interviews, the Dietary Manager stated that nursing staff were responsible for labeling and dating food brought in by visitors for residents before placing it in the nourishment refrigerators, that food could be stored for seven days before being discarded, and that he or dietary staff checked the nourishment refrigerators daily when restocking to discard expired food. The DON similarly stated that all nursing staff, including nurses and nurse aides, were responsible for labeling and dating any food brought in by family for residents, that food should be discarded within seven days, and that no personal staff food should be stored in the nourishment refrigerators. The DON also stated that dietary staff were responsible for ensuring all food was discarded after seven days. The Administrator confirmed that residents’ food should be labeled and dated before being placed in the nourishment refrigerators and that staff should follow policy for residents’ food brought in by families, with dietary staff ensuring expired food was discarded.
Failure to Date and Remove Expired Multi-Dose Insulin Pens From Medication Cart
Penalty
Summary
Surveyors identified a failure to properly date and remove multi-dose insulin pen injectors from a medication cart on the 500-hall. During an observation of the cart with a nurse, two open and undated Lantus insulin pen injectors were found. Review of the manufacturer's instructions showed that Lantus multi-dose vials are to be discarded 28 days after opening, but there was no way to determine when these pens had been opened due to the lack of dating. Further inspection of the same cart's second drawer revealed additional issues with expired insulin pens. One opened Lispro insulin pen was marked as expired on 2/10/26, one opened Aspart Flex insulin pen was marked as expired on 1/15/26, and one opened Glargine insulin pen was marked as expired on 2/9/26, yet all remained in the cart. In interviews, the nurse stated that nurses assigned to the carts were responsible for discarding open and undated multi-dose vials and that training required dating vials upon opening, but she acknowledged she had not checked opening or expiration dates at the start of her shift. The DON also stated that nurses were responsible for checking opening and expiration dates on medications in the carts at the beginning of each shift and expected that no expired items remain in the carts.
Failure to Notify Legal Guardian of Resident's Refusal for Hospital Transfer
Penalty
Summary
The facility failed to communicate with a resident's Legal Guardian regarding the resident's abdominal pain and the resident's refusal to go to the hospital. The resident, who had a history of hypertensive heart disease with heart failure, diabetes mellitus type 2, dementia, and hypomagnesemia, was admitted with a court-appointed Legal Guardian responsible for making medical decisions. On the day of the incident, the resident complained of mild abdominal pain and was initially agreeable to hospital evaluation but later refused. The nurse, assessing the resident as alert and oriented, did not inform the Legal Guardian of the resident's refusal or the change in condition, instead proceeding with labs and x-rays at the facility as ordered by the Nurse Practitioner. Subsequent staff interviews revealed that the Legal Guardian was not notified of the resident's abdominal pain or refusal to go to the hospital on the day it occurred. The following day, the resident's condition worsened, and the nurse on duty notified the Legal Guardian about the transfer to the emergency room and the events of the previous day. The Legal Guardian expressed that he should have been contacted earlier, as he was responsible for medical decisions and believed the resident would have followed his advice to seek hospital evaluation. Interviews with facility leadership, including the DON and Administrator, confirmed that the resident was not capable of making his own medical decisions and that the Legal Guardian should have been contacted regarding the refusal of hospital transfer. The failure to notify the Legal Guardian prevented the representative from exercising the resident's rights as required.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to properly secure the indwelling urinary catheter for a resident with neuromuscular dysfunction of the bladder, leading to potential complications. The resident was admitted with a physician's order to use an indwelling catheter with a closed drainage system and a catheter securing device to reduce tension and facilitate urine flow. Observations revealed that the catheter was not secured to the resident's leg, and the tape used for securement was loose and not attached. The resident's care plan included instructions to position the catheter bag and tubing below the bladder level and to secure the catheter with tape on the leg. During observations, it was noted that the catheter tube was not secured, and the urine in the tubing appeared dark with sediment. A nurse aide admitted to not knowing how to secure the catheter, and the tape was dated several days prior. Interviews with staff, including a nurse and the wound nurse, indicated a lack of consistent checking and securement of the catheter. The Director of Nursing confirmed that all residents with indwelling catheters should have a securement device attached and checked every shift.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management and storage practices, as observed during a survey. On Hall 3's medication cart, an expired bottle of Bisacodyl was found, and Nurse #3 was unaware of its expiration, attributing the responsibility to night shift nurses. Additionally, loose pills were discovered in the medication carts for Halls 1, 2, and 4. Nurse #4 was unaware of a loose pink pill in the cart for Halls 1 and 2, while Nurse #2 did not notice two loose pills in Hall 4's cart. Furthermore, an open vial of lidocaine without a documented open date was found in Hall 4's cart, with Nurse #2 unaware of its status. The Assistant Director of Nursing (ADON) explained that third shift nurses were tasked with cleaning the medication carts, checking for expired medications, and ensuring open dates were documented. However, the nurses assigned to each cart were also responsible for these tasks. Despite the ADON's assertion that the nurses were aware of their duties, the deficiencies were still present, indicating a lapse in adherence to medication management protocols.
Failure to Provide Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide adaptive eating utensils to a resident who required lightweight utensils with a rubber grip, as per the physician's order and care plan. The resident, who was admitted with multiple sclerosis and muscle weakness, was observed during a lunch meal to have received heavy weighted utensils instead of the prescribed lightweight ones. The resident expressed her inability to eat with the heavy utensils and mentioned that no staff had checked on her since her meal was delivered. The Dietary Manager confirmed the error but did not rectify it, leaving the resident without the proper utensils and unable to eat her meal. Interviews with staff revealed a lack of adherence to procedures for ensuring residents receive the correct meal accommodations. The Nursing Assistant admitted to not reading the meal ticket and was unaware of the resident's need for lightweight utensils. The Dietary Aide, who was still in training, acknowledged mistakenly providing the wrong utensils. The Dietary Manager, upon realizing the mistake, failed to provide the correct utensils or offer to reheat the resident's meal, as the resident had stated she would not eat cold food. The Administrator was informed of the situation but noted that the Dietary Manager did not take corrective action after the resident's complaint.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) during catheter care for a resident with an indwelling catheter. The facility's policy required the use of gowns and gloves for high-contact resident care activities, such as catheter care. A nurse aide was observed performing urinary catheter care without wearing a gown, although she wore gloves throughout the procedure. The resident had a physician order for the use of an indwelling catheter due to neuromuscular dysfunction of the bladder, and enhanced barrier precautions were ordered for every shift. The nurse aide admitted to forgetting to wear the gown during the procedure. Interviews with the Director of Nursing and the Administrator confirmed that staff should wear gloves and gowns when performing catheter care under EBP.
Inaccurate RN Staffing Documentation
Penalty
Summary
The facility failed to post accurate Registered Nurse (RN) staffing information for 51 out of 103 days reviewed. The daily posted nurse staffing sheets from August 2024 through November 2024 were examined, revealing that on numerous days, there was no RN documented as working for all three shifts. This discrepancy was confirmed through interviews with the Office Assistant, Scheduler, Director of Nursing (DON), and Administrator. The Office Assistant, responsible for completing the daily staffing sheets, stated that she was trained by the Scheduler and was aware that an RN needed to be present in the building for at least 8 hours a day. However, she was informed that salaried RNs could not be counted on the staffing sheets, even though they were present in the building. The Scheduler confirmed the training provided to the Office Assistant and acknowledged the requirement for an RN to be present for at least 8 hours daily. However, there was a lack of communication regarding the inclusion of salaried RNs on the staffing sheets. The DON admitted there was no process in place to verify the accuracy of the daily posted nurse staffing sheets, although she reviewed assignment sheets daily. The Administrator used the staffing sheets to determine who was providing hands-on care, not who was present in the building, and confirmed that an RN was present every day for at least 8 hours. This oversight in accurately documenting RN presence on the staffing sheets led to the deficiency identified by the surveyors.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
