Emerald Ridge Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Asheville, North Carolina.
- Location
- 25 Reynolds Mountain Boulevard, Asheville, North Carolina 28804
- CMS Provider Number
- 345447
- Inspections on file
- 25
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Emerald Ridge Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with major depressive disorder, PTSD, bipolar disorder, and recent suicidal behavior was admitted from an inpatient psychiatric facility with an order for scheduled nightly olanzapine, which was incorrectly transcribed as a PRN medication and given only once, despite the psychiatrist’s intent for continuous dosing. Multiple providers and the DON did not reconcile or clarify this discrepancy, even after a pharmacy consult noted that the hospital listed olanzapine as routine while the facility had it as PRN. The resident’s care plans and trauma‑informed assessment did not include individualized suicide precautions or approaches addressing her prior suicide attempts, and staff, including nurses and NAs, were not informed of her suicide history or any suicide precautions. Behavioral monitoring was not documented, resident statements about being better off dead were not recorded or communicated, and staff later reported episodes of agitation and yelling. The resident was subsequently found in her room with a safety razor and multiple shallow lacerations to her wrists, antecubital areas, and neck, unresponsive except to painful stimuli, leading to emergency transfer.
Over an extended period, the facility failed to properly log, investigate, and communicate outcomes of concerns raised in Resident Council meetings. Repeated grievances about housekeeping (unclean bathrooms, delayed trash removal, slow laundry, missing basic supplies), dietary services (missing tray items, incorrect or incomplete meals, poor food quality, inconsistent portions), and nursing services (delayed call light response, improper disposal of soiled briefs, inconsistent showers, medication accuracy, negative staff attitudes, excessive noise, staff using phones) were documented in meeting minutes without corresponding documentation of follow-up or resolution. Grievances from the Resident Council were largely absent from the grievance log for many months, and when they were logged, they lacked detail on the complaints and actions taken. Several residents, including the Resident Council President, reported never receiving information or written communication about what was being done to address their concerns and felt ignored as the same issues recurred without documented resolution.
A resident admitted for respite care with an anxiety disorder had PRN Lorazepam supplied from home, and staff documented an initial count of more than the labeled quantity. Discrepancies arose between the MAR and the narcotic sign-out sheet, and staff interviews showed that controlled medications from home were not consistently counted at each shift change once the resident was hospitalized, resulting in 31 unaccounted Lorazepam tablets. In a separate issue, narcotic records for a medication cart showed mismatched counts between the number of controlled medication cards/liquids and the Inventory Sheet, with missing times, signatures, strengths, and incorrect totals after a pharmacy delivery of additional controlled medications, indicating inaccurate and incomplete narcotic documentation.
Staff failed to follow facility policies for Enhanced Barrier Precautions (EBP) and hand hygiene during incontinence and wound care. For a resident on EBP due to a wound and MDRO in the urine, staff twice provided incontinence care wearing only gloves despite posted EBP signage requiring gown and gloves, and one aide handled stool, resident skin, linens, and room items without changing gloves or performing hand hygiene until after disposing of soiled items. During wound care for two residents with pressure ulcers, a Treatment Nurse removed and cleansed multiple wounds and handled contaminated items while repeatedly changing gloves without performing hand hygiene between glove changes or between different wound sites, and in some instances used the same pair of gloves across multiple wounds. The DON, acting as Infection Preventionist, confirmed that residents with devices, open wounds, or MDROs were placed on EBP and that staff were expected to wear gowns and gloves and perform appropriate hand hygiene, which did not occur in these observed episodes.
A resident with respiratory failure, CVA-related hemiplegia/hemiparesis, CKD, and chronic pain, who was cognitively intact and care planned to use the call bell for supervised toileting and hygiene, did not have a reliably functioning call system. The in-room call panel light illuminated when activated, but the corresponding hall light was so dim it was not visible from typical hallway vantage points, and staff reported ongoing, hall-wide issues with dim or non-illuminating call lights and intermittent failures of the nurse’s station switchboard to identify specific rooms. The resident reported repeatedly telling aides that the call bell did not always work and sometimes had to yell for help, while multiple NAs and a nurse acknowledged awareness of call light problems for months without effective use of the electronic work order system, and the Administrator remained unaware of the issue due to lack of submitted work orders and trend reporting.
A resident admitted with multiple serious mental health diagnoses, including PTSD, bipolar disorder, psychotic disorder, and major depressive disorder with psychotic features, had only a Level I PASRR on file and was receiving antipsychotic and antidepressant medications. The SW, who was responsible for PASRR submissions, relied on the hospital’s Level I PASRR and did not review the resident’s diagnoses or request a Level II evaluation, stating he only submits Level II requests when new mental health diagnoses arise after admission. The Administrator reported that Admissions should verify PASRR status and that the facility did not clearly identify the resident’s mental health diagnoses from hospital discharge information, acknowledging that a Level II PASRR request should have been submitted.
A resident who was cognitively intact, frequently incontinent, and required substantial assistance with toileting reported being incontinent of urine and stool and requesting incontinence care from a NA, then waiting an extended period without being changed. During an observation, staff noted a urine and feces odor in the room, and the NA was seen walking the hall without entering the resident’s room, later stating she would address the resident during incontinence rounds and that the resident preferred two staff for care. Multiple NAs and a MA reported that the NA had not requested their help before lunch, and the assigned nurse was unaware of the resident’s prolonged wait. When incontinence care was finally provided by the NA and a MA, the resident’s brief was heavily soiled and the drawsheet was wet, and leadership later acknowledged that such a delay in incontinence care was not acceptable for maintaining resident dignity.
The facility failed to follow its abuse, neglect, and exploitation reporting policy after a resident was found during rounds with an externally rotated right leg and sent to the ER for evaluation and treatment. The 24-hour allegation report, completed by the DON, documented that law enforcement was not notified and did not show whether APS was contacted. A subsequent investigation report noted staff interviews, no evidence of a fall, the resident’s unassisted ambulation with unsteady gait, and no bruising or edema, as well as assessments of other residents with no additional findings, but again did not document notification to law enforcement or APS. The state agency later informed the Administrator that it had not received the required 5-day investigation report, and neither the DON nor the Administrator could confirm or produce evidence that the report had been submitted.
A resident with major depressive disorder, PTSD, bipolar disorder, delusional disorders, and cataract was found in bed holding a safety razor with multiple shallow lacerations and was sent to the hospital via 911. The discharge MDS coded the transfer as an unplanned discharge with return anticipated. Hospital psychiatry later cleared the resident, and the hospital case manager contacted the facility about readmission, but the ADON reportedly stated the resident had been discharged from the facility due to a suicide attempt and would not be accepted back. The resident’s POA believed the resident would return but was later told to pick up the resident’s belongings because the resident would be discharged home, while the Ombudsman reported that the facility refused readmission and did not return her call. Facility staff, including the ADON and DON, described an internal decision that the resident would not come back for safety reasons and referenced a clinical grid and Central Admissions process, while the Administrator denied personally refusing readmission and the Medical Director stated the resident was appropriate for the facility and that the facility could not refuse to admit her under the circumstances.
Two residents did not receive required ADL assistance when staff failed to provide timely incontinence care and scheduled showers. One cognitively intact, frequently incontinent resident who required substantial/maximal assistance with toileting remained in a heavily soiled brief and on a wet drawsheet for more than two hours after reporting an incontinence episode, despite a care plan directing frequent brief changes and perineal cleansing with each episode. Another cognitively intact resident with a chronic leg ulcer, who preferred showers and was scheduled for supervised showers twice weekly, went multiple scheduled shower days without receiving a shower and was repeatedly observed with oily, unkempt hair, as assigned NAs either did not return after offering a shower or reported they did not have enough time and deferred the task to the next shift without it being completed.
A resident with cognitive deficits and recent aggressive behaviors, including wandering, exit-seeking, and physical altercations, was not accurately assessed in the MDS for behaviors, wandering, or use of a wanderguard bracelet. Despite documented incidents and interventions during the look back period, the MDS was completed without reflecting these issues due to staff not updating the assessment as required.
A resident's pressure ulcer progressed to stage III due to the facility's failure to conduct weekly skin assessments. The order for these assessments was entered incorrectly, preventing it from appearing on the MAR, leading to staff being unaware of the need to perform them. The resident's pressure ulcer was not identified until it had progressed significantly, highlighting issues in communication and order entry within the facility.
The facility was found deficient in food storage and cleanliness standards. Observations revealed undated opened thickened liquids and a sticky, debris-filled refrigerator in the kitchen. Additionally, expired chocolate milk was found in the secured unit's nourishment room. The Dietary Manager, new to the role, was unaware of cleaning schedules and the presence of expired items, while the Administrator emphasized the need for proper maintenance and removal of expired food.
A facility failed to include an indwelling catheter in a resident's baseline care plan upon admission. The catheter was documented in the admission assessment but omitted from the care plan. Interviews with staff, including the admitting nurse, MDS Nurse, and DON, revealed the omission was an oversight, and there was no review process for baseline care plans.
A resident with fractures and moderate pain was not provided with a comprehensive care plan for pain management. Despite being cognitively intact and receiving PRN opioid medication, the care plan lacked a pain management strategy. The MDS nurse admitted to an oversight, and both the DON and Administrator acknowledged the deficiency.
Two residents requiring respiratory care were found with improperly maintained oxygen concentrators. One resident's concentrator lacked an air filter and cover, while another's had a filter covered in dust. Despite observations and notifications to staff, no corrective actions were taken.
A facility failed to act on a pharmacy recommendation to add a stop date for a PRN antipsychotic medication for a resident with PTSD, schizophrenia, and bipolar disorder. The medication order lacked a 14-day stop date, and the recommendation was not signed until months later. Staff were unaware of the stop date requirement, and the recommendation was misplaced, leading to a delay in addressing the issue.
A facility failed to include a 14-day stop date for a PRN antipsychotic medication prescribed to a resident with PTSD and schizophrenia bipolar disorder. The resident, who was severely cognitively impaired, had an active order for the medication without the required stop date. Interviews with the DON, NP, and Pharmacy Representative revealed a lack of awareness and oversight regarding this regulatory requirement.
A resident with severe cognitive impairment and dysphagia was given thin liquids instead of the required honey thickened fluids during a meal. The Speech Therapist identified the error and replaced the beverage. The oversight was acknowledged by the Regional Dietary Consultant, and the Administrator noted the need for double-checking meal trays.
A resident with atrial fibrillation and COPD had an indwelling urinary catheter without a documented medical indication, and the facility failed to maintain proper catheter care. Observations showed the catheter bag and tubing on the floor, increasing infection risk. Staff interviews confirmed a lack of awareness and adherence to infection control protocols.
Failure to Provide Necessary Behavioral Health Care and Suicide Precautions After Psychiatric Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary, person-centered behavioral health treatment and services to a resident with severe psychiatric diagnoses and a recent history of suicidal behavior. The resident, an older adult female with major depressive disorder, PTSD, bipolar disorder, delusional disorder, and recent visual loss, had been admitted from an inpatient psychiatric facility after presenting with suicidal ideation and superficial wrist lacerations. At the psychiatric facility, she was treated with olanzapine, which was titrated and continued as a scheduled nightly medication for psychosis, mood stabilization, sleep, and appetite, and she was discharged with an order for olanzapine 5 mg disintegrating tablet every night at bedtime for mood symptoms. The psychiatrist later confirmed that olanzapine was intended as a scheduled bedtime medication and that it does not work as a PRN for depression or psychosis, and that abrupt discontinuation in a person with bipolar disorder could lead to recurrence of psychotic and mood symptoms. Upon admission to the facility, the discharge order for scheduled nightly olanzapine was inaccurately transcribed by the admitting nurse as a PRN medication to be given every 24 hours as needed for mood for 14 days. This incorrect PRN order was then carried forward in the medical record and was administered only once during the resident’s stay, with no documented reason for its use. Multiple providers, including two NPs and a psychiatric‑mental health NP, later stated they were not aware that the olanzapine had been entered as PRN instead of scheduled, and they did not reconcile the facility’s orders against the psychiatric discharge summary. A pharmacy consultation identified the discrepancy between the hospital’s scheduled order and the facility’s PRN order, but the DON assumed the PRN status had been intentionally changed by a provider and did not clarify the order, despite signing off on the pharmacy recommendation. As a result, the resident did not receive the intended continuous antipsychotic therapy following discharge from inpatient psychiatry. In addition to the medication error, the facility did not develop or implement an individualized, trauma‑informed care plan addressing the resident’s history of suicide attempts and suicidal ideation. The care plans referenced antipsychotic and antidepressant use and included general interventions such as administering medications as ordered, monitoring side effects, and short‑term 15‑minute checks "as needed," but there were no specific suicide precautions or individualized approaches related to her prior self‑harm. The trauma‑informed care assessment documented that the resident denied listed traumatic events, despite an existing PTSD diagnosis, and the social services director did not explore the basis for that diagnosis. Multiple staff members, including nurses and NAs who regularly cared for the resident, reported they were not aware of her prior suicide attempts and were not informed of any suicide precautions. Statements by the resident indicating she would be better off dead than staying at the facility were not documented or communicated to all staff. Behavior monitoring was not documented on the MAR, and daily progress notes from admission through the days before the incident described her mood as pleasant with no unwanted behaviors, despite reports from staff of agitation and yelling. On the morning of the self‑harm event, staff noted unusual behaviors, including the resident going into other residents’ rooms and agitation the prior night, but there is no documentation of behavioral monitoring or intervention related to suicide risk. Later that morning, the resident was found in her room with the door closed, lying in bed holding a safety razor, with copious blood on her hands, wrists, and abdomen and multiple shallow lacerations to both wrists, both antecubital areas, and the right side of her neck. She was unresponsive except to painful stimuli, with labored breathing, tachypnea, and low oxygen saturation, and was transferred to the emergency department. The surveyors determined that the facility failed to provide necessary behavioral health care and to prevent the resident from obtaining a safety razor and engaging in self‑harm, despite her recent admission from inpatient psychiatry for suicidal behavior and her documented psychiatric conditions and history.
Failure to Track, Resolve, and Communicate Resident Council Grievances
Penalty
Summary
The deficiency involves the facility’s failure to resolve and communicate outcomes of concerns raised through Resident Council meetings over an extended period. Review of the grievance logs from April 2025 through March 2026 showed that no grievances were filed on behalf of the Resident Council from April 2025 through December 2025, despite multiple documented concerns in the Resident Council minutes. When grievances began to be logged in January, February, and March 2026, there was no documentation of the specific complaints, plans to resolve them, or actions taken. Resident Council minutes across multiple months documented repeated grievances related to housekeeping, dietary, and nursing services, but the minutes generally did not show the facility’s responses to concerns voiced at prior meetings. Resident Council minutes from April 2025 through November 2025 showed recurring issues. In April 2025, residents reported housekeeping problems such as bathrooms not consistently cleaned, delayed trash removal, and slow laundry services; dietary issues including missing tray items, incorrect or incomplete meals, and unavailable alternatives; and nursing concerns such as delayed response to emergency call lights and nursing assistants’ reluctance to assist across halls. In May and June 2025, residents continued to report inconsistent room cleaning, delays in receiving basic supplies, cold and bland meals, missing tray items, and incomplete room cleaning and laundry delays, with no documented facility response to the previous month’s grievances. In July and August 2025, residents again raised unresolved dietary complaints, poor food quality, nurse aides’ reluctance to assist, unprofessional or negative staff attitudes, improper disposal of soiled briefs, and bathrooms not consistently stocked with toilet paper, with minutes still lacking documentation of how prior concerns were addressed. In subsequent months, similar patterns persisted. September and October 2025 minutes documented ongoing concerns about staff disposing of used briefs in resident trash cans, medication accuracy, poor staff attitudes, and shower schedules not being followed, with either no documented response or only general references to “updates” without details. November 2025 minutes noted that nursing had addressed issues such as briefs thrown on the floor, medication accuracy, negative staff attitudes, and medication timeliness, but there was no documentation of the facility’s specific responses. In January 2026, residents reported ongoing issues with staff attitudes, soiled briefs left in trash cans, medication accuracy, missing personal belongings, inconsistent showers, and delayed call light response, with no documented follow-up from November’s grievances. February 2026 minutes stated that all concerns had been documented and forwarded to departments, including missing belongings, inconsistent showers, staff attitudes, medication accuracy, dirty briefs in trash cans, delayed call light response, and staff using phones during work, but again lacked documentation of the facility’s responses. In March 2026, dietary concerns about inconsistent portion sizes and nursing concerns about excessive night-shift noise were recorded, with the Old Business section marked “Resolved” without further explanation. Resident interviews during the April 1, 2026 Resident Council meeting revealed that multiple residents, including the Resident Council President, agreed they were never provided information about what was being done to address their concerns and did not receive written communication regarding outcomes. Several residents reported feeling ignored, that their voices did not matter, and that they were frustrated by raising the same concerns repeatedly without follow-up or resolution. The Activity Director stated she organized the meetings, took minutes, and verbally communicated concerns to department heads and the Social Service Manager, but acknowledged she never received written documentation of investigations or outcomes and that, after a change in the grievance process in December 2025, she no longer received updates regarding grievance outcomes. The Social Services Manager, who served as the Grievance Official, acknowledged he had not been recording Resident Council grievances on the grievance logs until January 2026, tracked resolution by reviewing subsequent Resident Council minutes, and did not receive written notification of resolutions, instead assigning a standard 14-day resolution date. These actions and omissions resulted in a lack of documented investigation, tracking, and communication back to the Resident Council regarding the concerns raised over the 11 of 12 months reviewed. When asked, the Activity Director indicated that she stopped getting updates regarding the outcomes of grievances after the grievance process changed in December 2025.
Inaccurate Reconciliation and Documentation of Controlled Medications
Penalty
Summary
The deficiency involves the facility’s failure to consistently and accurately reconcile and document controlled medications, particularly Lorazepam, brought from home for a resident admitted for a respite stay, and to maintain accurate narcotic counts on a medication cart. One resident admitted with an anxiety disorder had a PRN order for Lorazepam 1 mg. On admission, staff counted 152 Lorazepam tablets in a home-supplied bottle and initiated a sign-out sheet. The MAR for the month showed multiple PRN administrations, and the sign-out sheet documented doses removed from the bottle. However, there were discrepancies between the MAR and the sign-out sheet: at least one dose recorded on the MAR was not documented on the sign-out sheet, and two doses documented on the sign-out sheet were not recorded on the MAR. After the last recorded sign-out, the ending count on the sheet was 142 tablets. Subsequently, while the resident was in the hospital and the Lorazepam bottle remained in the narcotic drawer, a nurse discovered that 31 Lorazepam tablets were missing. Staff interviews revealed that the bottle had come from home, that it contained more than the labeled 90 tablets at admission, and that not all staff consistently counted this controlled medication at each shift change once the resident was hospitalized. One medication aide acknowledged that controlled medications from home were not being counted every shift, even though they were stored in the narcotic drawer. Another nurse stated she did not count the Lorazepam while the resident was in the hospital because the bottle was taped shut with signatures, and she believed there was no reason to count a large bottle with over a hundred pills. Although some staff reported that they always counted the pills when they had that cart, others did not, resulting in an inconsistent counting process and 31 unaccounted Lorazepam tablets. A separate deficiency was identified in the narcotic documentation for a medication cart serving another hall. Observation of the narcotic drawer showed 38 controlled medication cards/liquid narcotics and 38 corresponding Utilization Sheets, but the Inventory Sheet entries did not accurately reflect this number. The Inventory Sheet showed a count of 33 medications and 33 Utilization Sheets at one time point, followed by an undated entry also listing 33, and then lacked a documented count for the next shift change. Pharmacy records showed that 5 additional controlled medications had been delivered and signed for, which should have increased the total to 38. Interviews with the nurses responsible for the shift counts revealed that they had counted the narcotics but had not verified that the total number of medications matched the number of Utilization Sheets, and one nurse believed the count had been recorded on a different page. Review of the narcotic records with nursing leadership showed entries that were out of chronological order, missing times, missing signatures, missing strengths for added medications, and incorrect totals, all contributing to inaccurate and incomplete narcotic count documentation.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinence and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policies for Enhanced Barrier Precautions (EBP) and hand hygiene during incontinence and wound care. The facility’s EBP policy required staff to wear gowns and gloves for high-contact resident care activities such as changing briefs, assisting with toileting, and wound care for residents placed on EBP. The hand hygiene policy required hand hygiene after handling contaminated objects, before and after PPE use, after handling items potentially contaminated with body fluids, and when moving from a contaminated to a clean body site, and specified that glove use does not replace hand hygiene. Despite these policies, multiple staff members did not use required PPE or perform hand hygiene as required during observed care. In two separate observations of incontinence care for a resident on EBP with a wound and MDRO in the urine, staff failed to wear gowns and, in one instance, failed to change gloves and perform hand hygiene after contact with stool and soiled items. In the first observation, a nurse aide and a medication aide entered the resident’s room, noted to have an EBP sign requiring gown and gloves for high-contact care, but only washed their hands and donned gloves without gowns. The nurse aide cleaned stool from the resident’s buttocks using both hands, then, without removing gloves, reached into the resident’s drawer for moisture barrier cream and applied it to the buttocks and abdominal fold. She removed the soiled brief and drawsheet, placed them at the foot of the bed, then placed a clean brief and drawsheet and completed the incontinence care. She then removed only one glove, carried the soiled items to the soiled utility room with the other gloved hand, disposed of them, removed the remaining glove, and washed her hands. Both the nurse aide and medication aide later stated they did not notice or pay attention to the EBP sign and acknowledged they should have worn gowns; the nurse aide also acknowledged she forgot to remove gloves and perform hand hygiene after cleaning stool. In the second incontinence care observation for the same resident on EBP, two nurse aides again entered the room without gowns despite the EBP sign requiring gown and gloves for high-contact care. They washed their hands and donned gloves only, then unfastened the resident’s brief and performed perineal and buttock cleansing with disposable wipes. One aide removed her gloves and washed her hands, then donned new gloves and assisted with transferring the resident using a total mechanical lift. After positioning the resident in a wheelchair, both aides removed their gloves and washed their hands. Both aides later reported they did not see or were not paying attention to the EBP sign and stated they knew gowns and gloves were required for incontinence care for residents on EBP. Additional deficiencies were observed in wound care performed by the Treatment Nurse for two residents. During wound care for a resident with multiple pressure ulcers on the left posterior thigh, left buttock, and right heel, the Treatment Nurse donned a gown and gloves, removed dressings from multiple wounds, and wiped the buttock without changing gloves or performing hand hygiene between wounds. She removed gloves and donned new ones without hand hygiene, then cleansed each wound sequentially with gauze moistened with wound cleanser, again without changing gloves between wounds. After another glove change without hand hygiene, she applied calcium alginate and dressings to each wound in sequence without changing gloves or performing hand hygiene between sites, then completed incontinence care and repositioning before removing PPE and washing her hands. The Treatment Nurse later stated she knew she was supposed to perform hand hygiene before and after wound care, after discarding used items, and after removing gloves and before applying new gloves, and acknowledged she should have used separate gloves and treated each wound separately. In a separate wound care observation for another resident with a sacral pressure ulcer, the Treatment Nurse washed her hands, donned a gown and gloves, and set up supplies. She touched the trash can with a gloved hand to move it closer, then removed her gloves and donned new gloves without performing hand hygiene. She removed the old sacral dressing with moderate light brown drainage, cleansed the wound with gauze moistened with wound cleanser, then again removed gloves and donned new gloves without hand hygiene before applying collagen to the wound bed and covering it with a hydrocolloid dressing. She then adjusted the resident’s brief and pillow, removed her gown and gloves, and washed her hands. In an interview, the Treatment Nurse reiterated that she knew hand hygiene was required before wound care, after the procedure, after discarding used items, and between glove changes, but stated she had forgotten to bring hand sanitizer and that there was no hand sanitizer in the rooms. The DON, who also served as the Infection Preventionist, confirmed that residents with catheters, feeding tubes, central lines, open wounds, or MDROs were placed on EBP and that staff were expected to wear gowns and gloves for care, and acknowledged that the observed staff did not follow EBP and hand hygiene requirements during the cited care episodes.
Failure to Ensure Reliable Call System Functioning for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a consistently functioning resident call system for a resident whose care plan required use of the call bell to request assistance. The resident had acute and chronic respiratory failure with hypoxia, CVA with hemiplegia and hemiparesis, chronic kidney disease, and chronic pain syndrome, but was cognitively intact with adequate hearing and vision and no upper extremity functional impairment. Her care plan directed staff to encourage her to use the call bell for assistance and indicated she required supervision by one staff member for toileting and personal hygiene. During an interview, the resident reported that her call bell did not always work and that she sometimes had to yell from her doorway to get staff attention, stating she had informed aides about the problem multiple times. Surveyor observations confirmed that when the resident pressed her call bell, the small yellow light on the call bell panel in her room illuminated, but the corresponding hall light next to her door appeared white and only showed a very dim yellow color when viewed from close range, not visible from other locations in the hallway. The resident did not have a hand bell available at the time of the initial observations and interviews. Nursing staff acknowledged awareness of intermittent problems with the resident’s call bell signaling, including that the hall light did not always light up, and one nurse stated she had left a note at the receptionist’s desk earlier in the week to request a work order because she did not know how to enter work orders into the electronic system. Multiple nurse aides and the Maintenance Director described ongoing issues with the call light system, particularly on the resident’s hall, including very dim room lights, difficulty seeing which room’s light was activated when multiple call bells were in use, and occasions when the nurse’s station switchboard lights did not reliably indicate which room had called. Staff reported that these problems had been occurring for a couple of months and that the dim lights made it hard to identify the specific room from the nurse’s station or from the far end of the hall. Despite this, there were no documented pending work orders in the electronic system, and the Administrator stated she was unaware of the call bell system problems and relied on staff to submit work orders and maintenance to report trends. This combination of known but uncorrected call system malfunctions and lack of effective reporting resulted in the resident not having a reliably functioning call system as required by her care plan.
Failure to Request Level II PASRR 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 with serious mental health disorders. A PASRR Determination Notification letter dated 9/04/25 showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including post-traumatic stress disorder, bipolar disorder in remission, delusional disorders, and major depressive disorder, single episode, severe with psychotic features. 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 depression, bipolar disorder, psychotic disorder, and post-traumatic stress disorder, and the use of antipsychotic and antidepressant medications during the assessment period. The Social Worker stated he was responsible for submitting Level II PASRR requests and explained that because the resident came from the hospital with a Level I PASRR, he did not believe it was necessary to request a Level II evaluation, assuming the hospital would have done so if warranted. He also reported that when a resident arrives with a halted or Level I PASRR, he does not review their diagnoses, and only submits for Level II if a new mental health diagnosis is made after admission. The Administrator reported that Admissions was supposed to verify a current PASRR before admission and that the Social Worker was responsible for the PASRR process afterward. She indicated the hospital discharge information did not clearly list bipolar disorder or post-traumatic stress disorder, and acknowledged that someone at the facility should have identified the resident’s mental health diagnoses and submitted a Level II PASRR request.
Failure to Provide Timely Incontinence Care Resulting in Loss of Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care in a manner that maintained a resident’s dignity. Resident #102, who was cognitively intact, had adequate vision, required substantial/maximal assistance with toileting hygiene, and was frequently incontinent of urine and bowel, reported being incontinent of urine and stool at 11:45 AM and activating her call light at that time. During an observation beginning at 1:24 PM, the resident was found lying in bed with no call light on, and there was a faint odor of urine and feces in the room. The resident stated she had been waiting to be changed since 11:45 AM, that she had informed Nurse Aide (NA) #8 of her need for incontinence care, and that NA #8 told her she needed to get someone to help and that staff probably needed to serve lunch trays first. The resident reported that having to wait a long time to be changed made her feel bad. During the observation period, at 1:36 PM, NA #8 was seen walking up and down the hall twice without stopping at the resident’s room. At 1:45 PM, NA #8 acknowledged that the resident had asked to be changed but could not recall whether it was before or after lunch and stated she planned to address the resident during upcoming incontinence rounds. NA #8 also stated the resident preferred two staff members for incontinence care and claimed she had asked other aides for help, though she could not identify which staff she had approached. Multiple staff members, including NA #9, NA #10, NA #11, and NA #12, later reported that NA #8 had not asked them for assistance with this resident before lunch, and NA #12 recalled being asked only after lunch while she was occupied giving a shower. Medication Aide (MA) #1 reported that NA #8 requested her help only about five minutes before they entered the room to provide care. At 1:50 PM, NA #8 and MA #1 entered the resident’s room and provided incontinence care. The resident’s brief was found to be heavily soiled with urine and feces, and the drawsheet underneath was visibly wet. NA #8 later stated she did not normally work the day shift, was the only nurse aide on the hall, and felt overwhelmed, but confirmed that she had responded to the resident’s call light and knew the resident required two staff for incontinence care. Nurse #4, who was assigned to the resident, stated she was not aware the resident had been waiting to be changed since before lunch and that NA #8 had not asked her for help. The Director of Nursing and the Administrator both stated that it was not acceptable for a resident to wait as long as this resident had for incontinence care and that residents should be assisted within a much shorter time frame, especially after a bowel movement, to maintain dignity.
Failure to Timely Report Injury of Unknown Origin to Required Agencies
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy regarding timely reporting and notification to required agencies for an allegation of injury of unknown origin involving Resident #105. The facility’s policy required that all alleged violations be reported to the Administrator, state agency, APS, and law enforcement (when applicable) within specified timeframes, and that the results of the investigation be reported to the state agency within 5 working days. An initial 24-hour report dated 4/20/25 documented that Resident #105 was found during rounds with an externally rotated right leg and was sent to the emergency room for evaluation and treatment. The 24-hour report, completed by the DON, documented that law enforcement was not notified and did not indicate whether APS was notified. An investigation report dated 4/22/25, also completed by the DON, showed that staff interviews were conducted and that no evidence of a fall was found. Documentation indicated Resident #105 ambulated unassisted on the unit with an unsteady gait at times, and skin assessments revealed no bruising or edema consistent with a fall; assessments of all other residents on the locked unit showed no additional findings. The investigative report did not document any notification to law enforcement or APS. On 4/30/25, the state agency’s complaint intake unit notified the Administrator that the 5-day investigation report related to the 4/20/25 allegation had not been received. In subsequent interviews, the DON could not recall whether law enforcement or APS had been notified or whether the 5-day report had been faxed, and the Administrator was unable to locate any efax confirmation, acknowledging that the investigation report should have been sent to the state agency within 5 days but appeared not to have been submitted.
Failure to Readmit a Hospitalized Resident After Suicide Attempt
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident to return to the first available bed following a hospital transfer for medical and psychiatric evaluation, resulting in the resident remaining in the hospital for 11 days and ultimately being discharged home. The resident had been admitted with major depressive disorder, PTSD, bipolar disorder, delusional disorders, and cataract. On the date of the incident, a Change in Condition form documented that the resident was found in bed holding a safety razor with copious blood on her hands, wrists, and abdomen, and multiple shallow lacerations to both wrists, both antecubital areas, and the right side of the neck. The facility’s intervention at that time was to call 911 for emergency medical transport. The discharge MDS assessment coded the discharge as unplanned with return anticipated and indicated the resident had modified independence in decision-making and no behavioral symptoms. Hospital case management notes showed that psychiatry evaluated the resident in the ED and that she was placed in observation status while arrangements were made for transfer. Within several days, the hospital anticipated psychiatric clearance and contacted the facility to confirm readmission. According to the hospital case manager’s documentation, the facility’s ADON reported that the resident had been discharged from the facility due to a suicide attempt and would not be accepted back. Subsequent hospital notes indicated that behavioral health cleared the resident and that social work attempted to secure SNF placement, but other SNFs and ALFs declined. The hospital case manager involved the Ombudsman and APS, and documented that the facility would not take the resident back and would accept a penalty fee, leading to a plan for discharge home with home health and community services. Interviews further detailed the facility’s actions and inactions related to the refusal to readmit the resident. The resident’s POA stated she was initially informed only that the resident had been sent to the hospital after cutting herself with a razor and believed the resident would return to the facility when discharged. She later learned from the hospital social worker that the resident’s belongings should be picked up from the facility because the resident would be discharged home, and was told that no nursing facility would accept her and that the original facility refused to take her back. The Ombudsman reported being contacted by the hospital about the facility’s refusal to readmit and stated she left a message for the DON that was never returned and did not further pursue the matter with facility staff. Facility staff interviews revealed internal decisions not to allow the resident to return. The ADON stated that during a morning meeting after the hospital transfer, it was decided the resident would not come back for safety reasons, citing the resident’s statements that she would take her own life regardless of interventions. The Social Services Manager reported not knowing whether the POA was notified about the resident’s ability to return and did not recall discussion of the discharge at morning meetings. The Admissions Director acknowledged a call from the hospital case manager asking what had happened but stated there was no official referral for readmission and that complex readmissions were handled through Central Admissions and sometimes required approval from a regional operations leader. The DON stated that Central Admissions had accepted the resident initially and that a clinical grid indicated the facility could not meet her needs after a suicide attempt, and that the Administrator and Regional President of Operations would ultimately decide about readmission. The Administrator stated she did not deny readmission, believed the resident probably chose to go elsewhere, and did not track her further. The Medical Director, however, stated the resident was appropriate for the facility, that the facility could not refuse to admit her if she denied suicidal ideation and was not accepted to inpatient psychiatry, and that she was not consulted about whether the resident should be allowed to return.
Failure to Provide Timely Incontinence Care and Scheduled Showers for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care to a resident who was frequently incontinent and required substantial/maximal assistance with toileting hygiene. The resident was cognitively intact, had reduced mobility, and her care plan documented an ADL performance deficit, bladder incontinence, and the need for maximum assistance by one to two staff for toileting, with interventions to change disposable briefs frequently, clean the perineal area with each incontinence episode, and check frequently for incontinence. On the day of the survey observation, the resident reported she became incontinent of urine and stool at 11:45 AM, activated her call light, and requested to be changed at that time. She stated that a nurse aide told her she needed another staff member to help and that staff likely needed to serve lunch trays first, and she remained soiled while waiting. During continuous observation from 1:24 PM to 2:00 PM, there was a faint odor of urine and feces in the resident’s room, and her call light was not on at the start of the observation. The resident reiterated that she had been waiting since 11:45 AM to be changed. The assigned nurse aide acknowledged that the resident had asked to be changed but could not recall whether it was before or after lunch and stated she planned to address the resident during incontinence rounds. The aide also stated the resident required two staff for incontinence care, that she was the only nurse aide on the hall, and that she felt overwhelmed. Other nurse aides and the nurse assigned to the resident reported that the aide had not asked them for assistance with this resident prior to the observed care. The DON stated that the resident often complained of waiting two hours to be changed, that it was not acceptable for residents to wait long, and that staff were instructed to assist residents within 15 to 20 minutes. At approximately 1:50 PM, more than two hours after the time the resident reported becoming incontinent, the nurse aide and a medication aide entered the room and provided incontinence care. Upon removal of the brief, there was dried feces stuck to the resident’s buttocks, the brief was heavily soiled with urine and feces, and the drawsheet underneath was visibly wet. The aides cleaned the perineal area and buttocks, removed the soiled brief and drawsheet, and applied a clean brief and drawsheet. The observation confirmed that the resident had remained in heavily soiled incontinence products and on a wet drawsheet for an extended period, contrary to the care plan interventions to change briefs frequently and clean the perineal area with each incontinence episode. The deficiency also includes the facility’s failure to provide scheduled showers to a newly admitted resident who preferred showers and required supervision or touch assistance for bathing. The resident was admitted with a non-pressure chronic ulcer on the left lower leg and was placed on the shower schedule for Saturday and Wednesday on dayshift. Despite this schedule, the resident reported that she had not received a shower since admission and was observed with very oily, unkempt hair several days later. She stated that on her scheduled shower day, a nurse aide asked if she wanted a shower between breakfast and lunch, she agreed, but the aide never returned to provide it. The nurse aide later stated that the conversation about a shower occurred in the evening while she was working as a medication aide and that she asked the evening-shift aide to shower the resident, but she did not provide the shower herself. The nurse assigned to the hall that day confirmed that the aide on dayshift would have been responsible for showers. On the next scheduled shower day, the resident again did not receive a shower. The resident reported that the assigned aide told her she would provide a shower but later stated she had to leave soon and would inform the next-shift aide. The day-shift aide confirmed that the resident requested pain medication before showering and that, after two checks, the resident still reported pain, and the aide told her there was not enough time left in the shift to complete the shower and that the next-shift aide could do it. By the following day, the resident reported she still had not received a shower, and the evening-shift aide had told her there was not enough time to provide one. The resident continued to be observed with oily hair until a later time when she finally received a shower and hair washing. The DON and Administrator both stated that the expectation was for residents to receive showers on their assigned shower days and times, and if staff were unable to provide a shower, it should be communicated to the next shift or completed the next day. Despite these expectations and the resident’s documented shower preferences and schedule, the resident did not receive showers as planned on multiple scheduled days.
Inaccurate MDS Assessment for Resident Behaviors and Wanderguard Use
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for a resident in the areas of behaviors, wandering, and the use of a wanderguard bracelet. The resident, who had a history of cerebral infarction, cognitive deficits, and was newly diagnosed with adjustment reaction with aggression, exhibited multiple concerning behaviors during the MDS look back period. These included being combative with staff, physically abusive, exit-seeking, wandering the unit, and causing injury to a roommate. Despite these documented behaviors and the application of a wanderguard bracelet, the 5-day admission MDS inaccurately indicated that the resident was cognitively intact, had no behaviors, and was not using a wanderguard. Interviews with facility staff revealed that the Social Worker Manager did not update the MDS to reflect the resident's behaviors or use of a wanderguard, citing that the incident occurred after he completed his portion of the assessment. However, the MDS Nurse clarified that the look back period included the dates when these behaviors occurred and that any changes during this period should have been incorporated into the MDS. The MDS Nurse acknowledged the omissions and indicated that the MDS should have been marked for wandering, behavioral issues, and wanderguard use. The Administrator noted her absence during the assessment period and believed the MDS would have been completed correctly had she been present.
Failure to Identify and Treat Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and identify a pressure ulcer on a resident's buttock, which later developed into a stage III pressure ulcer. The resident, who was admitted with a left femur fracture and a surgical procedure, was initially documented to have a stage I pressure area to the coccyx. However, there were no treatment orders for this pressure ulcer, and the Braden scale assessment indicated a low risk for developing pressure ulcers. Despite this, the admission MDS assessment noted the resident was at risk of developing a pressure ulcer, yet no skin or ulcer treatments were documented. The facility's failure to conduct weekly skin assessments as ordered contributed to the oversight. The order for weekly skin integrity reviews was entered incorrectly, preventing it from appearing on the MAR, which meant nurses were unaware of the need to perform these assessments. As a result, the resident's pressure ulcer was not identified until it had progressed to stage III. Interviews with staff revealed confusion and miscommunication regarding the reporting and assessment of the resident's skin condition, with some staff members recalling seeing a wound and others not. The Wound Care Nurse and Wound Care NP confirmed the presence of a stage III pressure ulcer on the resident's left buttock, which was not the same as the stage I area initially documented on the coccyx. The Wound Care NP noted the presence of hyperpigmentation, suggesting prior wounds, but could not confirm if there was a previous wound in the same area. The Director of Nursing and the Administrator acknowledged the error in the order entry and the importance of skin assessments in identifying new skin issues, which were missed due to the order not appearing on the MAR.
Deficiency in Food Storage and Cleanliness
Penalty
Summary
The facility failed to adhere to proper food storage and cleanliness standards, as observed during a survey. In the kitchen's reach-in refrigerator, three containers of thickened liquid were found opened without an open date, and the bottom of the refrigerator was sticky and contained food debris. The Dietary Manager (DM), who had recently started working at the facility, was unaware of when the refrigerator was last cleaned and acknowledged that the liquids should have been dated. Additionally, in the secured unit's nourishment room, four cartons of unopened chocolate milk were found with an expired date. The DM was unsure who placed the expired milk in the refrigerator, and the Administrator confirmed that all food storage areas should be maintained and expired items removed.
Failure to Include Indwelling Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop an accurate baseline care plan for a resident upon admission, as the care plan did not include the presence of an indwelling catheter. This oversight was identified for one of the two residents reviewed for baseline care plans. The resident was admitted with an indwelling catheter, which was documented in the admission nursing assessment by Nurse #1. However, the baseline care plan created on the same day did not reflect this critical information. Interviews with the nursing staff, including Nurse #1, the MDS Nurse, and the Director of Nursing (DON), revealed that the omission was an oversight. Nurse #1 acknowledged the error, and the MDS Nurse confirmed that the indwelling catheter should have been included in the baseline care plan. The DON explained that the baseline care plan is completed by the admitting nurse and then scanned into the resident's electronic medical record without a review process for accuracy. The Administrator also acknowledged the omission, indicating a lack of a systematic review process for baseline care plans.
Failure to Include Pain Management in Care Plan
Penalty
Summary
The facility failed to develop an accurate comprehensive care plan for a resident who was admitted with unspecified fractures of the left femur and upper end of the left humerus. The resident was cognitively intact and experienced moderate pain almost constantly, as documented in the Minimum Data Set (MDS) assessment. Despite receiving as-needed pain medication, including an opioid, the resident's care plan did not include a plan of care for pain, which was a deficiency identified during the survey. The Care Area Assessment indicated that the resident had triggered for pain and should have been care planned accordingly. However, the MDS nurse admitted to an oversight, stating that she had started a care plan for pain but failed to complete it. Both the Director of Nursing and the Administrator acknowledged that the care plan should have included pain management, but it was missed by the MDS nurse. This oversight resulted in the facility's failure to meet the resident's needs for pain management in their care plan.
Failure to Maintain Oxygen Concentrators for Residents
Penalty
Summary
The facility failed to ensure proper maintenance of oxygen concentrators for two residents requiring respiratory care. Resident #25, diagnosed with chronic respiratory failure, was observed multiple times without an oxygen air filter or filter cover on their oxygen concentrator, despite physician orders for continuous oxygen therapy at 2 liters per minute. Observations over several days confirmed the absence of the necessary filter and cover, and both the Unit Manager and Director of Nursing were informed but did not provide comments on the issue. Resident #78, diagnosed with Chronic Obstructive Pulmonary Disease, was also observed receiving oxygen therapy with a concentrator that had a visibly dirty air filter covered in grayish/white dust. Despite the Unit Manager acknowledging the dirty filter, no action was taken to address the issue. The Director of Nursing was informed of the condition of the filter but did not comment on the dust accumulation. The facility administrator acknowledged that the air filters should be clean and present, indicating a failure in maintaining the equipment properly.
Failure to Implement Pharmacy Recommendation for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to act on a pharmacy recommendation to add a stop date for a PRN antipsychotic medication prescribed to Resident #17. The resident, who was admitted with diagnoses including PTSD, schizophrenia, and bipolar disorder, had an active order for Haloperidol injection without a stop date. A pharmacy recommendation made in December 2024 noted that PRN antipsychotic orders should have a maximum duration of 14 days. However, this recommendation was not acted upon until March 2025, when it was signed by the Nurse Practitioner (NP) and the medication was stopped. The deficiency was further compounded by a lack of awareness among staff regarding the requirement for a 14-day stop date for PRN antipsychotic medications. The Director of Nursing (DON) acknowledged that the recommendation was misplaced and not signed off by the new psychiatry provider, who had not yet added Resident #17 as a patient. The Consultant Pharmacist confirmed that he communicated the need for a 14-day stop date during monthly reviews, but no further recommendations were documented after the initial one. The NP admitted to not being aware of the 14-day requirement and typically referred antipsychotic medication evaluations to psychiatry.
Failure to Include 14-Day Stop Date for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to include a 14-day stop date with an order for a PRN antipsychotic medication for a resident diagnosed with post-traumatic stress disorder and schizophrenia bipolar disorder. The resident was admitted with severe cognitive impairment and had an active order for an antipsychotic medication to be administered intramuscularly every 4 hours as needed for agitation. This order, dated December 1, 2024, did not include the required 14-day stop date, which is a regulatory requirement for PRN antipsychotic medications. Interviews with the Director of Nursing (DON), Nurse Practitioner (NP), and a Pharmacy Representative revealed a lack of awareness and oversight regarding the 14-day stop date requirement. The DON acknowledged the oversight and stated that the PRN medication was stopped. The NP admitted to not being aware of the requirement and typically referred antipsychotic medication reviews to psychiatry. The Pharmacy Representative confirmed the necessity of a 14-day stop date for PRN antipsychotic medications. The Administrator also acknowledged the requirement for a 14-day stop date when such medications are ordered.
Failure to Provide Correct Liquid Consistency for Resident
Penalty
Summary
The facility failed to provide drinks consistent with a resident's thickened liquid needs, leading to a deficiency. A resident with severe cognitive impairment and dysphagia was admitted with a physician's order for a regular diet with dysphagia puree texture and honey thickened fluids. During a meal observation, the Speech Therapist identified that the resident received thin liquids on their meal tray instead of the required honey thickened liquids, as specified on the meal ticket. The resident had not consumed the thin liquid, and the Speech Therapist replaced it with the correct honey thickened beverage. The Regional Dietary Consultant acknowledged that the oversight occurred on the tray line, and the Administrator noted the need for double-checking meal trays to ensure correct liquid consistency.
Inadequate Catheter Care and Lack of Medical Justification
Penalty
Summary
The facility failed to ensure that a resident had a medical diagnosis to support the use of an indwelling urinary catheter and did not maintain proper catheter care to prevent infection. Resident #303, who was admitted with diagnoses including atrial fibrillation and COPD, had an indwelling urinary catheter without a documented medical indication. The discharge summary and admission assessments did not provide a reason for the catheter, and the baseline care plan did not address its use. Interviews with the Nurse Practitioner and Director of Nursing confirmed the absence of a diagnosis supporting the catheter's necessity, highlighting the increased risk of infection due to the indwelling device. Additionally, the facility did not adhere to proper infection control practices regarding the catheter's drainage system. Observations revealed that the catheter bag and tubing were repeatedly found on the floor, contrary to infection prevention protocols. Staff interviews indicated a lack of awareness and adherence to proper catheter positioning, as both the nurse and nurse aide acknowledged that catheter bags should not be on the floor due to contamination risks. The Director of Nursing and Administrator reiterated the importance of keeping catheter bags off the floor to prevent infection, yet these practices were not consistently followed.
Latest citations in North Carolina
A resident with hemiplegia after a cerebral infarction and chronic atrial fibrillation was receiving rivaroxaban 20 mg daily as an anticoagulant, as documented in active medication orders, the MDS, and the MAR over several months. However, the comprehensive care plan, from admission through a later update, did not include any problem, goal, or intervention related to anticoagulant use. The MDS Coordinator stated she reviews and updates care plans after MDS completion and acknowledged she had overlooked adding anticoagulant use to the care plan, while the Administrator reported an expectation that all high-risk medications, including anticoagulants, be reflected in resident care plans.
A resident with a chronic heel wound with drainage, classified as high risk under the facility’s Enhanced Barrier Precautions (EBP) policy, received wound care from a Wound Nurse and a NA who wore masks and gloves but did not don gowns during multiple high-contact wound care activities on both lower extremities. The facility’s EBP policy requires both gloves and gowns for high-contact care, including wound care, for residents with chronic wounds. At the time of care, there was no EBP sign on the door and no PPE caddie or supplies outside the room. In subsequent interviews, the Wound Nurse and NA reported they did not wear gowns because there was no sign on the door and the nurse was not wearing one, while the IP and DON stated they would have expected gown use and confirmed that wound care is considered a high-contact activity under the policy.
Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A resident was admitted with documented PTSD and COPD, and hospital records showed PTSD as a chronic condition monitored during hospitalization. Although the care plan and MDS admission assessment identified PTSD as an active psychiatric/mood disorder and the resident received an antidepressant, the PASRR Determination Notification reflected only a Level I PASRR, and the FL2 form from the hospital did not list PTSD. The SW, who was responsible for PASRR submissions, relied on quarterly audits of admission paperwork and the MDS to identify cases needing Level II PASRR, resulting in no timely Level II request being submitted for this resident’s PTSD diagnosis.
Surveyors found multiple opened nutritional supplement containers in unit nourishment refrigerators that were either undated or stored beyond the manufacturer’s specified use-by timeframe. A one-quart shake in one unit refrigerator lacked an opening date despite a label requiring use within four days of opening, while two dated one-quart shakes and an opened, undated diabetic shake in another unit refrigerator were not managed according to their labeled time limits. The DM reported that nursing staff, not dietary, were responsible for dating and discarding resident nutritional shakes, while dietary staff only checked and restocked kitchen-provided items. A nurse and the Administrator both confirmed that the person opening the shake was responsible for dating it and ensuring it was used or discarded within the manufacturer’s guidelines.
A resident with ESRD, peripheral vascular disease, and an AV fistula returned from dialysis with a gauze dressing applied by the dialysis nurse, which remained in place into the following day. A physician order and care plan required nursing staff to remove the AV fistula dressing on the night of dialysis and assess the site for complications and signs of infection. The assigned nurse acknowledged she knew she was required to remove the dressing and assess the site but forgot because she was busy with another resident. The physician emphasized the importance of post-dialysis AV fistula assessment due to the resident’s vascular disease and prior complications, and the DON stated she expected staff to follow the order and routinely assess the fistula site.
A resident admitted with bipolar disorder, generalized anxiety disorder, vascular dementia with severe behavioral disturbance, and active BPSD was maintained on multiple psychotropic medications, including an antipsychotic with a documented contraindication to gradual dose reduction, but only had a Level I PASRR on file. At admission, the SW verified that a PASRR existed in NC MUST but did not confirm that the resident’s mental health diagnoses were captured, and no Level II PASRR request was submitted. The SW reported she relied on prior guidance that a Level I PASRR was sufficient unless there was a change in condition, and the Administrator confirmed the SW was responsible for Level II PASRR submissions, resulting in the failure to obtain a required Level II determination.
A resident with dementia, stroke, dysphagia, and severe cognitive impairment, who was edentulous and dependent for ADLs, was care planned and listed on the NA Kardex to receive assisted oral care at least twice daily. Over nearly a month, NA documentation showed denture care was provided only three times, and surveyors observed the resident’s upper and lower dentures with brown stains and debris buildup. One NA, assigned on several day shifts, believed the resident did not have dentures and only offered mouthwash and a basin, while another NA, aware the resident wore dentures, usually did not perform denture care because the resident was already in bed and did not want to remove them. The DON later confirmed the dentures had visible debris and staining and that the care plan required regular oral care and proper denture cleaning.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
The facility failed to maintain and implement its antibiotic stewardship and infection surveillance program, as required by its own policy. For most months reviewed, there were no infection control records, including antibiotic order listings, documentation confirming infections, surveillance logs, or trend analyses, and the only available data for one month was an unstructured list of residents who received antibiotics without formal tracking of infection rates or antibiotic use. The DON, who was also expected to serve as the Infection Preventionist, reported being unable to locate infection control reports or surveillance data for an extended period, and the Administrator confirmed that, during a time of multiple interim DONs, infection control tracking and analysis of infection and antibiotic use trends had not been completed.
Failure to Care Plan for High-Risk Anticoagulant Therapy
Penalty
Summary
The facility failed to develop an individualized comprehensive care plan addressing anticoagulant medication use for a resident who had been prescribed rivaroxaban 20 mg daily with the evening meal for a history of cerebral infarction. The resident was admitted with hemiplegia following a cerebral infarction and chronic atrial fibrillation, and the active medication orders showed continuous administration of rivaroxaban from its start date through the survey review period. The quarterly MDS assessment documented that the resident was receiving an anticoagulant, and the Medication Administration Record confirmed daily administration of rivaroxaban over several months. Despite this ongoing anticoagulant therapy and the resident’s relevant diagnoses, the comprehensive care plan dated at admission and updated later did not include any focus area, goals, or interventions related to anticoagulant use. During an interview, the MDS Coordinator acknowledged that the care plan did not address the anticoagulant medication and stated that she must have overlooked it when updating the care plan after completing the MDS assessment. In a separate interview, the Administrator stated that her expectation was that all resident care plans reflect high-risk medications, including anticoagulants.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Control policies and procedures for Enhanced Barrier Precautions (EBP) during wound care for a resident. The facility’s EBP policy, last revised on 04/15/26, requires staff to don both gloves and a gown for high-contact care activities with high-risk residents, including those with chronic wounds. High-contact activities listed in the policy include wound care, and the policy specifies that residents with chronic wounds should remain on EBP for the duration of their stay or until the wound resolves. Resident #12 was admitted with a chronic heel wound with drainage, placing the resident in the high-risk category under the EBP policy. During an observation of wound care on 05/12/26 at 12:33 PM, the Wound Nurse and Nurse Aide (NA) #1 entered the resident’s room wearing masks and gloves but no gowns. There was no EBP sign on the door and no PPE caddie or supplies outside the room. The resident was seated in a wheelchair beside the bed with the door open. The Wound Nurse performed multiple wound care steps on the resident’s right leg, right heel, left third toe, and left heel, repeatedly donning and doffing gloves and performing hand hygiene, while NA #1 assisted by holding the resident’s legs. At no point during these high-contact wound care activities did either staff member wear a gown. In interviews following the observation, the Wound Nurse stated he did not wear a gown because there was no sign on the door indicating the resident was on EBP and later acknowledged learning that a gown should have been worn. NA #1 similarly reported that she did not wear a gown because there was no sign on the door and the Wound Nurse was not wearing one, and she later learned that both should have worn gowns. The Infection Preventionist (IP) stated that the resident should have had an EBP sign on the door and a PPE caddie available, and explained that the sign and supplies were likely left on the resident’s previous room after a move. The IP and the Director of Nursing both stated they would have expected the Wound Nurse and NA #1 to wear gowns while providing wound care, and the DON identified wound care as a high-contact activity requiring gown use under the facility’s EBP policy.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Failure to Request Level II PASRR for Resident With PTSD Diagnosis
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident admitted with a serious mental health disorder. The resident’s hospital course and treatment note documented chronic post-traumatic stress disorder (PTSD), which was monitored during that hospitalization. A PASRR Determination Notification letter showed the resident only had a Level I PASRR with no expiration date. The North Carolina Medicaid FL2 Level of Care Screening Tool completed by the hospital social worker and sent to the facility did not list PTSD as a diagnosis, even though the resident was admitted with diagnoses including COPD and PTSD. The resident’s care plan, initiated shortly after admission, identified a risk for impairments or complications due to a history of PTSD and included interventions such as approaching the resident calmly, avoiding triggers, building a trusting relationship, obtaining psychiatric referrals as needed, and involving the resident in care decisions. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but it did list PTSD as an active psychiatric/mood disorder diagnosis and documented that the resident received an antidepressant during the assessment period. The facility social worker, who was responsible for submitting Level II PASRR requests, acknowledged that the resident had a PTSD diagnosis that was not included on the FL2 and stated she conducted PASRR audits on a quarterly basis by reviewing admission paperwork and the MDS to identify diagnoses requiring Level II submission. She reported she was in the process of completing these audits and preparing to submit requests, including one for this resident. The administrator stated that the social worker should have reviewed the admission diagnoses and MDS triggers and requested a Level II PASRR evaluation for the resident’s PTSD at the time of admission or within a month of admission or new diagnosis, rather than waiting for quarterly audits.
Failure to Date and Discard Opened Nutritional Supplements per Manufacturer Instructions
Penalty
Summary
The deficiency involves the facility’s failure to properly date and discard opened containers of nutritional supplements stored in nourishment room refrigerators on the North and South Units. During observations of these refrigerators with the Dietary Manager, surveyors found a one-quart nutritional shake in the North Unit refrigerator with no date indicating when it was opened, despite the manufacturer’s label stating it must be used within four days after opening if refrigerated. In the South Unit refrigerator, surveyors observed two one-quart nutritional shakes dated 4/24 and 4/28, both beyond the manufacturer’s four-day use-by period, as well as an opened and undated 8-ounce diabetic nutritional shake whose label required use within 48 hours of opening. In interviews, the Dietary Manager stated that dietary staff did not stock the nutritional shakes in the nourishment refrigerators and that nurses were responsible for the nutritional shakes given to residents, including dating them when opened and discarding them when past the use-by date. The Dietary Manager also explained that dietary staff checked the nourishment refrigerators twice daily only for items provided by the kitchen, including restocking and checking expiration dates on those snacks and drinks. A nurse confirmed that a physician’s order was required for a resident to receive a nutritional shake and that nurses were responsible for dating the shakes when opened and ensuring they were used and discarded according to the manufacturer’s instructions. The Administrator stated that the person who opened a nutritional shake was responsible for writing the date opened on the container and noted that historically dietary staff checked dates on food and drinks stored in the nourishment refrigerators.
Failure to Remove Dialysis AV Fistula Dressing and Perform Ordered Assessment
Penalty
Summary
The facility failed to follow a physician’s order to remove a dressing and visually assess a resident’s arteriovenous (AV) fistula after dialysis. The resident, who had diagnoses including AV fistula, end stage renal disease, dialysis, and peripheral vascular disease, was cognitively intact and received dialysis. A physician order dated 2/2/2026 directed staff to remove the dressing to the AV fistula on the night of dialysis every Monday, Wednesday, and Friday to avoid skin breakdown and damage to the AV fistula. The resident’s care plan, updated on 2/27/2026, included interventions to check and change the AV fistula dressing as ordered and to observe the site for signs and symptoms of infection. On observation, the resident was noted to have a gauze dressing with tape on the left upper arm AV fistula the day after dialysis, and the resident reported that the dressing had been applied by the dialysis nurse after treatment. The nurse assigned to the resident on the 3:00 PM to 11:00 PM shift acknowledged that she was supposed to remove the dressing and assess the AV fistula site when the resident returned from dialysis but stated she forgot because she was busy with another resident. The physician stated that it was important for nursing staff to remove the dressing and assess the AV fistula after dialysis due to the resident’s significant vascular disease and history of complications with hypotension and falls after dialysis, and described the AV fistula as the resident’s lifeline. The DON stated that nursing staff usually removed the dressing and assessed the AV fistula site after dialysis and that she expected staff to follow physician orders and assess for signs and symptoms of infection.
Failure to Request Level II PASRR Evaluation for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to submit a request for a Level II PASRR evaluation for a resident admitted with serious mental health disorders. A PASRR Determination Notification letter showed the resident had only a Level I PASRR with no expiration date. The resident was admitted with diagnoses including bipolar disorder, generalized anxiety disorder, and vascular dementia with severe behavioral disturbance. A psychiatric progress note documented a long history of bipolar disorder and recent behavioral and psychological symptoms of dementia, with active diagnoses of bipolar disorder, bipolar depression, and generalized anxiety disorder. The resident was receiving multiple psychotropic medications, including duloxetine, clonazepam, quetiapine (in both morning and bedtime doses), and trazodone. The admission MDS assessment indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite active psychiatric/mood disorder diagnoses of anxiety disorder and bipolar disorder and ongoing antipsychotic use with a physician-documented contraindication to gradual dose reduction. An NC MUST inquiry confirmed that only a Level I PASRR, effective more than a year prior, was on file and that no PASRR requests for a Level II determination had been submitted prior to the survey date. The Social Worker reported that she checked NC MUST for a current PASRR at admission but did not verify whether mental health diagnoses were included in the initial screening, and she relied on prior guidance from a PASRR evaluator that a Level I PASRR was sufficient unless there was a change in condition. The Administrator stated the Social Worker was responsible for submitting Level II PASRR requests and acknowledged that, based on this prior guidance, a Level II request for this resident was not completed.
Failure to Provide Ordered Denture and Oral Care for Dependent Resident
Penalty
Summary
The facility failed to provide ordered assistance with denture and oral care for a dependent resident with severe cognitive impairment, dementia, stroke, dysphagia, and edentulism. The resident’s admission MDS documented severely impaired cognition, a need for setup or clean-up assistance with oral hygiene, and no refusal of care or behaviors. The care plan and NA Kardex both directed staff to provide or assist with oral care at least twice daily using a soft toothbrush or foam swabs, and identified the resident as at risk for oral and dental health problems and dependent in ADL self-care. However, NA documentation showed denture care was recorded as provided only three times over nearly a month-long period. During observation, the resident reported wearing upper and lower dentures and displayed dentures with brown stains and debris buildup around the teeth and gums, stating he could brush his dentures if he had a toothbrush and toothpaste. One NA, assigned on multiple day shifts, stated she provided only mouthwash and a basin because the resident had difficulty brushing, believed the resident did not have dentures, and confirmed she had not provided denture care. Another NA on night shift acknowledged knowing the resident wore dentures, having seen them on the bed or nightstand, but stated she usually did not perform denture care because the resident was already in bed and did not want to remove them, and described denture care only as soaking them overnight. When the DON later observed the dentures, he confirmed visible debris and brown staining, and acknowledged that the care plan and Kardex required oral care at least twice daily and that dentures should be brushed and soaked overnight.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Failure to Maintain Facility-Wide Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a facility-wide system to monitor antibiotic use as required by its Antibiotic Stewardship Program policy. The policy, last revised in December 2016, required that all clinical infections treated with antibiotics undergo review by the Infection Preventionist or designee, including review of antibiotic utilization, antibiotic orders, clinical documentation confirming infections, infection surveillance logs, microbiology testing, and trends in infection and antibiotic use data. Surveyors found that for eight of nine months reviewed—July, August, September, October, November, and December 2025, and February and March 2026—the facility was unable to provide any infection control data, including listings of antibiotic orders, clinical documentation confirming infections, surveillance logs, or trending of infections. For January 2026, the facility had only a list of residents who exhibited symptoms and were treated with antibiotics, but did not use a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections. During interviews, the DON, who assumed the position on April 13, 2026 and was also expected to function as the Infection Preventionist, reported being unable to locate Infection Control reports, surveillance records, or infection tracking data for July 2025 through April 2026, except for the January list of residents who received antibiotics. The Administrator confirmed that multiple interim DONs had served since July 2025 and acknowledged that tracking of infection control data, including infection trends and antibiotic use, had not been completed, despite the facility’s stated intent for a comprehensive Infection Control Program that included surveillance, tracking, and trend analysis.
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