Fuquay-varina Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fuquay Varina, North Carolina.
- Location
- 410 S Judd Parkway Se, Fuquay Varina, North Carolina 27526
- CMS Provider Number
- 345561
- Inspections on file
- 25
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Fuquay-varina Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to provide required information about advance directives to a resident’s representative and did not obtain or maintain copies of advance directives for two residents. One cognitively impaired resident was care planned as full code without any documented discussion or written information about advance directives provided to the representative. For another resident, the responsible party repeatedly reported that an advance directive existed and confirmed full code status, but staff did not consistently follow up to obtain the document, and no advance directive was filed in the medical record despite multiple care plan meetings and psychosocial assessments noting its existence.
A resident with a documented Doxycycline allergy, noted in both a hospital after-care summary and the EMR allergy banner, was prescribed Doxycycline 100 mg BID for seven days after testing positive for an infectious disease. An RN texted the physician about the test result without the EMR open and entered the Doxycycline order, reporting no recall of an allergy alert. The physician, who did not have EMR access and relied on nursing staff to report allergies, was unaware of the allergy. A Guardian later identified the contraindicated order while reviewing the MAR. The DON stated nurses are expected to have the EMR open when contacting physicians, and the Administrator acknowledged that the physician ordered a medication to which the resident was allergic and that the nurse did not inform him of the allergy.
A resident with a tracheostomy and acute respiratory failure with hypoxia had physician orders and a care plan for routine trach care, including changing or cleaning the inner cannula as applicable. On two night shifts, an RN provided trach care and later reported that on one of those shifts there were no extra single-use disposable inner cannulas in the resident’s room. Instead of obtaining a new cannula from other supplies, the RN used a trach care kit with sterile gloves, sterile water, and a sterile brush to clean the disposable inner cannula and reinserted it, despite knowing it was labeled for single use and acknowledging that reuse could pose an infection risk. The DON and Administrator later confirmed that only single-use disposable inner cannulas are used and that they are not to be cleaned and reused.
Surveyors found a wound care cart at a nursing station left unlocked and unattended for several minutes while housekeeping staff, CNAs, visitors, and a resident passed by. No staff were in visual range of the cart during this time, and the nurse present could not identify who last accessed it. The cart contained multiple wound care supplies and medications, including topical agents and medicated dressings. A nurse and the DON both acknowledged that nurses are responsible for the cart and that it should remain locked when not attended due to safety concerns for confused residents.
The facility failed to ensure daily posting of nurse staffing information in a visible area for residents and visitors when the designated Scheduler was not on duty. Surveyors observed that the posted staffing sheet was several days out of date, and interviews revealed that the Scheduler, who did not work weekends, was solely responsible for creating and posting these sheets. The Scheduler acknowledged that no process existed to ensure postings occurred during her absence and that she had not discussed such a process with the Administrator. The Administrator confirmed reliance on the Scheduler and was unaware that staffing information was not being posted when the Scheduler was out of the office.
A resident with recent fractures and moderate cognitive impairment was left calling for help and with an unanswered call bell while a nurse aide used her personal cell phone at the nursing station. The resident's family member and other staff observed the aide ignoring the resident's needs for over 13 minutes, until another staff member intervened and provided care. Staff interviews confirmed the aide's inaction and inappropriate use of a personal device during the incident.
A resident with dementia recovering from femur surgery was prescribed Oxycodone for pain management. Discrepancies were found in the controlled drug records, including incorrect initial counts and multiple doses signed out before the medication was delivered. A nurse documented removing more tablets than prescribed and could not explain the inconsistencies, with no backup supply records supporting her actions. The issue was identified during a shift change and confirmed by pharmacy and staff interviews, resulting in a deficiency for misappropriation of a resident's medication.
A nurse with a history of drug diversion and active license restrictions was hired and allowed to work, despite the facility being aware of her disciplinary status. While caring for a resident, the nurse was unable to account for missing Oxycodone tablets, and discrepancies were found in medication records. The nurse was subsequently reported, suspended, and terminated after the incident.
A resident alleged being slapped by a nurse aide, but the accused staff member was not immediately suspended and the incident was not promptly reported to the Administrator, resulting in delayed investigation and failure to meet regulatory reporting timeframes. Staff interviews revealed confusion and breakdowns in communication regarding abuse reporting procedures.
A resident with a history of stroke, dysphagia, and renal disease was switched from bolus to continuous enteral feeding, but the previous bolus order was not discontinued in the MAR. This led to staff continuing to administer bolus feedings and not consistently providing the continuous feeding as ordered, due to confusion and lack of clear documentation. The issue persisted until identified during a survey, with staff interviews confirming the oversight and lack of communication.
The facility failed to accurately code MDS assessments for several residents, leading to documentation errors in hospice care, vision impairment, functional abilities, and dialysis treatment. A resident receiving hospice care was incorrectly coded as not receiving such services, while another resident who was legally blind was documented as having adequate vision. Additionally, a resident's functional limitations were not accurately reflected, and another resident with ESRD on dialysis was not coded for these conditions due to an oversight during a system transition.
The facility failed to schedule an RN for at least 8 consecutive hours a day, 7 days a week, for 25 out of 61 days reviewed. This issue arose due to significant staff turnover following a change in ownership and reliance on staffing agencies, which could not consistently provide the required coverage. Interviews revealed a lack of awareness and communication regarding staffing requirements among facility staff.
The facility did not resolve concerns raised by the Resident Council about staffing issues affecting residents' ability to get out of bed and receive showers. Despite repeated discussions in meetings, no resolutions were provided, and the DON was unaware of the issues due to a communication breakdown with the Activities Director.
The facility failed to provide advance directive information and opportunities for two residents to formulate directives. One resident with acute respiratory failure and another with dementia had no documentation of advance directive discussions, only code status was addressed. The responsibility for these discussions was moved to Social Services after a change in ownership, but the expected discussions were not conducted.
A facility failed to include the application of splints and multi podus boots in a resident's care plan. The resident, who was severely cognitively impaired, had physician orders for these interventions, but they were omitted when the facility switched computer systems. The MDS Coordinator and Administrator acknowledged the oversight.
Expired medications were found in the Rehab Medication Cart, including aspirin and Allergy Relief tablets. A CMA confirmed the presence of expired medications, stating it was the nurses' responsibility to check for them. A nurse acknowledged his responsibility but clarified that all nurses should check their carts. The Administrator expected nursing staff to discard expired medications.
A Physical Therapist Assistant and a Physical Therapist failed to wear gowns as required by Enhanced Barrier Precautions (EBP) while transferring a resident with an indwelling upper chest dialysis catheter. Although gloves were worn, the staff did not adhere to the facility's EBP policy, which mandates the use of gowns and gloves during high-contact activities. The staff acknowledged their oversight despite being trained on EBP protocols.
Two residents experienced misappropriation of property by an agency nurse. One resident, who was cognitively intact, had his air pods removed and tracked to the nurse's address. Another resident, with moderate cognitive impairment, had his debit card stolen and used for unauthorized transactions. Both incidents highlight a failure in the facility's security and oversight measures.
A facility failed to apply necessary orthotic devices for a resident with limited range of motion and contractures, as ordered by the physician. The resident, who was severely cognitively impaired, had orders for multi podus boots, a left-hand splint, and elbow extension splints. Observations and interviews revealed these devices were not applied, and staff were unaware of the orders due to a lack of communication and care planning.
A resident with Parkinson's disease was not scheduled for a neurology appointment despite a referral and hospital discharge instructions. The facility's scheduler and a nurse failed to ensure the appointment was made, leading to a deficiency in providing necessary medical services.
The facility failed to maintain accurate medical records for two residents. A resident's hospital transfer was not documented due to a reported computer glitch, and another resident's medication administration was not consistently recorded, despite being administered. The DON confirmed missing documentation in both cases.
The facility failed to provide written notification to the Resident Representative and Ombudsman for two residents transferred to the hospital. One resident's representative was aware of the transfer but did not receive written notice, while the other resident, who was her own representative, also did not receive written notice. The Social Worker, new to the facility, was unaware of the requirement, and the Administrator was not informed of the lack of notifications.
A facility failed to invite a resident with Alzheimer's disease and their representative to care plan meetings. The resident's representative reported not being invited since admission, and the social worker confirmed the oversight, unaware of the requirement to include them. The administrator acknowledged the lapse, noting the social worker's responsibility for invitations.
The facility was found to have several deficiencies in maintaining a safe and homelike environment, including stained privacy curtains, broken fixtures, and a black greenish substance around commodes. Damaged drywall and missing light covers were also observed. Interviews with staff revealed that these issues were known but not yet addressed, with the Administrator acknowledging ongoing efforts to improve the living environment.
Failure to Provide Information and Maintain Documentation of Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to provide required information about advance directives and to obtain and maintain documentation of residents’ advance directives in the medical record. For one resident admitted on an unspecified date, the admission MDS showed severe cognitive impairment, and the care plan dated 1/26/26 listed the resident as full code. However, there was no documentation in the record that the resident’s representative had been provided written information about the right to refuse medical or surgical treatment or to formulate an advance directive. The resident’s representative reported that no facility representative had discussed any information regarding an advance directive, and the social worker confirmed she had been on leave at the time of admission and indicated it would have been the previous social worker’s responsibility to address advance directives. For a second resident, multiple care plan notes and psychosocial discharge planning assessments documented that the responsible party reported the resident had an advance directive and confirmed full code status, and that guardianship paperwork would be brought in. Despite this, there was no documentation that the social worker requested or obtained a copy of the advance directive beyond the initial conversation, and subsequent care plan notes did not reflect follow-up requests. The psychosocial assessments repeatedly recorded that the resident was assessed to have an advance directive per the responsible party, but the medical record contained no copy of the advance directive. Interviews with social work staff and the administrator confirmed that the facility’s practice was to discuss advance directives upon admission, determine whether an advance directive existed, and request a copy for the medical record, with follow-up at subsequent care conferences if the document was not initially provided. In the case of the second resident, the current social worker acknowledged that the responsible party had not brought in the advance directive and that she did not follow up, and the prior social worker stated she believed she had not followed up due to difficulty reaching the responsible party. The administrator stated she expected social workers to discuss advance directives within three days of admission and to obtain and maintain copies in the medical record, which did not occur for these two residents.
Allergic Resident Prescribed Contraindicated Antibiotic
Penalty
Summary
A resident with a documented allergy to Doxycycline, causing shortness of breath, was prescribed this medication despite the allergy being clearly listed in multiple parts of the medical record. The hospital after-care summary and the allergy section on the resident’s EMR banner both identified Doxycycline as an allergen. On 1/19/2026, after the resident tested positive for an infectious disease, a nurse contacted the physician via text message about the positive test result without having the EMR open to review allergies. The physician responded by ordering Doxycycline 100 mg twice daily for seven days, and the nurse transcribed this as a telephone order in the EMR. The nurse later stated she did not recall any allergy alert appearing when she entered the order. The physician reported he was unaware of the resident’s Doxycycline allergy and did not have access to the EMR, stating that nursing staff typically inform him of allergies. Another nurse explained that allergies are displayed beneath the resident’s name in the EMR and that an alert appears when a contraindicated medication is entered. The resident’s Guardian discovered the Doxycycline order while reviewing the MAR and notified the facility of the known allergy. The DON stated that nurses are expected to have the EMR open when contacting physicians so they can review allergies, and the Administrator acknowledged that the physician prescribed a medication to which the resident was allergic and that the nurse did not inform the physician of the allergy when the medication was prescribed.
Improper Reuse of Single-Use Tracheostomy Inner Cannula
Penalty
Summary
The deficiency involves the facility’s failure to provide tracheostomy care consistent with professional standards of practice when a nurse cleaned and reused a single-use disposable tracheostomy inner cannula for a resident. The resident had been admitted with acute respiratory failure with hypoxia and had a physician’s order for tracheostomy care every shift and as needed, including cleaning or changing the inner cannula as applicable. The resident’s care plan identified a risk of complications related to the tracheostomy, with an intervention for tracheostomy care as ordered. Documentation on the Treatment Administration Record and nursing progress notes showed that the same nurse provided tracheostomy care on two consecutive night shifts, during which the care was documented as well tolerated. In a later interview, the nurse stated that the resident’s tracheostomy inner cannulas were always single-use disposable types and that during one of those night shifts there were no extra inner cannulas in the resident’s room. She reported that, needing to provide tracheostomy care, she used a tracheostomy care kit with sterile gloves, sterile water, and a sterile brush to clean the disposable inner cannula and then reinserted it instead of discarding it and using a new one, acknowledging she knew this was not permitted and that reusing a disposable inner cannula could risk infection. She also stated she did not look for additional cannulas outside the resident’s room and did not have access to the supply room. The DON and Administrator later confirmed they were unaware of the incident at the time and affirmed that the facility used only disposable inner cannulas intended for single use and that they should not be cleaned and reused.
Unlocked and Unattended Wound Care Cart Containing Medications
Penalty
Summary
Surveyors observed that the Station 2 wound care cart was left unlocked and unattended for at least seven minutes during a continuous observation period on a Sunday morning from 10:29 AM to 10:36 AM. During this time, there were no staff, residents, or visitors positioned so that they could see the cart. Multiple individuals, including housekeeping staff, nurse aides, visitors, and a resident, walked past the unlocked cart while it remained unattended. The cart was located at the nursing station, and no staff member was identified as the last person to access it. When the cart was inspected with a nurse at 10:39 AM, it was found to contain various wound care supplies and medications, including calcium alginate dressing, iodoform packing strips, collagen wound filler, xeroform medicated petrolatum dressing, zinc oxide paste, Silvasorb gel, diclofenac sodium topical gel 1%, 70% isopropyl alcohol, lidocaine ointment USP 5%, carbamide peroxide 6.5%, ciclopirox olamine cream USP 0.77%, nystatin cream USP 100,000, gentamicin sulfate cream USP 0.1%, and nystatin topical powder. The nurse interviewed stated that all nurses were responsible for the cart, acknowledged that it should be locked when unattended because it contained medications, and noted that many confused residents lived in the facility. The DON also stated that wound care carts should be locked at all times when not attended by a nurse due to safety concerns for confused residents.
Failure to Ensure Daily Posting of Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing information in a location visible to residents and visitors on one of four survey days, and the lack of an effective process to ensure this information was posted every day, including weekends. On a Sunday at 10:00 AM, surveyors observed that the daily staffing information sheet at the reception desk was dated three days earlier, indicating that current staffing information for the intervening days had not been posted as required. No residents or specific patient conditions were mentioned in relation to this deficiency. Interviews and record reviews showed that the Scheduler was solely responsible for preparing and posting the daily staffing information sheets and did not work on weekends or certain weekdays. The Scheduler acknowledged that she had not completed or posted the daily staffing information sheets for the days she was off and stated that there was no process in place to ensure postings occurred in her absence. She also reported that she had not discussed implementing such a process with the Administrator. The Administrator confirmed that the Scheduler was responsible for posting the staffing sheets and stated she was unaware that postings were not occurring when the Scheduler was out of the office, and that the facility had no process to ensure daily postings when the Scheduler was absent or on weekends.
Failure to Respond to Resident's Call for Help Due to Staff Cell Phone Use
Penalty
Summary
A deficiency occurred when a nurse aide failed to respond to a resident's verbal calls for help and an activated call bell, instead choosing to use her personal cell phone at the nursing station. The resident involved had a history of left hip surgery and recent fractures, including a left acetabular fracture and a sacral ala fracture, and was admitted to the facility with moderate cognitive impairment. He required substantial to maximum assistance for mobility and was receiving pain medication for significant discomfort. On the day of the incident, the resident was heard yelling for help by a family member who was approaching the facility. The family member observed a staff member at the nursing desk engrossed in her personal phone, ignoring both the resident's calls and the activated call light. The call light remained unanswered for approximately 13 to 14 minutes, during which time the resident continued to call out for assistance. The family member eventually confronted the staff member, who did not respond to the resident's needs and instead cursed at the family member. Another nurse aide, passing by, noticed the situation and provided the necessary care to the resident, after which the resident's distress subsided. Multiple staff interviews confirmed that the nurse aide at the desk was using her personal phone and did not respond to the resident's needs, despite being aware of the call light and the resident's vocalizations. Other staff members corroborated that this behavior was not an isolated incident. The nurse aide in question admitted to being at the nursing station with her personal phone and did not attend to the resident, citing a confrontation with the family member as her reason for not responding. The incident was witnessed by other staff and reported to facility leadership.
Failure to Protect Resident from Misappropriation of Controlled Medication
Penalty
Summary
A resident with dementia was admitted to the facility for rehabilitation following surgical repair of a fractured femur. Upon admission, the resident was prescribed Oxycodone 5 mg every six hours as needed for pain and Acetaminophen 500 mg on a scheduled basis. Pharmacy records confirmed that 28 tablets of Oxycodone were delivered to the facility and received at 4:20 AM. However, documentation on the controlled drug receipt record showed discrepancies, including the initial count being marked as 26 tablets instead of 28, and multiple doses being signed out at times before the medication was actually delivered. Nurse documentation indicated that two tablets were removed at each administration, despite the order being for one tablet, and that four tablets were signed out prior to the medication's arrival at the facility. The nurse responsible could not provide a satisfactory explanation for these discrepancies, and there was no record of Oxycodone being removed from the facility's backup supply for the resident. The inconsistencies were identified by another nurse during a shift change and subsequently reported to the acting DON, who verified the discrepancies with the pharmacy and reviewed the documentation. Interviews with staff and pharmacy confirmed that the medication counts and documentation did not align with the actual delivery and administration records. The nurse involved was suspended and later terminated, and the incident was reported to the appropriate regulatory and law enforcement agencies. The facility's failure to accurately account for and protect the resident's controlled medication resulted in a deficiency related to misappropriation of resident property.
Failure to Prevent Employment of Nurse with Active Disciplinary Action for Drug Diversion
Penalty
Summary
The facility failed to ensure that it did not employ a nurse with an active disciplinary action on her professional license due to a history of drug diversion. Nurse #13 was hired despite having restrictions on her license imposed by the North Carolina Board of Nursing (NCBON) following an incident in 2021 where she admitted to diverting Oxycodone and having a substance abuse disorder. The facility was aware of these restrictions at the time of hiring, as they had obtained documentation from the NCBON outlining the disciplinary measures and employment limitations, including prohibitions on supervisory roles and certain types of employment. During her employment, Nurse #13 was involved in an incident where multiple Oxycodone tablets could not be accounted for while she was responsible for the care of Resident #2. The investigation revealed discrepancies in the number of tablets received and administered, with Nurse #13 unable to reconcile the missing medication or provide an adequate explanation. The facility reported the suspected drug diversion to the state agency and subsequently suspended and terminated Nurse #13. Interviews with facility staff and the NCBON compliance case analyst confirmed that Nurse #13's license restrictions were still in effect at the time of her hire and during the incident. The restrictions included specific employment limitations due to her participation in the Alternative Program for Chemical Dependency. Despite these known restrictions and her disciplinary history, the facility proceeded with her employment, which led to the deficiency identified in the report.
Failure to Timely Report and Respond to Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse policy when a staff member accused of slapping a resident was not immediately suspended, and the incident was not reported to the Administrator in a timely manner. According to the facility's policy, all employees are required to report suspected or witnessed abuse to the Administrator or Director of Nursing (DON) within two hours, and allegations of abuse should result in staff suspension and prompt investigation. In this case, the alleged incident occurred, but the Administrator was not informed until the following day, delaying both the suspension of the accused staff member and the initiation of an investigation. The incident involved a resident who alleged being slapped in the face by a nurse aide. Interviews with staff revealed that the resident was yelling and reported to a nurse that she had been slapped. The nurse assessed the resident and found no injuries, then reported the situation up the chain of command. However, the nurse aide accused of abuse was not immediately suspended and continued working. Other staff interviews indicated confusion about the reporting process and whether the DON had been adequately informed. The DON only became aware of the incident the next day and then took appropriate action, including suspension and starting an investigation. Further interviews revealed that the communication breakdown extended to the Administrator, who was also not informed until the day after the incident. The delay in reporting resulted in the facility failing to meet regulatory timeframes for reporting to state agencies and initiating an investigation. Additionally, there was inconsistency in staff understanding of the abuse policy and reporting requirements, contributing to the deficiency.
Failure to Discontinue Outdated Enteral Feeding Order Resulting in Incorrect Administration
Penalty
Summary
A deficiency occurred when the facility failed to discontinue a previous enteral feeding order after a new order was initiated for a resident with a history of stroke, dysphagia, cognitive impairment, and renal disease. The resident was initially receiving bolus tube feedings as ordered, but due to poor oral intake and refusal of bolus feedings, the Registered Dietician (RD) recommended switching to a continuous enteral feeding regimen. The new order for continuous feeding was entered into the electronic system, but the previous bolus feeding order was not discontinued, resulting in both orders appearing simultaneously on the Medication Administration Records (MARs). As a result, nursing staff continued to administer bolus feedings based on the old order, while the continuous feeding was not consistently provided as per the new order. Multiple staff members, including nurses and medication aides, were unaware of the change to continuous feeding or did not see the new order reflected on their shift's MAR. Documentation inconsistencies were noted, with some staff documenting administration of the continuous feeding when it had not actually been given, and others providing bolus feedings in error. Interviews revealed confusion among staff regarding which order was current, and no one sought clarification until the issue was identified during the survey. The resident's intake varied, but weights remained stable, and there was no reported negative outcome from the failure to implement the continuous feeding as ordered. The deficiency was attributed to the failure to discontinue the outdated bolus feeding order, leading to ongoing administration of the incorrect feeding regimen and lack of proper documentation and communication among staff.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in the documentation of hospice care, vision impairment, functional abilities, and dialysis treatment. Resident #6, who was receiving hospice care, was incorrectly coded as not receiving such services in the quarterly MDS assessment. This error was acknowledged by MDS Nurse #1, who admitted to miscoding the hospice details. Similarly, Resident #13, who was legally blind due to absolute glaucoma, was inaccurately documented as having adequate vision in the MDS assessment, despite clear documentation and staff acknowledgment of the resident's blindness. Resident #56's MDS assessment failed to accurately reflect his functional limitations in the lower extremities, despite physician orders for podus boots to address foot drop. The MDS Coordinator admitted to the oversight. Additionally, Resident #350, who had end-stage renal disease (ESRD) and was on dialysis, was not coded for these conditions in the MDS assessment due to an oversight during a transition of electronic systems. The MDS Nurse acknowledged the error, and the Administrator confirmed the expectation for accurate coding. These inaccuracies highlight a pattern of documentation errors in the facility's MDS assessments.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 25 out of 61 days reviewed. This deficiency was identified through a review of daily assignment schedules from April 1, 2024, to May 28, 2024. The specific dates on which the facility did not provide the required RN coverage were listed, indicating a pattern of insufficient staffing. The issue arose amidst significant staff turnover, including RNs, following a change in facility ownership in June-July 2024. The facility had been relying on staffing agencies to fill gaps but was unable to consistently secure 8 hours of RN coverage. Interviews with facility staff revealed a lack of awareness and communication regarding the staffing requirements. The facility Scheduler was unaware of the necessity to schedule an RN for 8 consecutive hours daily. The Director of Nursing (DON), who assumed the role on November 25, 2024, acknowledged the staffing issues and the absence of RNs in supervisory roles. The Administrator also confirmed awareness of the RN coverage problem, both before and after the ownership change, and noted the facility's reliance on agency staff, including Medication Aides. However, the Administrator was not informed of the Scheduler's difficulties in filling the RN shifts.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to address and resolve concerns raised by the Resident Council regarding staffing issues that affected residents' ability to get out of bed and receive showers on their scheduled days. The Resident Council minutes from July 2024 documented these concerns, but no resolutions were provided by the administration. Subsequent minutes from August 2024 also showed a lack of administrative response to the issues raised in July. Interviews with residents revealed ongoing dissatisfaction with the facility's handling of grievances, as the same concerns were repeatedly discussed without resolution. The Director of Nursing (DON) was unaware of the concerns from the July 2024 Resident Council meeting, indicating a breakdown in communication between the Activities Director and the nursing department. The Administrator confirmed that the Activities Director, who resigned in November 2024, was responsible for forwarding concerns to the appropriate department heads. The failure to address these concerns highlights a lapse in the facility's process for managing and resolving resident grievances, particularly those related to staffing and care provision.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written advance directive information and an opportunity to formulate an advance directive for two residents. Resident #14 was admitted with acute respiratory failure, dysphagia, and end-stage renal disease, but there was no documentation in the medical record regarding education or an opportunity to formulate an advance directive. Interviews with the Director of Social Services and the Admissions Director revealed that prior to a change in ownership, only code status was discussed, and the responsibility for advance directive discussions was moved to Social Services in June 2024. The Director of Nursing and the Administrator both expected that advance directives should be discussed and documented upon admission. Similarly, Resident #17, who was readmitted with dementia, stroke, and diabetes, had a DNR order but no documentation of advance directive education or opportunity. Interviews with the Director of Social Services and the Regional Director of Clinical Services confirmed that only code status was discussed, and the responsibility for advance directive discussions was assigned to the Director of Social Services. A statement about advance directives was included in the current admissions packet, but the discussions were not being conducted as expected.
Omission of Splints and Multi Podus Boots in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically omitting the application of splints and multi podus boots. The resident, who was severely cognitively impaired, had physician orders for bilateral multi podus boots to be worn up to four hours daily and a left hand splint to be applied when sitting in a wheelchair. Additionally, the resident was to wear bilateral elbow extension splints daily. However, the comprehensive care plan revised on 10/22/2024 did not include these interventions. During an interview, the MDS Coordinator acknowledged that the current care plan did not include the necessary interventions for splints and multi podus boots. The omission occurred when the facility switched computer systems, and the care plan related to these interventions did not transfer over. The Administrator confirmed that the resident's care plan should have included these interventions, indicating a lapse in ensuring the care plan was comprehensive and up-to-date.
Expired Medications Found in Rehab Medication Cart
Penalty
Summary
The facility failed to dispose of expired medications in one of the three medication carts observed, specifically the Rehab Medication Cart. During an observation, a bottle of aspirin 325 mg tablets with an expiration date of 09/2024 and a bottle of Allergy Relief tablets with an expiration date of 04/2024 were found in the top drawer of the cart. Certified Medication Aide (CMA) #1, who was working with the Rehab Medication Cart, confirmed the presence of expired medications and stated that it was the responsibility of the nurses to check for expired medications. Nurse #8, during an interview, acknowledged that it was his responsibility to check the Rehab Med Cart for expired medications, but clarified that all nurses were responsible for checking their medication carts. The Administrator stated that it was her expectation for nursing staff to check and discard expired medications from the medication carts and storage rooms.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to implement infection control policy and procedures when a Physical Therapist Assistant and a Physical Therapist did not don Protective Equipment (PPE) for Enhanced Barrier Precautions (EBP) while providing high-contact resident care activities. This deficiency was observed during the transfer of a resident with an indwelling upper chest dialysis catheter from a wheelchair to a bed using a Hoyer lift. Although gloves were worn, the staff did not wear gowns as required by the facility's EBP policy. The facility's policy on Enhanced Barrier Precautions mandates the use of gowns and gloves during high-contact activities, such as transferring residents. An EBP sign was posted by the resident's room door, indicating the need for PPE during specific care activities. Despite this, the staff involved acknowledged their failure to adhere to the policy, citing forgetfulness, even though they had been trained on EBP protocols. Interviews with the Regional Director of Clinical Services and the Administrator confirmed that the staff should have donned gowns during the resident's transfer.
Misappropriation of Resident Property by Agency Nurse
Penalty
Summary
The facility failed to protect the property of two residents, leading to incidents of misappropriation. Resident #152, who was cognitively intact, reported that his air pods were removed from his room while he was away. The air pods were tracked to an address linked to a nurse who was assigned to him, indicating a breach of trust and security within the facility. The nurse was found to be in possession of the air pods, which were taken without the resident's consent. Another incident involved Resident #97, who had moderate cognitive impairment. The resident's family member discovered that his debit card was missing from his wallet, which was usually kept in his front shirt pocket. Unauthorized transactions were made using the card, and video surveillance at a local gas station identified the same nurse as the perpetrator. This incident further highlights the facility's failure to safeguard residents' belongings. Both incidents involved the same nurse, who was agency staff, and indicate a failure in the facility's oversight and security measures. The nurse's actions were in direct violation of the facility's policy on misappropriation of property, and the facility's initial response did not prevent these occurrences.
Failure to Apply Orthotic Devices for Resident with Contractures
Penalty
Summary
The facility failed to apply necessary orthotic devices for a resident with limited range of motion and contractures, as ordered by the physician. The resident, who was severely cognitively impaired, had orders for bilateral multi podus boots, a left-hand splint, and bilateral elbow extension splints to be applied at specific times of the day. Observations on multiple occasions revealed that these devices were not applied as required. Interviews with the resident's family member confirmed that the splints and boots were not applied during her visits, which spanned several hours each day. Interviews with facility staff, including a nursing assistant, a licensed nurse, and a certified occupational therapy assistant, revealed a lack of awareness and communication regarding the resident's need for these devices. The MDS Coordinator indicated that the splints and boots were not included in the care plan, which led to the omission of these tasks from the resident's information sheet and the nursing assistants' task list. This oversight resulted in a system failure, as the nursing staff was not informed of the need to apply the orthotic devices, leading to the deficiency.
Failure to Schedule Neurology Appointment for Resident
Penalty
Summary
The facility failed to ensure that a neurology appointment was scheduled for a resident who was admitted with diagnoses including Parkinson's disease, hypothyroidism, and failure to thrive. The resident, who was cognitively intact, expressed a desire to confirm her Parkinson's diagnosis with a neurologist. Despite a referral being made to neurology by the facility scheduler, the local neurology office indicated that the notes provided were insufficient, and no appointment was made. Following a hospital visit initiated by the resident's call to 911, discharge instructions again emphasized the need for a neurology appointment. However, the scheduler did not send a new referral after the hospital visit, as she was informed by a nurse that a referral already existed. The Director of Nursing acknowledged that either the scheduler or the nurse should have ensured the appointment was scheduled, but this did not occur, resulting in a deficiency in providing medically-related social services to the resident.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents, leading to deficiencies in documentation. For Resident #250, there was no entry in the medical record indicating the resident's transfer to the hospital on 08/09/24, nor was there documentation of the resident's condition at the time of transfer. Nurse #2, who was responsible for the resident, stated that she documented the transfer in the electronic chart, but the information was lost due to a computer glitch after the resident was marked as discharged. The Director of Nursing (DON) confirmed the absence of a transfer order in the resident's medical record, and the Administrator noted that a verbal order for transfer should have been documented. For Resident #350, the facility failed to document the administration of sevelamer, a medication prescribed for high phosphate levels, on multiple occasions in February and March 2024. Although the medication was reportedly administered as ordered, it was not consistently documented in the Medication Administration Record (MAR). Interviews with nurses revealed that the medication was given with meals as prescribed, but documentation was missed. The DON acknowledged the issue of missing documentation despite the medication being administered.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the Resident Representative and Ombudsman regarding the transfer of two residents to the hospital. Resident #56 was discharged to the hospital on June 20, 2024, and readmitted to the facility later. The medical record did not contain any documentation of written notice of transfer being provided to the Resident Representative or Ombudsman. The Resident Representative was aware of the transfer because she was present at the facility but confirmed she did not receive any written notice. The facility's Social Worker, who had recently started, admitted to not notifying the Ombudsman or the Resident Representative in writing, citing a lack of awareness of the requirement. Similarly, Resident #21 was discharged to the hospital on November 14, 2024, due to concerning laboratory results and was later readmitted. The medical record lacked documentation of written notice of transfer to the resident or Ombudsman. Resident #21, who was her own representative, confirmed she did not receive any written notice. The Social Worker again acknowledged not notifying the Ombudsman or the resident in writing, attributing it to her recent start at the facility and lack of knowledge about the requirement. The Administrator was unaware of the lack of notifications and the regulatory requirement for written notification to the resident or their representative.
Failure to Invite Resident and Representative to Care Plan Meetings
Penalty
Summary
The facility failed to conduct care plan meetings or invite residents and their representatives to these meetings for one of the residents reviewed. The resident in question was admitted with a diagnosis of Alzheimer's disease and was assessed as severely cognitively impaired. Despite the requirement to hold care plan meetings quarterly, the resident's representative reported not being invited to any care plan meetings since the resident's admission. The social worker confirmed that the representative had not been invited and was unaware of the requirement to include the resident or their representative in the care plan meetings. The administrator also acknowledged being unaware of the oversight, indicating that the responsibility for inviting participants to the care plan meetings lay with the social worker.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several deficiencies observed during a survey. In resident room 304, large stains were found on the privacy curtain, a bedside dresser handle was broken, and a towel rack was missing. Additionally, a black greenish substance was noted around the base of commodes in rooms 304, 309, 708, 713, and 714, indicating a lack of proper maintenance and cleaning. Damaged drywall was observed in rooms 306, 309, 503, 605, and 713, and missing overhead bed light covers were noted in rooms 714 and 718. Interviews with the Housekeeping Supervisor and Maintenance Director revealed that these issues were known but had not been addressed in a timely manner. The Housekeeping Supervisor acknowledged the need for curtain replacement and stated that maintenance was responsible for other repairs. The Maintenance Director admitted to being behind on repairs due to limited resources. The Administrator confirmed that improvements were ongoing but acknowledged that several areas still required attention to ensure a safe and homelike environment for residents.
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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