Harmony Hall Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kinston, North Carolina.
- Location
- 312 Warren Avenue, Kinston, North Carolina 28501
- CMS Provider Number
- 345156
- Inspections on file
- 22
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Harmony Hall Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with type 2 DM, who was cognitively intact and on insulin therapy, received a dose of glargine insulin from a pen that had been open beyond the manufacturer’s 28‑day discard date. Surveyors found an open glargine pen on the med cart labeled with an opening date that showed it was expired, as well as a second, unopened and undated pen for the same resident. The nurse who administered the insulin reported she did not check the expiration date before giving the dose and acknowledged she should have discarded the expired pen. The Pharmacy Consultant confirmed the 28‑day discard requirement, while the NP, DON, and Administrator each stated that nursing staff were expected to check med carts daily and ensure no expired medications were present or administered.
Surveyors found an open insulin glargine pen on a medication cart that remained in use past the 28-day discard period specified by the manufacturer. The pen was labeled with an opened date and an expiration date that had already passed, yet it was still stored on the cart during the survey. A medication aide assigned to the cart, the covering nurse, the Pharmacy Consultant, the DON, and the Administrator all acknowledged that nursing staff, including medication aides, were expected to check carts daily and remove expired medications, but this did not occur for the insulin pen on Station 2 medication cart #1.
A cognitively intact resident with hemiplegia and documented tobacco use, assessed and care planned as a safe, independent smoker, was found in his room with a pack of cigarettes and a lighter hidden under his shirt, contrary to facility policy requiring all smoking materials to be locked in a medication cart and accessed only with staff assistance. Staff, including a nurse, NA, medication aide, DON, and Administrator, reported that the resident normally obtained smoking materials from staff before going to the designated smoking area and returned them afterward, and that staff were responsible for ensuring the materials were secured. On this occasion, the resident kept his cigarettes and lighter after returning from smoking, reportedly because no staff were present at the medication cart, resulting in unsecured smoking materials in violation of the facility’s smoking policy.
A resident with a g-tube for nutrition and medication was found to have their 60 cc feeding syringe stored with the plunger inside the barrel and visible water droplets present, contrary to facility policy requiring separation of parts to prevent bacterial growth. Staff interviews confirmed the improper storage practice and awareness of the correct procedure.
A resident with dementia was observed with bilateral quarter length side rails in use without evidence of attempted alternatives, a completed side rail assessment, entrapment risk evaluation, or informed consent. Staff interviews revealed confusion about responsibility for assessments, and facility leadership confirmed that required assessments and documentation were not completed.
Two residents were left with medication cups on their bedside tables without being assessed for self-administration. Both residents were cognitively intact and had multiple medications prescribed. Nurse #3 left the medications unattended, leading to a confrontation with one resident and an admission of oversight. The DON confirmed that neither resident had been assessed for self-administration, and medications should not have been left unsupervised.
The facility failed to provide complete SNF ABN forms for two residents prior to their discharge from Medicare Part A skilled services. One resident's form lacked the section for the decision to continue services, while another resident's form was missing both the decision section and the signature. The facility Social Worker and Administrator acknowledged these oversights.
The facility failed to secure smoking materials for two residents identified as safe smokers. One resident was found with cigarettes and lighters in his room, while another had a lighter attached to his bag. Staff interviews revealed a lack of awareness and adherence to the facility's smoking policy, which requires smoking materials to be secured by staff.
Two residents with urinary catheters were observed with their catheter bags resting on the floor, contrary to infection control protocols. Despite the residents' cognitive impairments and dependency on staff, the catheter bags were not properly positioned, as confirmed by staff interviews. The DON expected catheter bags to be attached to the bed frame to prevent floor contact.
Expired Insulin Pen Administered Due to Failure to Check Expiration Date
Penalty
Summary
Surveyors identified a failure to meet professional standards of quality related to insulin administration for one resident with type 2 diabetes mellitus. The resident was cognitively intact, used insulin, and had a care plan directing finger stick blood sugars as ordered, medications as ordered, and monitoring for signs and symptoms of hypoglycemia. Manufacturer instructions for the resident’s glargine insulin pen required it be discarded 28 days after opening. Review of the Medication Administration Record showed the resident received a glargine insulin injection on 2/25/26 at 8:00 p.m. by a nurse. Observation of the medication cart the following day revealed an open glargine insulin pen for this resident dated as opened on 1/20/26 with an expiration date of 2/17/26, indicating it had been used beyond the 28‑day period. A second glargine pen for the same resident was present, unopened and undated. In an interview, the nurse who administered the insulin on 2/25/26 stated she was unaware the pen had expired on 2/17/26 because she did not check the expiration date prior to administration and acknowledged she should have discarded the expired pen. The Pharmacy Consultant confirmed the pen should have been discarded 28 days after opening due to decreased potency after the expiration date. The Nurse Practitioner stated she was unaware the resident had received expired insulin and indicated nursing staff were expected to check medication carts daily for expired medications. The DON and the Administrator both stated that floor nurses were responsible for checking medication carts daily for expired medications, discarding any expired medications, and ensuring no expired medications remained in the carts.
Expired Insulin Pen Not Removed From Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication storage and labeling when they found an expired multi-dose insulin glargine injector pen on one of five medication carts reviewed (Station 2 medication cart #1). The insulin pen had a manufacturer’s instruction to be discarded 28 days after opening, with labeling indicating an opened date of 1/20/26 and a handwritten expiration date of 2/17/26, yet it remained on the cart when observed on 2/26/26. The pen was open and still stored on the cart beyond the 28-day discard date specified by the manufacturer. During interviews, the medication aide assigned to that cart stated she did not administer insulin injections but acknowledged the insulin glargine pen should have been discarded after 28 days. The nurse covering that cart confirmed the expired insulin pen should have been removed and discarded and stated that nursing staff, including medication aides, were expected to check medication carts daily for expired medications. The Pharmacy Consultant also confirmed the pen should have been discarded 28 days after opening. The DON and the Administrator both stated that floor nurses and nursing staff, including medication aides, were responsible for checking medication carts daily and ensuring there were no expired medications, indicating that this expected practice had not been followed for the insulin pen found on Station 2 medication cart #1.
Failure to Secure Resident Smoking Materials per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to secure smoking materials in accordance with its smoking policy, which requires all resident smoking materials to be kept in a secure area (medication cart) and accessible only with staff assistance. One resident, who was cognitively intact and assessed and care planned as a safe, independent smoker with a preference to smoke at times of his choice, was found in his room with a pack of cigarettes and a lighter tucked under his shirt against his stomach. The resident reported that he smoked and acknowledged having his smoking materials in his possession in his room. Staff interviews revealed that the resident was expected to turn in his smoking materials to staff after each smoking episode so they could be locked in the medication cart. Nursing staff, including a nurse, a nurse aide, and a medication aide, stated that the resident typically obtained his cigarettes and lighter from staff before going to the designated smoking area and returned them afterward, and that he was aware he was not allowed to keep them. The DON and Administrator both stated that residents deemed safe independent smokers could go to the smoking area whenever they wanted, and that staff were responsible for ensuring smoking materials were returned and secured. However, they acknowledged that the resident likely retained his smoking materials after returning from smoking because no staff member was present at the medication cart, resulting in unsecured smoking materials in the resident’s possession in his room and a failure to follow the facility’s smoking policy.
Improper Storage of Enteral Feeding Syringe
Penalty
Summary
A deficiency was identified when a plastic 60 cc syringe used for enteral feeding, medication, and water flushes for a resident with a gastrostomy tube was observed to be improperly stored. The syringe, after use, was rinsed and placed back into its original bag with the plunger still inside the barrel, and water droplets were visible inside the bag. This method of storage did not follow facility policy, which requires the barrel and plunger to be separated after rinsing to prevent bacterial growth. The resident involved had a history of dysphagia following a stroke and was severely cognitively impaired, requiring a gastrostomy tube for nutrition, hydration, and medication administration. Staff interviews confirmed that the nurse responsible for the syringe did not separate the components after use, despite being aware of the correct procedure. The facility's Infection Preventionist and Administrator both acknowledged that the syringe should have been stored with the barrel and plunger separated to prevent potential bacterial contamination.
Failure to Assess and Document Side Rail Use Prior to Implementation
Penalty
Summary
The facility failed to follow required procedures before the use of bilateral quarter length side rails for a resident with Alzheimer's disease and non-Alzheimer's dementia. The resident, who required partial to moderate assistance with bed mobility and was moderately cognitively impaired, was observed on two occasions with both side rails raised. There was no evidence in the resident's electronic medical record that alternative interventions were attempted prior to the use of side rails, nor was there documentation of a side rail assessment, entrapment risk evaluation, or a review of risks and benefits with the resident or their representative. Informed consent for the use of side rails was also not obtained. Interviews with facility staff revealed a lack of clarity regarding responsibility for completing side rail assessments. The nurse interviewed stated she did not perform side rail assessments and was unsure who was responsible. The DON indicated that assessments were only completed if side rails appeared necessary for positioning and mobility, and was unaware that alternatives needed to be attempted and documented. The Administrator confirmed that side rail assessments were not completed on admission or quarterly for the resident in question.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of two residents to self-administer medications before leaving their medications on the bedside table. Resident #25, who was cognitively intact, had several medications prescribed, including atorvastatin, gabapentin, metoprolol, sertraline, amoxicillin, and doxycycline. There was no documentation in the Electronic Medical Record (EMR) indicating that Resident #25 had been assessed for self-administration, nor was there a physician's order or care plan addressing this. On the morning of the observation, Nurse #3 left a medication cup with several pills on Resident #25's bedside table without supervision, leading to a confrontation when she attempted to retrieve the cup. Similarly, Resident #62, also cognitively intact, had multiple medications prescribed, such as amlodipine, aspirin, oxybutynin, empagliflozin, meloxicam, a multivitamin, omega-3, and metformin. Like Resident #25, there was no assessment, physician's order, or care plan for self-administration documented in the EMR. During an observation, a medication cup was found on Resident #62's bedside table, and Nurse #3 admitted to leaving it there due to being called away to another resident's room. Resident #62 mentioned that she preferred to take her medications with milk and that the medications were often left for her to take with breakfast. Interviews with the Director of Nursing (DON) confirmed that neither resident had been assessed for self-administration of medications, and it was acknowledged that medications should not have been left on the bedside tables. Nurse #3 admitted to the oversight in both cases, recognizing that she should have supervised the residents taking their medications instead of leaving them unattended.
Incomplete SNF ABN Forms for Two Residents
Penalty
Summary
The facility failed to provide a complete Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) for two residents prior to their discharge from Medicare Part A skilled services. For Resident #170, the SNF ABN was missing the section indicating the resident's decision to continue Medicare Part A services, although the resident's name, the date services were to end, the estimated cost of the services, and the resident's signature were present. The facility Social Worker acknowledged that Resident #170 did not choose an option and that this was not documented. Attempts to contact Resident #170 were unsuccessful, and the facility Administrator confirmed that the SNF ABN should have included the resident's decision. For Resident #7, the SNF ABN was incomplete as it lacked both the section for the decision about continuing Medicare Part A services and the resident's signature. The facility Social Worker admitted it was an oversight that Resident #7 did not choose an option or sign the form, and it was typically signed alongside the Notice of Medicare Non-Coverage. Resident #7 did not recall being presented with the ABN form. The facility Administrator confirmed that the SNF ABN should have been completed with the resident's decision and signature.
Failure to Secure Smoking Materials for Residents
Penalty
Summary
The facility failed to secure smoking materials for two residents who were identified as safe and independent smokers. Resident #23 was observed with a pack of cigarettes and two lighters on his bedside table, despite the facility's policy requiring smoking materials to be kept in a secure area accessible only by staff. Although Resident #23 was noted to be cognitively intact and had a care plan indicating he was a safe smoker, the presence of an oxygen concentrator in his room posed a potential hazard. Interviews with staff revealed that smoking materials should be locked in the medication cart, but Resident #23 admitted to keeping his lighters at his bedside, and staff were unaware of this practice. Similarly, Resident #106 was observed with a cigarette lighter attached to his bag during a Resident Council meeting, contrary to the facility's smoking policy. Although Resident #106 was also assessed as a safe and independent smoker, staff interviews indicated a lack of awareness regarding the lighter in his possession. The facility's policy required residents to return all smoking materials to staff after use, but Resident #106 stated he kept his lighter with him. The Director of Nursing confirmed that residents were not supposed to keep lighters, and the Administrator acknowledged the challenge of residents being resourceful in keeping smoking materials.
Failure to Prevent Catheter Bags from Touching the Floor
Penalty
Summary
The facility failed to prevent urinary catheter bags from touching the floor, which is a critical measure to reduce the risk of infection. This deficiency was observed in two residents, both of whom had urinary catheters. Resident #87, who was admitted with chronic kidney disease, benign prostatic hyperplasia, and urinary retention, was found with his catheter bag resting on the floor on multiple occasions. Despite being dependent on staff for all activities of daily living due to severely impaired cognition, the catheter bag was consistently observed touching the floor, indicating a lapse in proper catheter care. Similarly, Resident #91, who was admitted with chronic kidney disease, a urinary tract infection, and urinary retention, also had her catheter bag resting on the floor. Observations confirmed that the catheter bag was not properly positioned, and interviews with Nurse #3 revealed an acknowledgment that the bags should not touch the floor. The Director of Nursing also confirmed the expectation that catheter bags should be attached to the bed frame in a manner that prevents them from touching the floor, highlighting a failure in adherence to infection control protocols.
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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