Kannapolis Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Kannapolis, North Carolina.
- Location
- 1810 Concord Lake Road, Kannapolis, North Carolina 28083
- CMS Provider Number
- 345258
- Inspections on file
- 23
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Kannapolis Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, prior stroke, and dysphagia was on a physician-ordered mechanical soft diet with nectar thick liquids, yet family repeatedly brought in regular-consistency foods and thin liquids. Staff, including the DON, ADON, and therapy, knew of this pattern but did not document effective, interdisciplinary interventions or consistently involve the provider, and the care plan lacked clear, specific actions. On one evening, after the resident refused the ordered meal, a family member set up a burger, chicken nuggets, fries, and sweet tea at the bedside; the nurse warned of choking risk but left the resident unsupervised with the food while going on break. The resident was later found unresponsive with food in the mouth and a partially eaten hamburger in hand, and EMS records described food and vomit in the airway with suspected choking preceding cardiac arrest. In a separate incident, another resident was rolled out of an elevated air mattress during incontinence care, fell to the floor, and sustained a forehead laceration requiring ED treatment.
Surveyors identified that staff failed to properly date and discard multi-dose medications on two medication carts, including multiple ophthalmic solutions and insulin pens that either lacked open dates or were kept beyond manufacturer-recommended discard periods. One med aide reported she usually checked eye drop dates but had not done so that day and did not handle insulin, while another med aide stated she did not realize medications were expired or undated and cited time pressures as a factor. The ADON reported that nurses and med aides were expected to label multi-dose insulins with open and expiration dates and eye drops with open dates but was unaware this was not consistently occurring, and one eye drop bottle was found with conflicting dates written on different parts of the container.
A resident with a G-tube, malnutrition, and dysphagia had an order for scheduled water flushes, but the syringe used for these enteral flushes was repeatedly stored assembled, wet, and with visible condensation in a plastic bag at the bedside over multiple days. The resident reported that staff rarely left the syringe components apart to air dry after use. An RN who administered the morning flush confirmed she was unaware that the syringe and plunger needed to be separated and dried before storage, despite facility policy requiring syringes to be discarded every 24 hours and air-dried with the plunger removed to prevent bacterial growth.
A resident with dehydration was ordered 0.9% sodium chloride IV at a specified rate and volume, and the MAR reflected that these fluids were administered over several shifts, with one documented refusal. However, nursing documentation and direct observation later showed that D5NS was infusing instead of the ordered 0.9% sodium chloride, reportedly because the ordered solution was unavailable. One nurse acknowledged she did not visually verify the IV bag, tubing, fluid type, or rate against the provider’s order during her shift, and the Medical Director and DON both reported they had not been informed that a different IV solution was being used in place of the ordered fluid.
A resident who was cognitively intact but dependent on staff for transfers was found in a bed that could not be lowered, with the head elevated and electrical wiring hanging beneath the frame, including exposed and damaged wires. The resident reported the bed and remote had not worked for months, causing discomfort and difficulty sleeping, and stated she had reported the problem to maintenance multiple times without resolution. Staff later observed the bed in a high position, a frayed cord, and a broken remote missing the down button, while the maintenance log contained no work order for the bed. The Maintenance Director stated he had been unaware of the issue until the survey and, upon inspection, confirmed exposed wiring on both the bed and remote and acknowledged a potential risk of electrical shock when using the damaged control.
Two residents who were dependent on staff for ADLs did not receive timely incontinence care or assistance with changing soiled clothing. One resident with dementia and severe cognitive impairment, always incontinent and dependent for toileting hygiene, was observed lying in bed on a visibly urine-soaked sheet with wet clothing and brief, with no NA present on the hall; the assigned NA reported a prior refusal of care but did not return before going to lunch, and the nurse denied being informed of any refusal. Another resident with vascular dementia and severe cognitive impairment, who required substantial assistance with dressing, was observed over two consecutive days wearing the same long-sleeved shirt soiled with dried food and beverage spills; he stated he had worn it for several days, and staff interviews showed that the shirt had not been changed during routine morning or post-meal care despite expectations that residents remain clean and in clean garments.
A resident with COPD and chronic respiratory failure was receiving continuous oxygen therapy without a corresponding physician order in the medical record. Progress notes and the care plan documented chronic respiratory failure, continuous oxygen use, and an intervention for oxygen via nasal cannula, and the resident consistently used oxygen via concentrator at 2 L during multiple observations while reporting continuous use. An NP had previously documented a plan of care including continuous oxygen at 3 L, and staff, including a medication aide and the ADON, confirmed the resident’s continuous oxygen use but acknowledged there was no active physician order for the therapy.
A resident with type 2 DM and intact cognition had physician orders for scheduled Humalog, sliding-scale Humalog Kwikpen, and daily Lantus, with the care plan directing staff to provide diabetic meds as ordered. Review of the MAR for one month showed numerous blank entries where insulin doses were neither signed as given nor refused for all three insulin orders. The resident reported frequently having to ask staff about insulin injections. Multiple MAs stated they could not give insulin and had to find an RN or LPN, with no specific nurse assigned to insulin administration, and various nurses and leaders confirmed the MAR blanks and could not recall who administered the insulin on those dates. The physician expected insulin administration to be documented and, after reviewing the record, found no ill effects and blood glucose values at baseline, but the missing documentation of insulin administration remained unresolved.
The facility failed to provide required written notices of hospital transfer, including reasons for the transfers, to four residents and/or their responsible parties. In each case, residents were transferred for issues such as shortness of breath, abdominal pain, falls, and altered mental status and were later readmitted, but the medical records contained no documentation of written transfer notices. Staff, including a unit manager and social workers, reported that clinical documents and the bed-hold policy were sent with residents and that responsible parties were notified by phone, yet they were unaware of any requirement or designated responsibility for issuing written notices. The administrator also stated she was not aware that written notification of hospital transfers was required.
The facility failed to consistently post and accurately maintain daily nurse staffing information, including one instance where an outdated staffing sheet remained posted and multiple instances over a month where posted counts of NAs, LPNs, and RNs did not match the staffing schedules for various shifts. The DON, who was responsible for managing schedules and postings, acknowledged not updating the daily sheets, not counting MAs and Restorative NAs in NA totals, and not revising postings when additional staff came in to cover needs. The Administrator confirmed that posted staffing information was expected to match the actual staffing schedule for each shift.
The facility failed to provide required written grievance decisions and to document resolution details for multiple grievances. One cognitively intact resident filed a complaint about money not being returned to their resident fund; although the funds were reportedly deposited and verbally communicated, the grievance form lacked documentation of resolution, communication method, timing, and any written summary. Another resident with moderately impaired cognition had several grievances filed by a representative regarding missing clothing, notification issues, personal care, room cleanliness, and financial statements, but the forms did not consistently show whether the grievances were resolved or how and when results were communicated, and no written summaries were provided. A third cognitively intact resident filed a grievance about missed incontinence care, with no documentation of resolution or written response. The social worker who maintained the grievance logs and the Administrator both stated they were unaware that written grievance resolutions were required and had been addressing concerns only by phone or in person.
A resident with adrenal insufficiency experienced a significant medication error when hydrocortisone was misprescribed and abruptly stopped due to a transcription error by the Unit Manager. The resident went 18 days without the medication, leading to weakness and low blood pressure, and was later hospitalized. The error was not identified by other staff members, including the NP and physician, highlighting a lack of communication and verification of medication orders.
A privacy breach occurred when a resident's discharge summary and medication list were mistakenly sent home with another resident. The error was discovered when the incorrect records were returned to the facility. Interviews revealed that the nurse responsible did not ensure the correct records were sent, and the affected resident was not notified of the breach.
A resident with respiratory disease and obstructive sleep apnea was admitted to a facility without a CPAP machine, despite hospital discharge instructions indicating its necessity. The facility lacked physician's orders for the CPAP, and the resident's records did not reflect its provision. The DON acknowledged the oversight, and the resident was eventually sent back to the hospital due to pulmonary issues and the absence of the CPAP.
A resident with adrenocortical insufficiency did not receive a prescribed dose of hydrocortisone due to unavailability, and the physician was not notified. The nursing staff did not document any communication with the physician regarding the missed dose, and the physician confirmed he was not informed.
A facility failed to accurately code the MDS assessment for a resident with cerebral infarction and oropharyngeal dysphagia, indicating no swallowing disorders despite the resident experiencing choking and coughing. The Registered Dietician acknowledged the oversight, and the administrator expected accurate MDS coding.
A resident with multiple diagnoses required a midline IV, but the facility failed to transcribe orders for 0.9% NS solution and flushes due to staff miscommunication. The midline IV was placed, but necessary orders were not entered into the electronic medical record, leading to a deficiency in care standards.
Two residents were discharged without the correct documentation. One resident received another's discharge summary and medication list, while the other was sent home without any documents. The errors were attributed to a mix-up by the social worker and oversight by the nurses responsible for the discharge process.
A resident with rheumatoid arthritis was mistakenly given 300 mg of Lyrica instead of the prescribed 150 mg due to a nurse's oversight in reviewing the medication label. The error was documented, and staff interviews confirmed the mistake, with the NP noting that the extra dose was unlikely to cause serious side effects.
A resident with adrenal insufficiency did not receive prescribed hydrocortisone due to a transcription error and delay in uploading hospital discharge orders. The Consultant Pharmacist failed to identify the medication error during a remote review, as the necessary orders were not available in the electronic system.
The facility failed to accurately document RN hours on the daily nurse staffing sheets for three days. The Staffing Coordinator did not record hours for RNs who were present but not working on the floor, such as the Weekend Nursing Supervisor and the MDS Coordinator. The DON confirmed that RNs were present for at least 8 hours each day, but their hours were not accurately reflected on the staffing sheets.
Failure to Supervise Dysphagic Resident and Ensure Safe Care, Resulting in Fatal Choking and Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards for residents with known swallowing difficulties and modified diets. One resident with dementia, prior stroke, dysphagia, and a physician-ordered mechanical soft diet with nectar thick liquids was repeatedly given regular-consistency foods and thin liquids by a family member. The medical record and therapy notes documented that the resident had a history of pocketing food, coughing, and choking with increased texture, and that speech therapy had specifically ordered a mechanical soft diet with nectar thick liquids, pureed fruit, no straws, and limited regular-consistency items. Staff, including the DON, ADON, speech therapist, and nursing staff, were aware that the family member frequently brought in foods such as cheeseburgers, fries, hard candy, beef stew, cheese puffs, and thin liquids that were inconsistent with the ordered diet. Despite this knowledge, the facility did not implement effective, documented interventions to manage the ongoing issue of the family bringing in unsafe foods. The care plan noted that the family brought in foods not conducive to the diet order and that the resident required supervision and assistance with meals, but it did not specify clear, actionable steps such as who to notify or how to respond when unsafe foods were provided. Interviews with the ADON, unit manager, DON, and therapy staff revealed that although they reported having multiple conversations with the family about choking risks, there were no corresponding progress notes or documented care plan meetings addressing these discussions or any formalized strategy. The physician and nurse practitioners reported they were not informed of the family’s noncompliance with diet orders and did not participate in discussions with the family about the risks, despite the resident being severely cognitively impaired and unable to understand the dangers of eating foods outside his prescribed diet. On the evening of the fatal incident, the resident had refused his ordered mechanically soft dinner tray. Later that night, the family member brought in a burger, chicken nuggets, french fries, and sweet tea with a straw and set the food up at the bedside. The assigned nurse informed the family member that the resident was on a mechanical soft diet with nectar thick liquids and should not have the meal due to choking risk, but the family member insisted he could eat a regular diet and left the food in front of the resident before exiting the facility. The nurse checked the resident shortly after, attempted to remove the food, but left it in place when the resident refused and did not thicken the tea. The nurse then left for break, instructing a nurse aide to check on the resident. When the aide went to the room, the resident was found pale, unresponsive, with food in his mouth and a partially eaten hamburger in his hand, and CPR and EMS were initiated but unsuccessful. EMS documentation indicated food and vomit in the airway and esophagus, and EMS believed the resident went into cardiac arrest after possibly choking on food. The facility also failed to provide safe incontinence care to another resident, who was rolled out of bed from an air mattress raised to the highest position, resulting in a forehead laceration and transfer to the emergency department. The second resident involved in the deficiency was receiving incontinence care on an air mattress that had been raised to its highest position. During the provision of care, staff rolled the resident, and the resident fell from the bed to the floor, striking the forehead. The fall resulted in a two-centimeter laceration to the left forehead, requiring transfer to the emergency department for treatment before the resident returned to the facility the same shift. This incident demonstrated that in addition to the lack of effective supervision and intervention for the resident with dysphagia, the facility also failed to ensure safe techniques and environmental controls during routine care activities, contributing to another avoidable accident.
Removal Plan
- Conduct an audit of all current residents with modified diets (mechanical soft, puree, thickened liquids) to identify those potentially affected.
- Verify tray tickets match physician diet orders for residents on mechanically altered diets and thickened liquids; address any discrepancies.
- Interview staff to identify any residents on mechanically altered diets and/or thickened liquids who are consuming foods/liquids inconsistent with physician diet orders; address any concerns.
- Educate all nursing staff on immediate removal of food/drink inconsistent with physician diet orders and notification to licensed nurses.
- Require licensed nurses to educate residents and/or family on risks versus benefits of consuming food/drink inconsistent with ordered diets.
- Educate the Director of Rehab (DOR) to communicate with the rehab team after clinical meetings regarding therapeutic diet orders and related processes.
- Use clinical meetings to communicate new admissions and/or physician orders for therapeutic diets and ensure the Social Worker/IDT schedules care plan meetings to review informed care decisions.
- Use clinical meetings and review of progress notes, change of condition documentation, and SBARs to trigger scheduling of care plan meetings (via Social Worker) as needed to obtain informed care decision consents and to initiate speech therapy referrals.
- Complete an interfacility communication form and provide it to the Director of Rehab (DOR) for speech referrals and to the Certified Dietary Manager for physician diet orders.
Improper Dating and Storage of Multi-Dose Medications on Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multi-dose medications were properly dated upon opening and that expired medications were discarded, as required by manufacturer instructions. During an inspection of one medication cart in the presence of a medication aide, surveyors observed multiple multi-dose ophthalmic solutions and several insulin dial-a-dose pens without any documented open dates. These included neo-polymyxin B, tobramycin, and latanoprost eye drops, as well as various types of insulin pens, all of which have specific discard timeframes after opening according to the manufacturers’ directions. The lack of open dates meant compliance with these discard timeframes could not be verified. On a second medication cart inspected with another medication aide, surveyors found a multi-dose bottle of timolol eye drops with no open date, again contrary to manufacturer requirements that it be discarded a set number of days after opening. In addition, this cart contained multiple clearly expired multi-dose medications that remained available for use. These included an insulin glargine pen, two insulin lispro pens, neo-polymyxin eye drops, tobramycin eye drops, and several latanoprost eye drop bottles, all of which had open dates indicating they were beyond the manufacturer-specified discard periods. Interviews with the medication aides and the Assistant Director of Nursing (ADON) further clarified the circumstances leading to the deficiency. One medication aide acknowledged that all multi-use medications should be dated upon opening and stated she normally checked eye drop dates but had not done so that day, and she did not handle insulin, which she said was the nurse’s responsibility. The second medication aide stated she did not realize the eye drops were expired or undated and explained that time pressures contributed to her oversight. The ADON stated that both medication aides and nurses were expected to write open and expiration dates on multi-dose insulin vials/pens and open dates on eye drops, and she was unaware that staff were not consistently labeling medications as required. One latanoprost bottle was found with two different dates written on it, and the medication aide explained she had added a new date that morning after being told everything in the cart should have a date, indicating inconsistent and inaccurate dating practices.
Improper Storage and Drying of Enteral Flush Syringe
Penalty
Summary
The deficiency involves the facility’s failure to properly store and dry a plastic syringe used for enteral water flushes for a resident with a gastrostomy tube. The resident was admitted with muscle weakness, malnutrition, adult failure to thrive, gastrostomy status, and dysphagia, and was receiving tube feeding with an average fluid intake of 501 cc/day or more via IV fluids or tube feeding. The resident had a physician’s order for 60 ml water flushes four times a day through the feeding tube. During an observation and interview, the syringe used for these ordered water flushes was found on the bedside table with the plunger inserted and visible clear condensation inside. The syringe was stored in a plastic bag dated several days earlier, and the resident reported that nursing staff rarely left the syringe apart to allow it to air dry after use. The resident stated that around 9:00 AM that day, a nurse had administered the ordered water flush and then reassembled the syringe and left it on the bedside table. Review of the Medication Administration Record confirmed that the nurse had signed off the morning flush at that time. In an interview, the nurse acknowledged providing the water flush earlier in the shift and stated she was not aware that the syringe needed to be dried before being placed back in the storage bag, and that while she knew to wash the syringe if residue was present, she did not know the plunger should be separated to air dry to prevent bacterial growth. A subsequent observation with the DON showed the syringe at the bedside still wet with the plunger inside. The DON stated that the syringe and plunger should be washed and the plunger left out to air dry to prevent bacterial growth, and that facility policy required plastic syringes to be discarded every 24 hours and stored with the plunger removed after use. The Administrator also stated that the nurse should have washed the syringe and allowed it to dry completely to prevent bacterial growth.
Failure to Administer Ordered IV Fluids as Prescribed
Penalty
Summary
The deficiency involves the facility’s failure to administer IV fluids according to the physician’s order for a resident receiving treatment for dehydration. The resident, cognitively intact and admitted with chronic pain, had a verbal order from the Medical Director for 0.9% sodium chloride IV solution at 80 mL/hr for a total of 2 liters. This order was transcribed onto the MAR, which showed the IV fluids as administered on multiple shifts from late February into early March, with one documented refusal on a night shift. The MAR entries indicated that the ordered sodium chloride IV fluids were being given as prescribed. On March 1, MAR documentation by nursing staff showed that instead of 0.9% sodium chloride, D5NS (5% dextrose in 0.9% sodium chloride) was infusing because the ordered 0.9% sodium chloride was reportedly unavailable. An observation that afternoon confirmed a one‑liter bag of D5NS infusing through a saline lock in the resident’s forearm, with the bag labeled only with a date and no initials. The resident reported receiving IV fluids for dehydration, stated she did not like to drink, and believed she had been receiving IV fluids all day, but was unable to identify the type of fluid. In interviews, Nurse #2 stated she received report that the IV fluids had completed during the night and that a new bag had been hung just before shift change, but she did not visually inspect the IV bag or tubing during her shift and could not confirm which fluids had been given. She acknowledged she was required to verify the fluid type, amount infused, and flow rate against the provider’s order but did not do so. The Medical Director reported he had not been informed that D5NS was administered instead of the ordered 0.9% sodium chloride and stated he expected staff to notify a provider of any medication administration issues. The DON stated she was not aware that the wrong IV fluid had been administered or that staff had documented using D5NS due to unavailability of 0.9% sodium chloride, and indicated staff were expected to administer IV fluids as ordered and to use pharmacy‑supplied, resident‑specific labeled fluids.
Failure to Maintain Resident Bed in Safe Working Condition
Penalty
Summary
A resident’s right to a safe, clean, comfortable, and homelike environment was not honored when the facility failed to maintain the resident’s bed in safe working condition. Surveyors observed that the cognitively intact resident, who was dependent on staff for transfers, was in a semi-private room in a bed positioned above its lowest setting with the head of the bed elevated. The bed was unplugged, and electrical wiring was hanging beneath it, including multiple visible internal wires and a gold-colored exposed wire that appeared damaged and not properly secured to the bed frame. The facility’s maintenance work order log contained no documentation of any work order for this bed during the review period. The resident reported that the bed had not been functioning properly for several months, that she had informed the Maintenance Director, and that maintenance staff had come to look at the bed several times but never completed repairs. She stated the bed remote did not work, she could not independently adjust or move the bed, and the bed remained partially elevated in a sitting position, causing back soreness, discomfort, and difficulty sleeping. Staff interviews revealed that the NA who typically cared for the resident observed the bed in a high position, a frayed electrical cord, and a missing “down” button on the remote, which prevented lowering the bed, but she had not previously noticed that the bed would not lower and reported the resident had not voiced concerns to her. The housekeeper who routinely cleaned the room stated she had not previously noticed concerns but, upon observation, saw the broken remote and inability to lower the bed. The Maintenance Director, who stated he was unaware of any concerns before the surveyor’s inquiry, observed exposed wiring beneath the bed and exposed internal wiring on the damaged remote and stated that pressing the damaged button posed a potential risk of electrical shock. The Administrator stated her expectation was that staff promptly identify and report maintenance concerns and ensure resident equipment is maintained in safe working condition.
Failure to Provide Timely Incontinence Care and Clothing Changes for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with changing soiled clothing for two dependent residents. Resident #18, admitted with dementia and care planned for bowel and bladder incontinence, was documented as severely cognitively impaired, always incontinent, and dependent on staff for toileting hygiene. During a continuous observation from 1:03 PM to 1:25 PM, he was seen lying in bed with his brief exposed and the bed sheet beneath him visibly wet with a straw-colored area approximately 10 inches around his lower body, surrounded by a yellowish-brown dried border about 3 inches wide. No nursing assistants were present on the hall during this observation. The DON later confirmed that the resident’s clothing, brief, and linens were wet and required changing, and another NA verified that his clothing, brief, and linens were wet with urine. Nursing Assistant #6, identified as the direct care NA for Resident #18, stated she had provided incontinence care between 8:15 AM and 8:30 AM and that at 11:30 AM she found his brief wet and in need of changing, but reported the resident refused care. She stated she notified Nurse #2 of this refusal, did not return to the resident’s room after 11:30 AM, and went to lunch at 1:30 PM without changing him, explaining that she needed to get food. NA #7, who was orienting with NA #6, confirmed they had provided incontinence care around 8:30 AM and that on a later visit before lunch the resident said he was tired and asked them to return later; he stated that neither he nor NA #6 returned before lunch and that he was not aware of any notification to Nurse #2 about a refusal. Nurse #2 later reported that NA #6 had not notified her at any time that the resident had refused incontinence care. The deficiency also includes failure to ensure a resident’s clothing was changed when soiled. Resident #87, admitted with intermittent explosive disorder and vascular dementia, was severely cognitively impaired and required substantial assistance with dressing. Observations on one day at 11:43 AM and 2:52 PM showed him in bed wearing a long-sleeved shirt with dried food particles and dried white and tan spill marks while he was eating lunch and later resting. The following morning at 10:00 AM, he was again observed wearing the same soiled shirt, still with dried food and spill marks; he stated he had been wearing it for three days and that it needed to be changed, though he was unsure if he had asked anyone to change it. A medication aide confirmed the shirt was soiled and the same one from the previous day and stated she assumed the assigned NA would have changed it during morning care or after lunch the prior day. The NA assigned to him on the second day acknowledged she had not yet provided morning care when notified around 10:30 AM that his shirt was soiled and had been worn since the previous day, and then went to provide care. The DON stated residents were expected to remain neat, clean, and dressed in clean garments, and that staff were expected to change clothing after meals if soiling occurred, and reported she was not aware that this resident’s ADL needs had not been met.
Lack of Physician Order for Continuous Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to obtain and maintain a physician’s order for continuous oxygen therapy for a resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. The resident was admitted with these diagnoses and had a physician progress note indicating chronic respiratory failure on 3 liters of oxygen via nasal cannula. A quarterly MDS documented that the resident was cognitively intact and used oxygen, and the active care plan identified COPD with risk for respiratory distress, with an intervention for oxygen via nasal cannula as ordered. An NP progress note later documented that the resident utilized 3 liters of oxygen continuously, and nursing progress notes over several months showed the resident was using oxygen continuously. Despite this ongoing use, reviews of the resident’s physician orders for multiple consecutive months showed no order for oxygen. During several observations, the resident was seen in bed with oxygen flowing at 2 liters via nasal cannula and reported using oxygen continuously, without signs of shortness of breath at those times. A medication aide who frequently cared for the resident confirmed the continuous oxygen use, believed the resident used 2 liters, and verified there was no corresponding order in the medical record, without being able to explain the omission. The ADON also confirmed the resident required continuous oxygen for COPD, verified there was no order for continuous oxygen in the record, and stated that an order should have been present. An NP later stated that at the last assessment she made no changes to the plan of care, which included continuous oxygen at 3 liters via nasal cannula, and that she would expect the facility to have an order for this therapy.
Failure to Ensure Ordered Insulin Administration and Documentation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from significant medication errors, specifically involving insulin administration and documentation. The resident, who was cognitively intact and had a diagnosis of type 2 diabetes, had physician orders for multiple insulin regimens, including scheduled Humalog insulin 12 units subcutaneously three times daily, Humalog Kwikpen per sliding scale before meals and at bedtime, and Lantus Solostar 38 units subcutaneously daily. The resident’s care plan directed staff to provide diabetic medications as ordered by the physician. Review of the June 2025 MAR showed numerous instances where these insulin doses were not signed as given or refused, leaving multiple blank entries across the month for all three insulin orders. Record review revealed that for June 2025, there were missing documentation entries for scheduled Humalog doses on at least 13 days, missing entries for daily Lantus doses on several days, and missing entries for sliding-scale Humalog Kwikpen doses before meals and at bedtime on multiple occasions. The blanks on the MAR did not indicate whether the insulin had been administered or refused. A subsequent quarterly MDS again documented that the resident was cognitively intact and receiving insulin injections, and the active care plan continued to require that diabetic medications be provided as ordered, but the contemporaneous MAR for June 2025 did not reflect consistent documentation of insulin administration. Interviews with the resident and staff further described how insulin administration was handled and contributed to the deficiency. The resident reported that during June 2025 she frequently had to ask nursing staff about receiving her insulin injections and was repeatedly told that someone would administer it, though she could not recall specific dates. Multiple medication aides stated they were not permitted to administer insulin and had to locate a nurse—such as the floor nurse, ADON, unit manager, or MDS nurse—to give insulin when due, and there was no designated nurse responsible for insulin injections on any shift. These staff, along with the ADON, MDS nurse, and a floor nurse, all reviewed the June 2025 MAR and confirmed the presence of multiple blank insulin entries, and none could recall who administered the insulin on the referenced dates. The physician stated he expected nursing staff to document when insulin was provided as ordered and, upon review of the record, noted there were no ill effects and that the resident’s accuchecks remained at baseline, but the documentation gaps remained unexplained.
Failure to Provide Required Written Hospital Transfer Notices to Residents and Responsible Parties
Penalty
Summary
The deficiency involves the facility’s failure to provide residents and their responsible parties (RPs) with written notices of transfer to the hospital, including the reasons for those transfers, for four residents reviewed for hospitalization. For Resident #33, who was cognitively intact per a quarterly MDS assessment, the medical record showed multiple hospital transfers for shortness of breath, nausea, vomiting, and abdominal pain between May and December 2025. Although the RP reported always being informed by phone of these hospital transfers, there was no documentation that any written notice of transfer, including the reason for each transfer, was provided to either the resident or the RP for any of these hospitalizations. Resident #53, who had moderately impaired cognitive skills for daily decision making per a quarterly MDS assessment, was transferred to the hospital following a fall and on two additional occasions for altered mental status. The resident was readmitted after each hospitalization. The medical record contained no documentation that written notices of transfer, including the reasons for the transfers, were provided to the resident or the RP for any of these hospitalizations. Attempts to interview the RP were unsuccessful. Staff interviews revealed that the RP was notified by phone of the change and reason for the hospital transfer, but there was no identified process or responsible party for issuing the required written notice. Resident #69, who had moderately impaired cognition per a quarterly MDS assessment, was transferred to the hospital for shortness of breath and later readmitted. The medical record lacked documentation that a written notice of transfer, including the reason for the transfer, was provided to the resident or the RP. The RP confirmed being informed by phone of the hospital transfer but reported not receiving anything in writing. Resident #31, who was cognitively intact and listed as her own RP, was transferred to the hospital with complaints of shortness of breath and low oxygen saturation and was later readmitted. The record similarly showed no documentation that a written notice of transfer, including the reason for the transfer, was provided to the resident or her emergency contact. Across all four cases, interviews with Unit Manager #1 indicated that when residents were transferred to the hospital, clinical documents such as the face sheet, medication list, any DNR information, other pertinent information, and the bed-hold policy were sent with the resident, and the RP was notified by phone of the change and reason for transfer. However, Unit Manager #1 did not know who was responsible for providing the written notice of transfer. Social Worker #1, who had been employed for approximately three weeks at the time of the survey and was not present during many of the transfer dates, stated she was unaware that a written notice of transfer including the reason for the hospital transfer was required and therefore did not provide such notices. Former Social Worker #2, who worked at the facility for about seven months, also stated she was unaware of the requirement for written notices of transfer and had not been informed to provide this document for any of the residents’ hospital transfers. The Administrator, employed since November 2025, similarly stated she was not aware that written notification was required to be given to the resident and/or RP when a resident was transferred to the hospital.
Failure to Post and Accurately Maintain Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post and accurately maintain the required daily nurse staffing information. During observation on 3/1/26 at 10:40 AM, the daily nurse staffing sheet posted outside the DON’s office was dated 2/17/26, indicating that current staffing information was not being posted that day. The DON stated she had been at the facility since 2/5/26, was responsible for the schedule and daily posted staffing sheets, and acknowledged that she had failed to update the posted daily nurse staffing sheets, resulting in an outdated posting remaining in place. Further record review of the facility’s daily nurse staffing postings for the 28-day period from 2/1/26 through 2/28/26, compared to the daily staffing schedules, showed multiple discrepancies between the number and type of staff actually scheduled and the numbers documented on the posted sheets. On numerous dates, the posted sheets reflected incorrect counts of NAs, LPNs, and RNs for specific shifts. Examples included days when the posted number of NAs on the 7:00 AM–3:00 PM shift was higher or lower than the schedule, and days when the posted number of LPNs or RNs on the 3:00 PM–11:00 PM or 11:00 PM–7:00 AM shifts did not match the staffing schedule. In an interview on 3/4/26 at 9:35 AM, the DON reviewed the staffing schedules and daily postings and confirmed that the numbers did not match for multiple dates. She explained that she had failed to include Medication Aides and Restorative NAs in the total NA count and had not updated the posted staffing sheet when additional staff came in to cover staffing needs. In a separate interview on 3/4/26 at 1:28 PM, the Administrator stated that the daily staff schedule posting and the staffing schedule should match the number of staff who worked on any given shift, confirming that the posted information was expected to accurately reflect actual staffing.
Failure to Provide Required Written Grievance Decisions and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to follow its own grievance policy and federal requirements to provide written grievance decisions to residents or their representatives. The facility’s grievance policy dated 11/14/25 states that the Grievance Official will issue a written decision at the conclusion of each investigation, including the date the grievance was received, investigative steps taken, a summary of findings or conclusions, whether the grievance was confirmed, any corrective action taken or to be taken, and the date the written decision was issued. Review of grievance logs from April 2025 through February 28, 2026, showed that these required elements were not documented for multiple grievances, and there was no indication that written grievance summaries were provided to complainants. For one cognitively intact resident, a grievance was filed regarding having leftover change from a shopping trip deposited back into his resident funds. The grievance form did not indicate whether the grievance was resolved, how or when the results were communicated to the resident, or whether a written summary was provided. The Business Office Manager reported that the funds were deposited and that she verbally informed the resident but did not provide anything in writing. The resident stated he could not recall if anyone discussed the resolution with him and that he had never received or been offered a written resolution of his grievance. For another resident with moderately impaired cognition, multiple grievances were filed by the resident’s representative regarding missing clothes, notification concerns, and issues with showers, room cleanliness, and receiving statements. The grievance forms either lacked indication of resolution or did not document how or when the results were communicated, and there was no indication that written summaries were provided. The representative reported that concerns were typically addressed by phone or in person and that she had never received anything in writing and was not always satisfied with the resolutions. A third cognitively intact resident filed a grievance about not receiving incontinence care on a specific date; the grievance form did not indicate if it was resolved or how and when the results were communicated. This resident stated that the facility normally talked to her about results but that she had never received anything in writing. The social worker responsible for maintaining the grievance logs stated she provided resolutions by phone or in person and had not been issuing written grievance resolutions because she was unaware this was required, and the Administrator similarly stated she was not aware that written grievance resolutions were required.
Significant Medication Error Due to Misinterpretation of Orders
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was prescribed hydrocortisone for adrenal insufficiency. The resident missed a dose, received the wrong dose for two days, and then the medication was abruptly stopped. This error occurred because the Unit Manager misinterpreted the hospital discharge orders and transcribed them incorrectly, believing the medication was to be given for only three days. The Unit Manager did not seek clarification from the hospital, the endocrinologist, or other medical professionals, and the error went unnoticed by other staff members who reviewed the orders. The resident, who had a history of adrenal insufficiency, diabetes, malnutrition, and other health issues, went 18 days without receiving hydrocortisone. This led to a significant drop in cortisol levels, resulting in weakness and low blood pressure. The resident was eventually transferred to the hospital at the family's request, where she was admitted for these symptoms. Despite the endocrinologist's intervention to correct the medication error, the resident's condition worsened, leading to a surgical procedure and subsequent complications. Interviews with various staff members, including the Unit Managers, Nurse Practitioners, and the Physician, revealed a lack of communication and verification of the medication orders. The pharmacist's review did not identify any irregularities, and the physician did not review the transcribed orders in the electronic documentation system. The failure to administer hydrocortisone as prescribed was identified as a significant medication error, contributing to the resident's deteriorating health condition.
Removal Plan
- The facility recognizes that all newly admitted and readmitted residents have the potential to be affected from the prior noncompliance with significant medication errors. All newly admitted and readmitted residents' medication orders were audited by the Director of Nursing and or Unit Managers to ensure orders were transcribed correctly. 30 residents were audited with no discrepancies noted.
- A quality review was completed by the Director of Nursing and or Unit Manager of current residents with a diagnosis of adrenal insufficiency and with hydrocortisone orders to ensure medication is ordered, transcribed correctly, and being given as ordered, no discrepancies noted.
- A quality review of current residents admitted and readmitted within the past 30 days was conducted by the Director of Nursing and Unit Manager to ensure all other newly admitted or readmitted patients' medications are administered per physician orders and transcribed correctly on the Medication Admission Record (MAR).
- A Root Cause Analysis was completed by the Director of Clinical Services, and the Executive Director regarding omission of medication administration for resident #137. It was determined through root cause and analysis that the significant medication error was due to the oversight of transcribing the orders incorrectly and there was no verification conducted by a second nurse.
- The Director of Nursing and/or the nurse managers provided education to current nurses on the importance of transcribing all new orders from discharge summaries, verified by 2 nurses to ensure medications are transcribed and administered per physician orders to the residents. Newly hired nurses will be educated on hire during the orientation process.
- The Executive Director provides oversight for the education of nurses to ensure that 100% of all licensed staff were reeducated on the importance of administrating all ordered medications. Education was completed.
- The Director of Nursing and or Nurse Managers will conduct Quality Improvement Monitoring 5 times per week for 4 weeks, 1 time per week for 3 months and 1 time monthly for 3 months in clinical morning meeting to review the medication administration records of all new residents when admitted or readmitted to ensure all medications are transcribed correctly and medications are administered as ordered per physician.
- Upon receiving hospital discharge summaries medication orders are verified with the provider, 2 nurse verification system; 1 Nurse transcribes all orders, then 1 Nurse verifies/confirms that orders were transcribed correctly. They also review the previous days admissions during the morning meeting and verify during the meeting.
- When the deficient practice of transcribing orders that resulted in a significant medication error was identified the center Executive Director conducted an ADHOC Quality Assurance Performance Improvement (QAPI) meeting to determine the root cause analysis of the deficient practice.
- The QAPI committee put a plan of action in place to include quality improvement monitoring and the frequency of monitoring to ensure medication administration orders were transcribed correctly and medications were administered as ordered.
- The results of the quality monitoring will be brought to the Quality Assurance Performance Improvement meeting monthly to ensure ongoing compliance for 4 months. Quality Improvement schedule will be modified based on findings of the monitoring.
Privacy Breach in Resident Discharge Records
Penalty
Summary
The facility failed to protect the private health information of a resident when her discharge summary and medication list were mistakenly sent home with another resident. This incident involved two residents who were scheduled to discharge on the same day. The error was discovered when the resident who received the incorrect records returned to the facility to report the mistake and obtain her own discharge summary and medication list. The resident whose records were mistakenly shared was moderately cognitively impaired at the time of her admission. Interviews with facility staff revealed that the nurse responsible for the discharge did not ensure the correct records were sent with each resident. The Director of Nursing could not recall if the affected resident was notified of the privacy breach. The facility's administrator acknowledged that the staff should have informed the resident or her responsible party about the breach of privacy when the records were sent to the wrong individual.
Failure to Provide CPAP Machine for Resident with Respiratory Needs
Penalty
Summary
The facility failed to provide a resident with a Continuous Positive Airway Pressure (CPAP) machine, which was necessary for managing his respiratory disease and obstructive sleep apnea. The resident was admitted to the facility with a hospital discharge summary indicating the need for a CPAP machine during sleep. However, there were no physician's orders for a CPAP machine, and the resident's Medication Administration Record did not reflect its provision. The Director of Nursing (DON) acknowledged that the resident was admitted without CPAP supplies and that the nursing staff did not ensure the CPAP was in place. The DON attempted to contact the Respiratory Therapist but did not follow up adequately to ensure the resident received the necessary respiratory care. The resident, who was severely cognitively impaired, was admitted to the facility in poor condition, and the Nurse Practitioner expressed concerns about his discharge from the hospital. Despite the resident's critical state, the facility did not provide the required CPAP machine, and the resident was eventually sent back to the hospital due to pulmonary edema and the absence of the CPAP. Interviews with staff, including the Respiratory Therapist and the Nurse Practitioner, revealed a lack of documentation and follow-up regarding the resident's respiratory needs, contributing to the deficiency in care.
Failure to Notify Physician of Missed Hydrocortisone Dose
Penalty
Summary
The facility failed to notify the physician when a prescribed dose of hydrocortisone was not administered to a resident with adrenocortical insufficiency. The resident was admitted with a diagnosis that required careful management of cortisol levels, as a deficiency could lead to a life-threatening crisis. A physician's order specified that the resident should receive hydrocortisone 10mg, 1.5 tablets by mouth in the afternoon for three days. However, on the day of admission, the medication was not administered because it was unavailable, and there was no documentation indicating that the physician was informed of this omission. Interviews with the nursing staff revealed that Nurse #1, who documented the missed dose, did not recall why the medication was unavailable and admitted that she likely did not notify the physician, as there was no documentation of such a call. Unit Manager #1 also did not recall being informed about the unavailability of the medication and was unaware if the physician had been notified. The physician confirmed that he was not informed about the missed dose and expressed that he would have expected to be notified of any medication not administered.
Inaccurate MDS Coding for Swallowing Disorders
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of swallowing. The resident, who was admitted with diagnoses including cerebral infarction and oropharyngeal dysphagia, had a care plan indicating a nutritional problem due to a mechanically altered diet related to obesity, cerebral infarction, and dysphagia. Despite this, the resident's quarterly MDS assessment incorrectly indicated no swallowing disorders. During a phone interview, the Registered Dietician confirmed that the resident did have swallowing problems, which led to choking and coughing when eating and drinking fluids. The dietician acknowledged the oversight in not accurately coding the MDS assessment. The facility administrator stated that he expected MDS assessments to accurately reflect residents' conditions and diagnoses.
Failure to Transcribe IV Orders
Penalty
Summary
The facility failed to transcribe orders for a midline IV, 0.9% normal saline (NS) solution, and flushes for a resident with cerebral infarction, diabetes mellitus, and diverticulitis. The resident was admitted with moderately impaired cognition. A physician's order dated January 1, 2025, indicated the need for a midline IV, but the orders did not include the necessary details for NS at 500 ml/hour or flushes to maintain patency. The midline IV was placed by a specialized healthcare company on January 2, 2025, but the required orders for the peripheral IV, NS fluids, and flushes were not transcribed into the electronic medical record due to miscommunication among staff. Interviews with staff revealed that Nurse #3 did not enter the orders, assuming Supervisor #1 had done so. Supervisor #1 had communicated the orders verbally and expected Nurse #3 to transcribe them. Unit Manager #1 acknowledged forgetting to transcribe the flush orders after the midline was inserted. The Director of Nursing and the Administrator were unaware of the oversight, with both expecting the nurse who received the order to transcribe it immediately. The failure to transcribe these orders resulted in a deficiency in maintaining professional standards of quality care for the resident.
Discharge Documentation Errors for Two Residents
Penalty
Summary
The facility failed to provide two residents with the correct discharge documentation upon their release. Resident #188, who was cognitively intact and planned to discharge home, was mistakenly given another resident's discharge summary and medication list. This error was not corrected until three days later. Nurse #2, responsible for the discharge, admitted to accidentally picking up the wrong packet but was not aware of the mistake at the time. Resident #189, who was mildly cognitively impaired and also planned to return home, was discharged without any discharge summary or medication list. The family had to return to the facility to obtain the necessary documents. Nurse #1, who was involved in the discharge process, stated that the social worker had mixed up the discharge folders, leading to the error. The Director of Nursing confirmed that both nurses were responsible for ensuring the correct discharge paperwork was sent home with the residents.
Medication Administration Error with Lyrica
Penalty
Summary
The facility failed to prevent a medication error involving a resident who was prescribed Lyrica for pain management due to rheumatoid arthritis. The physician's order specified that the resident should receive two 75 mg capsules of Lyrica every 12 hours. However, on a specific date, the resident was mistakenly administered 300 mg of Lyrica instead of the prescribed 150 mg. This error occurred because Nurse #3 did not review the medication label, which indicated that the capsules were 150 mg each, and inadvertently gave two capsules, resulting in an overdose. The incident was documented in a facility report, and interviews with staff, including the nurse practitioner and the Director of Nursing, confirmed the error. The nurse practitioner noted that the extra dose was unlikely to cause serious side effects, as the resident had been on the medication for an extended period, and only drowsiness was expected. The Director of Nursing emphasized the expectation that the correct dosage should be administered as ordered. The incident highlights a lapse in medication administration procedures, leading to the resident receiving an unnecessary drug dosage.
Pharmacist Fails to Identify Medication Error Due to Incomplete Records
Penalty
Summary
The deficiency involved a failure by the Consultant Pharmacist to recognize a medication error for a resident with adrenal insufficiency. The resident was discharged from the hospital with orders for hydrocortisone to manage their condition, which requires precise dosing to prevent life-threatening complications. However, upon admission to the facility, the orders were incorrectly transcribed, and the resident did not receive the medication as prescribed. Specifically, the resident missed doses on multiple days, and the medication was not administered from September 1 to September 18. The Consultant Pharmacist conducted a remote review of the resident's medication regimen but did not identify any irregularities, as the hospital discharge orders were not available in the electronic documentation system at the time of review. The delay in uploading these orders was due to a procedural issue where the orders were emailed to the Director of Nursing instead of being entered by the corporate admissions team. This oversight led to the pharmacist not having access to the complete information needed to identify the medication error.
Inaccurate RN Staffing Documentation
Penalty
Summary
The facility failed to post accurate Registered Nurse (RN) hours on the daily nurse staffing sheets for three specific days. On 11/23/24, 1/06/25, and 1/07/25, the staffing sheets did not document any RN hours for any of the three shifts. Observations conducted on 1/06/25 and 1/07/25 confirmed the absence of RN hours on the posted sheets. The Staffing Coordinator, responsible for completing these sheets, revealed that she only documented RN hours if they worked on the floor and provided direct resident care. Consequently, the hours worked by the Weekend Nursing Supervisor and the MDS Coordinator, who were present in the facility but not working on the floor, were not recorded. The Director of Nursing (DON) confirmed that there was an RN in the facility for at least 8 hours each day, including roles such as the MDS Coordinator, Assistant Director of Nursing, or the Weekend Nursing Supervisor. However, the RN hours for the specified dates were inaccurately documented. The DON acknowledged that the Weekend Nursing Supervisor worked the first shift on 11/23/24, and the MDS Coordinator worked the first shift on 1/06/25 and 1/07/25, and their hours should have been included in the posted nurse staffing sheets.
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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