Linden Place Center For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensboro, North Carolina.
- Location
- 1201 Carolina Street, Greensboro, North Carolina 27401
- CMS Provider Number
- 345014
- Inspections on file
- 24
- Latest survey
- January 10, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Linden Place Center For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple failures in medication storage and labeling, including expired medications in the med storeroom refrigerator and on shelves (such as an RSV vaccine, a compounded IV antibiotic solution, hemorrhoidal suppositories, nicotine patches, Vitamin C tablets, and sore throat spray), as well as an opened multi‑dose vial of Tuberculin PPD without an open date to determine its 30‑day discard time. On a med cart, an opened sore throat spray lacked a resident name and was expired, and a bottle of lactulose for a resident remained on the cart past its labeled stop and discard‑after dates. Staff interviews confirmed that specific personnel had been designated to monitor medication expirations and that medication storage concerns had been discussed previously.
A resident’s room and bathroom were not maintained in good repair, resulting in a door that would not latch closed and a bathroom sink that repeatedly held one to two inches of standing water without draining. The Maintenance Director acknowledged prior unsuccessful repair attempts on the door and recognized that the sink required fixing to drain properly. Facility leadership later agreed that residents should be able to close their room doors and acknowledged that a non-draining sink did not support a homelike environment.
The facility failed to act upon and resolve group grievances raised in Resident Council meetings and did not consistently communicate follow-up to residents. Council minutes over several months documented repeated concerns about staff attitudes and foul language, medications left in rooms, call lights not in reach or not answered, staff voicing confidential information in public areas, unsanitary shower and bathroom conditions, poor communication about room changes, excessive staff noise, delayed staff responses, staff using personal phones while in rooms and on the hall, and staff rushing residents during meals. Although the Activities Director documented these concerns and forwarded them to the Administrator, grievance forms were incomplete, lacked evidence of investigation or resolution, and several issues were not addressed at subsequent meetings, leading residents to report that their grievances were repeatedly voiced without being fully resolved.
A resident with cancer, generalized muscle weakness, and moderately impaired cognition had conflicting code status documents maintained by the facility. A bright yellow/orange DNR form indicating no expiration date and a MOST form ordering CPR were both stored in the paper advance directive binder at the nursing station, while the EMR and care plan documented the resident as full code/CPR. The SW described a process in which she obtained and routed advance directives for provider review, after which nursing staff documented and retained the orders, and a nurse reported she would rely on either the binder or EMR in an emergency, creating potential confusion due to the contradictory documents.
Surveyors found that the facility did not accurately code MDS assessments for two residents. One resident had a documented PASRR Level II determination for serious mental illness and a care plan reflecting this status, yet the annual MDS indicated the resident was not considered to have a serious mental illness or related condition by the state PASRR process. Another resident with cerebrovascular disease had a terminal prognosis, active hospice enrollment, and current hospice certification and physician orders, but the quarterly MDS did not reflect hospice services, despite the DON confirming the resident was on hospice.
Surveyors found that the facility failed to develop comprehensive care plans for three residents’ identified needs. One resident admitted with a colostomy and indwelling urinary catheter had detailed MD orders and a triggered CAA for urinary incontinence and catheter use, yet no care plan addressed colostomy or catheter care. Another resident with ESRD had standing orders and a regular schedule for hemodialysis with AV shunt monitoring, and confirmed receiving dialysis three times weekly, but the care plan contained no dialysis-related goals or interventions. A third resident with metabolic encephalopathy had an MDS-documented goal to return to the community, social work notes describing plans for assisted living placement, and personal requests for help with community discharge, but the comprehensive care plan lacked any discharge planning focus or interventions.
A resident with systolic CHF and severely impaired cognition had PRN orders for supplemental O2 via nasal cannula at 2 L/min to maintain SpO2 above 90%. On multiple observations, the resident was in bed receiving O2, but no oxygen signage was posted on or near the room entrance, and only a general "No Smoking" sign was present at the main entrance. Interviews with the DON, Administrator, Regional Nurse Consultant, Medical Records/Central Supply clerk, a hall nurse, and a Unit Manager showed that staff had differing and unclear views about who was responsible for posting oxygen signage when a resident used supplemental O2, and no consistent process was identified.
A resident with metabolic encephalopathy, muscle weakness, and moderate cognitive impairment, care planned to receive supervision and assistance with personal hygiene, repeatedly requested that staff trim his mustache because it was curling into his mouth. Despite these requests over several weeks, observations showed his beard and mustache remained untrimmed. The assigned NA acknowledged the resident's need for assistance and his ongoing requests, believed the Transportation Aide was responsible due to the need for clippers, and stated she had reported the request, while the Transportation Aide reported never being informed. Nursing staff, the DON, and the Administrator each stated that NAs were responsible for facial hair care and that clippers were available, but none could explain why the grooming assistance was not provided.
A resident with severe cognitive impairment, multiple comorbidities, and documented stage 3 pressure ulcers on the sacrum and both buttocks did not have a physician order in place for treatment of the right buttock ulcer, even though the wound had been identified and was being treated by the wound care nurse. Treatment orders and TAR entries existed for the sacral and left buttock ulcers only, and the right buttock ulcer lacked an order until later, despite ongoing care. In addition, the resident’s pressure-relieving air mattress was repeatedly observed set to 350 lbs, while the resident weighed about 133 lbs, and nursing staff interviews showed a lack of awareness and clarity about responsibility for ensuring the mattress weight setting matched the resident’s actual weight.
Surveyors observed that a medication aide committed two medication administration errors, resulting in an 8% medication error rate. In one case, a resident receiving Breo Ellipta for reactive airway disease was given water to drink immediately after inhalation instead of being instructed to rinse and spit as ordered. In another case, a different resident ordered a daily multivitamin without minerals was instead given a multivitamin with minerals from a stock bottle on the med cart because the aide did not verify the correct product, leading to administration inconsistent with the physician’s order.
The facility failed to provide required written notification to the Ombudsman for emergency hospital transfers involving two residents who were sent out for evaluation and treatment of chest pain, seizures, and seizure-like activity, with one resident not returning after transfer. Record review showed no documentation of Ombudsman notification for any of these transfers, and interviews revealed that the Social Worker had not sent any emergency transfer notifications and was unclear about responsibility for this task, while the Ombudsman reported no such notifications had been received for several months and the Administrator believed the Social Worker was responsible.
The facility failed to transmit required MDS assessments within regulatory timeframes for two residents. For one resident with type 2 DM and HTN, a quarterly MDS was completed but not transmitted as expected, which the DON attributed to a system glitch that prevented automatic submission. For another resident who had been discharged, a discharge MDS was completed but not transmitted or accepted by the CMS system, and the DON acknowledged that the MDS nurse should have monitored transmission reports and ensured submission within the required 14-day window.
A resident with chronic obstructive pulmonary disease expressed concerns about receiving morning medications late, affecting his schedule. Despite being cognitively intact and having communicated his preference multiple times, the facility failed to honor his request. Nurse #4 admitted to running behind on the medication pass, resulting in late administration. The DON acknowledged the issue and indicated a willingness to adjust medication times.
A resident with multiple diagnoses, including atrial fibrillation on anticoagulant, showed neurological changes such as lethargy and sluggish pupil reaction. Nurse #1 documented these symptoms but failed to fully inform the on-call NP, only mentioning drowsiness. The NP, reliant on nurse reports due to lack of record access, was not aware of the full condition, leading to a deficiency in the facility's notification protocol.
A resident with a history of diabetes, atrial fibrillation, and end-stage renal disease experienced a change in condition that was not promptly identified by the facility staff. After undergoing dialysis, the resident showed signs of lethargy and unresponsiveness, which were initially attributed to fatigue. Despite elevated blood pressure and other symptoms, the staff delayed recognizing the severity of the situation, leading to the resident being sent to the hospital in critical condition.
The facility failed to maintain a clean and sanitary environment, with issues observed in resident rooms, a linen closet, and a dining room. Residents reported inadequate cleaning despite daily housekeeping, and staff interviews confirmed that deep cleaning was not consistently performed. An ongoing PIP aimed at improving environmental services was in place, but deficiencies persisted, indicating ineffective implementation.
The facility failed to maintain effective pest control, with pests observed in hallways and residents' rooms. Residents reported flies and bugs, while staff confirmed sightings of roaches in various areas. Despite an ongoing PIP and increased exterminator visits, pest issues persisted, indicating ineffective interventions.
The facility failed to develop a comprehensive care plan for a resident, missing care plans for cognitive loss/dementia, urinary incontinence, functional abilities, dehydration, dental care, pain, communication, nutritional status, and pressure ulcers. Staff interviews confirmed the oversight, and the DON acknowledged the care plans should have been completed within seven days of assessment.
The facility's QAPI Committee failed to maintain procedures and monitor interventions following previous surveys, leading to repeated deficiencies in developing comprehensive resident-centered care plans. The deficiencies included failure to address various needs such as cognitive loss, urinary incontinence, and nutritional status for a resident.
Expired, Unlabeled, and Undated Medications in Storeroom and Med Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication management related to labeling, dating, and removal of expired drugs and biologicals. In the North Hall medication storeroom, an unopened single-use vial of Arexy RSV vaccine dispensed for a specific resident was found in the refrigerator with a manufacturer’s expiration date that had already passed, indicating it was kept beyond its expiration. A compounded IV bag of 0.9% sodium chloride with cefazolin for another resident was also stored past the pharmacy-labeled stop date and discard-after date. Additionally, a stock box of hemorrhoidal suppositories, a stock box of nicotine transdermal patches, two opened stock bottles of 500 mg Vitamin C tablets, and an unopened bottle of sore throat spray were all found on storeroom shelves with manufacturer expiration dates that had already passed. The surveyors further observed failures to properly date multi-dose medications to determine shortened expiration periods. In the medication storeroom refrigerator, one opened multi-dose vial of Tuberculin PPD injectable solution dispensed from the pharmacy had no label or box notation indicating the date it was opened, preventing determination of its 30‑day post‑opening discard date. A second opened multi-dose vial of Tuberculin PPD had an auxiliary pharmacy sticker indicating an open date and corresponding shortened expiration date, but the first vial lacked this required information. These findings showed inconsistent practices in documenting open dates for medications that require shortened beyond‑use dating. On North Hall Medication Cart #2, surveyors found an opened 6‑ounce bottle of sore throat spray that was not labeled with any resident’s name, and the med aide assigned to the cart could not identify which resident it belonged to; the bottle also bore a manufacturer’s expiration date that had passed. The same cart contained a bottle of lactulose solution dispensed for a resident, with pharmacy labeling that included a stop date and a “discard after” date that had already elapsed, indicating the medication was expired but still stored on the cart. During interviews, facility leadership acknowledged that responsibilities for monitoring expiration dates in the storeroom and on med carts had been assigned to specific staff, and that concerns about medication storage had been previously discussed.
Failure to Maintain Resident Room Door and Bathroom Sink in Good Repair
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s room door in good repair so that it would properly latch and remain closed. During an initial observation of the resident’s room, the door latch was found not to secure the door. In a subsequent observation with the Maintenance Director present, the door again failed to latch despite multiple attempts to close it. The Maintenance Director acknowledged he had previously worked on the door and that the repair had not resolved the problem, and he stated the door would likely need to be replaced. In a later interview, the Administrator and Regional Nurse Consultant agreed they would expect residents to be able to close the door to their room. The deficiency also includes the facility’s failure to maintain the resident’s bathroom sink in working order so that it would properly drain. An initial observation of the resident’s bathroom revealed one to two inches of standing water in the sink that was not draining. A follow-up observation several days later with the Maintenance Director present again showed one to two inches of standing water in the sink, indicating the problem persisted over time. When informed that the same issue had been observed earlier, the Maintenance Director stated the sink would need to be fixed to ensure proper drainage. In a subsequent interview, the Administrator acknowledged that a sink that failed to drain water did not create a homelike atmosphere.
Failure to Address and Resolve Resident Council Group Grievances
Penalty
Summary
The facility failed to honor residents' rights to have group grievances from Resident Council meetings acted upon, resolved, and communicated back to them. Resident Council minutes from 10/14/25 documented multiple grievances, including staff having poor attitudes and using foul language, medications being dropped off and left in resident rooms, call lights not in reach, staff voicing confidential resident information in public areas, unsanitary shower rooms and bathrooms, and lack of communication regarding room changes. Only one grievance form was completed by the Administrator for that date, and it did not address the concerns about staff voicing confidential information, unsanitary shower rooms and bathrooms, or lack of communication about room changes. Resident Council minutes from 11/18/25, completed by the current Activities Director, showed that old business and follow-up on grievances were reviewed and approved as corrected, but there was no evidence that the specific grievances from 10/14/25 regarding staff voicing confidential information, unsanitary shower rooms and bathrooms, and lack of communication about room changes were discussed, addressed, or resolved. The 11/18/25 minutes documented a repeat grievance about staff being rude and new grievances about call lights not being answered on 2nd and 3rd shifts, bugs being observed, staff turning off call lights and leaving without returning, residents not being told who their assigned nursing assistant was, and staff noise levels being too loud in the hallways. A grievance form completed by the Administrator on 11/18/25 listed some of these concerns, but there was no indication of investigation, interventions, or resolution for them. Resident Council minutes from 12/16/25 again indicated that old business and follow-up on grievances were reviewed and approved, but there was no evidence that the previously voiced concerns about staff turning off call lights and not returning, residents not being told their assigned nursing assistant, and excessive staff noise were addressed. The 12/16/25 minutes documented a repeat grievance about medications being left in residents' rooms and new grievances that staff were not responding to residents in a timely manner, staff were using personal phones in resident rooms and on the hall, and staff were rushing residents when eating. During a Resident Council meeting on 1/7/26, the Resident Council President and several other residents stated that grievances had been repeated month after month without being fully addressed or resolved. The Activities Director reported that she forwarded the minutes to the Administrator and relied on him for follow-up information, and the Administrator acknowledged that the process for documenting and resolving all Resident Council concerns had not been fully carried out, describing this as an oversight.
Conflicting Advance Directive Documents for a Resident’s Code Status
Penalty
Summary
The facility failed to maintain accurate and consistent advance directive information for one resident when conflicting code status documents were kept in the paper advance directive binder at the nursing station. The resident, who had cancer, generalized muscle weakness, and moderately impaired cognition, had a bright yellow/orange Do Not Resuscitate (DNR) form in the binder indicating DNR status with no expiration date. The same binder also contained a Medical Order for Scope of Treatment (MOST) form signed by the resident’s Nurse Practitioner that directed staff to attempt cardiopulmonary resuscitation (CPR) if the resident had no pulse and was not breathing. At the same time, the resident’s electronic medical record contained a physician’s order for full code/CPR, and the care plan documented the resident as a full code. The Social Worker reported that she was responsible for obtaining advance directives at or shortly after admission, reviewing them with the resident or family depending on cognition, and then placing the signed forms in the provider’s box for review, after which nursing staff were responsible for documenting and retaining the orders. The nurse assigned to the resident stated that in an emergency she would look for advance directive information either in the 3-ring binder at the nursing station or in the EMR, indicating reliance on both sources. During interviews, the Social Worker acknowledged the potential for confusion caused by having both the DNR and MOST forms in the binder, and the DON and Regional Nurse Consultant confirmed that the DNR form should not have been in the binder and likely came from the hospital, yet it remained stored with the resident’s advance directive documents, creating inconsistent and contradictory information regarding the resident’s code status.
Inaccurate MDS Coding for PASRR Level II Status and Hospice Services
Penalty
Summary
The facility failed to accurately code the MDS assessment for a resident with a documented PASRR Level II status. The resident’s EMR contained a PASRR Level II Determination Notification letter issued on 11/22/23 with no expiration date, and the resident’s diagnoses included schizophrenia and major depressive disorder. The resident’s care plan included a focus area indicating a Level II PASRR status related to serious mental illness due to schizophrenia, initiated on 3/25/25. Despite this, the resident’s most recent annual MDS dated 11/15/25 was coded to indicate that the resident was not considered by the state Level II PASRR process to have a serious mental illness or related condition. During interviews, the DON stated she believed a corporate MDS nurse had completed the assessment, and the social worker confirmed upon review that the resident did have a PASRR Level II status. The facility also failed to accurately code hospice services on the MDS for another resident. This resident was admitted with a diagnosis of cerebrovascular disease and had a care plan, last updated on 06/14/2024, that documented a terminal prognosis related to cerebrovascular disease and enrollment in hospice services. Physician orders dated 06/12/2024 confirmed hospice admission, and a hospice recertification dated 10/27/2025 documented a certification period from 11/25/2025 to 01/23/2026, with a corresponding hospice physician order reflecting the same certification period. However, the resident’s quarterly MDS assessment dated 11/02/2025 did not reflect hospice services. In an interview, the DON verified that the resident was receiving hospice care and that the MDS should have been coded to reflect hospice services.
Failure to Develop Comprehensive Care Plans for Specialized Treatments and Discharge Goals
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans addressing specific clinical needs and discharge goals for three residents. One resident was admitted with necrotizing fasciitis, soft tissue disorders, rectal hemorrhage, and had both a colostomy bag and an indwelling urinary catheter. Physician orders directed staff to check the catheter strap and monitor urinary output every shift, and to check, empty, and replace the colostomy bag as needed. The admission MDS documented that the resident was cognitively intact and had both an indwelling catheter and an ostomy bag, and the CAA summary showed that urinary incontinence and indwelling catheter triggered a care area to be addressed in the care plan. Despite this, the comprehensive care plan dated after admission contained no care plan for colostomy care or indwelling urinary catheter care, and the DON and Administrator acknowledged these areas should have been included but could not explain the omission. Another resident with end stage renal disease had physician orders for dialysis, including monitoring the AV shunt every shift for thrill, bruit, and signs of bleeding, and scheduled dialysis at a kidney center three times weekly. The admission MDS indicated the resident was cognitively intact and received dialysis treatment, and the resident confirmed in interview that he had been receiving dialysis three times a week since admission. However, the comprehensive care plan last reviewed in early October contained no goals or interventions related to dialysis treatment. The DON stated that the MDS nurse was responsible for developing care plans and that a dialysis care plan should have been added, describing the absence of such a plan as an oversight, and the Administrator agreed that a dialysis care plan should have been developed. A third resident, admitted with metabolic encephalopathy, had an admission MDS showing moderate cognitive impairment and participation in discharge planning with a goal to return to the community. A social work progress note documented that the social worker and the resident’s emergency contact discussed seeking placement at an assisted living facility. The resident reported requesting assistance from the social worker and his emergency contact for placement in an assisted living facility or return home. Despite this documented discharge goal and discussions, the comprehensive care plan contained no interventions or goals related to discharge planning. The social worker, identified as responsible for discharge planning and related care plans, acknowledged awareness of the resident’s discharge wishes and support from the emergency contact but stated she did not know why a discharge focus area was not included and characterized it as an oversight; the DON and Administrator also stated that a discharge care plan should have been added.
Failure to Post Oxygen Signage for Resident Receiving Supplemental Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to post cautionary oxygen signage at the entrance to a resident’s room while supplemental oxygen was in use. The resident had systolic congestive heart failure and severely impaired cognition, and had physician orders for PRN supplemental oxygen via nasal cannula at 2 L/min to maintain oxygen saturation above 90%. On multiple observations on one survey date, the resident was seen in bed receiving oxygen via nasal cannula, yet there was no oxygen signage on or near the room entrance. A general “No Smoking” sign was posted at the facility’s main entrance, but it did not indicate that supplemental oxygen was in use within the facility or specifically for this resident’s room. Further review of the electronic medical record showed the resident had been sent to the hospital and then readmitted, with new orders again for PRN supplemental oxygen at 2 L/min. On a subsequent observation date, the resident was again noted in bed with oxygen via nasal cannula and still no oxygen signage at the room entrance. Interviews with the DON, Administrator, Regional Nurse Consultant, Medical Records/Central Supply clerk, a hall nurse, and a Unit Manager revealed inconsistent and unclear understanding of who was responsible for ensuring oxygen signage was posted when a resident used supplemental oxygen. Staff members variously believed responsibility lay with Medical Records/Central Supply, nursing staff, the hall charge nurse, or the Unit Manager, and there was no clear process identified for residents who began oxygen use without advance notice or after new oxygen orders were written.
Failure to Assist Resident With Requested Facial Hair Grooming
Penalty
Summary
Failure to provide assistance with activities of daily living occurred when staff did not trim a resident's mustache despite multiple requests. The resident, admitted with metabolic encephalopathy, need for assistance with personal care, and muscle weakness, had an admission MDS showing moderate cognitive impairment and a need for supervision or touching assistance with personal hygiene. A care plan documented that the resident required staff supervision/touching assistance with personal hygiene and assistance by staff with personal hygiene. On two separate observations, the resident was noted to have a full beard about an inch long and a mustache about 1/2 inch long that covered the full top lip and curled inward toward the mouth. During interview, the resident stated he had repeatedly asked nursing assistants to have his mustache trimmed, was not concerned about the beard length, and was frustrated that no one had assisted him, despite being told someone would come to trim it and that several weeks had passed without this occurring. The assigned nursing assistant confirmed the resident required staff assistance for facial hair trimming, acknowledged he had requested mustache trimming "for a while," and stated she believed the Transportation Aide was responsible because clippers were needed; she reported having notified the Transportation Aide but could not recall when and did not know why it had not been done. The Transportation Aide, however, reported she was never informed of any request for this resident. The nurse on duty stated she was unaware of the resident's requests and that NAs normally shaved men's facial hair per preference, and the DON reported that NAs were responsible for facial hair trimming and that clippers were available to all nursing staff. The Administrator stated he did not know why the resident's facial hair had not been trimmed and that he expected staff to complete all ADL care for all residents.
Failure to Obtain Wound Treatment Order and Incorrect Pressure-Relieving Mattress Setting
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician order for treatment of a documented stage 3 pressure ulcer and failure to correctly set a pressure-relieving air mattress for a resident with multiple pressure ulcers. The resident was admitted with diagnoses including cerebrovascular disease, type 2 diabetes, hypertension, a sacral pressure ulcer, and peripheral vascular disease, and had severe cognitive impairment and dependence in ADLs. The care plan identified a coccyx pressure ulcer and risk for further breakdown, with goals for healing and interventions such as skin assessments and weekly wound documentation. Weekly skin reviews and wound measurements beginning on 12/23/25 showed stage 3 pressure ulcers on the sacrum and left buttock, and later documentation showed an additional stage 3 ulcer on the right buttock. Physician orders dated 12/24/25 were present for treatment of the sacral and left buttock stage 3 pressure ulcers, specifying cleansing with Dakin’s/normal saline, application of honey fiber, and coverage with a silicone super absorbent pad. However, there was no corresponding treatment order for the right buttock ulcer, despite the wound being identified on 12/23/25 and documented as a stage 3 pressure ulcer with specific measurements on 01/07/26. The Treatment Administration Records for December 2025 and January 2026 showed wound care being provided to the sacral area and left buttock starting 12/23/25, but no documented treatment order for the right buttock ulcer in December. The Wound Care Nurse reported that all three wounds (left buttock, right buttock, and sacrum) were identified on 12/23/25 and that she had been treating all of them, but she had not realized there was no physician order in place for the right buttock. A separate deficiency was identified regarding the pressure-relieving air mattress settings for the same resident. Observations on consecutive days showed the resident in bed with the air mattress set at 350 lbs, while the medical record documented the resident’s weight as 133.5 lbs. Nursing staff interviews revealed that the nurse assigned to the resident was not aware she was responsible for checking the weight setting on the pressure-relieving mattress. The Wound Care Nurse stated that it was the hall nurse’s responsibility to ensure the mattress weight setting was correct. These observations and interviews demonstrated that the mattress was not set according to the resident’s actual weight and that staff were unclear about their responsibility for verifying and adjusting the mattress settings.
Medication Administration Errors Result in Elevated Medication Error Rate
Penalty
Summary
Surveyors identified a medication error rate of 8% (2 errors out of 25 opportunities), exceeding the required rate of less than 5%. In the first instance, a medication aide administered Breo Ellipta 200-25 mcg inhalation powder as one puff by mouth to a resident with an order initiated on 12/24/25 for reactive airway disease. The physician’s order and the manufacturer’s prescribing information both specified that after inhalation the patient should rinse the mouth with water and spit it out to help reduce the risk of oropharyngeal candidiasis. During observation, after the resident inhaled one puff of Breo Ellipta, the medication aide offered water, which the resident drank and swallowed immediately. The aide did not prompt the resident to rinse and spit as required by the order. Subsequent review of the MAR and interview confirmed that the order included the rinse-and-spit notation and that the aide had allowed the resident to swallow the water instead. In the second instance, the same medication aide prepared and administered a multivitamin with minerals taken from a stock bottle on the medication cart to another resident. The current physician’s order for this resident, initiated on 7/17/24, specified a multivitamin without minerals to be given once daily for vitamin deficiency. During interview and review of the MAR, the nurse confirmed that the order was for a multivitamin only, without added minerals. The medication aide acknowledged uncertainty about whether a stock bottle containing only multivitamins (without minerals) was available on the cart, and the nurse indicated that such a bottle was present. The aide had not verified the stock bottle label closely enough and administered a multivitamin with minerals instead of the ordered multivitamin without minerals, constituting a second medication error contributing to the elevated error rate.
Failure to Notify Ombudsman of Emergency Hospital Transfers
Penalty
Summary
The facility failed to provide required written notification to the Ombudsman regarding residents’ emergency transfers to the hospital. For one resident, identified as Resident #99, nursing progress notes documented that the resident was out of the facility for an appointment and was transferred to the hospital for further evaluation due to chest pain. The medical record showed that this resident was discharged from the facility on the same day and did not return. The facility was unable to produce any documentation that the Ombudsman was notified in writing of this emergency transfer and discharge. For another resident, identified as Resident #88, nursing progress notes documented two separate emergency transfers to the hospital related to seizures and seizure-like activity, one initiated at the request of a family member. The medical record showed that the resident was discharged to the hospital on both occasions and later returned to the facility. In both instances, the facility could not provide documentation that the Ombudsman was notified of the emergency transfers. During interviews, the Social Worker stated she had not sent any Ombudsman notifications for emergency transfers since being hired and did not know who was responsible for doing so, while the interim Ombudsman reported that no emergency transfer notifications had been received from the facility since a prior month. The Administrator stated he was unaware that notifications had not been sent and believed it was the Social Worker’s responsibility to notify the Ombudsman of emergency hospital transfers.
Failure to Transmit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the State and CMS within the required timeframe for two residents. For Resident #1, who was admitted with diagnoses including type 2 diabetes and hypertension, a quarterly MDS with an Assessment Reference Date (ARD) of 11/14/25 was completed on 11/26/25 but had not been transmitted as of the time of review. The MDS coordinator was unavailable for interview, and the Director of Nursing (DON) verified that this quarterly MDS had not been transmitted, stating there was a system glitch and that it should have automatically transmitted when completed. The Administrator stated it was his expectation that all MDS assessments be transmitted on time. For Resident #30, the electronic medical record showed an admission and subsequent discharge on 9/18/25. A discharge MDS with an ARD of 9/18/25 was signed as completed by the facility’s MDS nurse on 10/3/25, but the record did not show that this discharge MDS had been transmitted to or accepted by the CMS system. During interviews, the DON and Administrator confirmed that the MDS nurse was unavailable and acknowledged that the 9/18/25 discharge MDS had not been transmitted. The DON further stated that the MDS nurse should have been monitoring a print-out that would indicate whether MDS assessments were successfully transmitted and accepted, and acknowledged that the discharge MDS should have been transmitted within 14 days of the ARD.
Failure to Honor Resident's Medication Timing Request
Penalty
Summary
The facility failed to honor a resident's request to have medications administered at a desired time, which is a violation of the resident's right to self-determination and choice. Resident #64, who was admitted with chronic obstructive pulmonary disease and was cognitively intact, expressed concerns about receiving morning medications late, sometimes close to lunchtime. Despite having communicated this issue multiple times, the resident's request was not addressed, as evidenced by interviews and a review of the electronic medication administration record showing scheduled times for morning medications. On one occasion, Resident #64 had not received his medications by 9:46 AM, and he had to approach the medication cart at 10:30 AM to request them. Nurse #4 admitted to running behind on the medication pass, which resulted in the late administration of medications. The resident expressed frustration as the delay affected his schedule, including making him late for bible study. The Director of Nursing acknowledged the issue and indicated a willingness to change the medication times to accommodate the resident's preference.
Failure to Notify On-Call NP of Neurological Change
Penalty
Summary
The facility failed to notify the on-call nurse practitioner when a resident experienced a change in neurological status. The resident, who was admitted with diagnoses including diabetes, atrial fibrillation on anticoagulant, and end-stage renal disease dependent on dialysis, showed signs of lethargy, sluggish pupil reaction, and lack of motor function in all extremities. Despite these symptoms being documented by Nurse #1 at 7:30 pm, the nurse did not communicate the full extent of the resident's condition to the on-call nurse practitioner at 11:30 pm, only mentioning the resident's drowsiness and sleepiness. The nurse practitioner's interview revealed that the on-call service providers rely solely on the information provided by the nurses, as they do not have access to the facility's records. The physician emphasized the importance of reporting any change in a resident's neurological status immediately. The failure to report the resident's complete condition, including the sluggishness of the eyes, lethargy, diaphoresis, and immobility of extremities, constituted a deficiency in the facility's protocol for notifying medical staff of significant changes in a resident's health status.
Failure to Identify Change in Condition
Penalty
Summary
The facility failed to identify a change in condition for a resident, leading to a deficiency in care. The resident, who had a history of diabetes, atrial fibrillation on anticoagulant therapy, and end-stage renal disease requiring dialysis, was admitted with specific medical orders, including a do-not-resuscitate directive and limited additional interventions. On the day of the incident, the resident underwent dialysis and was assessed by the Director of Nursing and a nurse, who noted no changes in her condition before dialysis. However, later that evening, the resident exhibited signs of lethargy, sluggish pupil response, and lack of motor function, which were not immediately recognized as a change in condition. Nurse #1, who was on duty during the night shift, documented the resident's deteriorating condition, including elevated blood pressure, lethargy, and unresponsiveness. Despite these observations, the nurse initially attributed the resident's symptoms to fatigue from dialysis and did not suspect a neurological change. The nurse held the resident's evening medications due to her inability to swallow and notified the on-call nurse practitioner, who advised holding the medications. The resident's condition continued to decline, with fixed pupils and unresponsiveness noted in the early morning hours. The nursing assistant assigned to the resident also observed the resident's drowsiness and quiet demeanor, attributing it to post-dialysis fatigue. It was not until the resident became unresponsive and exhibited severe symptoms, such as diaphoresis and fixed pupils, that the staff recognized the severity of the situation. The resident was eventually sent to the hospital by emergency medical services after the Director of Nursing was informed of the resident's critical status. The failure to promptly identify and respond to the resident's change in condition resulted in a deficiency in the care provided by the facility.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in several areas, including resident rooms, a linen closet, and a dining room. Observations revealed issues such as a sink pulling away from the wall, a light fixture filled with dead bugs, peeling baseboards, and debris on the bathroom floor in one room. Another room had dust and debris on the floor and broken vinyl tiles in the bathroom. The dining room had dust and cobwebs on the doors and vending machines, and a roach bait station was found covered in dust and debris. Interviews with residents indicated that while housekeepers cleaned daily, they did not perform thorough cleaning. One resident mentioned that dried bowel movement remained on the commode lid despite daily cleaning, and another resident noted difficulty in picking up belongings due to back pain, which hindered thorough cleaning. Staff interviews revealed that cleaning routines involved basic tasks like collecting trash and mopping floors, but deep cleaning was not consistently performed. The facility had an ongoing Performance Improvement Project (PIP) aimed at improving environmental services, including pest control. However, the PIP lacked a completion date, and the issues observed during the survey indicated that the interventions were not effectively implemented. The Administrator acknowledged the findings and stated that work orders were supposed to be submitted for repairs and pest sightings, but the deficiencies persisted, highlighting a gap in maintaining a clean and homelike environment for residents.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of pests in one of three hallways and two of three residents' rooms reviewed for pest activity. Observations revealed flies and brown bugs in residents' rooms, with one resident reporting flies around her face and dead flies in the light fixture since her admission. Another resident reported seeing bugs coming in and out of her bathroom, with the bathroom observed to have peeling baseboards and broken vinyl tiles. Common areas were also affected, with flies observed near the dining room door entrance. Interviews with staff members, including nurse aides and environmental specialists, confirmed sightings of roaches and other pests in various locations within the facility. Staff reported seeing roaches in linen closets, hallways, and residents' bathrooms, with some indicating that they had submitted work orders when pests were observed. The environmental specialist noted live baby roaches in a resident's room and flies in the break room, while a floor technician reported finding a roach in his mop bucket. The facility had an ongoing Performance Improvement Project (PIP) on environmental services, including pest control, which started in March 2024. The administrator stated that the exterminator was contracted monthly but changed to weekly visits in May 2024. Despite these efforts, pests continued to be reported by residents and staff, indicating that the interventions were not fully effective. The administrator acknowledged the presence of pests and stated that the facility was working on decluttering residents' rooms and sealing cracks in the walls.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed a resident's individual care needs. Specifically, for one resident, the facility did not create care plans for cognitive loss/dementia, urinary incontinence and indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury. The resident was admitted with multiple fractures and pressure ulcers and was later discharged to the hospital without returning to the facility. The only care plan available for this resident was related to nutrition, dated 11/8/23. Interviews with staff revealed that the comprehensive care plans were not completed. MDS Nurse #1 and MDS Nurse #2 both confirmed that the care plans were missing and were unsure why this occurred. The Director of Nursing stated that comprehensive care plans should be based on the Care Area Assessments (CAAs) and completed within seven days from the resident assessment. However, this protocol was not followed in this case, leading to the deficiency.
Failure to Maintain Effective QAPI Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that were put into place following previous surveys. This failure was evident during three federal surveys, including the most recent complaint investigation survey. The deficiency was specifically related to the development of comprehensive resident-centered care plans. The facility failed to develop care plans addressing various needs such as cognitive loss/dementia, urinary incontinence, indwelling catheter, functional abilities, dehydration/fluid maintenance, dental care, pain, communication, nutritional status, and pressure ulcer/injury for one of the residents reviewed. During the recertification and complaint investigation surveys, the facility repeatedly failed to develop comprehensive care plans. In one instance, the facility did not include the daily use of antipsychotic and antianxiety medication in a resident's care plan. In another instance, the facility failed to create a care plan with measurable goals and objectives to address a resident's nutrition. An interview with the Administrator and the Director of Nursing revealed that the QAPI Committee was working on issues such as falls with injuries, pest control, and had recently added care plans to their focus areas. However, the continued failure to sustain an effective QAPI Program was evident in the repeated deficiencies.
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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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