Lotus Village Center For Nursing And Rehabilitatio
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparta, North Carolina.
- Location
- 179 Combs Street, Sparta, North Carolina 28675
- CMS Provider Number
- 345261
- Inspections on file
- 30
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lotus Village Center For Nursing And Rehabilitatio during CMS and state inspections, most recent first.
A resident admitted for rehab after an exploratory laparotomy with new colostomy had a hospital discharge order for twice-daily wet-to-dry NS dressings to a 4 cm abdominal wound with seropurulent drainage, but this order was not transcribed onto the physician orders or TAR. The admitting nurse reviewed the discharge summary only for medications, and the DON skimmed the summary and later forgot to recheck for incision care orders, resulting in no wound treatment being set up. Subsequent nurses assessed the incision but did not provide wound care, and the PA later stated that staff should have read the entire discharge summary and contacted him if no incision orders were found.
A resident admitted after abdominal surgery with a new colostomy had no documented assessments of the colostomy or abdominal incision for the entire stay. Multiple RNs and the DON reported that they assessed the colostomy and incision and that new admissions should have shift-by-shift documentation focused on the reason for admission, but each either forgot to chart or could not confirm their assessments when shown the lack of entries. The Regional Nurse Consultant confirmed the absence of any such documentation, and a PA noted he relies on nursing assessments in the medical record for treatment planning, demonstrating that required clinical assessments were not recorded.
A resident with a neurogenic bladder and chronic indwelling urinary catheter did not have their catheter changed as ordered due to a failure to transcribe the physician's order onto the MAR/TAR. Staff interviews confirmed the omission, and the DON acknowledged that the order was not visible to nursing staff, resulting in the catheter not being changed as scheduled.
A resident with multiple chronic conditions experienced a worsening allergic reaction, including a spreading rash and low-grade fever, after starting an antibiotic. A one-time IM dose of methyl prednisolone was ordered but not administered as scheduled, and nursing staff failed to notify the physician of the delay. The medication was not given until five days later, despite the resident's ongoing symptoms and the nurse practitioner's expectation for timely administration or notification.
A resident with a worsening allergic reaction did not receive a prescribed one-time IM methylprednisolone injection for five days due to nursing staff failing to check the backup medication supply, despite the medication being available. The resident experienced severe itching and rash during this period, and the error was only discovered after the NP followed up on the unadministered order.
A resident's MDS assessment was inaccurately coded in the dental section because the remote MDS Coordinator did not request or ensure a dental assessment was completed during the required period. Nursing documentation confirmed that no dental assessment was performed, and facility leadership expected the dental status to be accurately documented.
A resident with multiple chronic conditions was scheduled for dental extractions, but the facility failed to withhold aspirin as ordered by the NP. The order to hold the antiplatelet medication was documented but not transcribed to the MAR, resulting in continued administration of aspirin and a delay in the dental procedure. Communication lapses among staff contributed to the failure to follow the physician's order, and the resident later required antibiotics and eventually received the extractions.
A resident with severe cognitive impairment was found with Sodium Polyacrylate and solidified fruit punch within reach, posing a potential ingestion hazard. The facility staff, including nurse aides and the DON, were unable to determine how the substance entered the facility. Despite monitoring the resident for gastrointestinal symptoms, no adverse effects were observed.
A cognitively impaired resident in a memory care unit managed to remove a windowpane and exit the facility unsupervised after being denied a smoke break. The resident walked to a nearby gas station before being found and returned by law enforcement. The incident revealed lapses in supervision and security, as the resident had no prior history of elopement and was not considered at risk.
A facility failed to notify the medical provider of an alleged sexual abuse incident involving two residents. Despite staff reporting the incident to the Administrator and DON, the medical provider and family were not informed immediately. The NP was only notified days later, delaying potential medical intervention. The Administrator assumed the notification would be handled the next day, resulting in a deficiency.
A resident with cognitive impairments hit another resident in the eye, believing the victim was viewing inappropriate content on a shared computer. The victim, who had aphasia, avoided the aggressor and the computer for over a week. Staff intervened, and the aggressor was placed under supervision. The facility's computer system was designed to prevent access to inappropriate content.
A facility failed to prevent illegal substances from entering, affecting resident safety. A resident, legally blind, mistakenly ingested methamphetamine left in her room by an unknown individual. Another resident tested positive for THC, linked to a shared vape pen. Drug canines detected scents, but no substances were found. A known drug dealer's visit raised security concerns.
A resident with a history of brain damage, dysphagia, hypertension, and gastrostomy experienced severe septic shock, UTI, and necrotic changes to the left testicle, necessitating its removal. The facility did not recognize the urgency of a Nurse Practitioner's order for a urology appointment following an ultrasound indicating decreased vascular flow. The appointment was scheduled for a later date, resulting in delayed care. Additionally, the facility failed to conduct thorough and ongoing nursing assessments and did not notify the NP or MD when the appointment was not scheduled as ordered, leading to an acute change in the resident's condition.
A facility failed to promptly address decreased vascular flow to a resident's left testicle, despite reports of scrotal swelling and tenderness. Initial assessments led to an ultrasound and antibiotics, but delays in scheduling a urology consultation prolonged necessary medical interventions. The resident's condition worsened, resulting in severe septic shock, a urinary tract infection, and necrotic changes, ultimately necessitating the removal of the testicle. Multiple staff members were aware of the issue, but consistent documentation and follow-up were lacking, and scheduling challenges further delayed care.
A facility experienced a communication breakdown when a urology consult could not be scheduled as ordered by the NP for a resident with a history of anoxic brain injury, persistent vegetative state, and neurogenic bladder. An ultrasound indicated decreased vascular flow to the resident's left testicle, prompting the NP to order an urgent urology consult. The Scheduler faced difficulties in securing the appointment and did not notify the NP or MD, leading to a delay. This delay resulted in the resident developing severe sepsis and requiring an emergency left orchiectomy.
The facility's QAA committee failed to maintain procedures and monitor interventions, leading to repeated deficiencies in Notification of Change, Neglect, and Quality of Care. A resident experienced severe sepsis and an emergency orchiectomy due to delayed medical consultations and inadequate nursing assessments.
Failure to Transcribe and Provide Ordered Surgical Wound Care on Admission
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and implement a physician’s order for surgical wound care upon admission, resulting in the absence of ordered treatment for a resident’s abdominal incision. The resident was admitted following an exploratory laparotomy with creation of a colostomy related to diverticulitis with perforation. The hospital discharge summary documented that on the day of discharge the physician opened a 4 cm portion of the wound below the umbilicus due to seropurulent drainage and ordered wet-to-dry dressing changes with normal saline twice daily. Review of the admission physician orders and the Treatment Administration Record for the admission and following day showed no orders for wet-to-dry dressings or any surgical wound care. The resident’s discharge MDS later documented discharge to home/community with return not anticipated. Nurse #1, who admitted the resident, stated she reviewed the hospital discharge summary only for medication orders and did not read the entire summary, resulting in failure to transcribe the wound care order to the TAR. She reported having a very busy day and acknowledged that between herself and the DON, the treatment order should have been entered. The DON confirmed she assisted with the admission, entered medication orders, assessed the incision, and skimmed the discharge summary, recognizing later that she had not seen incision care orders and then forgot to recheck the summary. Nurse #2 and Nurse #3, who cared for the resident on subsequent shifts, recalled the resident and his new colostomy but indicated they would need to review the record to identify any treatment orders; Nurse #3 confirmed she assessed the incision but did not provide treatment. The Physician Assistant stated nurses are expected to read the entire discharge summary for all discharge orders and that, in the absence of incision care orders, the facility should have contacted him for interim orders.
Failure to Document Assessments for New Colostomy and Abdominal Incision
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident admitted after an exploratory laparotomy with creation of a new colostomy. From admission to discharge, the resident’s chart contained no documented assessments of the abdominal incision or the new colostomy. Multiple nurses, the DON, and the Regional Nurse Consultant all acknowledged that assessments should be documented every shift for new admissions, particularly related to the reason for admission, yet no such documentation existed for this resident during the entire stay. Nurse #1 reported assessing the resident’s new colostomy and abdominal incision, describing a damp gauze packed in the bottom of the incision with a dry gauze over it, but admitted she did not document her assessment, intending to do so later and then forgetting after the resident was discharged. Nurse #2 stated that assessments should be documented every shift and recalled the resident had a colostomy, but when informed there was no assessment documented, she could not confirm whether she had assessed the colostomy or incision and said she would need to refer to the record. Nurse #3 stated she assessed the colostomy, which was almost full with a good seal, and also assessed the abdominal incision, but when shown there was no documentation, she acknowledged she must have forgotten to chart it. The DON stated she also looked at the resident’s colostomy and incision but did not document her assessment and did not follow up with nurses when she later noted the absence of documentation. The Regional Nurse Consultant confirmed there were no documented assessments of the colostomy or incision, and the Physician Assistant stated he relies on nurses’ assessments in the medical record for treatment planning, underscoring the absence of required documentation.
Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
A resident with a history of neurogenic bladder and a chronic indwelling urinary catheter was admitted to the facility with physician orders specifying that the catheter should be changed on a particular date. The order for the catheter change was transcribed into the resident's medical record by a nurse, but it was not entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR). As a result, the scheduled catheter change was not performed as ordered. Interviews with facility staff, including the nurse responsible for the admission and the Director of Nursing (DON), confirmed that the omission occurred because the order was not properly processed to appear on the MAR or TAR. The DON acknowledged that without the order on these records, nursing staff would not be aware of the need to change the catheter. The Nurse Practitioner (NP) and Administrator both stated that their expectation was for the catheter to be changed as ordered, but this did not occur during the resident's stay.
Failure to Notify Physician of Missed Steroid Dose for Allergic Reaction
Penalty
Summary
The facility failed to notify the physician when a one-time dose of methyl prednisolone, ordered for the treatment of an allergic reaction, was not administered as prescribed. Nursing staff documented that the medication was on order but did not inform the physician of the delay or request further instructions. The medication, intended to address a worsening rash, increased redness, hives, itching, and a low-grade fever, was not given until five days after it was ordered. The nurse initialed the Medication Administration Record (MAR) and noted the medication was on order, but did not communicate the missed dose to the physician as expected. The resident involved had a history of heart failure, hypertension, and chronic pain, and developed a severe rash after starting an antibiotic. The rash worsened over several days, spreading and causing significant discomfort, including intense itching and skin peeling. Despite the resident's deteriorating condition and the nurse practitioner's expectation for prompt administration or notification if the medication could not be given, the physician was not notified of the delay, resulting in a significant lapse in care.
Failure to Administer Ordered Steroid Injection Resulting in Significant Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure a one-time dose of methylprednisolone (a steroid) intramuscular injection, prescribed for the treatment of an allergic reaction, was administered as ordered. The resident, who had a history of heart failure and chronic pain, developed an itchy, erythematous rash with hives and a low-grade fever after being treated with clindamycin for a gum abscess. The nurse practitioner (NP) discontinued clindamycin and prescribed alternative medications, including oral and topical treatments, but as the rash worsened, the NP ordered a one-time intramuscular injection of methylprednisolone. Despite the order, the injection was not administered for five days. Nurse #1, who was responsible for giving the injection, did not find the medication on the cart and was incorrectly informed by another nurse that it was not available in the backup medication supply. Although the backup supply did contain the medication, Nurse #1 did not access it and instead passed the responsibility to the oncoming nurse, assuming the medication would be administered once delivered by pharmacy. The medication remained unadministered until the NP discovered the omission during a subsequent visit and directed that the injection be given. Interviews with facility staff, including the Director of Pharmacy Operations, confirmed that the medication was available in the backup supply and had not been removed or administered as ordered. The Director of Nursing and Administrator acknowledged that the nurse should have checked the backup supply and administered the medication as ordered. The resident continued to experience significant discomfort, including widespread rash and severe itching, during the delay in administration.
Inaccurate MDS Dental Assessment Due to Lack of Coordination
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of dental for one resident. The resident was admitted to the facility and had a significant change MDS assessment completed, which indicated that the dental status was unable to be examined. The MDS Coordinator responsible for this assessment was working remotely at the time and was no longer employed by the company, making them unavailable for follow-up. Interviews with the Administrator and Director of Nursing (DON) revealed that the remote MDS Coordinator did not reach out to nursing staff or the DON to request a dental assessment during the lookback period, and a review of nursing documentation confirmed that no dental assessment was completed at that time. Both the Administrator and DON stated that they expected the dental status to be accurately completed on the MDS assessment.
Failure to Withhold Antiplatelet Medication Prior to Dental Procedure
Penalty
Summary
The facility failed to withhold an antiplatelet medication, specifically aspirin, as ordered by the Nurse Practitioner prior to a scheduled dental extraction for a resident with diagnoses including heart failure, hypertension, and chronic pain. The physician's order to hold aspirin for three days before the dental procedure was documented on the dental consent form but was not transcribed to the Medication Administration Record (MAR). As a result, nursing staff continued to administer aspirin to the resident from 11/1/24 through 11/6/24, contrary to the order. This oversight led to the cancellation of the scheduled dental extractions, as the dental provider could not proceed while the resident was still taking aspirin. Interviews with facility staff revealed a breakdown in communication and process regarding the handling and transcription of physician orders related to dental procedures. The DON and Administrator stated that the expected process was for the signed dental form to be given to the Unit Manager and then to the assigned nurse for transcription to the MAR, but this did not occur. The Unit Manager reported not receiving the relevant dental notes or forms. The resident did not report pain at the time of the missed extraction, but later developed a gum abscess requiring antibiotics and eventually underwent extractions after the medication issue was resolved.
Potential Hazard from Sodium Polyacrylate in Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from potential hazards when Sodium Polyacrylate, a super-absorbent powder, and a glass of solidified fruit punch were left within reach of a resident with severe cognitive impairment. The resident, who required extensive assistance for daily activities and was on a dysphagia mechanical diet, was found with these items on his bedside table. The presence of these items posed a risk of ingestion, which could lead to gastrointestinal obstruction, as noted by Poison Control. The incident was discovered by a nurse aide who found the bottle of Sodium Polyacrylate and the solidified fruit punch during her shift. She reported the findings to the nurse, who then contacted Poison Control for guidance. Despite the uncertainty of whether the resident ingested the substance, the facility's staff monitored the resident for any signs of gastrointestinal distress as advised by Poison Control. The resident showed no symptoms and was stable throughout the monitoring period. Interviews with various staff members, including the Dietary Manager, Nurse Aides, and the Director of Nursing, revealed that the source of the Sodium Polyacrylate was unknown, and it was not a substance typically used or ordered by the facility. A search of the facility did not uncover any additional Sodium Polyacrylate, and the maintenance and supply staff confirmed that they had not ordered or used the substance. The facility was unable to determine how the Sodium Polyacrylate ended up in the resident's room, highlighting a lapse in ensuring a safe environment for residents.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, leading to the resident exiting the locked memory care unit unsupervised. The resident, who had Alzheimer's disease, dementia, and other conditions, was able to remove a windowpane and exit through a window. This incident occurred after the resident requested to go outside to smoke and was told by staff that it would be a while before they could take him out. The resident returned to his room, and staff continued with their duties, unaware of his subsequent actions. The resident managed to exit through a window in an adjoining room, which was 79 inches from the ground, and walked approximately 2/10 mile to a convenience store. The staff discovered the resident missing during routine rounds and initiated a search. The resident was found by a staff member at a nearby gas station and was returned to the facility by law enforcement. The incident highlighted a significant lapse in supervision and security measures, as the resident was able to remove a heavy glass windowpane and leave the facility unnoticed. Interviews with staff and law enforcement revealed that the resident had no prior history of elopement and was not considered at risk for such behavior. The facility's maintenance staff had previously conducted audits to ensure windows could not open more than 7 inches, but the resident was still able to remove the windowpane. The incident raised concerns about the facility's ability to prevent similar occurrences, given the resident's cognitive impairments and the potential for serious harm.
Failure to Notify Medical Provider of Alleged Abuse
Penalty
Summary
The facility failed to notify the medical provider of an alleged sexual abuse incident involving Resident #2. On the night of the incident, Nurse Aides reported to Nurse #4 that Resident #1 had confessed to being sexually inappropriate with Resident #2. Nurse #4, who was not directly responsible for either resident, informed Nurse #5, the supervisor, about the allegation. Both nurses then contacted the facility Administrator and Director of Nursing (DON) for further instructions. However, neither the medical provider nor the family of Resident #2 was notified immediately, as the Administrator assumed the notification would be handled the following day. The Nurse Practitioner (NP) was not informed of the alleged abuse until several days later, which delayed any potential medical examination or intervention. Upon learning of the incident, the NP conducted a vaginal examination on Resident #2, which showed no signs of trauma. The DON expected that the medical provider and family would be notified, but this did not occur. The Administrator acknowledged that the notification was not completed as expected, leading to a deficiency in the facility's response to the alleged abuse.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident hit another resident in the left eye with a closed fist. This incident occurred after the aggressor believed the victim was looking at inappropriate pictures on a shared facility computer. The victim, who had a red area under his left eye, avoided the aggressor and the use of the shared computer for approximately a week and a half following the incident. The victim, identified as Resident #4, was admitted to the facility with diagnoses including aphasia, which affected his ability to communicate verbally. His care plan emphasized the importance of engaging in meaningful daily routines, including using the computer. Despite being moderately cognitively impaired, Resident #4 was usually able to make himself understood and had no prior behaviors. The aggressor, identified as Resident #7, was admitted with diagnoses including schizophrenia and generalized anxiety. He was also moderately cognitively impaired and exhibited signs of delirium and delusions. On the day of the incident, staff members, including nurses and nurse aides, responded to the altercation. Resident #7 was placed on one-on-one supervision following the event. Interviews with staff and residents revealed that Resident #7 was confused and had difficulty being redirected, while Resident #4 was known to spend significant time on the computer without accessing inappropriate content. The facility's computer system was designed for the elderly population, making it unlikely for inappropriate content to be accessed.
Failure to Prevent Illegal Substances in Facility
Penalty
Summary
The facility failed to prevent illegal substances from entering the premises, affecting the safety and supervision of residents. Resident #3, who is legally blind and has a history of methamphetamine use, reported that an unknown individual in a wheelchair entered her room and left a substance on her table, which she mistakenly identified as candy. Upon tasting it, she recognized it as methamphetamine laced with fentanyl. The resident's family member, a Sheriff's Deputy, confirmed the substance's identity after testing it at the police department. Despite the resident's inability to identify the individual, the incident raised concerns about the facility's security measures and supervision protocols. Resident #1, who is cognitively intact, was involved in a separate incident where he tested positive for THC after being transferred to the hospital. During a police investigation, drug canines detected a scent at Resident #1's room, although no illegal substances were found. Resident #1 initially claimed to have received marijuana from another resident but later admitted to sharing a vape pen containing marijuana with his girlfriend, Resident #6. The vape pen was reportedly stolen from a staff member, although the staff member denied owning it. The facility's administrator was informed of these incidents and requested a search of the facility using drug canines. The investigation revealed that a known drug dealer had visited the facility earlier, raising further concerns about the facility's ability to control access and prevent illegal substances from entering. The administrator's efforts to address the situation included interviewing staff and residents, but the incidents highlighted significant lapses in the facility's supervision and security protocols.
Delayed Urology Appointment Leads to Severe Medical Complications
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when they did not identify the seriousness of a left swollen testicle for Resident #1. Despite a Nurse Practitioner's order for a urology appointment due to decreased vascular flow noted in an ultrasound, the facility scheduled the appointment for a later date, leading to a delay in care. Resident #1 experienced a serious adverse outcome with severe septic shock, urinary tract infection, and necrotic changes to the left testicle, ultimately requiring its removal. Immediate Jeopardy was identified when the facility did not recognize the urgency of the situation, resulting in a delay in necessary medical intervention. The deficiency was further highlighted by the failure to complete thorough and ongoing nursing assessments of the testicle and to notify the Nurse Practitioner or Medical Doctor when the urology appointment was not scheduled as ordered. This lack of timely action led to Resident #1's acute change in condition, requiring emergency care and eventual orchiectomy. The deficiency was exacerbated by the facility's failure to promptly address the medical concerns for Resident #1, who had a history of brain damage, dysphagia, hypertension, and gastrostomy upon admission. The delay in scheduling the urology appointment, inadequate assessments, and lack of communication regarding the testicle's condition culminated in a serious medical emergency for Resident #1, underscoring the facility's failure to protect the resident from neglect.
Delayed Urology Consultation and Inadequate Documentation of Vascular Flow Issues
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to recognize and address the seriousness of decreased vascular flow to Resident #1's left testicle. Despite reports of scrotal swelling and tenderness, thorough and ongoing nursing assessments of the left testicle were not documented. The Nurse Practitioner (NP) ordered an ultrasound and antibiotics upon initial assessment of the swelling, but delays in scheduling a urology consultation prolonged the Resident's access to necessary medical interventions. The Resident's condition deteriorated, leading to a diagnosis of severe septic shock, urinary tract infection, and necrotic changes in the left testicle, ultimately resulting in the removal of the testicle. Multiple staff members, including Nurse Practitioners, Wound Physicians, and Nurse Aides, were aware of the Resident's scrotal swelling but there was a lack of consistent documentation and follow-up on the issue. The facility's Scheduler faced challenges in scheduling a timely urology consultation, leading to significant delays in the Resident receiving appropriate care. Despite concerns raised by the Resident's family member and healthcare providers, the urgency of the situation was not fully recognized or acted upon promptly, contributing to the Resident's worsening condition.
Communication Breakdown in Scheduling Urology Consult Leads to Acute Condition
Penalty
Summary
The facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order for Resident #1, who had a history of anoxic brain injury, persistent vegetative state, and neurogenic bladder. The Nurse Practitioner ordered a urology consult as soon as possible after an ultrasound showed decreased vascular flow to Resident #1's left testicle on 02/19/24. However, the Scheduler encountered difficulties in scheduling the appointment promptly, leading to a delay in Resident #1 receiving the necessary urology consultation. This delay resulted in Resident #1 experiencing an acute change in condition on 03/11/24, leading to a diagnosis of severe sepsis and necessitating an emergency left orchiectomy. Despite the Nurse Practitioner's order for an urgent urology consult, the Scheduler faced challenges in promptly securing an appointment for Resident #1. The Nurse Practitioner was unaware of these difficulties and assumed the appointment had been made, highlighting a breakdown in communication within the facility. This lack of notification to the medical providers about the scheduling issues prevented timely intervention that could have potentially averted the adverse outcome experienced by Resident #1.
Repeated Failures in Quality Assessment and Assurance
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following previous surveys. This failure resulted in repeat deficiencies in the areas of Notification of Change, Neglect, and Quality of Care. Specifically, the facility did not notify the Nurse Practitioner or Medical Doctor when a Urology Consult could not be scheduled for a resident with decreased vascular flow to the left testicle, leading to severe sepsis and an emergency orchiectomy. Additionally, the facility failed to identify the seriousness of the resident's condition, complete thorough nursing assessments, and schedule timely medical consultations, resulting in delayed care and treatment. The deficiencies were observed in multiple instances, including a failure to notify the Medical Director during an acute change in condition, neglecting to seek medical assistance, and not performing necessary skin assessments and treatments. These repeated failures indicate a pattern of the facility's inability to sustain an effective QAA program. The deficiencies affected the quality of care provided to residents, leading to serious adverse outcomes, including severe septic shock and the need for emergency medical interventions.
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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