Macgregor Downs Health Center By Harborview
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenville, North Carolina.
- Location
- 2910 Macgregor Downs Road, Greenville, North Carolina 27834
- CMS Provider Number
- 345168
- Inspections on file
- 24
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Macgregor Downs Health Center By Harborview during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was found to be living in a room where window curtains had scattered red stains, dried brown liquid remained on the floor beneath a tube feeding pole, and the PTAC unit contained visible dust-like black debris on and inside the vents. Over multiple days, housekeeping staff either did not recognize or did not effectively address these issues, with one housekeeper attempting but failing to remove the hardened brown liquid and not reporting the stained curtains, and another focusing only on trash and flooring and reporting that everything appeared fine. The housekeeping manager and administrator later acknowledged that these cleanliness concerns should have been identified and corrected, and that the window curtains were old and awaiting replacement.
A resident with Parkinson’s disease, dementia, significant visual and hearing impairment, and multiple comorbidities, who had no prior documented aggressive behaviors, was observed by nursing staff in an aggressive incident with a roommate and was sent to the hospital for evaluation. ED and psychiatric assessments found no acute psychiatric illness and cleared the resident for SNF-level care, while ED case management notes show the facility first indicated the resident could return once a private room was available, then later stated he would not be accepted back. The resident’s spouse reported being told by hospital staff that the facility refused readmission and by the DON that there was no appeal or recourse. Facility social workers and admissions staff stated they were not involved in the decision, which the Administrator and DON acknowledged making based on the incident and hospital records, without contemporaneous physician documentation that the facility could not meet the resident’s needs. The resident ultimately did not return and was discharged home with home health services arranged by the hospital.
The facility failed to prevent potential cross contamination by improperly storing a sugar scoop in the bulk sugar bin with the handle touching the sugar. A dietary aide and the dietary manager confirmed that the scoop should be stored separately. A staff member admitted to accidentally leaving the scoop in the sugar after use, which was acknowledged by the administrator.
The facility failed to adhere to infection control policies, with staff not wearing required PPE or performing hand hygiene in rooms with residents on droplet precautions. A housekeeper, the DON, a nurse, and an administrative ambassador entered rooms without proper PPE, and a nurse failed to perform hand hygiene before and after glove use. The facility lacked documentation of infection control training for one nurse.
The facility failed to document and communicate advance directives for two residents, one cognitively intact and the other severely impaired. Staff interviews revealed confusion over responsibility for discussing and documenting advance directives, resulting in a lack of documentation in residents' records. The facility's policy on advance directives was not effectively implemented, leading to deficiencies in supporting residents' rights.
Two residents in an LTC facility rolled out of bed during care due to improper turning techniques by nurse aides, resulting in injuries such as skin tears and a hematoma. Both residents were cognitively intact and required assistance with bed mobility. The facility failed to ensure staff followed proper procedures, and comprehensive corrective actions were not implemented.
A resident with multiple diagnoses was found with medication cups at her bedside without a self-administration assessment or physician's order. The nurse left the medications intending to return but forgot, leaving the resident unsure which medications to take. The DON confirmed that medications should not be left at the bedside, leading to a deficiency.
A facility failed to provide a SNF/ABN to a resident after their Medicare Part A coverage ended. The resident continued to stay in the facility without being informed of their financial responsibility for services not covered by insurance. Staff interviews confirmed the oversight.
A facility failed to include pain management in a comprehensive care plan for a resident with a left leg fracture and severe cognitive impairment. Despite constant pain affecting the resident's sleep and activities, the care plan lacked a focus on pain, which was an oversight acknowledged by the MDS Coordinator and confirmed by the DON.
A resident with a left leg fracture and severe cognitive impairment experienced a deficiency in care when a nurse applied a lidocaine patch to the resident's back instead of the left hip as per the physician's order. The nurse acted on the resident's request without obtaining a new order, which was confirmed as inappropriate by the DON, the physician, and the administrator.
A facility failed to implement diabetes management orders for a resident, resulting in a lack of blood sugar monitoring and insulin administration. The admissions nurse overlooked the hospital discharge instructions, and the resident's physician was unaware of the need for these orders until later. The Director of Nursing noted that the admissions process was not followed correctly.
A facility failed to attempt and document alternatives to bed rail use for a resident with severe cognitive impairment and a left leg fracture. The resident's family consented to bed rail use without being informed of alternatives. Interviews with staff revealed a lack of awareness and discussion about alternatives, indicating a systemic issue in the facility's approach.
A resident, moderately cognitively impaired, reported receiving unwanted pork products due to the facility's failure to assess and document her food preferences. The Dietary Manager confirmed the absence of documented preferences and noted that an assistant previously responsible for these assessments was no longer available. The Administrator expected the Kitchen Manager to conduct these assessments upon admission, which was not done for this resident.
A resident receiving enteral nutrition had an inaccurate MAR entry when a nurse began administering the formula, but the resident refused it. Despite the refusal, the MAR indicated the dose was given. Interviews with staff confirmed that refusals should be documented, highlighting a failure in accurate record-keeping.
A resident with limited mobility experienced multiple incidents of mice in her bed due to the facility's ineffective pest control program. Despite weekly pest control services, mice were found in the resident's room, and staff communication and documentation were inadequate. The issue was linked to nearby construction, and the facility's measures to address the problem were insufficient.
A resident with obstructive and reflux uropathy was found with urinary catheter drainage tubing lying on the floor, posing an infection risk. Despite care plans and staff training, the tubing was improperly positioned, indicating a deficiency in infection control practices. Staff interviews revealed a lack of awareness and oversight regarding the tubing's position.
Failure to Maintain Clean Curtains, Flooring, and PTAC in a Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and comfortable environment in one resident’s room, including failure to properly clean window curtains, flooring under medical equipment, and the PTAC unit. The resident involved had a quarterly MDS indicating severe cognitive impairment. On multiple observations over three consecutive days, surveyors noted two window curtains with scattered red stains, two pools of dried brown liquid on the floor underneath the tube feeding pole near the head of the bed, and dust-like black bits, fragments, and pieces on and inside the PTAC near the filter insertion site. These conditions remained unchanged across observations on 4/27, 4/28, and 4/29. Housekeeper #1, primarily assigned to that hall and to the resident’s room on two of the three days, stated that housekeeping duties included trash removal, sweeping, mopping if there was a spill, bathroom cleaning, changing hand sanitizer, and replenishing bathroom supplies, and that housekeeping was responsible for identifying stained window curtains and PTAC cleaning. During an in-room interview, Housekeeper #1 confirmed the stained curtains, dried brown liquid on the floor, and dusty black substance on and inside the PTAC, and reported she had attempted but failed to remove the hardened brown liquid and had not notified the Housekeeping Manager/Maintenance Director about the stained window curtains. She also stated she had not been instructed to inspect window curtains and had confused them with privacy curtains. Housekeeper #2, who cleaned the room on the intervening day, reported focusing only on trash and flooring and stated everything looked fine. The Housekeeping Manager/Maintenance Director and Administrator both acknowledged that the cleanliness issues in the room should have been identified and addressed, and that the window curtains were old and in the process of being replaced.
Failure to Allow Hospitalized Resident to Return After Clearance for SNF-Level Care
Penalty
Summary
The deficiency involves the facility’s failure to allow Resident #129 to return to the facility after a hospital transfer, despite the hospital determining he was appropriate for skilled nursing facility (SNF) level of care. Resident #129 had multiple chronic conditions, including Parkinson’s disease, bilateral sensorineural hearing loss, bilateral unqualified visual loss, hypertension, diabetes mellitus, hyperlipidemia, dementia, anxiety disorder, depression, and asthma. His medical record from admission through 4/18/26 showed no evidence of behaviors. A late entry nursing note dated 4/20/26 documented that on 4/19/26 he was observed kneeling on the floor over his roommate, appearing very aggressive and intending harm. The two residents were separated, assessed with no injuries noted at that time, the provider and responsible parties were notified, and Resident #129 was sent to the hospital for evaluation. Interviews with multiple nurse aides indicated that prior to this incident, Resident #129 had not exhibited aggressive or violent behaviors toward other residents. Staff reported that he could become irritable and yell at staff to leave his room, but he would calm down and apologize after a short period, and they were surprised to learn of his aggression toward his roommate. One nurse aide recalled that during the incident the nurse had already separated the residents when she entered the room, and she observed the roommate with a small laceration near the left eye that healed within two days. Law enforcement was notified, and Resident #129 was transferred to the hospital. A transfer/discharge notice was provided to him, stating that the transfer/discharge was necessary for his welfare, that his needs could not be met in the facility, and that the safety of individuals in the facility was endangered due to his clinical or behavioral status. Hospital records from 4/19/26 through 4/21/26 showed that Resident #129 was evaluated in the Emergency Department (ED) for agitation. A psychiatry and behavioral medicine consultation noted his history of Parkinson’s disease with worsening confusion, no prior psychiatric history of aggression or agitation, and his report that he became upset when he found someone in his bed. The psychiatric evaluation found no acute psychiatric illness and that he did not meet criteria for inpatient admission. ED documentation also noted that he was blind and hard of hearing. ED case management notes indicated that the facility initially stated he could return when a private room became available the next day, but later informed the hospital that he would not be allowed to return at all. The ED/Behavioral Health Case Manager confirmed that the ED providers had cleared him for SNF-level care and that the facility’s hospital liaison, after consulting with the Administrator, stated the resident could not return. The resident’s responsible party (his spouse) reported being informed by the facility nurse that he was being sent to the hospital for confusion, delusions, and anger toward his roommate. She stated that a hospital case manager later told her the facility initially required a 24-hour wait for a private bed, then later said the resident would not be accepted back, and that other facilities were not accepting him. She reported being told by the hospital that he had to go home, and that when she spoke with the facility’s Director of Nursing she was told she had no appeal or recourse. Social workers at the facility stated they were not involved in decisions about whether a resident could return, indicating that such decisions were handled by Admissions, the Administrator, and the Director of Nursing. The Admissions Director and Admissions Ambassador both stated they had no role in deciding whether a resident was allowed to return and that the decision regarding this resident was made by the Administrator and Director of Nursing. The Nurse Practitioner stated she was informed of the incident the following morning and was not involved in the decision to refuse readmission, but agreed with the conclusion that the facility could not provide the level of care he needed at that time, citing his cognitive decline and visual impairment and the concern that he could again attack someone if he misperceived a situation. The Physician similarly stated that the decision not to allow the resident to return was made by the Director of Nursing and Administrator without his involvement; he was informed afterward and agreed with the decision but did not document that the facility could not care for the resident. The Administrator reported that the decision not to allow Resident #129 back was based on the incident and the hospital records, which showed only a psychiatric assessment and clearance to return the same day. She stated she believed the facility could not guarantee the safety of other residents if he returned and confirmed that the facility’s hospital liaison informed the hospital that the resident would not be returning. There was no documentation in the report that the facility completed or documented a comprehensive assessment demonstrating that the resident’s needs could not be met in the facility or that the safety of individuals was endangered in a manner that justified refusing his return after the hospital cleared him for SNF care. As a result, Resident #129 did not return to the facility and was ultimately discharged home with his spouse with home health services arranged by the hospital. The responsible party expressed concern that he did not receive additional therapy before returning home but stated he did not appear to have psychosocial harm and was doing “okay” at home. The deficiency centers on the facility’s failure to allow the resident to return following a hospital transfer, despite the ED’s determination that he was appropriate for SNF-level care and the lack of prior documented aggressive behavior in the facility record, and on the decision-making process by the Administrator and Director of Nursing that led to his non-readmission without documented physician involvement at the time of the decision or documented evidence that the facility could not meet his needs.
Improper Storage of Sugar Scoop in Pantry
Penalty
Summary
The facility failed to store a sugar scoop in a manner that prevented potential cross contamination. During an observation in Hall 2 pantry, the sugar scoop was found stored directly in the bulk sugar bin with the handle in contact with the sugar. Dietary Aide #1, who was assigned to the Hall 2 pantry, stated that the scoop was not in the sugar when she went on her break earlier that day. She acknowledged that the scoop should always be stored separately to maintain sanitary conditions and prevent cross contamination. The Dietary Manager confirmed that the scoop should never be stored in the sugar bin to avoid contamination. [NAME] #1 admitted to using the sugar from the bulk bin to make sweet tea for the residents' supper meal and acknowledged that he accidentally left the scoop in the sugar. The Administrator also confirmed that the scoop should not be stored in the sugar bin after use and stated that [NAME] #1 was aware of this protocol. This incident was observed and reported by surveyors, indicating a deficiency in the facility's food storage practices.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection control policies and procedures, as evidenced by multiple staff members not adhering to droplet contact precautions. Housekeeper #1 was observed cleaning the room of two residents diagnosed with Influenza A without wearing an isolation gown, despite signage indicating the need for a gown, mask, and gloves. The Director of Nursing (DON) also entered a resident's room on droplet precautions without the required gown and gloves, mistakenly believing it was an enhanced barrier precautions room. Further observations revealed that Nurse #3 and the Administrative Ambassador entered the room of two residents on droplet precautions without performing hand hygiene or donning the necessary PPE. Both individuals acknowledged their oversight, with Nurse #3 expressing concern over a beeping noise and the Administrative Ambassador admitting awareness of the signage and policy. The DON confirmed that all staff had been trained on infection control practices, including the use of PPE. Additionally, Nurse #1 failed to perform hand hygiene before and after glove use during a blood glucose check, and used a glove that had fallen on the floor, which is considered contaminated. The DON reiterated the importance of hand hygiene and proper glove use, noting that anything dropped on the floor should not be used on residents. The facility was unable to find documentation of Nurse #1's infection control training since her hire date.
Failure to Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives were properly documented and communicated, as evidenced by the cases of two residents. Resident #105, who was cognitively intact, did not have documentation in her record regarding education or opportunities to formulate advance directives. Interviews with various staff members, including social workers and the admissions nurse, revealed a lack of clarity and responsibility regarding who was tasked with discussing and documenting advance directives. Each staff member believed it was someone else's responsibility, leading to a gap in the resident's care plan. Similarly, Resident #114, who was severely cognitively impaired, did not have any documentation of discussions about advance directives in his medical record. His family member confirmed that no one from the facility had discussed or requested copies of existing advance directive documents, such as a living will or health care power of attorney. Interviews with the admissions nurse, admissions director, and social workers indicated that there was no consistent process for addressing advance directives during the admissions process, resulting in the absence of these critical documents in the resident's record. The facility's policy on residents' rights regarding treatment and advance directives was not effectively implemented, as evidenced by the lack of documentation and communication about advance directives for the two residents reviewed. The staff interviews highlighted a lack of clear responsibility and communication among the team members, leading to the failure to support and facilitate residents' rights to formulate and document advance directives as per the facility's policy.
Inadequate Supervision Leads to Resident Falls During Care
Penalty
Summary
The facility failed to provide care in a safe manner, resulting in two residents rolling out of bed during care and sustaining injuries. Resident #42, who was on blood thinner medication and had a history of falls, was being changed by a nurse aide who improperly turned her away from herself, causing the resident to slide off the bed. This resulted in skin tears on both arms and a hematoma on the left hip. The resident was cognitively intact and required assistance with transfers and activities of daily living. Despite the resident's initial reluctance, she was sent to the hospital for further evaluation. Resident #92, who had functional impairments and required substantial assistance for bed mobility, experienced a similar incident. During a bed sheet change, the nurse aide turned the resident away from herself, causing the resident to fall off the bed. The resident sustained a skin tear on the right arm but did not report any pain or head injury. The resident was cognitively intact and had not experienced any falls since the prior assessment. Both incidents highlight a failure in the facility's procedures for safely turning and repositioning residents. The nurse aides involved did not follow the standard practice of turning residents towards themselves, which could have prevented the falls. The facility did not complete a 100% audit or in-service training for all staff following these incidents, indicating a lack of comprehensive corrective action to prevent future occurrences.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess the ability of a resident to self-administer medications, leading to a deficiency. Resident #42, who was cognitively intact and had diagnoses including anemia, heart failure, hypertension, diabetes, and respiratory failure, was observed with two medication cups at her bedside. These medications were left by Nurse #2 without a physician's order for self-administration or an assessment of the resident's ability to self-administer medications. The resident was unsure which cup contained her regular medications and which contained vitamins, resulting in her not taking the medications. Nurse #2 admitted to leaving the medications on the bedside table when she was called to assist another resident, intending to return shortly but forgetting to do so. The Director of Nursing confirmed that medications should not be left at the bedside and should be administered by the nurse, ensuring the resident takes them before leaving the room. If the nurse needs to leave, the medications should be secured in the locked medication cart. This oversight in medication administration protocol led to the deficiency observed by the surveyors.
Failure to Provide SNF/ABN to Resident
Penalty
Summary
The facility failed to provide a CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) to a resident who was reviewed for beneficiary notices. The resident was admitted to the facility and began receiving Medicare Part A services on January 6, 2025, with the last covered day being January 19, 2025. Despite remaining in the facility after the discharge from Medicare Part A, there was no evidence that a SNF/ABN form was provided to the resident or their representative. During interviews, both the social worker and the administrator acknowledged that the SNF/ABN was missed and should have been provided to inform the resident or representative about the costs they would be responsible for out of pocket if they continued services no longer covered by insurance.
Failure to Address Pain Management in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing pain management for a resident who was admitted with a left leg fracture and was severely cognitively impaired. The resident was on a scheduled pain medication regime and experienced constant pain that affected sleep and daily activities, rating the pain as a 10 on a scale of zero to 10. Despite the Care Area Assessment (CAA) for pain being triggered, the comprehensive care plan initiated on 1/27/25 did not include a focus area for pain. Interviews with facility staff revealed that the MDS Director acknowledged the care plan should have been developed by 1/27/25, based on the comprehensive admission MDS assessment date of 1/14/25. The MDS Coordinator admitted to completing the assessment and recognized the oversight in not including the resident's pain in the care plan. The Director of Nursing also confirmed that the resident's pain should have been included in the comprehensive care plan.
Improper Application of Lidocaine Patch
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following a physician's order for the application of a lidocaine patch on a resident's left hip. Instead, the patch was applied to the resident's back. The resident, who was admitted with a left leg fracture and was severely cognitively impaired, experienced constant pain that affected his sleep and daily activities. The physician's order specifically directed the application of a 5% lidocaine patch to the resident's left hip, but documentation showed that Nurse #10 applied the patch to the resident's lower back without a corresponding physician's order. During an interview, Nurse #10 admitted to applying the patch to the resident's back after the resident requested it, despite knowing that a physician's order was required for such a change. The Director of Nursing and the resident's physician both confirmed that Nurse #10 should have obtained a physician's order before applying the patch to a different body part. The facility's administrator also acknowledged that the nurse acted outside of the physician's directive by applying the patch to the back without proper authorization.
Failure to Implement Diabetes Management Orders
Penalty
Summary
The facility failed to clarify and implement orders for blood sugar monitoring and insulin administration for a resident with diabetes following their discharge from the hospital. The hospital discharge summary for the resident included instructions to monitor blood sugars closely and to administer both short-acting and long-acting insulin. However, upon admission to the facility, these orders were not transcribed into the resident's medical record or Medication Administration Record (MAR), resulting in the resident not receiving necessary blood sugar monitoring or insulin administration since admission. The deficiency was identified when it was discovered that the admissions nurse overlooked the instructions for diabetes management in the discharge summary. The nurse admitted to not noticing the instructions and failing to contact the on-call physician or Nurse Practitioner for specific orders. The resident's physician was unaware of the need for these orders until informed later, at which point orders were written for blood sugar checks and insulin administration. The Director of Nursing noted that the admissions process was not followed correctly, as the admissions nurse signed off on the orders without a second nurse's review.
Failure to Attempt Alternatives Before Bed Rail Use
Penalty
Summary
The facility failed to attempt and document alternatives to bed rail use for a resident before installing them. The resident, who was admitted with a left leg fracture and diagnosed with severe cognitive impairment, had bed rails installed without a physician's order or documentation of alternative measures being considered. The resident's family member consented to the use of bed rails, believing they would assist with repositioning, but was not informed of any alternatives. Interviews with facility staff, including the Admissions Nurse and the Director of Nursing, revealed a lack of awareness and discussion regarding alternatives to bed rail use. The Admissions Nurse admitted to not discussing or attempting alternatives with residents or their families, and the Director of Nursing was unaware of any alternatives used by the facility. The Administrator also did not know what alternatives were attempted prior to the use of bed rails, indicating a systemic issue in the facility's approach to bed rail use.
Failure to Assess and Document Resident Food Preferences
Penalty
Summary
The facility failed to assess and document food preferences for a resident, leading to the provision of unwanted food items. A resident, who was moderately cognitively impaired, expressed dissatisfaction with receiving pork products, which she disliked, and stated that no one had inquired about her food preferences. Upon review, the Dietary Manager confirmed that there was no documentation of the resident's food preferences in the system and could not locate a paper assessment. The Dietary Manager mentioned that an assistant previously handled these assessments until two weeks prior. The Administrator expected the Kitchen Manager to ensure that food preference assessments were conducted upon admission, but this was not done for the resident in question.
Inaccurate MAR Documentation for Enteral Nutrition
Penalty
Summary
The facility failed to maintain a complete and accurate Medication Administration Record (MAR) for a resident who was receiving enteral nutrition. The resident, identified as Resident #333, had a physician's order for enteral formula Osmolite 1.5 to be administered every six hours. On one occasion, Nurse #4 began administering the formula, but the resident expressed a desire not to receive it, prompting the nurse to stop the administration. Despite this, the MAR inaccurately reflected that the midnight dose was given as prescribed. Interviews with other nursing staff, including Nurse #6 and Nurse #8, revealed that their practice would be to document any refusal of enteral formula on the MAR. The Director of Nursing and the Administrator both confirmed that refusals should be documented accurately, indicating that the administration was incomplete and the resident refused. The discrepancy in documentation suggests a failure to adhere to the facility's protocol for recording medication administration accurately.
Pest Control Deficiency Leads to Mouse Infestation in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mouse infestation that directly affected a resident. The resident, who was cognitively intact but had limited physical mobility due to a stroke, experienced multiple incidents where mice were found in her bed. These incidents occurred despite the facility having a contract with a pest control company that serviced the facility weekly. The pest control logs indicated that no mice were found during inspections, yet the resident reported seeing mice in her room and on her dresser. The facility's maintenance director acknowledged receiving reports of rodent activity shortly after construction began near the facility. However, there was a lack of clear communication and documentation regarding the reports of mice sightings. Staff members, including nurse aides and nurses, reported the presence of mice to each other, but there was no consistent follow-up or assessment of the resident involved. The maintenance director was unaware of mice being found in a resident's bed, and there was no log of where glue traps were placed or how many mice were caught. Interviews with staff and residents revealed that the facility had a problem with mice for several months, and the issue was linked to nearby construction. Despite efforts to address the problem, such as placing glue traps and rebaiting exterior bait stations, the facility's pest control measures were insufficient. The lack of effective communication and documentation, along with inadequate pest control measures, contributed to the deficiency, which posed a high likelihood of affecting other vulnerable residents in the facility.
Improper Urinary Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to maintain proper care for a resident with an indwelling urinary catheter, leading to a deficiency in infection control practices. The resident, who was admitted with obstructive and reflux uropathy, was observed with the urinary catheter drainage tubing lying on the floor beneath his wheelchair. This improper positioning of the tubing was noted during an observation, and it was confirmed that the tubing should not have been in contact with the floor as it posed an infection risk. The care plan for the resident included checking the catheter tubing for proper drainage and positioning, but this was not adhered to. Interviews with the nursing staff, including a nurse and two nursing assistants, revealed a lack of awareness and oversight regarding the catheter tubing's position. The nurse assigned to the resident was unaware of the tubing's contact with the floor, and the nursing assistants acknowledged that the tubing should not touch the floor due to infection concerns. The Director of Nursing confirmed that the tubing should have been secured properly to prevent contact with the floor and stated that staff received training on catheter care. However, the failure to ensure the tubing was off the floor was identified as a deficiency in the facility's infection control practices.
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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