Maggie Valley Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Maggie Valley, North Carolina.
- Location
- 75 Fisher Loop, Maggie Valley, North Carolina 28751
- CMS Provider Number
- 345102
- Inspections on file
- 23
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Maggie Valley Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to provide residents with access to their personal trust funds for more than two months during a transition to new bank accounts after a change in ownership. A cognitively intact resident who relied on staff to shop for toiletries using his trust account reported that staff had stopped making purchases, and his family had been supplying his personal items instead. Another resident with moderate cognitive impairment, who typically received monthly cash from her trust account to buy phone minutes, did not receive her usual payments for over two months and only received a partial amount later. Facility leadership and business office staff confirmed that there was no cash box, no cash available, and that residents and responsible parties had been unable to access any trust account funds during this period, affecting all residents with such accounts.
The facility failed to request Level II PASRR evaluations for two residents after new serious mental illness conditions were identified. One resident with a prior Level I PASRR later developed nighttime hallucinations requiring antipsychotic therapy, yet no PASRR reevaluation was submitted in NC MUST. Another resident with a Level I PASRR was subsequently diagnosed with PTSD and depression and started on prazosin and sertraline, with these diagnoses reflected on the MDS, but no Level II PASRR request was made. The SW reported being responsible for Level II PASRR submissions but stated she was not always informed of new mental health diagnoses and acknowledged these omissions as oversights, which the administrator confirmed as residents being overlooked during PASRR reviews.
A resident admitted with non-Alzheimer’s dementia, anxiety disorder, major depressive disorder, and bipolar disorder, and treated with antianxiety, antidepressant, and anticonvulsant medications, had only a Level I PASRR on file. The existing PASRR did not include the resident’s mental health diagnoses, and no Level II PASRR request was submitted through NC MUST. The regional social worker/discharge planning consultant and the SW both acknowledged that the presence of mental health disorders with only a Level I PASRR should have triggered a Level II request, and the SW, who was responsible for these submissions, stated the omission was an oversight. The Administrator confirmed the SW’s responsibility for Level II PASRR requests and indicated this resident’s PASRR was overlooked during auditing.
Staff failed to follow the facility’s special droplet contact precautions for a Covid-19 positive resident. Policy and posted signage required hand hygiene before room entry and use of gown, N95, eye protection, and gloves. Instead, two NAs entered the resident’s room wearing only surgical masks, did not perform hand hygiene before entry, and provided direct physical assistance with positioning and meal setup. On another occasion, a third NA entered wearing a gown, gloves, eye protection, and a surgical mask instead of an N95 while repositioning the resident. Staff later acknowledged they had not read or followed the posted precautions or had been in a hurry and used the wrong mask.
Two residents, both cognitively intact and with significant medical conditions, experienced physical abuse from visiting family members during separate incidents. In both cases, the family members pinched and caused bruising to the residents' arms or shoulders during arguments, resulting in pain and distress. Staff intervened and reported the incidents, but the facility's existing policies did not prevent the abuse, which was attributed to inadequate background screening of visitors.
A resident with osteoporosis and hypertension, who was cognitively intact, experienced physical abuse by a family member resulting in pain and bruising. The facility did not report the abuse allegation to DHSR and APS within the required 2-hour timeframe, as staff misunderstood the reporting requirements and failed to complete the necessary notifications.
During a COVID-19 outbreak, the facility failed to follow CDC guidance by delaying broad-based testing and not providing N95 masks for staff caring for COVID-19 positive residents. Staff did not consistently wear required PPE, and the facility allowed COVID-19 positive staff to return to work prematurely. The facility's policies were outdated, and there was a lack of understanding of CDC recommendations among the Infection Preventionist and Director of Nursing.
The facility failed to manage medications properly, with undated and expired medications found on multiple carts. An undated Insulin Glargine pen was discovered, and an expired Geri-Lanta bottle was overlooked. Additionally, Latanoprost eye drops were improperly stored outside refrigeration. Nurses were unaware of proper protocols, and the DON acknowledged the need for better oversight.
A resident with aphasia and gastrostomy status did not receive privacy during tube feeding administration. The nurse left the door open and did not use the privacy curtain, exposing the resident's abdomen. This allowed another resident and staff to observe the procedure. The nurse admitted to not considering privacy measures when the resident's roommate was absent, and the DON confirmed that privacy should have been ensured.
The facility failed to remove expired nutritional supplements and ready-to-eat personal resident food from two nourishment rooms, potentially affecting residents. An expired supplement was found in the North nourishment room, and expired resident food was found in the South nourishment room. The Dietary Manager and Dietary Aide acknowledged the oversight, and the Administrator confirmed the items should have been discarded.
Failure to Provide Resident Access to Personal Trust Funds During Bank Transition
Penalty
Summary
The facility failed to honor residents' rights to manage their financial affairs by not providing access to personal trust accounts for more than two months. One resident, cognitively intact per a quarterly MDS assessment, reported that he maintained a trust account and routinely used his funds to purchase toiletries and personal items. He stated that facility staff had previously gone to the store monthly on his behalf and debited his account, but this practice had stopped for the past couple of months without explanation, and his family had been supplying his toiletries and other items during this time. Another resident, who was moderately cognitively impaired per a quarterly MDS assessment, reported that she had routinely received $70 in cash from her trust account at the beginning of each month but had not received any money for over two months until she was given $138 in cash by staff. She stated she used her money to buy phone minutes for herself and her son and indicated she was still owed additional funds. The Business Office Manager, Regional Business Office Manager, and Administrator each confirmed that, following a change in facility ownership and the transition to new bank accounts beginning in December, the facility had no cash box, no cash available, and residents and responsible parties had been unable to access trust account funds since January, affecting all residents with trust accounts and halting staff shopping for residents.
Failure to Request Level II PASRR Evaluations After New Mental Health Diagnoses
Penalty
Summary
The deficiency involves the facility’s failure to request Level II Preadmission Screening and Resident Review (PASRR) evaluations after new serious mental illness conditions were identified in residents who previously had Level I PASRR determinations. For one resident with a Level I PASRR dated 05/06/13, the admission MDS showed no serious mental illness per the state Level II PASRR process, although active diagnoses included major depressive disorder and anxiety disorder, and the resident was receiving antidepressant medication. On 11/19/25, a NP documented that the resident was experiencing nighttime hallucinations, with staff reporting the resident was screaming and terrified at night, and Seroquel 50 mg at bedtime was initiated. A psychiatric note on 02/27/26 documented follow-up after Seroquel was increased to 100 mg, with decreased hallucinations and mood disturbance. Despite these developments, an NC MUST inquiry on 03/17/26 showed no PASRR reevaluation requests had been submitted after 11/19/25. A second resident had a Level I PASRR dated 09/19/24, with no further screening required unless a significant change suggested a mental illness diagnosis or change in treatment needs. A psychiatric progress note dated 02/06/25 documented that on 01/30/25 the resident was started on prazosin 1 mg at bedtime and sertraline 50 mg daily for nightmares and PTSD symptoms, with diagnoses of PTSD and depression. The annual MDS later reflected active diagnoses of depression (other than bipolar) and PTSD, and antidepressant use, while still indicating the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability. An NC MUST inquiry on 03/17/26 confirmed no PASRR reevaluation requests had been submitted after 01/30/25. In interviews, the social worker stated she was responsible for submitting Level II PASRR requests but was not always notified of new mental illness diagnoses and acknowledged not submitting requests for these two residents as an oversight. The administrator confirmed the social worker’s responsibility for Level II PASRR requests and stated these residents were overlooked during PASRR reviews and audits.
Failure to Request Level II PASRR for Resident With Serious Mental Health Disorders
Penalty
Summary
The deficiency involves the facility’s failure to submit a required Level II PASRR evaluation request for a resident admitted with serious mental health disorders. A PASRR Determination Notification dated 12/05/25 showed the resident had a Level I PASRR with no expiration date. The resident was admitted with diagnoses including non-Alzheimer’s dementia, anxiety disorder, major depressive disorder, and bipolar disorder. A physician’s progress note dated 12/12/25 documented dementia and anxiety with depression, treated with escitalopram 10 mg daily, buspirone 15 mg three times daily, and divalproex sodium 125 mg every morning and 250 mg nightly. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, but listed active psychiatric/mood disorder diagnoses of anxiety disorder, depression (other than bipolar), and bipolar disorder, and documented the use of antianxiety, antidepressant, and anticonvulsant medications during the assessment period. A NC MUST inquiry on 03/17/26 confirmed the resident only had a Level I PASRR effective 12/05/25 with no subsequent PASRR requests submitted. During interviews, the Regional Social Worker/Discharge Planning Consultant explained that when a resident is admitted with mental health disorders not reflected on the existing PASRR, the social worker should submit a Level II PASRR request, and acknowledged that this was not done for this resident. The Social Worker confirmed she was responsible for submitting Level II PASRR requests, verified the resident had mental health diagnoses and a Level I PASRR on admission, and stated that failing to submit the Level II request was an oversight. The Administrator also stated that the Social Worker was responsible for Level II PASRR submissions per regulatory guidelines and indicated that this resident’s PASRR was overlooked during review and auditing.
Failure to Follow Special Droplet Contact Precautions for Covid-19 Positive Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to failure to follow special droplet contact precautions for a resident with confirmed Covid-19. Facility policy dated 10/24/24 required implementation of special droplet contact precautions for newly identified Covid-19 cases, and the resident’s positive Covid-19 test on 3/14/26 resulted in placement on these precautions with signage posted outside the room. The posted signage dated 11/22 instructed staff to perform hand hygiene before entering and to wear a gown, N95 mask, eye protection, and gloves upon entry. Despite this, on 3/16/26 at 12:52 PM, two nursing assistants entered the resident’s room wearing only surgical masks, without performing hand hygiene before entry and without donning a gown, gloves, eye protection, or an N95 mask, while physically assisting the resident to sit on the side of the bed and setting up the lunch tray. They washed their hands with soap and water only after exiting the room and later acknowledged they should have worn the required PPE but did not and could not explain why. On 3/17/26 at 8:55 AM, another nursing assistant was observed inside the same resident’s room wearing a gown, gloves, eye protection, and a surgical mask instead of the required N95 mask while physically repositioning the resident in bed. This staff member removed PPE and washed hands with soap and water after exiting the room but reported she had been in a hurry and did not put on an N95 mask. The DON stated that the first two nursing assistants reported they had not read the special droplet contact precaution signage posted at the resident’s door, and that the third nursing assistant had received education on special droplet contact precautions but still did not follow protocol, stating she put on the wrong mask outside the room. The Administrator confirmed staff should have followed the posted special droplet contact precaution signage and could not explain why they did not.
Failure to Protect Residents from Abuse by Visitors
Penalty
Summary
The facility failed to protect residents from abuse by visitors, resulting in two separate incidents involving physical abuse by family members during visits. In the first incident, a resident with heart failure and anxiety disorder, who was cognitively intact and required moderate assistance for transfers, was subjected to physical abuse by her spouse, who has dementia. The spouse was observed by multiple staff members pinching, twisting, and shoving the resident while she was in her wheelchair, causing pain, bruising, and distress. The incident occurred after a verbal argument and was witnessed by several staff, who intervened to separate the resident from the family member. The resident reported pain and bruising to her right shoulder and forearm, and was evaluated for anxiety following the event. In the second incident, another cognitively intact resident with osteoporosis and impaired upper extremity mobility was physically abused by a visiting family member during a disagreement over a phone passcode. The family member grabbed and pinched the resident's right arm, resulting in pain and a circular bruise near the inner elbow. The incident was reported by a nurse who responded to yelling and found the resident upset and injured. The resident confirmed the abuse and stated it was the first occurrence of such behavior from the family member. The nurse did not witness the physical act but observed the aftermath and reported the incident to the DON. In both cases, the facility identified the root cause as inadequate background screening of visiting family members. The incidents were considered unusual as they involved visitors rather than staff. Both residents were asked during admission about any history of trauma or abuse from family members and had denied such history. The facility's policies and procedures for abuse were in place, but the events occurred despite these measures, and the facility had limited authority to screen visitors prior to entry.
Failure to Timely Report Abuse Allegation to State Agency and APS
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding timely reporting of an abuse allegation involving a resident with osteoporosis and high blood pressure, who was cognitively intact and had adequate hearing and vision. The incident involved a family member visiting the resident, yelling at her, and physically grabbing and twisting her arm, resulting in pain and visible bruising. The abuse allegation was reported to the DON and Administrator, but the required notifications to the State Agency (DHSR) and Adult Protective Services (APS) were not made within the specified 2-hour timeframe as outlined in the facility's policy. The initial report to DHSR was submitted over 20 hours after the facility became aware of the incident, and there was no documentation to support that APS had been notified. Interviews revealed that the Social Service Director (SSD) attempted to report the incident to APS by phone but did not complete the process due to distractions and did not follow up. The SSD also misunderstood the reporting timeframe, believing she had 24 hours to report to DHSR instead of the required 2 hours. The DON, upon returning to the facility, discovered the delay and submitted the report to DHSR but did not complete the APS notification. The Administrator confirmed that staff are expected to follow the abuse reporting policy and procedures, which were not adhered to in this case.
Failure to Implement CDC Guidance During COVID-19 Outbreak
Penalty
Summary
The facility failed to operationalize updated infection control policies and procedures in accordance with current CDC guidance during a COVID-19 outbreak. On 12/26/24, a staff member and residents on two different halls tested positive for COVID-19, but the facility did not implement broad-based COVID-19 testing for staff and residents until 1/8/24, after surveyor intervention. This delay resulted in additional staff and residents testing positive for COVID-19. The facility also failed to implement staff source control measures to prevent transmission during the outbreak. The facility did not provide staff with N95 masks for the care of COVID-19 positive residents, as per CDC guidance. Observations revealed that facility staff did not wear all required personal protective equipment (PPE) when entering rooms under transmission-based precautions for COVID-19. Additionally, the facility allowed staff to return to work after testing positive for COVID-19, contrary to CDC guidance. The facility's COVID-19 policies and procedures were not updated to align with current CDC guidance for testing, PPE requirements, and work restriction guidance for healthcare personnel. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed a lack of understanding and implementation of CDC recommendations for COVID-19 testing and outbreak management. The IP and DON believed that testing was only necessary for symptomatic individuals, and the facility did not conduct contact tracing or broad-based testing until prompted by surveyors. The facility also failed to notify the local Health Department of the outbreak, which could have provided guidance and recommendations to mitigate the outbreak.
Medication Management Deficiencies in Facility
Penalty
Summary
The facility failed to properly manage and store medications across multiple medication carts, leading to deficiencies in medication labeling and storage. On the 400 hall medication cart, an undated Insulin Glargine pen was found, with the nurse unable to confirm if it was opened or not. The manufacturer's instructions specify that Insulin Glargine expires 28 days after opening and should be dated when removed from refrigeration. The nurse admitted to not noticing the pen due to its administration schedule and acknowledged that all nurses should check for undated and expired medications. On the 500 hall medication cart, an expired bottle of Geri-Lanta was found, which the nurse had overlooked during a quick check. Additionally, on the 200 hall medication cart, an unopened and undated bottle of Latanoprost eye drops was discovered, which should have been refrigerated until opened. The nurse was unaware of the storage requirements and the need to date the bottle upon removal from refrigeration. The Director of Nursing confirmed the need for proper dating and disposal of expired medications, indicating a lack of consistent oversight and adherence to medication management protocols.
Failure to Provide Privacy During Tube Feeding
Penalty
Summary
The facility failed to provide privacy during the administration of tube feeding for a resident diagnosed with aphasia following a stroke and gastrostomy status. The resident, who was rarely/never understood and had severely impaired cognitive skills, was observed receiving tube feeding in his room with the door wide open. Although there was a privacy curtain available, it was not used by Nurse #1, who exposed the resident's abdomen while administering the feeding. This lack of privacy allowed another resident and several staff members to observe the care being provided. Nurse #1 admitted during an interview that she typically used the privacy curtain when the resident's roommate was present but did not consider closing the door or using the curtain when the roommate was absent. The Director of Nursing confirmed that Nurse #1 should have ensured privacy by closing the door and using the curtain during the procedure. This oversight resulted in a breach of the resident's right to privacy during medical care.
Expired Food and Supplements Found in Nourishment Rooms
Penalty
Summary
The facility failed to remove expired nutritional supplements and ready-to-eat personal resident food from two nourishment rooms, which could potentially affect residents. During an observation of the North nourishment room, an expired unopened nutritional supplement was found stored in a cabinet. The Dietary Manager (DM) acknowledged that the supplement, stocked by kitchen staff, should have been discarded upon expiration. In the South nourishment room, expired resident food was found in the refrigerator, including three unopened individually packaged ready-to-eat containers. The DM stated that the nourishment rooms were checked twice daily, but the expired items were overlooked. The Dietary Aide responsible for checking the rooms confirmed that she did not notice the expired items during her morning check. The Administrator acknowledged that the expired items should have been removed and disposed of when expired.
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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