Pavilion Health Center At Brightmore
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 10011 Providence Road West, Charlotte, North Carolina 28277
- CMS Provider Number
- 345563
- Inspections on file
- 18
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Pavilion Health Center At Brightmore during CMS and state inspections, most recent first.
A cognitively impaired resident with poor balance and confusion exited the facility unassisted through the front door while the receptionist was present but did not recognize the individual as a resident. The resident walked along a busy road, fell, and was later transported to a hospital after being found by strangers. The facility's risk assessment and care plan did not identify the resident as an elopement risk, and staff were unaware of the resident's exit until a family member arrived and reported the absence.
A resident with multiple neurological and cognitive diagnoses was administered Seroquel without a clearly documented or observed indication for its use. Despite care plan references to behavioral disturbances, staff interviews and observations did not confirm such behaviors or other symptoms like hiccups or nausea. Pharmacy review highlighted the lack of an allowable diagnosis, yet the medication continued to be ordered and administered.
The facility failed to accurately code MDS assessments for three residents, including incorrect discharge status, omission of hospice care, and failure to document oxygen use and functional status. Staff interviews confirmed that the errors were due to oversight and inaccurate information gathering, despite clear evidence in the residents' records and care needs.
Two residents did not have accurate, individualized care plans: one resident's care plan failed to address ongoing oxygen therapy despite physician orders and continuous use, while another resident's care plan incorrectly included hand mitts that were never used, instead of accurately reflecting the use of an abdominal binder for feeding tube protection. These deficiencies were confirmed through record review and staff interviews.
A resident admitted with a fracture, falls, and incontinence did not have a comprehensive care plan developed within 7 days of the MDS assessment. The care plan failed to address key areas such as ADL function, falls, incontinence, pressure ulcers, and nutrition, despite these being identified in the CAA. Staff interviews confirmed the care plan was incomplete due to oversight.
A nurse failed to use sterile gloves and did not perform hand hygiene while providing tracheostomy care to a resident with a tracheostomy and acute respiratory failure. The nurse used non-sterile gloves, did not sanitize hands between glove changes, and did not use a tracheostomy kit, contrary to the care plan and physician orders. Facility leadership expected proper infection control practices, but these were not followed during the observed care.
A resident with a PEG tube received medications in a manner inconsistent with physician orders, as a nurse combined and administered all medications together instead of separately with required flushes. This resulted in 5 medication errors out of 27 opportunities, leading to a medication error rate of 18.52%, which exceeds the acceptable threshold. The DON confirmed that staff are expected to follow all medication orders.
The facility failed to accurately code the MDS assessments for four residents in areas such as wounds, hospice services, range of motion, and tube feeding. Discrepancies were found between clinical findings and MDS documentation, as confirmed by interviews with staff and administrators.
The facility failed to ensure group activities were planned and executed for rehabilitation residents, leading to residents not being reminded or assisted to attend activities. The Activities Assistant did not have time to ask residents on the rehabilitation side if they wanted to attend activities due to the absence of the Activities Director. This resulted in residents with cognitive impairments not being invited to or informed about group activities, as confirmed by interviews with staff and residents.
The facility's QAA Committee failed to maintain procedures and monitor interventions, resulting in repeat deficiencies in resident's rights, accuracy of assessments, nutrition and hydration status, and infection control. Issues included rough treatment of a resident, inaccurate MDS coding, failure to follow dietary recommendations, and poor hand hygiene practices.
The facility failed to implement their infection control policy when a nurse aide did not perform hand hygiene between residents during meal delivery and another nurse aide failed to doff soiled gloves and perform hand hygiene before exiting a resident's room after checking for incontinence. Both aides had received prior training but did not follow the correct procedures.
The facility failed to recognize the use of an abdominal binder as a physical restraint for a resident with a G-tube and dementia. The binder was used to prevent the resident from pulling out the feeding tube, but there was no care plan, physician order, or documented consent for its use. Staff were unaware that the binder could be considered a restraint, leading to the deficiency.
The facility failed to develop comprehensive care plans for two residents. One resident with severe cognitive impairment and multiple diagnoses had necrotic wounds that were not included in the care plan. Another resident with severe cognitive impairment and knee contractures was recommended to use bilateral knee splints, but this was not reflected in the care plan.
A resident's care plan was not updated to reflect the discontinuation of IV antibiotics and catheter, despite the IV treatment ending and the catheter being removed. This oversight was confirmed by the MDS Nurse and acknowledged by the Administrator.
The facility failed to maintain accurate electronic records for three residents, leading to deficiencies in medication administration, weight documentation, and treatment application. Medications and treatments were administered but not properly documented, and weights were recorded on paper but not entered into the electronic system.
A resident with moderate dementia was without a functional call light for three days, impacting her ability to request assistance. Despite reporting the issue, the call light was not repaired promptly, leading to the resident attempting to manage her incontinence care independently.
The facility failed to post daily nurse staffing information in a prominent location accessible to residents. The staffing sheet was placed on the receptionist's desk in the front lobby, which required residents to manually open double doors to access. Interviews with the DON and Administrator confirmed the long-standing placement and acknowledged its inaccessibility to residents.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A severely cognitively impaired resident with a primary diagnosis of toxic encephalopathy, along with other significant medical conditions such as cardiac arrest, atherosclerotic heart disease, and chronic kidney disease, exited the facility without staff knowledge for over two hours. The resident, who required partial to moderate assistance with most activities of daily living and was known to be confused and unsteady on his feet, was last seen in his room by a nurse aide at approximately 9:30 AM. Video footage later revealed that the resident walked unassisted through the lobby and out the front door while the receptionist was present but engaged in conversation with a visitor. The receptionist did not recognize the resident as a resident and did not intervene as he exited the building. After leaving the facility, the resident walked along a heavily trafficked road, fell, and was assisted by strangers who transported him to a fire station 20 miles away. The facility staff became aware of the resident's absence only after a family member arrived for a visit and could not locate him. A search was initiated, and law enforcement was notified. The resident was eventually found and transported to the hospital, where he was noted to have abrasions and swelling consistent with a fall. Interviews with staff and family confirmed that the resident was consistently confused, required supervision for ambulation, and was not safe to walk unassisted. The facility's risk assessment and care plan for the resident did not identify wandering or elopement risk, as there was no prior history of such behaviors. However, the resident's cognitive impairment, confusion, and poor balance were documented. Staff interviews indicated that the resident typically remained in his room and had not previously attempted to leave the facility. The front entrance was unlocked due to the presence of a receptionist, but there was no effective process in place to ensure that residents could not exit unnoticed, especially when staff were unfamiliar with all residents or distracted.
Removal Plan
- A head count was completed by Nurse Supervisor #1 for 100% of residents. All residents in facility were accounted for with no issues identified.
- The Director of Nursing reviewed clinical alerts dashboard and nursing notes for all residents for the past 30 days to identify any exit seeking behaviors. No issues identified.
- The Director of Nursing audited 100% of residents wandering risk assessments. All residents with low wandering risk were reviewed for changes in condition/function that may put them at risk to exit the facility. No issues identified.
- Risk assessments are completed upon admission by the admitting nurse, quarterly and any time a change of condition is noted by staff nurse or nurse manager.
- All residents at high-risk for wandering charts were reviewed by the Director of Nursing to ensure that they had appropriate wander prevention strategies in place to include wander guard bracelet in place and functioning properly, daily battery checks and every shift placement checks were present on the MAR and that care plan was current and appropriate interventions were on the care plan.
- The Nurse Supervisor checked 100% of current residents with wander guards for placement and function by observing that wander guard was on resident's person and utilized the wander guard checker device to ensure proper function. No issues were noted.
- All exit doors were checked by the Director of Nursing and Nurse Supervisor #1 to ensure they were functioning properly.
- Staff interviews were initiated for all staff by the Director of Nursing to identify any exit seeking behaviors. Interviews identified no other new onset of exit seeking behaviors.
- The QA Nurse Consultant rechecked all entrance/exit doors to include door with wander guard system, squealer boxes and on/off switches for mag lock doors (doors with keypad entry/exit) and all were functioning properly. No issues were identified.
- A Quality Assurance Performance Improvement meeting held with the Interdisciplinary Team members to discuss incident findings and plan to correct.
- The Director of Nursing began education of all full time, part time, and as needed staff including agency on the following topics: Elopement Prevention and Missing Person Policy. Education included what to do if resident was exhibiting wandering/exit seeking behaviors especially for those residents who normally stayed in their rooms. Staff educated to stop and communicate with the resident and redirect, ensure safety of the resident and immediately notify the nurse.
- The Administrator will ensure that any of the above identified staff who did not complete the in-service training will not be allowed to work until the training is completed.
- This in-service was incorporated into the new employee facility orientation for the above identified staff and will be provided by the Staff Development Coordinator during orientation and prior to working in patient care areas.
- The Administrator educated all receptionists that all visitors will need to sign in and out and wear a badge to identify them as a visitor when entering the facility through main entrance designated for visitor entry.
- All other exit doors are locked with signage above directing visitors to go to the main entrance to enter and exit the facility.
- All receptionists and nurses were educated by the Administrator that receptionists are to lock the main entrance door upon leaving front desk for any reason and nurses are to let visitors into and out of facility in receptionist's absence from receptionist area.
- Receptionists were educated to have all persons exiting facility to be identified prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility to ensure they are not a resident displaying exit seeking behaviors.
- If the person is noted to be a resident, receptionist is to maintain resident safety and immediately notify nurse assigned to resident to come assist resident.
- The Administrator will ensure that any newly hired receptionist or nurse will receive this education prior to working and this in-service was incorporated into the new employee facility orientation for the above identified staff.
- Visitors will be required to sign in and out and wear visitor badge while in the facility.
- Receptionists were educated that they are to lock the main entrance door upon leaving front desk area for any reason and if no one is available to provide coverage until they return, they are to notify nursing staff via phone that they will be leaving front desk area prior to leaving.
- Upon hearing doorbell ringing, nurses are to go to front entrance area and let visitor into the facility, have visitor sign in and provide them with a visitor's badge.
- For visitors leaving facility, nurse is to identify person prior to them exiting by looking for visitor badge and asking person to identify themselves, checking sign in/out log for name and having them sign out once identified on sign in/out log prior to exiting facility.
- A receptionist is scheduled to work 7 days a week. In the event that there is no receptionist available, facility front entrance doors will be locked and nurses on duty will be responsible for allowing visitors entry or exit to facility.
Failure to Ensure Proper Indication for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident had an appropriate indication and diagnosis for the use of an antipsychotic medication, specifically Seroquel (Quetiapine Fumarate). The resident in question was admitted with multiple diagnoses, including cerebral infarction, hemiplegia, aphasia, benign neoplasm of cerebral meninges, adult failure to thrive, and vascular dementia with mood disturbance and anxiety. Physician orders for Seroquel were present, and the care plan referenced its use for dementia with behavioral disturbances. However, the quarterly MDS assessment did not indicate potential indicators of psychosis, and staff interviews revealed that the resident did not exhibit behavioral disturbances or symptoms such as yelling, hitting, or pulling at medical devices. Observations showed the resident was largely non-responsive, unable to move extremities, and required significant assistance with care. A pharmacy review noted that the resident lacked an allowable diagnosis to support the use of Seroquel, and the provider subsequently documented indications such as hiccups and nausea associated with cancer, though staff had not observed these symptoms. Orders for Seroquel were updated to reflect these indications, but staff interviews and observations did not confirm the presence of behavioral disturbances, hiccups, or nausea. The medication continued to be reordered upon each readmission without clear evidence of a supporting diagnosis or observed need, leading to the deficiency related to the use of unnecessary psychotropic medication as a potential chemical restraint.
Inaccurate MDS Coding for Discharge, Hospice, and Oxygen Use
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for three residents. One resident was discharged to an assisted living facility, but the discharge MDS was incorrectly coded as a discharge to a hospital. The MDS Coordinator, who was new to the role, acknowledged the error and stated that the discharge status should have reflected the actual destination. Both the DON and Administrator confirmed that the MDS should be coded accurately, but were unaware of the reason for the incorrect coding. Another resident was admitted to hospice services prior to admission, but the admission MDS did not reflect hospice care due to an oversight by the MDS Coordinator. Additionally, a third resident with a history of CVA, hemiplegia, and oxygen dependence was not coded for oxygen use on the quarterly MDS assessment, and their functional status was inaccurately documented. Staff interviews confirmed the resident's dependence on oxygen and total care needs, but these were not accurately captured in the MDS. The Administrator and clinical staff indicated that information from therapy, nursing, and physician orders should be used for accurate MDS coding.
Failure to Develop and Implement Accurate, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents with specific clinical needs. For one resident with congestive heart failure, pneumonia, and a dependence on supplemental oxygen, the care plan did not include any interventions or care area addressing the resident's continuous oxygen therapy, despite physician orders and documentation showing ongoing use of oxygen since admission. This omission was confirmed by both the MDS Coordinator and the DON, who acknowledged that the resident's need for continuous oxygen was not reflected in the care plan due to oversight. For another resident with chronic respiratory failure, hypoxia, diabetes, and epilepsy, the care plan inaccurately included the use of bilateral hand mitts in addition to an abdominal binder for protection of a feeding tube. However, medical records, staff interviews, and the resident's MAR confirmed that only the abdominal binder was used, and there were no physician orders for hand mitts. The inclusion of hand mitts in the care plan was identified as a mistake by the MDS Coordinator, and staff confirmed that the resident never used them. The DON and Administrator both expected the care plan to accurately reflect the resident's current interventions.
Failure to Complete Comprehensive Care Plan After Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completing a comprehensive assessment for one resident. The resident was admitted with multiple diagnoses, including a left humerus fracture, history of falls, and urinary tract infection. The admission MDS assessment indicated significant care needs, such as upper extremity impairment, partial to moderate assistance with ADLs, frequent incontinence, risk for pressure ulcers, and a history of falls. The Care Area Assessment (CAA) identified several triggered care areas, including ADL function, urinary incontinence, falls, pressure ulcers, and nutrition, with care plan decisions completed for these areas. However, a review of the resident's medical record showed that the care plan only addressed discharge planning, mood disorder, and activities, and did not include focus areas or interventions for the triggered care areas identified in the CAA. Interviews with the MDS Coordinator and the Administrator confirmed that the comprehensive care plan had not been completed as required, and the omission was acknowledged as an oversight by the responsible staff.
Failure to Use Sterile Technique and Perform Hand Hygiene During Tracheostomy Care
Penalty
Summary
Nurse #1 failed to use sterile gloves and did not perform hand hygiene while providing tracheostomy care to a resident with a history of acute respiratory failure and a tracheostomy. During the observed care, Nurse #1 set up supplies without a tracheostomy kit, donned non-sterile gloves, and removed the resident's dirty dressing. After doffing gloves, Nurse #1 did not sanitize her hands before donning new gloves and continued care, including removing and replacing the inner cannula, all without using sterile technique or performing hand hygiene between glove changes. Handwashing was only performed at the end of the procedure. The resident's care plan and physician orders required tracheostomy care with attention to infection prevention. Interviews with Nurse #1 revealed she was aware of the missed hand hygiene but was not aware that sterile gloves were required for tracheostomy care. The Infection Preventionist/ADON and DON both stated their expectations for proper infection control practices, including hand hygiene and sterile technique, but were not aware of the specific deficiencies observed during this incident.
Medication Error Rate Exceeds 5% Due to Improper PEG-Tube Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 27 opportunities, resulting in an 18.52% error rate. The deficiency involved a resident with a percutaneous endoscopic gastrostomy (PEG) tube, who had specific physician orders for medication administration. The orders required each medication to be dissolved separately in water, administered individually, and flushed with water between each medication, with a final flush at the end. During observation, the Unit Manager combined all prescribed medications into a single mixture, crushed and mixed them together, and administered them as a single solution through the PEG tube, contrary to the physician's orders. The Unit Manager admitted to not reviewing the resident's medication administration order prior to administering the medications and stated that her usual practice was to combine all medications for PEG-tube administration. The Director of Nursing confirmed that staff are expected to follow all medication orders as written. The observed practice resulted in multiple medication errors for the resident, as the administration did not comply with the specific instructions provided by the physician.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for four residents in various areas, including wounds, hospice services, range of motion, and tube feeding. Resident #399 was admitted with multiple diagnoses, including a periprosthetic fracture and dementia. Despite having wounds on the right heel and great toe, the MDS assessment did not reflect these conditions. Interviews with the Nurse Practitioner (NP) and MDS Nurse revealed discrepancies between the clinical findings and the MDS documentation. The Director of Nursing (DON) and the Administrator both expressed expectations for accurate MDS coding based on the resident's clinical status. Resident #22 was admitted with diagnoses including venous insufficiency and type 2 diabetes. Although the care plan indicated palliative care, there was no documentation of hospice services in the medical record. The MDS assessment incorrectly coded hospice care, which was acknowledged as an error by the MDS Nurse. The Administrator reiterated the expectation for accurate MDS coding. Resident #11 had contractures in both knees and received physical therapy for limited range of motion. However, the MDS assessment did not reflect this condition. The Rehab Director and MDS Nurse confirmed the oversight. Resident #57, who was NPO and received nutrition via a PEG tube, was incorrectly assessed as requiring extensive assistance with eating instead of total staff assistance. The MDS Coordinator and Regional Quality Assessment & Assurance (QAA) Nurse identified the error, noting that the MDS was completed by a prn MDS staff member who no longer worked at the facility.
Failure to Include Rehabilitation Residents in Group Activities
Penalty
Summary
The facility failed to ensure group activities were planned and executed for rehabilitation residents, which was important to them. The March 2024 activity calendar showed daily activities at 11:00 AM and 2:00 PM, including an ice cream social and bingo twice a week. However, the Activities Assistant admitted that she did not have time to ask residents on the rehabilitation side if they wanted to attend activities due to the absence of the Activities Director since the beginning of March. This led to residents not being reminded or assisted to attend activities, as the Activities Assistant was also responsible for other duties, including resident admissions. Resident #37, who was moderately cognitively impaired and had a care plan indicating an interest in group bingo events, was not asked to attend activities after being readmitted to the facility. His Responsible Party (RP) stated that no staff members had come to the room to ask if he wanted to attend activities, and she had to personally take him to the ice cream social. Interviews with the Nurse Aide and Nurse assigned to Resident #37 confirmed that they had not asked him about attending activities, assuming that someone from the Activities Department would do so. Resident #85, who had severe cognitive impairment and indicated a desire to be invited to out-of-room activities, was also not asked to attend group activities. She stated that she loved being around people but could not recall being asked to join any activities. Similarly, Resident #88, who had moderately impaired cognition and expressed interest in group activities, was not informed about or invited to participate in activities. Both residents' medical records lacked activity notes, and the Nurse Aide assigned to them could not recall if they were asked or assisted to attend group activities. The Administrator was unaware of these issues and the arrangement between the Activities Director and Activities Assistant regarding resident activity participation.
Repeat Deficiencies in QAA Program
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that were put into place following the recertification and complaint investigation survey. This failure resulted in four repeat deficiencies being cited again during the current recertification and complaint investigation survey. The deficiencies included issues related to resident's rights, accuracy of assessments, maintenance of nutrition and hydration status, and infection prevention and control. Specifically, a resident was treated roughly during personal care, causing her to cry, and another resident was left uncovered in bed in a soiled brief. Additionally, the facility failed to code the Minimum Data Set (MDS) assessment accurately in several areas, including wounds, hospice services, range of motion, and tube feeding for multiple residents. The facility also did not follow recommendations from the Registered Dietitian and Nurse Practitioner regarding reweighing a resident with significant weight loss and addressing subtherapeutic total protein lab results. Furthermore, the facility failed to implement their infection control policy, as observed with staff not performing hand hygiene between residents during meal delivery and assistance, and not doffing soiled gloves before exiting a resident's room to obtain incontinence care supplies. During the interview, the Administrator and the Regional QAA Nurse Consultant acknowledged the repeat deficiencies and attributed them to staff taking shortcuts, the use of agency staff, MDS staffing changes, and staff oversight despite continued efforts to re-educate staff. The Administrator stated that repeat deficiencies were reviewed during quarterly QA meetings, and re-education was provided if ongoing issues were identified. However, the continued failure to sustain an effective QAA Program was evident as the same deficiencies were cited during two federal surveys of record.
Failure to Implement Infection Control Policy
Penalty
Summary
The facility failed to implement their infection control policy when a nurse aide did not perform hand hygiene between residents during meal delivery and meal assistance. Specifically, the nurse aide was observed serving meal trays to multiple residents without sanitizing hands between each interaction, despite the presence of hand sanitizing dispensers in the hallway. The Assistant Director of Nursing (ADON) intervened and provided immediate hand hygiene education to the nurse aide, who acknowledged having received prior training on the matter. In another instance, a nurse aide failed to doff soiled gloves and perform hand hygiene before exiting a resident's room after checking for incontinence. The nurse aide was observed wearing the same soiled gloves while retrieving supplies from a clean linen closet, which is against the facility's infection control practices. The nurse aide admitted to knowing the correct procedure but did not follow it at the time. Interviews with the ADON, Director of Nursing (DON), and the Administrator confirmed that all staff had received hand hygiene education and were expected to follow the facility's infection control policies. The ADON, who is also the Infection Preventionist, stated that the staff would need re-education on proper hand hygiene and incontinence care procedures to prevent such deficiencies in the future.
Failure to Recognize Abdominal Binder as Physical Restraint
Penalty
Summary
The facility failed to recognize the use of an abdominal binder as a physical restraint for a resident admitted with diagnoses including intracranial hemorrhage, presence of a gastrostomy tube (G-tube), and dementia. The resident's baseline care plan did not include a care plan for the use of the abdominal binder as a restraint, and there was no physician order or documented consent for its use. Staff interviews revealed that the abdominal binder was used to prevent the resident from pulling out the feeding tube, but staff were unaware that it could be considered a restraint. The binder was unfastened during care but otherwise kept in place, and the resident was unable to remove it independently. Observations and interviews with various staff members, including nurses, nurse aides, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and a Nurse Practitioner, confirmed the consistent use of the abdominal binder since the resident's admission. Despite its use for safety reasons, there was no documentation of a restraint assessment or consent in the medical record. The staff's lack of awareness regarding the classification of the abdominal binder as a restraint led to the deficiency identified in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop an individualized, person-centered comprehensive care plan for two residents. Resident #399 was admitted with severe cognitive impairment and multiple diagnoses, including a periprosthetic fracture of the left hip and chronic embolism. Despite the presence of necrotic wounds on the right great toe and an open wound on the right heel, the care plan only addressed the risk for pressure ulcers and did not include the actual wounds. The MDS Nurse used the admission nursing assessment, which did not document any skin integrity issues, to complete the care plan and did not update it even after the Nurse Practitioner identified the wounds during an acute visit. Resident #11, who had severe cognitive impairment and contractures in both knees, was recommended to use bilateral knee splints by the Physical Therapy department. However, the care plan did not include this recommendation. The MDS Nurse acknowledged the oversight, and the Director of Nursing confirmed that the care plan should have been comprehensive and included the use of bilateral knee splints.
Failure to Update Care Plan for IV Medication
Penalty
Summary
The facility failed to revise the care plan for a resident receiving intravenous (IV) medication. Resident #22, who was admitted with diagnoses including diabetes and retention of urine, received Vancomycin via IV from 2/1/24 to 2/12/24. The IV catheter was removed on 2/14/24. However, the resident's care plan, last reviewed on 3/5/24, still included a focus area for receiving IV fluids via midline, despite the discontinuation of the IV antibiotics and catheter. This oversight was confirmed by the MDS Nurse during an interview on 3/14/24, who acknowledged that the care plan should have been updated. The Administrator also indicated that the care plan should accurately represent the resident's current status.
Failure to Maintain Accurate Electronic Records
Penalty
Summary
The facility failed to maintain accurate electronic records for three residents, leading to deficiencies in medication administration, weight documentation, and treatment application. For Resident #28, the Unit Manager administered an acid reflux medication but did not document it in the Medication Administration Record (MAR). The Director of Nursing confirmed that all administered medications should be documented in the MAR. Medication Aide #1, who was expected to sign off on the medication, was unavailable for an interview. Resident #71 had a physician's order for weekly weights, but the weights were not documented in the electronic medical record for the specified period. Nurse #10 recorded the weights on a report sheet but failed to enter them into the electronic system. For Resident #198, a physician's order specified the application of a medicated cream to the buttocks, but Nurse #12 applied the cream to a different area without proper documentation. The Director of Nursing stated that all treatments should be documented in the MAR and progress notes.
Failure to Provide Functional Call Light for Resident
Penalty
Summary
The facility failed to provide Resident #11 with a functional call light to request staff assistance for three consecutive days. Resident #11, who was admitted with moderate dementia and other conditions requiring extensive assistance, was observed on multiple occasions without a working call light. On 3/11/24, Resident #11 was found in her room with her pants and brief pulled down, stating she had used facial tissue due to a lack of toilet tissue and that her call light was not working. Despite pressing the call light, neither the wall panel light nor the light outside the room door turned on, indicating a malfunction. Nurse #6 confirmed the issue and reported it to the Maintenance Director, who acknowledged the problem and stated it was repaired on 3/13/24 after being reported on 3/12/24, although the nurse claimed to have reported it on 3/11/24. Interviews with various staff members, including Nurse Aides and the Maintenance Director, revealed that Resident #11 frequently used her call light for assistance but had been observed propelling herself into the hallway when the call light was not answered. The Maintenance Director admitted that the call light cord was burned out and replaced it, stating that call light audits were conducted monthly, with the last audit on 2/29/24. However, the malfunction was not identified until the call light was pressed and found to be non-functional. The Administrator and Regional Quality Assessment and Assurance Nurse Consultant confirmed that maintenance staff should ensure all call lights are functional for residents who use them. Despite the facility's procedures for daily room rounds and weekly call light audits, the deficiency in providing a functional call light for Resident #11 persisted for three days, impacting the resident's ability to request necessary assistance and maintain her activities of daily living.
Failure to Post Daily Nurse Staffing Information in Accessible Location
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent location that was readily accessible to residents on five consecutive days during the survey. Observations revealed that the daily nurse staffing sheet was placed on the ledge of the receptionist's desk in the front lobby, which was only accessible to residents by manually opening a set of double doors. This placement made the staffing information not readily visible or accessible to residents. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the current location of the posting had been in use for a long time and acknowledged that it was not in an area easily accessible to residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
