Pelican Health At Charlotte
Inspection history, citations, penalties and survey trends for this long-term care facility in Charlotte, North Carolina.
- Location
- 2616 East 5th Street, Charlotte, North Carolina 28204
- CMS Provider Number
- 345201
- Inspections on file
- 30
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Pelican Health At Charlotte during CMS and state inspections, most recent first.
A resident with a history of past emotional and physical abuse, and an active care plan for mood symptoms and coping, became involved in a confrontation with a CNA during assistance with a shower after expressing care preferences and requesting a different caregiver. The CNA allegedly responded by yelling, using profanity, and calling the resident derogatory names, while the resident also cursed in return. A second CNA intervened but was reported to have yelled a profane remark down the hallway in response to the resident stating she would call her father, and both CNAs were later heard at the nurse's station referring to the resident as a "b****" and a difficult resident within earshot of others. Multiple staff, including a nurse and a restorative aide, confirmed there was loud yelling and cursing between the CNA and the resident, that the CNA returned to the room to resume the argument after being removed once, and that the resident was very upset and angry about how she had been treated.
A resident on Eliquis for DVT prevention, with multiple comorbidities and a care plan identifying bleeding risk, sustained a left lower leg injury when a NA pulled her wheelchair backward and her leg struck a damaged bed footboard. The resident immediately reported 10/10 pain and significant bleeding; the NA’s towels became saturated before an RN applied pressure for about five minutes and placed a pressure dressing, documented the wound as a small skin tear, held the anticoagulant, and did not initiate EMS or hospital transfer. The DON did not assess the wound and accepted the report that bleeding was controlled, while the Medical Director was not informed of the mechanism of injury or the full extent of bleeding. The resident later contacted her RP, who observed blood on the dressing and called 911; EMS found the resident in severe pain with elevated BP and HR, and the ED identified a large hematoma and difficulty controlling bleeding at the facility. During hospitalization, the resident developed acute blood loss anemia requiring transfusion and surgical evacuation of a 16.2 cm hematoma with debridement and wound VAC placement, leading to prolonged wound care and ongoing pain management after return to the facility. Surveyors cited the facility for failing to adequately assess the injury, consider anticoagulant-related bleeding risk, and promptly initiate emergency medical intervention, resulting in Immediate Jeopardy for the resident.
A dependent resident on anticoagulant therapy, with severe lower extremity contractures and a documented need for two-person transfers, was moved via a one-person mechanical lift transfer and then pulled backward in a wheelchair, causing her leg to strike a damaged bed footboard with exposed pressboard. She sustained a leg laceration with significant bleeding, later found to be associated with a large hematoma, acute blood loss anemia, and skin necrosis requiring surgical intervention and a wound VAC. Another cognitively intact resident at high fall risk reported that a shower grab bar was loose, but the OT did not respond, and when the resident stood and pulled on the bar, it shifted and caused her to fall onto the shower chair and then the floor, necessitating use of a mechanical lift and hospital evaluation. Surveyors also found that residents who smoked were allowed to keep smoking materials on their person and in their rooms instead of having them secured at the nurses’ station, in violation of the facility’s smoking policy, demonstrating broader failures in environmental safety and supervision.
Surveyors identified improper garbage and refuse management in the outdoor trash and recycling receptacle area behind the kitchen, including open receptacle doors, trash bags hanging out of the receptacles, used gloves and loose trash on the ground, and multiple collapsed cardboard boxes and a trash bag floating in standing water. Staff interviews revealed that many staff from multiple departments used the dumpster area, often forgot to close the receptacle doors, and that rainwater pooled under the receptacles without draining. The Regional Housekeeping Supervisor and Dietary Manager reported that the trash pick-up company frequently caused materials to fall out of the receptacles and did not return them inside, while the Administrator stated she had not been aware of the standing water and expected staff who took out trash to maintain the area.
A resident with a right tibia fracture, muscle weakness, and physical debility had documented decreased bilateral lower extremity ROM, contractures, and limited wheelchair tolerance requiring leg elevation on pillows and leg rests. The care plan reflected dependence on staff for ADLs and use of a mechanical lift for transfers, and PT notes described severely decreased ROM and wheelchair use with legs elevated. However, the quarterly MDS assessment coded the resident as having no ROM impairment and no use of mobility devices. The MDS coordinator later acknowledged that, based on PT documentation, the assessment was completed incorrectly and should have reflected bilateral lower extremity impairment and wheelchair use.
A resident with acute systolic heart failure and hypokalemia, who was cognitively intact but had no order or care plan to self-administer medications, was found with a potassium citrate capsule left in a cup on the bedside table after a medication pass. The assigned nurse acknowledged that the resident preferred to take this large white pill later and admitted leaving it at the bedside when called away, instead of returning it to the med cart. The resident confirmed the pill was intentionally left for later use. The NP stated the resident had never been authorized to self-medicate and that medications should not be left at the bedside, while leadership confirmed there was no self-medication order and that the medication should not have been left in the room.
Surveyors found that a food preparation area had visible dirt and grime on a large fire suppression tank and its tubing above a toaster, along with food debris and grease buildup in the grout lines of the floor tiles in front of the cooking range. During a tour, the Head Cook stated that housekeeping was responsible for floor cleaning but was unsure of the cleaning schedule, acknowledged that grease and food debris accumulated in the grout, and was unaware of the grime on the fire suppression tank. These unsanitary conditions were present in one of two food preparation areas and had the potential to affect food served to residents.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy and posted instructions requiring gowns and gloves for high-contact care activities. In two separate instances, a nurse and a nurse aide provided urinary catheter care and assisted with a transfer for residents on EBP while wearing only gloves and no gown, despite EBP signs on the doors and PPE available in the rooms. In interviews, the nurse stated she did not know a gown was required for catheter care, and the nurse aide reported she did not realize the resident was on EBP, did not notice the differently colored sign, and was unaware that a gown was required for transfers and catheter-related care.
A cognitively intact resident with CKD stage 4 on hemodialysis and dependent on a mechanical lift consistently preferred to return to bed immediately after dialysis, a preference known to regular staff and reflected in her care planning. On an observed treatment day, she activated her call light shortly after arriving back from dialysis, but an agency NA turned off the call light, left to continue rounds, did not allow the resident to state her needs, did not seek help from other staff, and did not return. The resident had to reactivate her call light multiple times before another NA and a COTA ultimately assisted her back to bed via mechanical lift, after she reported feeling very tired, lightheaded, and having waited over 45 minutes. The delay resulted from the assigned NA’s lack of report on the resident’s routine, failure to communicate the need for assistance, and failure to promptly respond to the resident’s expressed choice to return to bed post-dialysis.
Surveyors found that two residents shared a room where both bed footboards were in disrepair, with missing laminate or banding and rough, exposed particle board surfaces, and no maintenance work orders had been submitted for these issues over the prior year. A NA acknowledged the damage had been present for some time but had not reported it, and an agency nurse had also noticed the damage weeks earlier and assumed Maintenance was already aware. The Maintenance Director stated he did not know about the condition of the beds until informed by the Administrator, and both the DON and Administrator reported they were unaware of the damaged footboards until surveyors pointed them out, despite staff having 24-hour access to submit maintenance requests.
A resident fell during a transfer using a mechanical lift due to a frayed strap breaking, resulting in a head injury and pain on the right side. The staff failed to inspect the lift sling for wear and tear before use, as required by the manufacturer's instructions. Additionally, the facility did not secure the mechanical lift brake during another resident's transfer, posing a risk of similar accidents.
Two residents in the facility experienced discomfort due to the use of incorrect size briefs and a lack of fitted sheets for bariatric beds. One resident reported that the facility often ran out of 2X briefs, leading staff to use smaller, uncomfortable briefs, while another resident faced similar issues with briefs and linens. Staff interviews confirmed the ongoing supply shortages, with the facility administrator acknowledging the problem and stating that a new company had been hired to address the issue.
The facility failed to provide sufficient linens and size 2x incontinent briefs for two residents requiring bariatric goods. This neglect was identified through record reviews, observations, and interviews, revealing the use of incorrect size briefs and lack of fitted sheets, compromising the residents' care and comfort.
The facility failed to provide RN coverage for at least 8 consecutive hours per day, 7 days a week, on multiple occasions in 2024. The Staff Scheduler and Administrator confirmed the absence of RN coverage on specific dates, citing challenges in finding replacements and ongoing recruitment efforts.
The facility inaccurately coded MDS assessments for two residents, leading to deficiencies in functional abilities and discharge status. One resident, dependent on staff and requiring a mechanical lift, was incorrectly coded as needing less assistance. Another resident's discharge status was inaccurately recorded as a hospital discharge instead of home. Staff interviews revealed lapses in verification and coding responsibilities.
A facility failed to develop a comprehensive hospice care plan for a resident with COPD and respiratory failure. The MDS Nurse admitted the oversight, and both the DON and Administrator were unaware of the missing care plan.
A resident with COPD and respiratory failure was receiving supplemental oxygen at 3.5 liters per minute without a physician's order. Facility staff, including a nurse, the unit manager, and the DON, confirmed that an order should have been present in the resident's chart, indicating a lapse in protocol.
A facility failed to follow infection control policies during wound care for a resident with a full-thickness wound. Nurse #1 did not wear a gown or perform hand hygiene between steps, as required by Enhanced Barrier Precautions (EBP). The nurse was unaware of the EBP requirement due to improper signage and lack of gowns outside the resident's room. The DON confirmed the oversight and acknowledged the need for proper infection control practices.
The facility failed to maintain daily nurse staffing records for 472 out of 519 days due to a change in ownership, resulting in the loss of access to previous records. Interviews with the Scheduler and Administrator confirmed the absence of these records, which should have been maintained for 18 months.
Verbal Abuse and Use of Profanity Toward a Resident During Care Dispute
Penalty
Summary
The deficiency involves a failure to honor a resident's right to dignity, respect, and self-determination when staff engaged in a verbal argument with the resident, using profanity and derogatory language. The resident was cognitively intact and had an active care plan addressing mood symptoms and poor coping strategies related to past emotional and physical abuse, with interventions focused on supporting communication, identifying stressors, and giving the resident control over her environment and care. Despite these identified needs and interventions, the resident reported that during an evening shift, a nurse aide became annoyed when she expressed her shower preferences and requested another staff member, leading to an escalating confrontation. According to the resident, the nurse aide began calling her a "b****" and repeatedly saying "f*** you" after the resident requested a different caregiver for her shower. The resident acknowledged that she responded by calling the aide names, including "nasty" and "b****," and telling the aide to get out of her room. A second nurse aide then came down the hallway during the argument; when the resident stated she was going to call her father about how she was being treated, this aide yelled down the hallway, "f*** your daddy." The resident reported that the first aide later returned to her room and resumed yelling and cursing, stating she was "sick and tired of this b****" and referencing a prior alleged incident in which another aide had supposedly slapped the resident, which the resident perceived as taunting. Multiple staff interviews corroborated that there was loud yelling and cursing between the resident and the first nurse aide, and that the conflict was audible down the hallway. The second aide reported hearing the argument from the nurse's station and stated that the first aide described the resident as a "b****" and complained that the resident did not want her to provide the shower. The restorative aide and a nurse both reported arriving at the room and observing the first aide and the resident yelling and cursing at each other, and both described that the first aide returned to the room after initially being removed and resumed yelling and calling the resident a "b****." The restorative aide further reported hearing both aides at the nurse's station talking about the resident as a "b****" and a difficult resident in an area where other residents could hear. The former DON and former Administrator both acknowledged that the aides should not have yelled or cursed at the resident and that the allegation of verbal abuse toward the resident by the two aides was substantiated.
Failure to Recognize Severity of Injury and Bleeding Risk in Anticoagulated Resident
Penalty
Summary
The deficiency involves the facility’s failure to recognize the severity of an injury and the increased risk of bleeding in a resident receiving daily anticoagulant therapy, and to initiate timely emergency medical intervention. The resident had multiple diagnoses including diabetes mellitus, a prior tibia fracture, hypertension, osteoporosis, history of DVT, and was on Eliquis 5 mg twice daily for DVT prevention. Her care plan identified anticoagulant use as a risk factor, with interventions to observe for abnormal bleeding or bruising. On the day of the incident, a nurse aide was providing a bed bath and then assisted the resident into a wheelchair, placing her feet on pillows on the leg rests. While pulling the wheelchair backward alongside the bed, the resident’s left lower leg struck the damaged corner of the bed footboard, where laminate was missing and pressboard was exposed. The resident immediately cried out in pain, reporting pain at 10/10, and her lower left leg began bleeding. The nurse aide attempted to control the bleeding by first using paper towels, which became saturated, and then a regular bath towel, while calling for a nurse. Nurse #1 entered, observed a one‑inch laceration on the resident’s left lower leg with increased bleeding, applied pressure for about five minutes, and then applied a pressure dressing. Nurse #1 documented the injury as a skin tear and noted that the resident’s anticoagulant was held, but did not initiate EMS or transfer the resident to a higher level of care, stating she did not think the resident needed to go to the hospital. Vital signs were documented as within or near normal limits, and no pain score was recorded in the SBAR note. The DON, who was in the facility at the time, did not go to the room or assess the wound and understood from Nurse #1 that the bleeding was controlled and that the resident did not need to be sent out immediately. The Medical Director later stated he was not informed that the resident’s leg had been struck on the footboard and that he would have sent her to the hospital due to her increased bleeding risk. After staff left the room, the resident called her Responsible Party, who came to the facility, observed red blood on the white dressing, and, after learning the facility was not sending her out, called 911. EMS records show they were told by the nurse that the resident had a 1–2 inch laceration to the left lower leg, that bleeding had been controlled with gauze and tape, and that pain medication had been administered. EMS noted the resident was in emotional distress with a pain level of 10/10, elevated blood pressure and heart rate, and bruising and swelling of the left lower leg. At the hospital ED, the resident was found to have a 2 cm skin tear with drainage and a large associated hematoma measuring approximately 4 x 7 inches, with difficulty controlling bleeding at the facility cited as a reason for referral. During hospitalization, imaging and assessment identified a large superficial soft tissue hematoma measuring 16.2 cm, with a documented decline in hemoglobin from 11.1 to 7.3 over two days, consistent with acute blood loss anemia requiring transfusion, and subsequent necrosis over the hematoma that required surgical evacuation, debridement, and wound VAC placement. The facility’s failure to adequately assess the injury, consider the impact of anticoagulant therapy, and promptly initiate emergency medical intervention for active bleeding in this anticoagulated resident constituted the cited deficient practice. Following discharge back to the facility, the resident required ongoing wound care and pain management. Wound care NP notes documented a large wound area on the left lower leg with necrotic tissue requiring daily dressing changes with Santyl and Dakin’s solution initially, later transitioning to xeroform and abdominal pads, with the wound described as improving but with a large surface area and low probability of full skin healing. The resident continued to report pain, particularly with dressing changes, and received frequent doses of oxycodone and acetaminophen for pain levels ranging from 0 to 10 on the pain scale. The Medical Director and Wound Care NP confirmed that the resident had sustained a significant hematoma requiring surgical intervention and that the wound remained a large open area. The surveyors determined that the facility’s failure to recognize the severity of the injury and the resident’s increased bleeding risk due to anticoagulant use, and to initiate timely emergency medical intervention, resulted in serious complications related to acute blood loss and extensive wound care needs for this resident. The survey findings also noted that Nurse #1 was an agency nurse working her first day in the facility and did not follow facility policy on anticoagulants or significant change in condition, including appropriate monitoring and physician notification for residents on anticoagulation who exhibit excessive bruising or bleeding. The DON and Administrator acknowledged that they were informed of the incident after it occurred and that the primary focus at the time was obtaining an order to hold the evening dose of the anticoagulant, rather than assessing the full extent of the injury or the need for immediate transfer. The Medical Director later stated that a “red flag” such as increased bleeding and pain in an anticoagulated resident would warrant consideration of hospital transfer. The survey concluded that Immediate Jeopardy began when Nurse #1 failed to recognize the severity of the injury and the resident’s increased risk of bleeding due to anticoagulant use, and that this deficient practice affected one of three residents reviewed for quality of care.
Removal Plan
- ADON audited the electronic health record order listing report to identify all residents receiving anticoagulant therapy and established this as an ongoing audit updated with each admission.
- DON audited all incident and accident reports for the past 30 days to ensure any incident resulting in injury received timely and appropriate treatment.
- Licensed nurses completed a facility-wide skin assessment for all residents receiving anticoagulant therapy to ensure no excessive bruising or bleeding and documented results in the electronic health record.
- Administrator and DON completed a root cause analysis identifying lack of recognition by an agency nurse of the need to transfer a resident to the ED and failure to follow the anticoagulant/significant change in condition policy.
- Held an ad hoc QAPI meeting to review the deficient practice and plan of correction.
- Administrator reviewed facility policy and clinical protocol for anticoagulation and change in condition and determined no changes were warranted.
- DON educated all licensed nurses, including agency nurses, on recognition and assessment of abnormal bruising and bleeding for residents on anticoagulants, use of e-interact tools, notifying MD/NP when an anticoagulated resident sustains an injury, and seeking a higher level of treatment for continued bleeding after 15 minutes of pressure or a pressure dressing.
- Incorporated the licensed-nurse education into orientation and onboarding for newly hired nursing staff, including agency nurses, with DON or designee to provide education and electronic training at onboarding.
- DON and ADON track and maintain education records to ensure staff receive the licensed-nurse education prior to start of their next shift.
- DON educated all nurse aides on recognizing changes in condition including excessive bleeding and on using the Stop and Watch Tool to immediately alert licensed nursing staff.
- Incorporated the nurse aide education on Stop and Watch and change in condition into orientation for newly hired staff, including agency staff, provided by DON or designee.
- Administrator is responsible for execution of the credible allegation and immediate jeopardy removal plan.
Unsafe Transfers, Damaged Equipment, and Policy Noncompliance Lead to Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents for multiple residents, including a dependent resident receiving anticoagulant therapy. One resident with diabetes mellitus, right tibia fracture, hypertension, muscle weakness, osteoporosis, history of DVT, and physical debility required two-person assistance with transfers and was on Eliquis, a medication with manufacturer guidance warning of serious bleeding risks. A PT evaluation documented severely decreased bilateral lower extremity range of motion, contractures, and an inability to tolerate upright positioning without both legs elevated on pillows and leg rests. Despite these needs, on the day of the incident a nurse aide performed a one-person mechanical lift transfer from bed to wheelchair and then pulled the resident’s wheelchair backward alongside the bed, striking the resident’s lower left leg against a damaged bed footboard with missing laminate and exposed pressboard. Following the impact with the damaged footboard, the resident immediately cried out in pain, reported severe pain at a level of 10/10, and had active bleeding from a one-inch laceration on the lower left leg. The aide initially attempted to control the bleeding with paper towels and then a bath towel, which became saturated, before calling a nurse. The nurse assessed a one-inch slit on the left lower leg, noted increased bleeding related to anticoagulant therapy, applied pressure for approximately five minutes, and then applied a pressure dressing. Documentation indicated the resident’s anticoagulant was held and that the wound nurse and NP were notified. EMS records later described the nurse reporting difficulty controlling bleeding at the facility and that the resident continued to complain of severe pain, with elevated blood pressure and heart rate during EMS assessment. Hospital records documented a large superficial soft tissue hematoma of the left lower extremity, a significant drop in hemoglobin consistent with acute blood loss anemia requiring transfusion, and subsequent skin necrosis over the hematoma that required operative evacuation, surgical debridement, and wound VAC placement. The deficiency also includes the facility’s failure to ensure environmental safety and adherence to policies for other residents. One cognitively intact resident with rheumatoid arthritis, generalized muscle weakness, diabetes mellitus, and a care plan identifying fall risk due to impaired mobility, lower extremity weakness, psychoactive medication use, and visual impairment reported falling in the shower after using a loose grab bar. During a therapy session in the shower room, the resident told the OT that the grab bar was loose, but the OT did not respond and instructed the resident to rinse off. When the resident stood and pulled on the grab bar, it moved significantly, causing her to fall back onto the shower chair and then slide to the floor on her buttocks. The resident could not get up due to chronic knee and leg weakness and the wet, slippery floor, and therapy staff had to use a mechanical lift to transfer her to her wheelchair before she was later evaluated at the hospital. Additional deficiencies were identified related to supervision and environmental safety for residents who smoked. The facility failed to follow its smoking policy by allowing residents to keep smoking materials on their person and in their rooms instead of having them locked at the nurses’ station. This practice was identified for multiple residents reviewed for supervision to prevent accidents. The combination of unsafe transfer practices, use of damaged furniture that created an accident hazard, failure to respond to a reported loose grab bar in the shower, and noncompliance with the smoking materials policy led surveyors to determine that the facility did not ensure a safe environment free from accident hazards or provide adequate supervision to prevent accidents for several residents.
Removal Plan
- Provided 1:1 education to NA #1 regarding following the mechanical lift policy requiring 2-person assistance for all mechanical lift transfers and safe movement of residents in their room/environment.
- Completed an audit of the electronic health record order listing report to identify all residents receiving anticoagulant therapy and established this as an ongoing audit updated with each admission.
- Conducted a 100% audit of the Resident Kardex to identify residents requiring a mechanical lift and reinforced that transfer status is evaluated by the IDT on admission/readmission/significant change/quarterly with care plan updates populated to the Kardex by the MDS nurse/designee.
- Reviewed all incidents and the accident log for the prior 30 days to identify any other residents injured while being maneuvered in their wheelchair in their environment.
- Reviewed Resident #25’s care plan by the MDS Nurse, Administrator, and DON.
- Replaced Resident #25’s damaged footboard.
- Inspected resident furniture/rooms (including bed frames and bedside tables) to ensure no rough edges or hazardous surfaces were present and immediately replaced any damaged/broken furniture identified.
- Completed a Root Cause Analysis identifying failure to follow 2-person mechanical lift transfer policy and lack of education on safely maneuvering residents in their environment.
- Provided education to nurses and nurse aides on the facility’s safe resident transfer policy and required return demonstration using the mechanical lift with competency validation on a skills checklist (including verifying transfer status via the Kardex).
Improper Outdoor Trash Receptacle Maintenance and Standing Water
Penalty
Summary
The deficiency involves improper disposal and maintenance of garbage and refuse in the outdoor trash receptacle area behind the kitchen. During an observation with the Head [NAME], surveyors noted three used disposable gloves and a clear trash bag containing trash on the ground next to the trash receptacle, as well as another clear trash bag with trash hanging out of an open receptacle door. There were five collapsed cardboard boxes floating in approximately 5 inches of standing water in the trash and recycling area, which spanned about 15 to 20 feet, and a blue trash bag containing trash was floating in the standing water between the trash and recycling receptacles. An empty cardboard carton was also observed under the front of the recycling receptacle. The Head [NAME] stated that many staff members used the dumpster area, staff frequently forgot to close the receptacle doors, and rainwater pooled under the dumpster area without draining, causing the standing water. A second observation showed that the trash receptacle door remained open, with a clear trash bag containing trash hanging out, a used glove on the ground, two collapsed cardboard boxes floating in about 3 inches of standing water between the trash and recycling receptacles, and an empty carton under the recycling receptacle. The Regional Housekeeping Supervisor reported that many staff from multiple departments used the dumpster area, that staff were continually reminded to keep the doors closed, and that the trash pick-up service often caused materials such as collapsed cardboard boxes to fall out of the receptacles. A third observation with the Dietary Manager and Administrator again found the trash receptacle door open with a clear trash bag containing trash hanging out, two collapsed cardboard boxes in about an inch of standing water next to the recycling receptacle, and an empty carton under the recycling receptacle. The Administrator stated she had not been aware of the standing water and expected all staff who took out trash to maintain the area, while the Dietary Manager indicated that the trash pick-up company dumped items out of the dumpster and did not place them back inside.
Inaccurate MDS Coding for Range of Motion and Mobility Device Use
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for a resident in the areas of range of motion and mobility devices. The resident was admitted with diagnoses including a right tibia fracture, muscle weakness, and physical debility, and had a care plan indicating the need for assistance with ADLs and use of a mechanical lift with two staff for transfers. A Physical Therapy evaluation documented decreased bilateral lower extremity range of motion due to contractures and weakness, limited bed and wheelchair mobility, and the need for the resident’s bilateral lower extremities to be elevated on pillows and leg rests when in a wheelchair. The physical therapist confirmed that the resident’s range of motion was severely decreased and that her legs remained elevated on pillows and leg rests with wheelchair use. Despite these documented impairments and use of a wheelchair, the quarterly MDS assessment coded the resident as having no range of motion impairment in the upper or lower extremities and no use of mobility devices during the assessment period. The MDS Coordinator, who completed the assessment, later acknowledged that review of the Physical Therapy notes showed the resident did have bilateral lower extremity impairment and used a wheelchair as a mobility device, and stated that the MDS had been completed incorrectly. The Administrator also confirmed that the MDS should have been coded to accurately reflect the resident’s range of motion status and mobility device use.
Unsecured Potassium Capsule Left at Bedside Without Self-Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to properly secure and store a prescribed medication, specifically a potassium citrate capsule, for a resident who did not have an order or care plan to self-administer medications. The resident, cognitively intact and admitted with acute systolic heart failure and hypokalemia, had a physician’s order for a daily 20 mEq potassium citrate capsule. Surveyors observed a large white pill in a medication cup left on the bedside table while the resident was in bed. Review of the EMR confirmed there were no orders or assessments authorizing self-administration of medications for this resident. During interviews, the nurse assigned to administer medications that morning acknowledged she had given the resident her medications and confirmed the pill at the bedside was the potassium citrate capsule. She stated the resident preferred to take that pill later and admitted she left it at the bedside after being called away by another staff member, instead of returning it to the medication cart. The resident confirmed she did not like to take the large white pill with her other medications and that the nurse did not remove it. The NP stated the resident had never had an order to self-medicate and would not be able to self-medicate, and that medications should never be left at the bedside. The DON and Administrator both indicated the resident had no self-medication order and that the nurse should have removed the pill rather than leaving it at the bedside.
Unclean Kitchen Surfaces and Equipment in Food Preparation Area
Penalty
Summary
Surveyors identified a deficiency in kitchen sanitation and food service practices when they observed visible dirt and grime buildup on a large fire suppression tank and its tubing located above a toaster in a food preparation area, as well as visible food debris and grease buildup in the grout lines of the floor tiles in front of the cooking range. During the initial kitchen tour with the Head Cook, it was noted that these areas were not clean, and the Head Cook reported that housekeeping was responsible for cleaning the kitchen floors but was unsure of the cleaning schedule. The Head Cook acknowledged that grease and food debris would accumulate in the floor grout and stated she was unaware of the visible dirt and grime on the fire suppression tank. These conditions were found in one of two food preparation areas and were determined to have the potential to affect food served to residents. Interviews with the Housekeeping Supervisor and the Administrator confirmed that the kitchen floors had been recently pressure washed and that a new degreasing product had been ordered due to the prior product not adequately cleaning the floors, but at the time of the survey the buildup of grime, grease, and food debris remained present in the identified areas.
Failure to Use Required PPE Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy and posted instructions for use of personal protective equipment (PPE) during high-contact care activities for residents on EBP. The facility’s undated EBP policy required staff to wear gowns and gloves for high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care such as urinary catheter care. For one resident on EBP with a urinary catheter, a nurse entered the room where an EBP sign was posted on the door and PPE was available behind the door. The sign indicated that both gloves and a gown were required for high-contact care such as urinary catheter care. The nurse performed urinary catheter care wearing only gloves, without donning a gown, then discarded supplies and gloves and performed hand hygiene. In a subsequent interview, the nurse acknowledged awareness that the resident was on EBP but stated she did not know a gown was required for urinary catheter care. A second deficiency occurred when a nurse aide provided high-contact care to another resident on EBP without using all required PPE. This resident’s room also had an EBP sign posted outside the door instructing staff to wear a gown and gloves for high-contact activities such as transfers and urinary catheter care, and PPE was available on the back of the door. The nurse aide applied hand sanitizer and donned gloves but did not put on a gown before assisting the resident with a stand-pivot transfer from wheelchair to bed and handling the resident’s urinary catheter bag, including moving the bag and emptying it into a urinal, then disposing of the urine and cleaning the urinal. In an interview, the nurse aide stated she was not aware the resident was on EBP, reported she did not notice the dark gray EBP sign because she was used to light blue signs with red stop signs, and stated she did not know a gown was required for transferring and providing care to residents with urinary catheters. The DON/Interim Infection Preventionist and the Administrator both stated that staff were expected to use PPE according to the EBP signs posted for each resident.
Failure to Honor Resident’s Post-Dialysis Preference to Return to Bed
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s clearly expressed preference to return to bed immediately after dialysis, despite staff awareness of this routine. The resident had chronic kidney disease stage 4 requiring hemodialysis three times weekly and type 2 diabetes mellitus, and was dependent on staff for transfers via mechanical lift. Her MDS indicated it was very important for her to choose her bedtime, and she had a dialysis care plan noting scheduled treatments on specific days. The resident reported that her dialysis days began at 2:00 AM and that she was extremely tired and ready to return to bed upon arrival back at the facility, yet she sometimes waited until after lunch to be placed back in bed. On an observed dialysis return day, the resident arrived back on the unit around 10:40 AM and activated her call light at 10:43 AM. An agency nurse aide (NA #10) entered the room at 10:45 AM, turned off the call light, and told the resident she was completing rounds and would return, but did not allow the resident to state her needs and did not request assistance from other staff. The call light remained off and the resident was not assisted back to bed at that time. The resident later reactivated her call light at 11:25 AM. Another nurse aide (NA #7) responded at 11:28 AM, turned off the call light, and informed the resident she needed another staff member to assist with the mechanical lift transfer, as two staff were normally required for such transfers. NA #7 attempted to assist the resident at 11:34 AM but had to leave to obtain help, stating she had requested assistance from another staff member. The resident reactivated her call light again at 11:40 AM. At 11:43 AM, the certified occupational therapy assistant (COTA #1) and NA #7 returned and transferred the resident back to bed with the mechanical lift without concerns. During this period, the resident reported feeling very tired and lightheaded from dialysis and stated she had been waiting over 45 minutes. Interviews with regular staff and the unit manager confirmed that staff were generally aware that the resident preferred to go to bed as soon as possible after dialysis, and that usual practice was to assist her within about 10–15 minutes. NA #10, however, as agency staff, reported not receiving a full report, was unaware of the resident’s preference, did not communicate the need to other staff, and did not return to the resident after assisting another resident, resulting in an extended delay in honoring the resident’s request to return to bed after dialysis. Additional interviews further clarified the sequence of inactions that led to the deficiency. NA #10 acknowledged that she was assigned to the resident that day for bathing and dressing, that the resident had voiced she was ready to lie down after dialysis, and that she did not notify or request assistance from other staff members despite being occupied with another resident on a different hall. She also stated she believed it was not the responsibility of other staff to address needs for residents on her assignment and that she had not received report regarding the resident’s post-dialysis preference. NA #7 and COTA #1 both confirmed that staff were aware the resident liked to go to bed upon return from dialysis and that the delay on the observed day was atypical. Facility leadership, including the unit manager, DON, and administrator, confirmed that staff were expected to respond promptly to call lights and that the resident, being alert and oriented, could clearly communicate her preferences and choices, including the request to return to bed after dialysis, which was not honored in a timely manner on the observed occasion.
Failure to Maintain Bed Footboards in Safe, Homelike Condition
Penalty
Summary
The facility failed to maintain bed footboards in good repair in a shared room occupied by two residents, resulting in exposed, rough particle board surfaces on both beds. During observation, one resident’s footboard was missing banding, leaving a 3–4 inch rough area of exposed particle board, while the other resident’s footboard had multiple damaged areas, each about 6 inches long, where the laminate covering was missing and particle board was exposed. Review of the facility’s online maintenance work order system over an approximately one-year period showed no documented requests for repair of these bed footboards. A nurse aide reported that the outer coating on one resident’s footboard had been missing for some time, exposing rough particle board, and confirmed that both footboards had exposed particle board, but she had not notified any staff members. An agency nurse stated she had observed damage to the outer coating of both residents’ footboards a couple of weeks earlier but assumed Maintenance was already aware and did not report it. The Maintenance Director, who had been employed since the previous April, stated he was unaware of the damage until notified by the Administrator and that staff were expected to submit work orders when beds were in disrepair. The DON and Administrator both stated they were not aware of any damage to the footboards until it was brought to their attention during the survey, despite nursing staff having access to a system to request maintenance concerns at all times.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to provide a safe transfer for a resident using a mechanical lift, resulting in a fall. During the transfer, a frayed strap on the lift pad broke, causing the resident to fall approximately three feet to the floor, hitting her head and landing on her right side. The resident was assessed by a nurse and found to have a large hematoma on the back right side of her head and reported pain on her entire right side. The resident was transported to the emergency department for further evaluation, where CT scans and x-rays showed no fractures or acute injuries. However, the resident experienced acute respiratory insufficiency related to rib pain and/or narcotic administration while in the emergency department. The incident was attributed to the failure of the staff to inspect the lift sling for wear and tear before use, as required by the manufacturer's instructions. The nurse aides involved in the transfer did not ensure the sling was in good condition, leading to the strap breaking during the transfer. Additionally, the facility failed to secure the mechanical lift brake when transferring another resident, which could have resulted in a similar accident. These deficiencies were observed in two of the six residents reviewed for accidents. The facility's failure to adhere to safety protocols and inspect equipment before use placed residents at risk of serious injury. The incident with the mechanical lift highlighted the need for staff to follow proper procedures and ensure equipment is in good repair before use. The facility's lack of compliance with these safety measures resulted in immediate jeopardy, which was later removed after implementing corrective actions.
Removal Plan
- One on one competency assessments were completed for the two nurse aides involved in the incident by Licensed Charge Nurse with emphasis on safety procedures including how to inspect lift slings for rips, tears, and frays, and to immediately remove any slings that are defective.
- The two nurse aides demonstrated correct usage of the mechanical lift.
- In-person education was provided to all nurse aides and licensed nurses on duty by the Maintenance Director on proper lift usage and safety procedures including how to inspect lift slings for rips, tears, and frays before each use, as well as to immediately remove any slings from use if they are defective and take them to their immediate supervisor.
- The in-person training was continued for all direct care staff, including agency staff, for those not on duty the day of the incident.
- All agency staff were in-serviced during facility orientation.
- The Director of Nursing was responsible for tracking the staff that required education and for providing the education.
- Staff were not allowed to work until education was completed.
- New hires, including agency staff, are required to complete education during orientation.
Facility Fails to Provide Adequate Bariatric Supplies
Penalty
Summary
The facility failed to accommodate the bariatric needs of two residents by not providing the correct size briefs and fitted sheets. Resident #64, who was admitted with diagnoses including cerebral infarction, obesity, and stress incontinence, reported that the facility often ran out of 2X briefs, leading staff to use smaller, uncomfortable briefs that left red marks on her thighs. Additionally, Resident #64 experienced a lack of fitted sheets for her bariatric bed, with staff citing a shortage of linens. Observations confirmed the absence of linens and towels in the supply closet, and staff interviews corroborated the ongoing issue of insufficient supplies. Resident #28, diagnosed with morbid obesity, chronic kidney disease, and amyotrophic lateral sclerosis, also faced similar issues with the facility running out of 2X briefs and having to use smaller, uncomfortable briefs. She reported that staff would hand out multiple briefs per resident as a sign of low supplies and mentioned that wipes were also in short supply. Resident #28 experienced having linen with holes and occasionally went without a fitted sheet. Staff interviews confirmed the frequent shortage of large briefs and linens, with some sheets having holes and residents sometimes going without fitted sheets. Interviews with various staff members, including nurse aides and nurses, revealed that the facility had been experiencing supply issues, particularly with bariatric briefs and linens. The supply clerk had quit four weeks prior, and staff had to ration supplies, often running out before the next shipment. The Regional Housekeeping Director mentioned that a linen cart was available for the third shift, but staff reportedly did not retrieve it. The facility administrator acknowledged the supply issues and stated that a new company had been hired to purchase briefs, and more linens had been ordered.
Neglect in Providing Bariatric Supplies
Penalty
Summary
The facility neglected to provide an adequate supply of linens and size 2x incontinent briefs for two residents who required bariatric goods. This deficiency was identified through record reviews, observations, and interviews with both staff and residents. The facility failed to accommodate the specific bariatric needs of these residents by using the incorrect size briefs and not providing fitted sheets, which are essential for their care and comfort.
Deficiency in RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was scheduled for at least 8 consecutive hours per day, 7 days a week, as required. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Reports and the facility's daily assignment schedules. Specifically, there were multiple dates across several months in 2024 where no RN coverage was documented, including specific days in January, February, March, May, June, October, November, and December. The absence of RN coverage was confirmed by the facility's Staff Scheduler, who acknowledged the difficulty in finding replacements when scheduled RNs called out, particularly on weekends. The facility's Administrator confirmed the lack of RN coverage on the identified dates and noted that the facility had come under new ownership in December 2024. Despite efforts to hire additional nursing staff, including the use of staffing agencies, the facility was unable to provide records of RN coverage for the dates in question. The Administrator acknowledged the requirement for RN coverage and the ongoing challenges in maintaining adequate staffing levels.
Inaccurate MDS Coding for Functional Abilities and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the areas of functional abilities and discharge status. Resident #76, who was admitted with a right tibia fracture, muscle weakness, and cognitive communication deficit, was documented as requiring substantial to maximal assistance with transfers in the MDS. However, staff interviews and nursing summaries indicated that the resident was totally dependent on staff and required a mechanical lift for transfers. The MDS Nurse was unable to recall if she verified the resident's transfer status with direct care staff, resulting in an inaccurate coding of the resident's dependency level. For Resident #82, the discharge MDS assessment inaccurately indicated a discharge to a general hospital, while nursing progress notes confirmed the resident was discharged home with family. The MDS Nurse attributed the error to the Social Worker, who was responsible for coding the discharge status. The Director of Nursing and the Administrator both emphasized the importance of accurate MDS coding, highlighting the discrepancies in the discharge information.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident receiving hospice services. The resident, who was admitted with chronic obstructive pulmonary disease and respiratory failure, was cognitively intact and receiving hospice care. However, upon review, it was found that there was no hospice care plan documented in the resident's comprehensive care plan. The MDS Nurse, responsible for completing the care plans, acknowledged the absence of the hospice care plan as an oversight. The Director of Nursing confirmed that the MDS Nurse was responsible for developing comprehensive care plans and was unaware of the missing hospice care plan. The Administrator also stated he was not aware of the deficiency.
Failure to Obtain Physician's Order for Supplemental Oxygen
Penalty
Summary
The facility failed to obtain a physician's order for the use of supplemental oxygen for a resident diagnosed with chronic obstructive pulmonary disease (COPD) and respiratory failure. The resident, who was cognitively intact, had been receiving oxygen therapy at a setting of 3.5 liters per minute via nasal cannula since admission. Despite the ongoing use of supplemental oxygen, a review of the resident's physician's orders revealed no documented order for this treatment. Interviews with facility staff, including a nurse, the unit manager, and the Director of Nursing (DON), confirmed that there should have been a physician's order for the resident's oxygen use. The nurse and unit manager both acknowledged the absence of the order and expressed uncertainty as to why it was missing. The DON also confirmed that an order should have been present in the resident's chart, indicating a lapse in the facility's protocol for managing oxygen therapy orders.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policies and procedures during wound care for a resident with a full-thickness wound. Nurse #1 did not wear a gown as required by the Enhanced Barrier Precautions (EBP) policy during high-contact care activities. Additionally, Nurse #1 did not perform hand hygiene after removing a soiled dressing, cleaning the wound, and before applying a new dressing. This deficiency was observed during wound care for a resident who required EBP due to the presence of a wound. Nurse #1, who was not the regular Wound Care Nurse, was unaware that the resident required EBP and did not notice the EBP sign at the head of the resident's bed. The Director of Nursing (DON), who also served as the Infection Control Nurse, confirmed that staff should perform hand hygiene and change gloves between each step of the wound care process. The DON acknowledged that the EBP sign was not properly placed on the resident's door, and gowns were not available outside the room, which contributed to the oversight.
Failure to Maintain Nurse Staffing Records
Penalty
Summary
The facility failed to maintain a record of the daily posted nurse staffing sheets for 472 out of 519 days during the period reviewed from September 1, 2023, through January 31, 2025. The deficiency was identified through record review and staff interviews, revealing that no nurse staffing information was available for each month from September 2023 through mid-December 2024. This lack of documentation was attributed to a change in facility ownership on December 16, 2024, which resulted in the loss of access to the previous records. Interviews with the Scheduler and the Administrator confirmed the absence of these records. The Scheduler, responsible for completing and maintaining the daily staffing sheets for 18 months, indicated that the change in ownership led to the unavailability of records prior to December 16, 2024. The Administrator corroborated this, stating that the records should have been maintained for 18 months but were not available due to the ownership transition.
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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