Pembroke Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pembroke, North Carolina.
- Location
- 310 E Wardell Drive, Pembroke, North Carolina 28372
- CMS Provider Number
- 345409
- Inspections on file
- 30
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Pembroke Center during CMS and state inspections, most recent first.
A resident without DM and with no insulin order received 10 units of insulin lispro when a nurse, distracted during med pass, confused two residents who shared the same last name and failed to verify the correct patient before administration. The resident, who was cognitively intact and admitted with influenza and pneumonia, had active orders for oxygen, albuterol, digoxin, and metoprolol but none for insulin, and the eMAR contained no insulin orders. After the injection, the resident questioned the medication, stating she was not diabetic, and subsequent interviews with the nurse, unit manager, DON, pharmacist, medical director, and administrator confirmed that the insulin was administered in error because the nurse did not follow the required resident-identification and medication-verification checks.
A resident with a feeding tube and GERD was given an expired compounded medication, Pantoprazole Suspension, for nine days via enteral administration. The medication's expiration was not checked by nursing staff before administration, resulting in eighteen doses of expired medication being given before the error was discovered. The resident was evaluated in the emergency department and had no adverse effects.
A facility failed to prevent the diversion of discontinued Hydrocodone-Acetaminophen tablets, resulting in 20 missing doses for a resident with pressure wounds. The medication order was not entered into the electronic record, and the medication card was not removed from the cart after discontinuation. Nursing staff did not consistently document administration or remove discontinued medications, and count sheets were altered without explanation. The resident did not experience missed pain medication, but the facility substantiated the misappropriation of controlled substances.
Surveyors found that medication carts were left unlocked and unattended, loose and unsecured pills were present in drawers, expired OTC medications were available for use, and inhalation medication vials were not labeled or dated as required. Staff and the DON confirmed these practices did not meet expected standards.
Staff failed to follow infection control and Enhanced Barrier Precautions protocols for multiple residents, including those with COVID-19, indwelling urinary catheters, gastrostomy tubes, and pressure ulcers. Observed lapses included not wearing required PPE such as gowns and gloves, improper handling and cleaning of equipment, and incorrect disposal of soiled linens, despite staff awareness of policies and recent infection control training.
The facility did not provide written grievance summaries to two residents with severe cognitive impairment after concerns were raised about nail care, dressing for appointments, and assistance with bathroom transfers. Staff, including the Administrator, DON, and Social Worker, were unaware of the requirement for written notification, resulting in missing or incomplete documentation of grievance resolutions.
Two NAs refused to provide transfer and incontinence care to a dependent, cognitively intact resident after a disagreement, leaving her in a soiled brief and wheelchair for several hours in a semi-private room. The resident was found distressed and humiliated, with care only provided after a shift change.
A resident dependent on staff for ADLs due to hemiplegia was left without incontinence care and assistance to bed after two NAs refused to provide care following a disagreement. The resident remained in a soiled brief for several hours until the next shift, when staff found her still in her wheelchair with dried fecal matter and visibly upset.
A resident with CHF and multiple comorbidities experienced significant, unverified weight fluctuations due to the facility's failure to ensure reweighs were performed when large discrepancies were recorded. Staff entered weights into the medical record without confirming accuracy, and nurse aides did not reweigh unless specifically instructed. The DON and physician confirmed that significant weight changes should have prompted reweighs, but this was not consistently done, resulting in inaccurate documentation.
A resident admitted with multiple advanced pressure ulcers and osteomyelitis did not receive timely initial wound assessments or wound care orders upon admission. Nursing staff failed to document wound descriptions, obtain necessary orders, or initiate wound treatments within the required timeframe. Delays were compounded by the unavailability of wound vac supplies and lack of a dedicated wound nurse, resulting in missed and delayed wound care interventions.
A nurse aide failed to follow the care plan and Kardex instructions requiring two-person assistance for a resident with hemiplegia and dementia during incontinence care. While providing care alone, the resident rolled off the bed, resulting in a head laceration and a C1 cervical spine fracture. The aide did not check the Kardex or request help from available staff, leading to the incident.
A resident with a history of a stage IV pressure wound and osteomyelitis had a discontinued order for Hydrocodone-Acetaminophen 5-325 mg, but the medication was not removed from the med cart as recommended by the consultant pharmacist. The DON missed the pharmacist's note to remove the discontinued medication, resulting in 20 missing tablets being discovered during a later count.
A resident with multiple stage IV pressure ulcers and osteomyelitis did not receive four scheduled doses each of Piperacillin and Vancomycin after admission due to failure to enter and communicate IV antibiotic orders in the electronic medical record and to the pharmacy, resulting in delayed administration.
A resident with cognitive intactness and significant physical impairments requested that her air conditioner remain on, but a NA turned it off against her wishes. After the resident protested, the NAs refused to provide incontinence care and assistance to bed, leaving the room without fulfilling her care needs. Facility leadership confirmed that staff failed to respect the resident's choices and should have provided care regardless of her response.
A resident with CHF and on diuretic therapy experienced a significant weight gain of 26.8 lbs over 19 days, but staff failed to notify the provider as required. The nurse entering the weight noted an alert for significant gain but did not compare previous weights or inform the provider or dietitian, resulting in no action being taken regarding the resident's change in condition.
Quarterly MDS assessments for two residents were not completed within the required 14-day timeframe after the ARD. Staff interviews confirmed that the MDS CRC was unable to complete assessments on time due to covering multiple facilities, and both the DON and Administrator were aware of the delays, which were attributed to a vacant MDS CRC position.
A resident with multiple chronic conditions experienced a significant weight gain of 26.8 pounds in 19 days. Staff did not verify the accuracy of this weight change or notify the RD for a nutritional assessment, despite the electronic medical record flagging the gain as significant. Required reweighting and communication protocols were not followed, and the RD was only made aware of the issue by the surveyor.
A required annual performance review was not completed for a nurse aide, as confirmed by personnel records and staff interviews. The DON, responsible for these evaluations, had not conducted any annual reviews for nurse aides since her hire, and the affected nurse aide confirmed she had not received her evaluation.
Two residents, both cognitively intact and requiring assistance with ADLs, became involved in a physical altercation over a privacy curtain, resulting in one resident sustaining multiple bruises, abrasions, and a suspected fracture while on a blood thinner. Neither resident had a behavioral care plan, and staff were unaware of any prior behavioral issues or incompatibility before the incident.
A resident with end stage dementia receiving hospice care did not have current hospice documentation, including care plans and physician orders, in the facility's medical record. Hospice staff maintained records on their tablets and did not provide timely documentation to the facility, while facility nurses did not receive reports or integrate hospice information into the care plan. The DON and administrator confirmed there was no process in place to ensure hospice documentation was monitored or included in the resident's care plan.
A resident received Hydroxyzine 25 mg daily instead of as needed due to a transcription error in the medication order. Despite multiple checks by staff, the error was not identified, and the medication was administered nightly for nearly two months. The resident experienced no adverse effects and was unaware of the daily medication.
A facility failed to apply an ace wrap to a resident's swollen foot as ordered by a physician after a fall, and also failed to monitor blood pressure before administering Hydralazine to another resident. The ace wrap was not applied despite visible swelling and pain, and blood pressure readings were not recorded for noon and bedtime doses of the medication, contrary to physician orders.
A facility failed to provide sufficient nursing staff, affecting a dependent resident who required two-person assistance for care. The resident experienced falls during care due to inadequate staffing, particularly on night shifts. Staff interviews revealed frequent staffing shortages, reliance on unreliable agency staff, and challenges in finding replacements for call-outs. The Director of Nursing acknowledged the issues and was assessing staffing agency reliability.
The facility failed to ensure 8 consecutive hours of RN coverage on multiple days due to a misunderstanding of agency staff credentials, resulting in LPNs being used instead of RNs. The issue was compounded by data entry errors in the PBJ report, which did not accurately reflect the presence of an RN on one of the days.
A facility failed to act on a Pharmacist's recommendations to clarify a resident's Hydralazine dosage and add blood pressure checks before administration. Despite repeated monthly reviews from July to October, the facility did not update the MAR or clarify the dosage, leading to continued confusion. The new DON was unaware of these issues due to staff turnover, and the Unit Manager only addressed it after consulting the physician.
A facility failed to maintain proper communication and coordination of hospice services for a resident, resulting in missing hospice documentation in the resident's medical record. Staff reported ongoing challenges in obtaining necessary documentation from the hospice provider, and hospice documents were found to be disorganized in a box, complicating access to information. A meeting was scheduled to address these issues with the hospice provider.
A resident with cognitive impairment wandered into another resident's room and took personal items, leading to a physical altercation when confronted. The resident who confronted the other responded to a swing by punching the other resident in the forehead. No injuries were reported, but the incident was substantiated as abuse. The facility failed to protect residents from physical abuse.
A resident with significant mobility impairments fell twice from their bed due to inadequate supervision and staffing in an LTC facility. Despite requiring two-person assistance, care was provided by a single aide on both occasions, leading to falls and minor injuries. The facility's failure to adhere to the care plan and ensure proper staffing contributed to these incidents.
The facility failed to maintain complete medical records for three residents, with missing documentation for medication administration and wound care treatments. An agency nurse did not sign off on medications for hypertension and diabetes, while several nurses could not recall completing or documenting wound care treatments. The DON was unaware of these issues until the survey.
A cognitively impaired male resident sexually abused a female resident deemed incompetent by the court. Despite the male resident's documented history of sexually inappropriate behaviors, the facility failed to adequately monitor or prevent him from accessing the female resident's room, leading to the incident. Previous warning signs were not acted upon, resulting in the abuse.
Insulin Administered to Wrong Resident Due to Failure to Verify Identity
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when insulin was administered without a corresponding order. A cognitively intact resident admitted with influenza and pneumonia, and without a diagnosis of diabetes, had active physician orders for oxygen, albuterol, digoxin, and metoprolol, but no orders for insulin. The resident’s electronic MAR for the month showed no insulin orders. Despite this, the resident received 10 units of insulin lispro during a medication pass. On the day of the incident, a nurse working on the medication cart administered 10 units of lispro insulin to this resident instead of to the intended resident who shared the same last name. The nurse reported being distracted and acknowledged that she failed to adequately verify the correct resident before administering the medication. The resident questioned the injection, stating she was not diabetic and did not take insulin, after being told it was her evening insulin. The unit manager later confirmed that the nurse had given insulin to the wrong resident. Interviews with the DON, pharmacist, medical director, and administrator confirmed that the resident had no insulin order and that the insulin was given in error due to failure to verify the right resident. The DON and administrator both stated it was their expectation that the nurse verify the right resident, right medication, right dose, and right route prior to administration, which did not occur in this case. The pharmacist and medical director confirmed that the insulin administration was unintended for this resident and that it occurred because the nurse confused two residents with the same last name during the medication pass.
Expired Compounded Medication Administered via Enteral Tube
Penalty
Summary
A resident with a history of stroke with aphasia, gastrostomy tube feeding, and gastroesophageal reflux disease (GERD) was administered an expired compounded medication, Pantoprazole Sodium Oral Suspension, via enteral tube for nine days, totaling eighteen doses. The medication, which had a shortened expiration date due to its compounded nature, was stored in the medication cart and not checked for expiration prior to administration. The error was discovered after the resident had already received the morning dose, prompting notification of the responsible party and subsequent transfer to the emergency department for evaluation. The resident was found to have no acute complaints or adverse effects from the expired medication and was discharged back to the facility. The deficiency was identified through review of medication administration records, interviews with staff, the consulting pharmacist, and the physician. The consulting pharmacist confirmed that compounded medications have a short shelf life and require close monitoring of expiration dates. The physician stated that while no adverse effects were expected, nursing staff are required to ensure that expired medications are not present or administered. The incident was brought to the attention of facility leadership several months after it occurred, following a grievance filed by the resident's responsible party.
Failure to Prevent Diversion of Discontinued Narcotic Medication
Penalty
Summary
The facility failed to implement effective safeguards and systems to prevent the diversion of discontinued narcotic pain medication, specifically Hydrocodone-Acetaminophen 5-325 mg tablets, resulting in 20 missing tablets for one resident. The resident, who was cognitively intact and had a history of stage IV and stage II pressure wounds, was re-admitted with orders for Hydrocodone-Acetaminophen. Two separate physician orders were issued: one from the hospital and another from the facility physician, but the second order was not entered into the electronic medical record. Medication deliveries were signed in by nursing staff, and declining count sheets were maintained, but discrepancies arose between the count sheets and the Medication Administration Record (MAR), with some administrations not documented on the MAR and some signatures on the count sheet being illegible. The process for handling controlled substances was not consistently followed. The order for 54 tablets was not entered into the electronic record, and the medication card remained on the medication cart beyond the 14-day period specified in the order. Nursing staff failed to remove the discontinued medication card from the cart and return it to the pharmacy as required. During shift counts, it was discovered that the count on the narcotic sheet had been altered, with 20 tablets unaccounted for. Interviews with staff revealed confusion about responsibilities for removing discontinued medications and inconsistent practices regarding shift counts and documentation. Consultant pharmacists conducted periodic audits but did not review the specific resident's medication card during the relevant period. Communication lapses were noted between the nurse practitioner, nursing staff, and the DON regarding order entry and medication management. The facility substantiated the misappropriation of the resident's property, and the investigation was unable to determine who took the missing medication. The resident reported no issues with pain management and did not experience any missed doses, but the facility's failure to maintain accurate records and secure discontinued controlled substances led to the deficiency.
Medication Storage, Labeling, and Security Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to the storage and labeling of drugs and biologicals. An unattended and unlocked medication cart was left facing the hallway for 13 minutes, during which time three staff members and a resident in a wheelchair passed by. The Unit Manager later acknowledged forgetting to lock the cart, and the DON confirmed that medication carts are expected to be locked when not in direct line of sight. Additionally, another medication cart was found to contain 11 loose, unsecured pills of various types, with both the nurse and DON stating that medication carts should be clean and free of loose pills. Further observations revealed expired over-the-counter medication (Vitamin B6) available for use in a medication storage room, which both the Unit Manager and DON agreed should not occur. On another medication cart, 20 vials of ipratropium bromide inhalation solution were found in an open foil package without a label or date opened, despite manufacturer instructions to discard the medication two weeks after opening. The nurse responsible was unaware of this requirement, and the DON stated that all medications should be labeled and dated when opened.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement its infection prevention and control policies and procedures in multiple instances involving residents requiring special contact and droplet precautions, as well as Enhanced Barrier Precautions (EBP). In one case, a resident who tested positive for COVID-19 was on special contact and droplet precautions, as indicated by signage on the door and the availability of PPE supplies nearby. Despite this, a nurse aide entered the resident's room without donning gloves or a gown, moved a mechanical lift out of the room into the hallway without cleaning it, and later re-entered the room again without appropriate PPE to assist the resident. The mechanical lift was left unattended in the hallway until instructed by a unit manager to clean and store it properly. The nurse aide admitted to forgetting the required PPE and expressed confusion between different types of precautions, despite having received infection control training. In another instance, two nurse aides provided a bed bath and repositioned a resident with an indwelling urinary catheter, who was on EBP, while wearing gloves but not gowns. Both aides acknowledged during interviews that they were aware of the resident's precaution status and the need for gowns but failed to comply, attributing the lapse to forgetfulness. The Director of Nursing confirmed that all staff had received infection control training, especially following a recent COVID-19 outbreak, and that PPE supplies were adequate and available. Additional deficiencies were observed when a nurse aide provided care to a resident with a gastrostomy tube and another with a pressure ulcer, both on EBP, while only wearing gloves and not a gown. The aide also placed soiled linens on the floor instead of in a plastic bag, contrary to facility policy and her training. The aide admitted to not following protocol due to being rushed or not bringing the necessary supplies into the room. Interviews with supervisory staff confirmed that the expectation was for staff to follow posted EBP signage and infection control procedures, and that further education was needed.
Failure to Provide Written Grievance Summaries to Residents
Penalty
Summary
The facility failed to provide written grievance summaries to residents or their representatives as required by its own grievance policy. For two residents who were both severely cognitively impaired, grievances were filed regarding concerns such as inadequate nail care, improper dressing for appointments, and lack of assistance with bathroom transfers. In both cases, the grievance logs and forms either lacked documentation of written notification of the resolution or contained written summaries that did not correspond to the specific concerns raised. Staff interviews revealed that key personnel, including the Administrator, Director of Nursing, and Social Worker, were unaware of the requirement to provide written grievance summaries to residents or their representatives. Instead, resolutions were communicated verbally or not at all, and written documentation was either missing or incomplete. This resulted in the facility not adhering to its policy and regulatory requirements for grievance resolution documentation.
Neglect Due to Refusal of Care by Nurse Aides
Penalty
Summary
A deficiency occurred when two nurse aides (NAs) on the 3:00 PM to 11:00 PM shift refused to provide necessary care to a dependent resident with hemiplegia, cerebral infarction, and anxiety disorder. The resident, who was cognitively intact and fully dependent on staff for transfers and incontinence care, requested assistance to be transferred to bed and to receive incontinence care after her evening routine. The NAs entered the resident's room with a mechanical lift, turned off her air conditioner against her wishes, and left the room without providing care after the resident used a curse word in response. The resident was left sitting in her electric wheelchair in a semi-private room, exposed to her roommate, and was not assisted to bed or provided incontinence care for several hours. The resident's roommate confirmed the sequence of events, stating that the NAs refused to provide care after the resident expressed her displeasure at the air conditioner being turned off. The roommate observed that the resident remained in her wheelchair until after midnight, when the next shift arrived. When the night shift NAs finally provided care, they found the resident's brief heavily soiled with dried, caked bowel movement, indicating that incontinence care had been delayed for a significant period. The resident expressed feelings of embarrassment and humiliation due to being left in this condition in front of her roommate. Interviews with the involved NAs revealed that they refused to provide care because they felt disrespected by the resident's language. Both NAs acknowledged that they left the facility at the end of their shift without assisting the resident. The nurse on duty was informed of the incident but was not aware that care had not been provided before the NAs left. The night shift NAs and nurse confirmed the resident's distress and the delay in care. The deficiency was identified through observations, record review, and interviews, demonstrating a failure to protect the resident from neglect and to uphold her right to receive necessary care.
Failure to Provide Incontinence Care and Assistance with ADLs
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to hemiplegia following a stroke, was not provided with necessary incontinence care and assistance to bed. The resident, who was always incontinent of bladder and bowel and required two staff members and a mechanical lift for transfers, requested help after soiling her brief. Despite activating her call light and requesting assistance, two nurse aides assigned to her care refused to provide the needed care after a disagreement regarding the room temperature and the resident's use of a curse word. The nurse aides admitted in interviews that they left the resident without care because they felt disrespected by her language. As a result, the resident remained in her wheelchair for several hours, waiting for the next shift to arrive. When the night shift nurse aides eventually assisted her, they found that she was still in her wheelchair, visibly upset, and had been incontinent for some time, with dried and caked fecal matter present. Interviews with additional staff, including the nurse on duty and the Director of Nursing, confirmed that the resident was not assisted to bed or provided incontinence care as required. The staff acknowledged that care should have been provided regardless of the resident's behavior, and that the refusal to provide care was not acceptable. The incident was corroborated by multiple staff interviews and direct observation of the resident's condition.
Failure to Verify Accuracy of Physician-Ordered Weights for Resident with CHF
Penalty
Summary
The facility failed to verify the accuracy of physician-ordered weights for a resident with congestive heart failure, resulting in inaccurate documentation of significant weight changes. The resident, who had multiple chronic conditions including CHF, COPD, and dementia, was at nutritional risk and had a care plan that included regular weight monitoring due to a history of weight fluctuations, fluid retention, and recent significant weight loss. Despite physician orders for weekly and monthly weights, and care plan interventions to weigh per policy, the facility did not ensure that weights were rechecked when large fluctuations were recorded. Review of the resident's medical record showed several instances of dramatic weight changes, such as a 20-pound loss in four days, without a reweigh being performed to confirm accuracy. Staff interviews revealed that nurse aides obtained weights and reported them to the unit manager, who entered them into the electronic medical record without always checking for significant changes. The unit manager acknowledged not directing staff to perform reweighs when large discrepancies occurred, contrary to facility policy. The nurse practitioner and physician both stated that significant weight changes should trigger a reweigh to ensure accurate data for clinical decision-making. Further interviews confirmed that nurse aides relied on instructions from nursing staff to perform reweighs and would not do so independently. The physician noted that some documented weights were implausible and had not been reported as changes in condition. The DON stated that staff were expected to review and compare weights, and to obtain a reweigh if there was a significant increase or decrease, but this process was not followed. As a result, inaccurate weights were documented, and significant changes were not verified or reported as required.
Failure to Complete Timely Wound Assessments and Initiate Wound Care on Admission
Penalty
Summary
A resident was admitted with multiple advanced pressure ulcers, including stage IV ulcers on the left ischium, sacrum, and right hip, a stage II ulcer on the right buttock, a deep tissue injury on the left heel, and osteomyelitis requiring intravenous and oral antibiotics. Upon admission, the facility failed to complete initial wound assessments within the first 24 hours, as required. There was no documentation of wound descriptions with measurements or physician orders for wound care until two days after admission. The initial wound care orders and assessments were not entered until the Unit Manager returned to work, and the responsible nurses on the weekend of admission were agency staff who did not complete the necessary documentation or obtain wound care orders. The resident's hospital discharge instructions included follow-up with a wound center and specific antibiotic regimens but did not provide detailed wound care orders. The facility did not initiate wound care treatments or document wound assessments until several days after admission. Orders for wound vac therapy and alternative wound dressings were delayed, and some were not administered or documented as completed on the days they were ordered. The wound vac was not available in the facility, and the order for its use was eventually discontinued by the Wound Care Physician due to lack of availability. The initial wound assessments with measurements were only completed three days after admission, and wound care treatments began at that time. Interviews with facility staff, including the Unit Manager, Medication Aide, Wound Care Nurse, Wound Care Physician, and DON, confirmed that the initial wound assessments and wound care orders were not completed as required upon admission. The lack of timely assessment and initiation of wound care was attributed to the failure of the weekend nursing staff to perform these duties, the absence of a dedicated wound nurse at the time, and the unavailability of necessary wound care supplies. The Wound Care Physician noted that the resident's wounds worsened during the stay, with factors including missed wound treatments and inadequate offloading.
Failure to Provide Required Two-Person Assistance During Bed Mobility Results in Resident Injury
Penalty
Summary
A deficiency occurred when a nurse aide provided incontinence care to a resident with a history of cerebral vascular accident (CVA), hemiplegia, and dementia, who was severely cognitively impaired and required extensive two-person assistance with bed mobility and activities of daily living. The resident's care plan and Kardex both indicated the need for two-person assistance for bed mobility. Despite this, the nurse aide proceeded to provide care alone, positioning the resident on her side and attempting to change the sheets while using only one hand to stabilize the resident. During the care, the resident began to move and subsequently rolled off the bed onto the floor, sustaining a laceration to the forehead and a nondisplaced fracture of the first cervical vertebrae (C1). The nurse aide immediately called for help, and nursing staff responded to provide emergency care and notify emergency medical services. The resident was transported to the hospital for evaluation and treatment, where the injuries were confirmed. Interviews and documentation revealed that the nurse aide did not check the Kardex prior to providing care, although she was aware from previous experience that the resident required two-person assistance. The assigned nurse and other staff were available and would have assisted if asked, but the nurse aide did not request help and attempted to perform the care alone, directly leading to the resident's fall and injury.
Failure to Remove Discontinued Narcotic Medication Leads to Missing Tablets
Penalty
Summary
The facility failed to act on the consultant pharmacist's recommendation to remove a discontinued narcotic pain medication, Hydrocodone-Acetaminophen 5-325 mg, from the medication cart after the order for a resident was discontinued. The resident, who had been re-admitted with a stage IV pressure wound and osteomyelitis, had a physician's order for Hydrocodone-Acetaminophen to be administered as needed for pain, which was completed as ordered. However, a subsequent delivery of 54 tablets was received and partially administered, with the order discontinued after 14 days. Despite the consultant pharmacist's note in the August pharmacy report instructing the removal and return of the discontinued medication, the medication remained on the cart. A random audit by the consultant pharmacist identified the issue, and the recommendation to remove the medication was communicated to the DON but was missed in error. As a result, 20 tablets of the discontinued narcotic were found to be missing when the count was checked several months later. Staff interviews confirmed that the pharmacist's recommendations were not routinely followed up on, and the DON acknowledged responsibility for acting on the monthly pharmacy reports but failed to do so in this instance.
Missed IV Antibiotic Doses Due to Failure in Order Entry and Communication
Penalty
Summary
A deficiency occurred when a resident admitted with multiple stage IV pressure ulcers, osteomyelitis, and paraplegia did not receive prescribed intravenous antibiotics (Piperacillin Sodium Tazobactam and Vancomycin) as ordered for the treatment of osteomyelitis. The hospital discharge instructions included specific orders for both antibiotics, but review of the Medication Administration Record (MAR) showed that the first doses were not administered until two days after admission, resulting in four missed doses of each antibiotic. There was no documentation in the resident's progress notes explaining the missed doses during this period. Interviews revealed that the Unit Manager, who was responsible for reviewing admission orders, did not ensure the antibiotic orders were entered into the electronic medical record upon admission. The admitting nurse did not send the antibiotic orders to the pharmacy or enter them on the day of admission. The pharmacy did not receive the orders until the following day, delaying delivery and administration. The Director of Nursing confirmed that the orders should have been entered and the antibiotics administered sooner.
Failure to Honor Resident's Right to Make Choices Regarding Room Temperature and Care
Penalty
Summary
A deficiency occurred when a nurse aide (NA) turned off a resident's air conditioning against the resident's explicit wishes, thereby failing to honor the resident's right to make choices. The resident, who had a history of hemiplegia, cerebral infarction, and anxiety disorder, was cognitively intact and dependent on staff for transfers and toileting hygiene. On the night of the incident, the resident requested assistance with incontinence care and to be helped to bed. When the two NAs entered the room, they asked if they could turn off the air conditioner due to the cold temperature, but the resident refused. Despite this, one NA turned off the air conditioner, prompting the resident to use a curse word in protest. Following the resident's response, both NAs refused to provide the requested care and left the room, stating they did not want to argue with the resident. The incident was witnessed by the resident's roommate, who confirmed that the NAs disregarded the resident's wishes and left after being spoken to disrespectfully. The NAs later reported the incident to the nurse on duty. Both NAs stated they had received training on resident rights, including the right to make personal choices. Interviews with facility leadership, including the DON and the Administrator, confirmed that the NAs should not have turned off the air conditioner without the resident's permission and should have provided care regardless of the resident's language. The staff's actions resulted in the resident's choices not being respected and necessary care being withheld.
Failure to Notify Provider of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the provider of a significant weight gain in a resident with a history of congestive heart failure (CHF) who was prescribed diuretic medications. The resident was admitted with multiple diagnoses, including CHF, atrial fibrillation, hypertension, and peripheral vascular disease, and had physician orders for daily weights and diuretic therapy. Over a 19-day period, the resident experienced a weight gain of 26.8 pounds, increasing from 220.2 lbs to 247 lbs. Despite this significant change, there was no documentation that the physician or nurse practitioner was notified of the weight gain, as required for residents with CHF. Interviews with facility staff revealed that the nurse responsible for entering the resident's weight into the electronic medical record noticed an alert indicating a significant weight gain but did not compare the current and previous weights to confirm the extent of the change. As a result, neither the medical provider nor the registered dietitian was informed. Both the DON and the NP confirmed that their expectation was for the provider to be notified of such changes, especially given the resident's CHF diagnosis and the potential need for treatment adjustments.
Late Completion of Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within 14 days of the Assessment Reference Date (ARD) for two residents. For one resident, the quarterly MDS assessment had an ARD of 7/10/25 but was not completed until 7/30/25. For another resident, the quarterly MDS assessment had an ARD of 7/23/25 and was completed on 8/20/25. Staff interviews revealed that the MDS Clinical Reimbursement Coordinator (CRC) was aware of the late assessments and attributed the delays to her responsibilities across multiple facilities, which prevented timely completion. The Director of Nursing (DON) and the Administrator both acknowledged awareness of the late MDS assessments, with the Administrator citing a vacant MDS CRC position as the reason for the delays.
Failure to Verify Significant Weight Gain and Notify Dietitian
Penalty
Summary
The facility failed to ensure the accuracy of a resident's weight measurement and did not communicate a significant weight gain to the Registered Dietitian for further nutritional assessment. A resident with multiple diagnoses, including right above the knee amputation, atrial fibrillation, hypertension, congestive heart failure, and peripheral vascular disease, experienced a weight increase of 26.8 pounds over 19 days. The care plan for this resident included monitoring for fluid volume excess and required staff to alert the dietitian and physician to any significant weight changes. Despite the electronic medical record flagging the weight gain as significant, staff did not perform a reweight within 24 hours as required by facility policy, nor did they review previous weights before entering the new value. Interviews with the Unit Manager, Nurse Practitioner, and Registered Dietitian confirmed that a reweight should have been conducted promptly for any weight change exceeding 5% in a month or 10% in six months. The Registered Dietitian was not notified of the significant weight gain until informed by the surveyor, and no additional weights were documented after the initial flagged entry. The Director of Nursing also confirmed that the expectation was for nursing staff to perform a reweight within 24 hours in the event of such discrepancies, which did not occur in this case.
Failure to Complete Annual Performance Review for Nurse Aide
Penalty
Summary
The facility failed to complete a required annual performance review for a nursing assistant, as evidenced by the absence of documentation in the personnel file for the nurse aide hired on 7/30/24. Record review confirmed that no performance evaluation had been conducted within the past year. Interviews with the Administrator and the Director of Nursing (DON) revealed that the DON, who was responsible for conducting these reviews, had not performed any annual performance reviews for nurse aides since being hired in March 2025. The nurse aide also confirmed that she had not received her expected annual evaluation.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident's right to be free from abuse was not protected, resulting in a resident-to-resident altercation. One resident, with a history of bipolar disorder and bilateral below-the-knee amputation, engaged in a physical altercation with her roommate, who had a history of cerebral vascular accident and was on a blood thinner for atrial fibrillation. The incident began as an argument over the room's privacy curtain, escalating when both residents attempted to control the curtain using a reacher. The resident with bipolar disorder scratched and hit her roommate, causing multiple bruises, abrasions, and a hematoma on the roommate's left hand and arm, which later required hospital evaluation and treatment for a suspected fracture. At the time of the incident, neither resident had a care plan addressing behavioral disturbances, and both were assessed as cognitively intact with no prior behavioral symptoms directed toward others. The altercation was witnessed by a nurse aide who heard yelling and attempted to intervene, but both residents were initially unwilling to let go of the curtain. The nurse aide called for additional staff, and the residents were separated. The injured resident was found with significant bruising, scratches, and bleeding, and was subsequently transferred to the hospital for further evaluation and treatment. Interviews with staff and the residents confirmed that the altercation was related to a disagreement over the privacy curtain, and that there had been no prior incidents or complaints between the two. The resident who initiated the physical contact had previously been involved in a minor altercation with another resident but had no documented behavioral care plan. The lack of a behavioral care plan and the absence of interventions to address potential roommate incompatibility contributed to the failure to prevent the abuse.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to coordinate a plan of care with the hospice provider and ensure that required hospice documentation was present in the medical record for a resident receiving hospice care. The resident, who had Alzheimer's disease and end stage dementia, was admitted to hospice services, but the facility's electronic medical record lacked current hospice orders, a signed election form, a hospice plan of care, hospice physician orders, hospice physician notes, a hospice medication list, and hospice nursing notes. The most recent hospice documentation in the facility's record was several months old, despite ongoing hospice services. Interviews with facility and hospice staff revealed that hospice assessments and notes were maintained on hospice staff tablets and were supposed to be sent to the facility, but this did not occur as required. Facility nurses reported that hospice staff would have them sign their tablets after visits but did not provide verbal or written reports, and hospice documentation was not integrated into the facility's care plan. The Director of Nursing confirmed that there was no collaboration between the facility and hospice staff to update the care plan, and that the process for obtaining and coordinating hospice documentation was lacking. The administrator and Director of Nursing acknowledged that there was no established process to monitor and update hospice documentation or to ensure that hospice information was included in the facility's care plan. As a result, the resident's care plan did not reflect current hospice interventions or coordination between the facility and hospice provider, and essential hospice documentation was missing from the resident's medical record for an extended period.
Medication Order Transcription Error
Penalty
Summary
The facility failed to accurately transcribe a medication order for a resident, resulting in the resident receiving Hydroxyzine 25 milligrams daily instead of as needed for itching. The resident, who was admitted with diagnoses including paraplegia and dementia, was cognitively intact and required extensive assistance with activities of daily living. The medication was administered nightly from September through early November, despite the order specifying it should be given as needed. The error was not identified during the admission medication review process, which involved multiple checks by the unit managers, admitting nurse, and the Pharmacist. Interviews with the Nurse Practitioner, Unit Manager, and Pharmacy Consultant revealed that the medication was considered low dose and not harmful, but the frequency error was not caught during the admission review. The resident did not experience any adverse effects from the medication and was unaware of the medications he received daily. The Director of Nursing acknowledged the error in the medication order entry, indicating that it should have been entered accurately as needed rather than scheduled nightly.
Failure to Follow Physician Orders and Monitor Blood Pressure
Penalty
Summary
The facility failed to follow a physician's order for a resident who sustained a fall and was experiencing swelling in her left foot. The resident, who was admitted with diagnoses including dementia and repeated falls, was found on the bathroom floor and complained of foot pain. A physician ordered an ace wrap to be applied to the resident's left foot as needed for swelling. However, observations on two consecutive days revealed that the ace wrap was not applied, despite the resident's complaints of pain and visible swelling and bruising. The nurse assigned to the resident did not apply the ace wrap, and the Director of Nursing was unaware of the order until later. Another deficiency involved the failure to obtain blood pressure readings before administering the antihypertensive medication Hydralazine to a resident with hypertension. The physician's order specified that the medication should be held if the systolic blood pressure was less than 120 mmHg. However, the Medication Administration Record (MAR) showed that blood pressures were recorded only for the morning dose, not for the noon or bedtime doses. This oversight persisted over several months, as evidenced by the lack of recorded blood pressures for the specified times in the resident's electronic medical record. The Consultant Pharmacist had addressed the need for blood pressure checks in her monthly reviews, but the issue remained unresolved. The Director of Nursing, who began working at the facility in October, was not aware of the Hydralazine order or the missing blood pressure checks. The failure to record and monitor blood pressure readings before administering the medication was a significant oversight, as the medication could cause a drop in blood pressure, necessitating careful monitoring.
Insufficient Nursing Staff Leads to Resident Falls
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure the necessary supervision and assistance level was implemented in accordance with the resident's plan of care. This deficiency affected a dependent resident who required two-person assistance for activities of daily living. The resident experienced falls from the bed during care on two occasions, resulting in minor injuries. Interviews with the resident and staff revealed that the facility often did not have enough staff, particularly during the night shift, leading to situations where only one nurse aide was available to provide care that required two people. Staff interviews further highlighted the staffing issues, with nurse aides and nurses indicating that they frequently had to provide care alone due to the lack of available staff. The facility relied heavily on agency staff, who often did not show up for their shifts, exacerbating the staffing shortages. The Nursing Scheduler/Payroll Manager and the Director of Nursing acknowledged the staffing challenges, noting difficulties in finding replacements for last-minute call-outs and no-shows. The Director of Nursing, who was new to the area, was in the process of evaluating the reliability of staffing agencies.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide 8 consecutive hours of Registered Nurse (RN) coverage on five specific days within a 60-day review period. The Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Year - Quarter 2, 2024, indicated that there was no RN coverage on several dates. Upon review, it was discovered that the facility mistakenly believed that agency nurses sent to cover shifts were RNs, when in fact, they were Licensed Practical Nurses (LPNs). This misunderstanding led to the absence of required RN coverage on the specified days. The Nursing Scheduler/Payroll Manager confirmed the lack of RN coverage on the identified dates and noted that an RN had worked on one of the days but did not punch the time clock due to being salaried. This discrepancy was not reflected in the PBJ report, likely due to data entry errors at the corporate level. The Administrator was unaware of the staffing issue and assumed the agency had provided RNs as requested. The facility's oversight in verifying the credentials of agency staff contributed to the deficiency.
Failure to Address Pharmacist's Recommendations for Medication Administration
Penalty
Summary
The facility failed to act on the Consultant Pharmacist's recommendations regarding the medication administration for a resident diagnosed with hypertension. The Pharmacist's monthly drug regimen review identified the need to clarify the dosage of Hydralazine and to add blood pressure checks prior to its administration. Despite these recommendations being made in July 2024, the facility did not update the Medication Administration Record (MAR) to include blood pressure checks, nor did they clarify the confusing dosage instructions. The resident was prescribed Hydralazine 25 mg to be taken three times a day, but the order was unclear whether the dose was 25 mg or 50 mg three times a day. The issue persisted through subsequent months, with the Pharmacist reiterating the need for clarification and blood pressure monitoring in September and October 2024. Interviews with the Consultant Pharmacist and facility staff revealed that the recommendations were not addressed due to staff turnover and lack of awareness by the new Director of Nursing (DON). The DON, who started in October 2024, was unaware of the outstanding pharmacy recommendations and had not prioritized them for correction. The Unit Manager eventually notified the physician, who confirmed the correct dosage and instructed to check blood pressure prior to administration.
Deficiency in Hospice Documentation and Communication
Penalty
Summary
The facility failed to maintain proper communication and coordination of hospice services for a resident receiving hospice care. The Nursing Facility Hospice Services Agreement required that hospice contact information and patient care details be documented in the resident's clinical record upon admission to hospice. However, the facility's records for the resident lacked essential hospice documentation, including the hospice agreement, provider order, certification for services, care plan, and visit notes from nursing, social work, and clergy. Interviews with facility staff revealed ongoing challenges in obtaining necessary documentation from the hospice provider. The social worker reported difficulties in acquiring a binder with the required hospice documentation and had been in contact with the hospice provider to address this issue. Despite efforts to communicate with the hospice director and arrange for documentation delivery, the facility continued to experience gaps in the resident's medical record. Further investigation showed that hospice documents were stored in an unorganized manner in a box in the medical records area, making it difficult for staff to access relevant information. The unit manager and medical records clerk acknowledged the disorganized state of the hospice documents and the lack of a systematic process for integrating hospice information into the electronic medical record. The administrator confirmed that a meeting was scheduled to address these communication issues with the hospice provider.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an altercation between two residents. Resident #80, who had a history of wandering and cognitive impairment due to vascular dementia, entered Resident #67's room and took several personal items. When Resident #67 confronted Resident #80 to retrieve her belongings, Resident #80 denied having them and swung at Resident #67. In response, Resident #67 punched Resident #80 in the forehead. Although no injuries were reported, the incident was substantiated as resident-to-resident abuse. Resident #80 was admitted with diagnoses including vascular dementia with behavioral disturbances and generalized anxiety disorder. Her care plan noted a history of wandering into other residents' rooms and taking their belongings, which had previously led to combative behavior. Resident #67, on the other hand, had intact cognition and no documented history of behavioral issues. The incident occurred when Resident #67 returned to her room and was informed by her roommate that Resident #80 had taken her belongings. This led to the confrontation and subsequent physical altercation. The facility's response included immediate notification of law enforcement and the Department of Social Services, as well as placing Resident #67 on one-to-one observation. Staff members, including Nurse #11, witnessed the incident and confirmed the sequence of events. The facility's investigation involved interviews with the involved residents and staff, and it was determined that Resident #80 did not recall the incident. Despite the lack of physical injuries, the facility's failure to prevent the altercation and protect residents from abuse was identified as a deficiency.
Inadequate Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to provide adequate care and supervision to a dependent resident, resulting in two falls from the bed during care. The resident, who had a history of brain neoplasm, hemiparesis, stroke, weakness, and seizures, required extensive assistance from two people for bed mobility and total assistance for transfers, toileting, and bathing. Despite these needs, the resident fell on two separate occasions due to inadequate staffing and failure to adhere to the care plan that required two-person assistance. On the first incident, a nurse aide attempted to provide incontinence care alone, despite knowing the resident required two-person assistance. The aide turned the resident onto her side, causing her to roll off the bed and sustain minor injuries. The facility was short-staffed, and the aide decided to proceed with care without assistance, leading to the fall. The resident was later transferred to the hospital for evaluation, where no significant injuries were found. In the second incident, another nurse aide also provided care alone, resulting in the resident sliding off the bed. The bolsters meant to aid in positioning were not properly attached, contributing to the fall. The resident was again assessed and found to have no significant injuries, but the incident highlighted ongoing staffing issues and failure to implement effective interventions to prevent further falls.
Incomplete Medication and Treatment Documentation
Penalty
Summary
The facility failed to maintain complete medical records for medication administration for three residents. Resident #36's Medication Administration Record (MAR) showed multiple instances where medications for conditions such as hypertension, hypocalcemia, constipation, anxiety, and depression were not signed off as administered by Nurse #13. Despite attempts to contact Nurse #13, there was no response, and the Director of Nursing (DON) was unaware of these omissions until the survey. Resident #38 also experienced similar issues with incomplete MAR documentation. Medications for hypertension and diabetes, including insulin administration, were not signed off by Nurse #13 on several occasions. The DON acknowledged awareness of documentation issues and noted that Nurse #13 was an agency nurse who failed to document medication administration and blood sugar checks as per physician orders. Resident #54's Treatment Administration Records (TAR) lacked documentation for physician-ordered wound care treatments on multiple dates. Interviews with several nurses revealed that they could not recall if the treatments were completed or why they were not documented. The DON, who was new to the position, expected accurate documentation of wound care treatments and recognized the existing issues with documentation inaccuracies.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect a female resident, who was deemed incompetent by the North Carolina Clerk of Court, from sexual abuse by a cognitively impaired male resident. On the morning of 05/15/24, a Nursing Assistant (NA) observed the male resident in the female resident's bed, performing oral sex on her. The female resident was incapable of giving consent due to her severe cognitive impairment. The male resident had a history of sexually inappropriate behaviors related to his cognitive loss and dementia, which was documented in his care plan. Despite this, the facility did not adequately monitor or prevent the male resident from accessing the female resident's room, leading to the incident of sexual abuse. The female resident had multiple diagnoses, including dementia with behavioral and psychotic disturbances, muscle weakness, hemiplegia, and chronic pain syndrome. Her care plan indicated she had tendencies to expose herself while lying in bed without privacy precautions. The male resident, who was moderately cognitively impaired, had a documented history of sexually inappropriate behaviors. On 05/11/24, the male resident was previously found attempting to get into the female resident's bed, but no further action was taken beyond removing him from the room. This lack of follow-up and monitoring allowed the male resident to re-enter the female resident's room on 05/15/24 and commit the act of sexual abuse. Interviews with staff revealed that the male resident had been restless and required frequent redirection on the night of the incident. Despite being placed at the nurses' station for observation, he was later returned to his room, where he managed to enter the female resident's room again. The facility's response to the initial incident on 05/11/24 was inadequate, as it did not involve a thorough investigation or increased monitoring of the male resident. This failure to act on the warning signs and the male resident's documented history of inappropriate behavior directly led to the sexual abuse of the female resident on 05/15/24.
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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