Person Memorial Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Roxboro, North Carolina.
- Location
- 615 Ridge Road, Roxboro, North Carolina 27573
- CMS Provider Number
- 345004
- Inspections on file
- 20
- Latest survey
- December 17, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Person Memorial Hospital during CMS and state inspections, most recent first.
A resident with anxiety disorder, colon cancer, and severe cognitive impairment, who was on hospice care, had a PRN Lorazepam order for anxiety that remained active for several months without a documented stop date or specified duration. The medication, a psychotropic and controlled substance, was administered two to three times weekly via PEG tube, while the EMR and MARs showed no 14-day limit or documented rationale for extending the PRN order. Nursing staff and a hospice nurse reported the resident experienced agitation and anxiety during care, and facility leadership and physicians acknowledged that PRN psychotropic medications should include a stop date, be reviewed within regulatory timeframes, and have a clear rationale and duration, which did not occur in this case.
Two residents receiving PRN Lorazepam for anxiety and agitation had ongoing psychotropic, controlled substance orders without stop dates, while the consultant pharmacist repeatedly identified this as an irregularity in monthly medication regimen reviews. The pharmacist emailed recommendation reports to the DON and Administrator, but due to leadership turnover, the process for forwarding these recommendations to physicians and obtaining documented acceptance or declination broke down. As a result, physicians did not review, sign, or respond to the pharmacist’s recommendations, and no physician documentation was entered into the residents’ medical records addressing the continued PRN psychotropic use without required stop dates.
Surveyors found that kitchen staff failed to keep two double-door ovens and a grill clean, with visible layers of burnt food, grease, and oil stains remaining after use. During a kitchen tour, a dietary aide acknowledged the equipment had been used earlier and needed cleaning. In addition, surveyors observed multiple food items in a reach-in and a walk-in refrigerator, including gravy, applesauce, and coleslaw, that were either only partially covered or not labeled or dated. The dietary director later confirmed that cooks were expected to clean equipment daily and that all dietary staff were responsible for labeling and dating leftover or opened food stored in the refrigerators, and the administrator stated that all leftover food should be covered and labeled, even if intended for an upcoming meal.
The facility failed to consistently post and maintain accurate daily nurse staffing information for residents and visitors. On observation, the staffing sheet displayed near a common area remained outdated and was not updated by nursing staff over multiple days. Over a multi‑week review period, multiple daily staffing postings were missing or unavailable, and several existing sheets lacked required Nursing Assistant names and hours for specific shifts. Staff interviews showed that the Scheduler was primarily responsible for preparing and maintaining these sheets, with the admission coordinator and nurses assisting when the Scheduler was unavailable, but missing and incomplete records persisted during this time of management turnover.
A resident with a history of stroke and left-sided weakness rolled off a raised bed during incontinence care, resulting in multiple severe fractures. The resident, who required extensive assistance and was dependent on staff for bed mobility, was positioned on her side and instructed to hold onto the upper side rail. She was unable to maintain her grip and fell from the bed, sustaining significant injuries. The care plan identified fall risk and called for side rail use and staff assistance, but only the top rails were up and the resident was expected to hold herself in position. Staff and family interviews confirmed the resident's limited mobility and the facility's awareness of her condition, yet no formal staff training on safe positioning or side rail use was conducted after the incident.
The facility failed to post and update daily nurse staffing information accurately, with discrepancies found between posted and actual staffing levels. Weekend nurses were unaware or forgot to update postings, and the scheduler did not consistently make necessary changes due to call-outs.
The facility failed to schedule an RN for at least 8 consecutive hours on two occasions. On these days, the RN was assigned to work as an NA, and no RN was present for the required shifts. The facility's practice of using RNs to fill NA roles when needed led to this deficiency.
The facility failed to manage medications properly, with expired and undated insulin vials found on medication carts, and loose pills discovered in cart drawers. Nurses did not check or clean the carts before shifts, contrary to facility expectations.
A facility failed to provide a written grievance summary for a resident with severe cognitive impairment. The resident's responsible party reported bruising, leading to an abuse investigation. Although management was notified and actions were taken, there was no documentation confirming the grievance resolution to the satisfaction of the complainant. The Social Worker was unaware of the grievance, and the Administrator did not document the resolution or provide written documentation to the family.
The facility failed to provide adequate nail care for two residents dependent on staff for ADL care. One resident with Parkinson's disease had excessively long and dirty fingernails despite requesting trimming, while another resident with severe cognitive impairment had long, deformed toenails. Miscommunication between facility and hospice staff led to neglect in nail care responsibilities.
The facility failed to assist three cognitively impaired residents with activities, despite their need for total assistance with transfers and locomotion. Staff often did not offer or provide the necessary help for residents to participate in activities of interest, such as music and religious services. The Activity Director had identified these residents' needs, but staff were unable to consistently assist due to other care responsibilities, resulting in missed activities.
The facility failed to make survey results accessible to residents in wheelchairs and did not post notices about their location. Observations revealed the survey book was placed out of reach, and residents were unaware of its location. Staff confirmed the absence of visible postings, and the Administrator acknowledged the inaccessibility.
Failure to Limit and Reevaluate PRN Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to limit the duration of a PRN psychotropic medication order to 14 days or document a specific duration and rationale for extending the order, as required by regulation. Resident #36, admitted with an anxiety disorder and diagnosed with colon cancer, was under hospice care and severely cognitively impaired, with no documented behaviors or rejection of care on the most recent MDS. On 5/9/25, the physician ordered Lorazepam Intensol 2 mg/ml, 1 ml via PEG tube every 2 hours PRN for anxiety. This PRN Lorazepam order, a psychotropic and controlled substance, remained active in the EMR from 5/9/25 through at least 12/17/25 without a documented stop date or specified duration beyond the initial order. Review of the MARs showed that the resident received two to three doses of PRN Lorazepam weekly from 5/9/25 through 12/17/25, with the last documented dose on 12/16/25. Nurse #1 and the hospice nurse both reported that the resident experienced agitation and anxiety during care and received PRN Lorazepam multiple times per week. The hospice nurse stated that hospice medications were reviewed every two weeks by the hospice interdisciplinary team, but the facility physician was responsible for writing and managing all medication orders and could accept or decline hospice recommendations. The interim DON, former Medical Director, and current Medical Director each acknowledged that PRN psychotropic medications should include a stop date, be reviewed within the regulatory timeframe, and have a documented rationale and specified duration, confirming that these requirements were not met for this resident’s ongoing PRN Lorazepam order.
Failure to Act on Consultant Pharmacist PRN Psychotropic Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that consultant pharmacist recommendations from monthly medication regimen reviews were acted upon and that physician responses were documented in the medical records for two residents receiving PRN psychotropic medications. For one resident with an anxiety disorder and a PEG tube, the physician ordered Lorazepam Intensol 2 mg/ml, 1 ml via PEG every 2 hours PRN for anxiety. This PRN psychotropic and controlled substance order, initiated in early May, remained active through mid-December without a stop date, while the medication was administered two to three times weekly. Monthly pharmacy consultation reports from July through December repeatedly recommended that the physician address the PRN Lorazepam order due to the missing stop date, but there was no evidence in the consultation reports or the resident’s EMR that any physician reviewed, accepted, declined, or otherwise responded to these recommendations. A second resident with major depression and an anxiety disorder had a physician order for Lorazepam 1 mg by mouth every 8 hours PRN for anxiety and agitation, also a psychotropic and controlled substance. This PRN order remained active from mid-October through mid-December without a stop date, and the medication was administered one to two times weekly. A pharmacy consultation report in November recommended that the physician address the PRN Lorazepam order due to the lack of a stop date, but there was no documentation that the physician reviewed or responded to this recommendation. A subsequent pharmacy medication regimen review note in December documented no irregularities or recommendations, despite the ongoing PRN Lorazepam order without a stop date. Interviews revealed that the consultant pharmacist completed monthly medication regimen reviews for all residents and, when regulatory concerns were identified, emailed recommendation reports to the DON and Administrator. The established process was for the DON to handle nursing-related recommendations, forward physician-related recommendations to the appropriate physician, and ensure that the physician reviewed, accepted, or declined them with documented rationale. The consultant pharmacist stated that PRN psychotropic medications required a stop date and physician review before renewal, and that he had sent the relevant reports to facility leadership. However, due to turnover among DONs and Administrators, the process was disrupted, and the pharmacist did not receive responses to his recommendations before the DON left. The interim DON and current Medical Director both reported being unfamiliar with the process and unaware of the unaddressed pharmacy recommendations, and a former Medical Director stated he had not received any pharmacy recommendation reports and confirmed that the consultation reports for the affected residents were not reviewed or signed by a physician.
Unclean Kitchen Equipment and Unlabeled Refrigerated Food Items
Penalty
Summary
The deficiency involves failure to maintain kitchen equipment in a clean condition and to properly label and date leftover food items. During an initial kitchen tour with a dietary aide, surveyors observed that two double-door ovens contained black burnt food stains inside, with oven floors covered by a black crust-like layer of burnt food and doors marked with dark brown oil stains. The grill surface was found with a thick black layer of burnt grease and food, along with some freshly cooked yellow-colored leftover food still present. The dietary aide stated the grill had been used that morning to cook chicken and acknowledged that the ovens needed to be cleaned. Surveyors also observed multiple unlabeled and partially covered food items in the reach-in and walk-in refrigerators. In the reach-in refrigerator, there was a large aluminum pan containing thick white creamy-textured food, covered only three-quarters with cling wrap and lacking any label or date, which the dietary aide identified as breakfast gravy. A white plastic container with a green lid, half-filled with a light yellowish smooth-to-chunky food, identified by the aide as applesauce, was also present without a label or date, and the aide was unsure when it had been placed there. In the walk-in refrigerator, a small aluminum pan of creamy white coleslaw was observed without a label or date; the dietary aide stated it was to be used for the afternoon lunch meal and therefore had not been labeled or dated. The dietary director later confirmed that cooks were expected to clean the ovens and grill daily and that all staff were responsible for labeling and dating leftover or opened food placed in the refrigerators, and the administrator stated that all leftover food should be covered and labeled, even if intended for an upcoming meal, and that kitchen equipment should be cleaned after each use.
Failure to Post and Maintain Accurate Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to consistently post and maintain accurate daily nurse staffing information as required. On one of four observed survey days, the daily nurse staffing sheet posted near the elevator was dated several days earlier and was not updated to reflect the current date, census, or staffing, and this outdated posting remained in place during multiple observations that day. Staff interviews revealed that the Scheduler typically prepared the daily nurse staffing sheets and placed them in a folder for nurses to update and post on weekends, but a nurse who worked multiple consecutive days did not notice that the posted sheet had not been updated. The admission coordinator stated that the Scheduler usually completed and posted the sheets, and when the Scheduler was unavailable, she attempted to complete and post them, while nurses were expected to ensure the postings were current and reflected actual staff working. A review of daily nurse staffing sheets over a 45‑day period showed that 10 days of postings were missing or unavailable for review, and on three additional days the sheets were incomplete, lacking required information and hours for Nursing Assistants on specific shifts. The admission coordinator reported that the Scheduler was responsible for maintaining and ensuring the accuracy of these records but was unable to locate the missing sheets. The administrator stated that the Scheduler filled out the daily nurse staffing sheets and provided them to the DON, and that significant management turnover contributed to the facility’s inability to locate the missing documents. No specific residents or clinical conditions were described in relation to this deficiency; the findings focused on documentation and posting of staffing information.
Failure to Ensure Safe Positioning During Bedside Care Results in Resident Fall and Severe Fractures
Penalty
Summary
A deficiency occurred when a resident with a history of stroke and left-sided weakness rolled off a raised bed during incontinence care, resulting in multiple severe fractures. The resident, who required extensive assistance with transfers and was dependent on staff for bed mobility, was being cared for by a nurse aide who positioned her on her left side and instructed her to hold onto the upper side rail with her right hand. During the care, the resident stated she could not hold on any longer, released the rail, and rolled off the bed, landing on her knees and sustaining significant injuries. The care plan for the resident identified her as being at risk for falls due to her medical history, with interventions including the use of side rails during care and staff assistance for repositioning. However, during the incident, only the two top side rails were up, and the two bottom rails were down. The nurse aide was standing on the right side of the bed, performing care while the resident was facing away and holding the rail. The bed was raised to the aide's waist height, and the resident was positioned close to the edge of the bed. Despite the resident's known weakness and dependence, she was expected to maintain her position by holding the rail, which she was unable to do, leading to the fall. Interviews with staff and family members confirmed that the resident had limited mobility, with severe left-sided weakness, and that the facility was aware of her condition. The family expressed concerns that appropriate safety measures were not in place to prevent the resident from rolling out of bed during care. Documentation and staff statements indicated that no formal training or in-service was conducted for staff regarding resident safety or the use of side rails during care following the incident. The facility's investigation concluded the event was accidental, but the lack of adequate supervision and failure to ensure safe positioning during care directly contributed to the resident's fall and subsequent injuries.
Removal Plan
- Quality oversight meetings discussing unit needs including staffing, resources, education, training, and quality issues.
- Audit by the Director of Nursing to review all residents' mobility and transfer needs to ensure correct assistance levels on care plans.
- Update MDS assessments for all residents, including functional abilities and goals.
- Verbal and return demonstration education provided to licensed nursing staff and certified nursing assistants on proper positioning in bed, use of side rails, and adjusting bed height during care.
- Instruction on correct techniques for turning, boosting, and positioning residents.
- Staff required to review care plan and Kardex and follow specified staffing needs for transfers and mobility.
- Mandatory completion of education for all staff prior to their next scheduled shift, with removal from schedule if not completed.
- Responsibility for initiating baseline care plan during admission assessment shifted from MDS RN coordinator to admitting licensed nurse, including interventions for safe positioning during care.
- Update new hire orientation process for certified nursing assistants and licensed nurses to include education on proper positioning in bed, ergonomics, body mechanics, and safety precautions with lifting and moving residents.
- Education materials reviewed by licensed physical therapist and include written materials.
- Risk meetings involving interdisciplinary team members to discuss resident-specific changes in condition, falls, weight loss, infections, and mobility needs, with documentation in the medical record and on paper.
- Use of a risk meeting form by the notetaker.
Failure to Update and Post Accurate Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information for residents and visitors on one of the four days of the survey period. On 9/15/24, the staffing sheet posted near the facility elevator was outdated, showing information from 9/13/24. Interviews revealed that the scheduler was responsible for preparing the staffing form for the weekend, but the weekend nurses were tasked with updating the posting. However, the MDS Nurse and other weekend nurses were either unaware of this responsibility or forgot to update the posting. Additionally, the facility did not update the daily staffing information to reflect actual staffing changes for six of the 33 days reviewed. Discrepancies were found between the posted staffing information and the staff clock-in sheets, indicating that the actual number of staff working often differed from what was posted. The scheduler mentioned that the staff schedule was prepared a month in advance, and any changes due to call-outs required updates to the posting, which were not consistently made. The Administrator confirmed that the charge nurse, scheduler, or MDS clerk were responsible for ensuring accurate postings during weekdays, with the charge nurse responsible over the weekend.
Failure to Schedule RN for Required Hours
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours a day on two occasions within a 33-day review period. On one of these days, the daily staff posting indicated an RN was scheduled for the day shift, but the staff clock-in sheet revealed no RN was present during the 7 AM to 3 PM shift. Instead, the RN, who was supposed to work from 7 AM to 7 PM, was assigned to work as a Nurse Aide (NA) from 11 PM to 7 AM. The RN confirmed during an interview that she worked as an NA and was not present in the facility from 7 AM to 7 PM. On another day, the staff clock-in sheet again showed no RN working the 7 AM to 7 PM shift, despite the daily staff posting indicating otherwise. The facility's scheduler and Administrator explained that when there was a call-out by an NA, nurses, including RNs and LPNs, were called to fill in as NAs. The Administrator stated that the requirement for an RN to be present for 8 hours was met as long as an RN was in the building, even if they were working as an NA. This practice led to the deficiency as the facility did not have an RN performing RN duties for the required 8 consecutive hours on the days in question.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as evidenced by the presence of expired and undated multi-dose vials of insulin on medication administration carts. During observations, it was found that one cart contained an opened and undated vial of Insulin Glargine, while another cart had multiple expired insulin products, including a Basaglar Kwik Pen, Humalog Pen, and Insulin Aspart Flex pen. Interviews with the nurses responsible for these carts revealed that they had not checked the dates of opening or expiration of the insulin vials at the beginning of their shifts, although they did not administer expired insulin during those shifts. The Director of Nursing confirmed that it was the nurses' responsibility to date and check medications for expiration every shift. Additionally, the facility failed to maintain cleanliness and organization in the medication carts, as loose pills were found in the drawers of two different medication carts. Observations revealed loose capsules and pills in the Rehabilitation Hall and Short Hall carts. The nurses responsible for these carts were unable to identify the loose pills and admitted to not cleaning the carts before their shifts. The Director of Nursing and the Administrator both emphasized that nurses were expected to ensure no loose pills or expired items were left in the medication carts, highlighting a lapse in adherence to the facility's medication management policies.
Failure to Provide Written Grievance Summary
Penalty
Summary
The facility failed to provide a written grievance summary for a resident who was severely cognitively impaired. The resident's responsible party (RP) reported concerns about bruising on the resident's arms, which led to an abuse investigation. The grievance form indicated that management was notified, an abuse investigation sheet was completed, law enforcement was informed, and the staff member in question was removed from the schedule. However, there was no documentation indicating that the complainant, resident, or family was contacted to confirm if the grievance was resolved to their satisfaction, and the grievance was not signed off as resolved. Interviews revealed that the Social Worker, who was the grievance coordinator, was unaware of the grievance and did not document it in the grievance log. The Administrator stated that he had spoken with the resident's RP about the abuse allegation shortly after the grievance was received and informed them that the investigation was ongoing. The Administrator did not document the resolution or record any information regarding his conversation with the family in the grievance form. Although the family was informed that the allegation was unsubstantiated, no written documentation regarding the resolution was provided to them.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate fingernail and toenail care for two residents who were dependent on staff for activities of daily living (ADL) care. Resident #37, diagnosed with Parkinson's disease and moderately cognitively impaired, was entirely dependent on staff for personal hygiene, including nail care. Despite being scheduled for regular bathing, observations revealed that Resident #37's fingernails were excessively long and dirty, and the resident expressed a preference for trimmed nails. Although the resident requested nail trimming from a nurse aide, the task was not completed, and the nurse aide did not notice the need for nail care during routine checks. Resident #24, with a diagnosis of secondary malignant neoplasm of the bone and severe cognitive impairment, was also dependent on staff for ADL care. Observations showed that Resident #24's toenails were excessively long and deformed, with no signs of discomfort reported. The resident received care from both facility and hospice staff, but there was a misunderstanding regarding responsibility for nail care. Facility staff believed hospice staff were responsible, while hospice staff indicated that nail care was the facility's responsibility. Interviews with staff, including the Director of Nursing (DON), confirmed that nurse aides were responsible for trimming nails for non-diabetic residents during bed baths or showers. However, the staff failed to perform this duty for both residents. The DON acknowledged that the assigned nurse aides should have trimmed the nails during routine care, highlighting a lapse in the facility's adherence to care plans and protocols for nail care.
Failure to Assist Residents with Activities
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of three cognitively impaired residents. These residents were identified as needing assistance with activities due to their cognitive impairments and physical limitations. Despite being coded for total assistance with transfers and locomotion, the residents were not consistently offered or assisted to participate in activities that matched their interests, such as music, religious services, and outside events. Observations revealed that staff often passed by the residents' rooms without offering assistance, and the residents were left in their rooms without engagement in scheduled activities. The Activity Director had developed a list of residents who required assistance to be transported to activities, and this information was shared with the management team. However, the staff, including nurse aides, failed to consistently assist these residents in getting up and ready for activities. Interviews with staff indicated that while they were aware of the residents' needs, they were often unable to assist due to other care responsibilities. This resulted in the residents missing out on activities they expressed interest in, such as church services and music events. The facility had in-serviced staff on the importance of assisting residents with activities, but there was a lack of consistent follow-up and documentation of resident participation or refusals. The Activity Director was unaware of the need to document resident participation in the resident record, and there were no activity notes available for the residents after their assessments. The deficiency was further compounded by the lack of communication and coordination among staff, leading to the residents' needs not being met.
Inaccessible Survey Results for Wheelchair Residents
Penalty
Summary
The facility failed to make the survey results accessible to residents in wheelchairs and did not post notices about the location of these results. During an initial tour, it was observed that the survey results were placed in a black caddy on a large bulletin board near the eye wash station, which was not accessible to residents in wheelchairs. This issue persisted over multiple days of observation, with no signage posted throughout the facility to inform residents, families, or visitors about the availability and location of the survey results. During a Resident Council Members meeting, several residents expressed that they were unaware of the location of the survey result notebook and had not seen any signage indicating its location. Interviews with the Social Worker and Activity Director confirmed the absence of visible postings about the survey results' location. They mentioned that the survey book was initially placed under the bulletin board with the master activity calendar, which was visible upon entry to the facility, but was later moved by the administrator without any notice. The facility Administrator acknowledged that the current location of the survey book was not accessible and that there was no visible posting to inform residents, families, or visitors of its location.
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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