Pruitthealth-trent
Inspection history, citations, penalties and survey trends for this long-term care facility in New Bern, North Carolina.
- Location
- 836 Hospital Drive, New Bern, North Carolina 28560
- CMS Provider Number
- 345371
- Inspections on file
- 22
- Latest survey
- February 6, 2026
- Citations (last 12 mo.)
- 5 (2 serious)
Citation history
Health deficiencies cited at Pruitthealth-trent during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including Type 2 DM, had a critically high blood glucose one week before a fatal decline, with only a one‑time insulin dose ordered and no ongoing BG monitoring documented afterward. Over the next several days, staff observed new respiratory symptoms, increasing sleepiness, markedly reduced oral intake, inability to drink through a straw, and decreased responsiveness, yet nursing staff notified the NP only of a cough and obtained an order for a CXR, without reporting the resident’s altered mental status, poor intake, or prior critical BG. Vital signs and BG checks were not consistently obtained despite these changes, and no additional provider consultation occurred until the resident was found extremely hot and in respiratory distress, prompting EMS transfer and subsequent death in the ED. Surveyors cited the facility for failing to notify the physician of all observed changes in condition and for not securing appropriate monitoring and treatment orders.
A resident with diabetes, CKD, intellectual disability, and multiple psychiatric and neurologic conditions had an elevated HgbA1C and later a critically high serum glucose, but providers did not initiate a diabetes treatment plan or order ongoing FSBS monitoring. After a one-time dose of SQ insulin for a glucose near 500 mg/dL, no further blood sugar checks or new orders were documented, and the care plan lacked specific diabetes interventions. Over subsequent days, staff noted the resident feeling like she had a cold, then becoming unusually sleepy, not eating three consecutive meals, developing a cough with coarse breath sounds, and losing the ability to drink through a straw, yet nurses did not obtain complete VS or FSBS despite these changes, focusing instead on ordering a chest x-ray. EMS later found the resident with a blood sugar reading of "high"; in the ED she was obtunded, severely hyperglycemic, febrile, and dehydrated, and she subsequently coded and died. Surveyors determined this constituted a failure to provide comprehensive assessment, monitoring, and treatment of diabetes and to perform acute monitoring and assessment when new respiratory symptoms developed.
A resident with diet-controlled diabetes had an elevated HgbA1C result, which was reviewed and signed by an NP without a corresponding progress note documenting a plan of care at that time. At the next regulatory visit, the NP referenced an older, lower HgbA1C value and documented that the diabetes remained diet controlled with a plan to continue a healthy diet, but did not address the more recent elevated HgbA1C result. In interview, the NP reported having discussed blood sugar monitoring and treatment options with the resident and the resident’s preference for diet control, but acknowledged that this discussion and plan were not documented in the medical record.
Surveyors found that the facility failed to maintain proper food storage and kitchen cleanliness, including unsealed cereal and grits in dry storage, grainy food particles on shelf liners, and multiple food items and debris on the dry storage floor, along with a span of dried grease under the oven. A dietary aide reported difficulty cleaning under the oven due to loose parts, while the Administrator noted that the former dietary manager had left abruptly and the current dietary manager worked only part time. The dietary supervisor stated staff were supposed to clean nightly but the conditions suggested this had not occurred, and the cleaning schedule in use did not include the dry storage area, despite the part-time dietary manager having previously created a schedule that did.
The facility failed to maintain effective kitchen sanitation and food storage practices and did not coordinate or communicate adequately with pest control technicians regarding pest-contributing factors in the main kitchen. Over multiple visits, pest control staff and a health department inspector documented roach activity, food and grease buildup under equipment, dirty and wet floors, dirty drains and strainers, structural issues such as holes and peeling wall covering, and repeated food debris throughout the kitchen. Surveyors later observed live and dead roaches, open and improperly sealed dry food items, food crumbs and miscellaneous items under shelving, dried grease under the oven, and peeling wall surfaces. Dietary staff cleaning routines did not cover the dry storage area per the corporate cleaning schedule, and facility leadership and maintenance did not consistently receive or act on detailed pest control reports describing sanitation and structural concerns.
A facility failed to include a resident's advanced directive in their medical record and did not honor the resident's DNR wishes. Despite the RP indicating the resident had a DNR order, the facility recorded the resident as full code. Staff interviews revealed a lack of follow-up to ensure the advanced directives were obtained and documented, leading to a discrepancy between the resident's wishes and the facility's records.
The facility failed to attempt alternatives before installing side rails for two residents, leading to a deficiency. One resident with a traumatic brain injury and another with hemiplegia had side rails installed without prior attempts at alternatives. Staff interviews revealed a lack of awareness about the requirement to try alternatives before using side rails, and observations confirmed the consistent use of side rails.
A resident with COPD was found with their inhaler at the bedside without a self-administration assessment or physician's order. The resident self-administered the medication, which was not documented as self-administered. Nurse #3 admitted to leaving the inhaler at the bedside inadvertently. The DON confirmed that medication should not be left at the bedside without proper assessment and orders.
A facility failed to accurately code the MDS assessment for a resident who experienced a fall. The resident's quarterly MDS assessment incorrectly indicated no falls since the prior assessment, despite documentation of a fall in nursing progress notes. The MDS Coordinator admitted the oversight, and both the DON and Administrator confirmed that MDS assessments should accurately reflect the resident's status.
A facility failed to follow infection control practices for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a hemodialysis catheter. Two nurse aides provided a bed bath without wearing gowns, despite signage indicating the requirement. Interviews revealed a misunderstanding of EBP requirements among staff, including the Director of Nursing and Unit Manager, who were unaware that a hemodialysis catheter necessitated EBP.
Failure to Notify Physician of Significant Change in Diabetic Resident’s Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of significant changes in a resident’s condition and to obtain appropriate medical orders for monitoring and treatment. The resident had a history of Type 2 diabetes, epilepsy, schizophrenia, schizoaffective disorder, hypertension, kidney disease, prior metabolic encephalopathy, feeding difficulties, and dysphagia, and was a full code. On 1/14/26, the resident’s blood glucose was critically elevated at 466–496, and the on‑call provider ordered a one‑time dose of Novolog insulin, a recheck in one hour, and placement in the acute book for PCP follow‑up with instructions to notify if glucose remained greater than 450. The recheck that evening was 386, but there were no further documented blood glucose checks or additional orders addressing blood sugars or abnormal labs from 1/14/26 through discharge. On 1/20/26, a nurse aide observed the resident sounding like she was getting a cold, with a deeper voice, dark circles and sunken eyes, and increased sleepiness, though the resident could still drink independently with a straw and assist with turning. On 1/21/26, a day‑shift nurse aide noted a significant change from the resident’s prior baseline: the resident remained sleepy all day, did not eat breakfast, lunch, or supper (only one bite at lunch), did not converse as usual, appeared darker in color, and could not pull fluid through a straw, requiring the aide to provide about one cup of fluids by sips. The aide reported to the nurse that the resident had not eaten breakfast or lunch and that she did not feel well. However, there was no documentation that the physician was notified of these changes, and no nursing progress notes on 1/21/26 reflected physician notification of a change in condition. On 1/21/26, the assigned nurse assessed the resident for a bad cough and coarse lung sounds, believed a respiratory issue was present, and contacted the NP only about the cough, obtaining an order for a chest x‑ray. The nurse did not obtain a blood glucose level, did not take full vital signs beyond a temperature of 98.5, and did not communicate the resident’s poor oral intake, altered responsiveness, or prior critical blood sugar to the provider. Subsequent nurses on the evening and night shifts were informed that the resident was not eating and that a chest x‑ray was ordered, but they did not obtain vital signs or blood glucose checks, and they did not notify or consult the physician about the resident’s diminished responsiveness and need for total assistance with turning. In the early morning hours of 1/22/26, a nurse aide found the resident extremely warm with labored breathing; the nurse then obtained abnormal vital signs, including a temperature of 104.6°F, hypotension, tachycardia, and low oxygen saturation, and EMS was called. EMS documented a blood sugar reading of “high,” and the hospital ED documented the resident as obtunded, severely dehydrated, with a blood glucose of 882 and multiple abnormal labs. The surveyors determined that the facility failed to notify the physician of all observed changes in condition on 1/21/26 and failed to consult regarding whether additional diagnostic tests, monitoring (including blood glucose, oxygen saturation, and vital signs), or treatment were needed, leading to the cited deficiency. Immediate jeopardy was determined to have begun on 1/21/26 when staff were aware that the resident had eaten only one bite in three consecutive meals, was not pulling up fluid through a straw, was not responding to staff per her baseline, and required total assistance to turn in bed and was no longer talking, without physician notification of these changes or consultation for further orders. The facility’s failure to notify the physician regarding all changes in condition and to obtain appropriate monitoring and treatment orders for the resident’s evolving symptoms on and after 1/21/26 constituted the core noncompliance identified by the surveyors.
Removal Plan
- Provide one-to-one education to NA #1 on the importance of communicating changes in condition timely to the charge nurse.
- Hold an ad hoc Quality Assurance Performance Improvement (QAPI) meeting including the Medical Director, Administrator, DON, Social Worker to address the breakdown in the nurse-to-provider notification process related to resident change in condition.
Failure to Monitor and Treat Diabetes and Acute Status Changes Leading to Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, monitor, and treat a resident’s diabetes and to provide acute monitoring and assessment when the resident later developed respiratory symptoms in the context of uncontrolled hyperglycemia. The resident had multiple diagnoses including type 2 diabetes, chronic kidney disease, intellectual disability, schizoaffective disorder, epilepsy, hypertension, and a history of feeding difficulties and dysphagia. A HgbA1C drawn on 10/14/25 was 8.1% (above the lab’s normal range of ≤5.7%), but there was no documented plan to address this elevated result. The consultant pharmacist notified the NP on 11/5/25, suggesting initiation of Metformin or Jardiance, but the NP initialed “no change” on 11/20/25 without documenting a rationale or creating a treatment plan, and no diabetic medications were ordered. The resident’s care plan, reviewed on 12/15/25, contained a problem related to diabetes-associated fatigue but did not include any interventions for blood sugar monitoring or diabetes management. On 12/18/25, the NP documented a regulatory visit and follow-up of chronic conditions, noting the resident’s diabetes as diet controlled based on an older HgbA1C of 6.5 from 9/1/24 and did not reference the elevated 10/14/25 HgbA1C of 8.1. On 1/5/26, a different NP saw the resident for chronic issues but addressed only hyperlipidemia, hypertension, and vitamin D deficiency, and did not review or plan for the resident’s diabetes, despite the elevated HgbA1C from October. A CMP drawn on 1/13/26 and reported on 1/14/26 showed a critically high serum glucose of 466, elevated creatinine, low potassium and chloride, high CO2, and a reduced estimated GFR. A nurse notified the on-call provider via the triage system, reporting the critical glucose, a finger-stick blood sugar (FSBS) of 496, stable vital signs, and the resident’s complaint of feeling sleepy all day, and requested insulin orders. The provider ordered a one-time dose of Novolog 10 units SQ, a recheck of glucose in one hour, and notification if the result remained above 450. The insulin was administered and a repeat FSBS was documented at 386, but no further blood sugar checks or additional orders addressing the abnormal labs were documented after 1/14/26. A progress note later received from the NP, dated for a service date of 1/15/26, stated that the resident was seen for an acute visit for elevated blood glucose, that labs were at baseline except for glucose, and that the resident was asymptomatic with no signs of infection or hyperglycemia. The NP documented that staff were encouraged to monitor for signs and symptoms of hyperglycemia and infection, to take FSBS, and to notify the PCP for status changes, and referenced risks such as diabetic ketoacidosis, hyperosmolar hyperglycemic state, blindness, kidney disease, heart attack, further decline, and rehospitalization if left untreated and unmonitored. However, no orders were actually written for FSBS monitoring or repeat HgbA1C, and no further blood sugar checks were documented from 1/14/26 through discharge. On 1/19/26, the resident received a COVID vaccine and had a recorded temperature of 97.6; this was the last documented vital sign before the acute decline. Over 1/19/26 and 1/20/26, nursing and NA staff reported the resident appeared at baseline. On the evening of 1/20/26, an NA noted the resident reported feeling like she was getting a cold, had a deeper voice, dark circles and sunken eyes, and was sleepy but still able to drink independently with a straw; the NA believed she informed a nurse but could not recall whom. On 1/21/26, multiple staff observed significant changes: the resident did not eat three consecutive meals (except for one bite at lunch), was unusually sleepy, did not converse at her baseline, and required assistance with drinking, with one NA unable to get her to pull fluid through a straw. A nurse caring for her that morning noted a bad cough and coarse breath sounds, difficulty administering medications in the morning due to somnolence, and only minimal intake at lunch. This nurse requested a chest x-ray from an NP, obtained an order, and verified it with the mobile x-ray company, but did not obtain a full set of vital signs or check the resident’s blood sugar, documenting only a temperature she recalled as 98.5 and citing a very busy day. Another nurse manager recalled being told the resident did not seem herself and knew a chest x-ray was ordered but did not perform an assessment. There were no nursing progress notes for 1/21/26 documenting vital signs or FSBS, and interviews with four nurses confirmed that no complete sets of vital signs or blood sugar levels were obtained despite the resident’s decreased intake, increased sleepiness, cough, and functional decline. In the early morning of 1/22/26, EMS was dispatched for the resident, and paramedics found a blood sugar reading of “high.” The resident was transported to the ED, where she was noted to be obtunded and dehydrated, with a glucose of 882, a temperature of 41.7°C (107.06°F), and other lab abnormalities. She coded at 6:53 AM and expired after unsuccessful resuscitation attempts. The survey identified that immediate jeopardy began on 1/15/26 when the facility failed to ensure ongoing monitoring and initiation of a treatment plan for the resident’s critically elevated blood glucose following the 1/14/26 lab result, in the context of a previously elevated HgbA1C and subsequent development of respiratory symptoms without appropriate acute monitoring, assessment, and treatment.
Failure to Document Diabetes Management Plan After Elevated HgbA1C Result
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the medical provider documented an appropriate plan of care for a resident’s diabetes during required regulatory visits. The resident was admitted with a diagnosis of diabetes, and during a regulatory visit in late September, the nurse practitioner (NP) documented that the diabetes was diet controlled. A Hemoglobin A1C (HgbA1C) lab ordered in mid-October showed an elevated result of 8.1%, significantly above the lab’s normal range of ≤5.7%. The electronic lab record showed the NP signed off on these results in early November, but there was no corresponding provider progress note on that date addressing the elevated HgbA1C. Following the September visit, the next documented regulatory visit by the NP occurred in mid-December. In that progress note, the NP documented that the resident’s Type 2 diabetes with chronic kidney disease was diet controlled, referenced an older HgbA1C of 6.5% from the previous year, and planned to continue a healthy diet. The NP did not reference or address the more recent elevated HgbA1C of 8.1% from October in this regulatory visit note. During interview, the NP stated she had discussed with the resident the option of more frequent blood sugar checks and treatment, and that the resident preferred diet control with reevaluation in three months, but she acknowledged that she had not documented this discussion or the diabetic plan in the regulatory progress note, and confirmed she should have done so.
Improper Food Storage and Inadequate Kitchen Cleaning Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s main kitchen related to improper food storage and inadequate cleaning practices. During observations in the dry storage room, an open bag of cereal was found in a container whose lid was on the floor under another shelving unit. A bag of grits on a metal shelf was not sealed, with the top only rolled up. Shelf liners on this and another shelf had visible fine grainy food particles. Underneath the shelving units in dry storage, surveyors observed multiple food items and debris, including loose dry cereal, a dried orange peel, closed packets of cookies, water bottles, condiment packets, a carbonated drink, a closed bag of Cheetos, a closed pudding cup, a loose cigarette, and a pair of sandal slides. Under the kitchen oven, there was about 12 inches of black, dried grease. Staff interviews further described the circumstances leading to the deficiency. A dietary aide stated they had to be careful when cleaning under the oven because part of the oven bottom would come off. The Administrator acknowledged seeing the unsealed food items and dirty dry storage floor and reported that the former Dietary Manager had left abruptly months earlier, and the current Dietary Manager was only present one to two days per week. The Dietary Supervisor stated she typically sealed opened food if staff forgot and that staff were supposed to sweep and clean nightly, but the condition of the dry storage area suggested this had not been done. She also provided a cleaning schedule that did not include dry storage. The part-time Dietary Manager reported that her own cleaning schedule, which included dry storage, had been replaced by a corporate schedule that did not address cleaning of the dry storage room, while also stating that staff had been instructed to clean and mop nightly and to ensure all food was sealed, covered, and dated.
Failure to Maintain Kitchen Sanitation and Coordinate Pest Control in Main Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to maintain effective kitchen sanitation and food storage practices to deter pests, and failure to communicate effectively with contracted pest control technicians regarding contributing factors to pest activity in the main kitchen. Pest control records showed repeated findings of roaches and sanitation problems over several months. A pest control technician documented roaches in the kitchen and sanitation issues such as food and grease buildup under the cook/steam line and on the kitchen floor, with repeated notations to "please clean regularly." A local health department inspection of the main kitchen later identified a large number of roaches in an electrical box above the three-compartment sink, general floor cleaning deficiencies, lack of cleaning under food equipment and shelving in the walk-in cooler, walk-in freezer, and dry storage, as well as wall damage throughout the kitchen. Subsequent pest control invoices continued to note pest activity and sanitation problems in the kitchen, including cockroaches coming out of the trash disposal door and other areas, dirty floor drains, dirty strainers, and floors that were consistently wet. Technicians repeatedly documented that standing water and food debris were present during most services and that these conditions could cause pest problems, again instructing the facility to clean regularly and keep the kitchen as dry as possible. One technician later documented structural concerns that could cause pest problems, including holes and gaps throughout the kitchen and peeling wall covering, along with food debris throughout the kitchen. The facility could not produce documentation of all follow-up night services that technicians reported they intended to perform, and there was a gap in available pest control records for certain months. During on-site kitchen observations, surveyors found a dead roach behind the ice machine and a live roach in a kitchen corner, open and improperly sealed dry food items such as cereal and grits in dry storage, and food crumbs and miscellaneous items under shelving, including loose cereal, a dried orange peel, snack items, beverage containers, a loose cigarette, and shoes. There was a 12-inch span of dried black grease under the oven, and a portion of wall covering was peeling near the sink. Staff interviews revealed that dietary staff were expected to sweep and clean nightly, but the posted cleaning schedule did not include the dry storage area. The part-time Dietary Manager reported she had created a cleaning schedule that included dry storage but was told to use a corporate schedule that did not. Pest control technicians reported consistently seeing sanitation issues such as trash and food particles on the floor, wet floors around the ice machine, food left in the dishwasher food trap, and an unrinsed prep sink during their visits. Maintenance and administrative staff reported that pest control technicians did not routinely communicate structural or sanitation issues directly to them, and that the facility did not routinely receive or review detailed pest control invoices noting these problems.
Failure to Honor Resident's Advanced Directives
Penalty
Summary
The facility failed to ensure that a resident's advanced directive was included in their medical record and did not honor the resident's expressed wishes regarding their code status. The resident, who was admitted with a diagnosis of dementia, had a hospital discharge summary indicating a full code status. However, the resident's Responsible Party (RP) had completed admission paperwork indicating the resident had a DNR order and advanced directives, which were not included in the resident's record. Interviews with facility staff revealed a lack of follow-up to ensure the advanced directives were obtained and included in the resident's medical record. The Admissions Director and Unit Managers did not verify the presence of these documents, and the Social Worker did not clarify the discrepancy between the resident's code status in the medical record and the RP's expressed wishes. The RP was unaware that the resident's code status was recorded as full code in the facility, contrary to the resident's wishes. The Director of Nursing and the Administrator acknowledged the system in place to verify advanced directives on admission but admitted that the process was not followed through in this case. The failure to ensure the resident's advanced directives were documented and honored resulted in a discrepancy between the resident's expressed wishes and the facility's records.
Failure to Attempt Alternatives Before Installing Side Rails
Penalty
Summary
The facility failed to attempt alternatives before installing side rails for two residents, leading to a deficiency. Resident #18, who was admitted with a diagnosis of diffuse traumatic brain injury, had side rails installed without prior attempts at alternative interventions. The restraint-adaptive equipment use assessment for Resident #18 did not indicate whether alternatives had been tried, and staff interviews revealed a lack of awareness about the requirement to try alternatives before using side rails. Observations confirmed that side rails were consistently in the raised position for Resident #18. Similarly, Resident #98, who was admitted with hemiplegia and hemiparesis following a stroke, also had side rails installed without prior attempts at alternatives. The assessment for Resident #98 similarly lacked documentation of alternative interventions being tried. Staff interviews indicated a general lack of awareness about the necessity of attempting alternatives before implementing side rails, and observations showed that side rails were in use for Resident #98. Interviews with the nursing staff, including the Director of Nursing and the Administrator, revealed a systemic issue where side rails were routinely installed on beds without considering or attempting alternative interventions. The staff was unaware of the requirement to explore alternatives before using side rails, leading to the deficiency identified during the survey.
Medication Administration Deficiency
Penalty
Summary
The facility failed to assess whether self-administration of medication was clinically appropriate for a resident before leaving medication at the bedside. This deficiency was identified for a resident with chronic obstructive pulmonary disease (COPD), who was cognitively intact and admitted to the facility with a physician's order for Trelegy Ellipta, a medication for COPD. The resident's medical record did not contain a self-administration assessment or a physician's order to self-administer medication. Despite this, the resident was observed with the inhaler at her bedside and self-administered a dose, which was not documented as self-administered in the Medication Administration Record (MAR). Nurse #3, who was responsible for the resident's care, reported administering the inhaler at 9:00 AM but inadvertently left it at the bedside. The Director of Nursing confirmed that medication should not be left at the bedside without proper assessment and orders. The Nurse Practitioner indicated that taking an additional dose would not have harmed the resident, but the medication should not have been left at the bedside. The Administrator noted that leaving medication at the bedside was unusual for Nurse #3, suggesting it was a one-time mistake.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of falls. The resident, who was admitted to the facility, experienced a fall from her bed, as documented in a nursing progress note. Despite this incident, the resident's quarterly MDS assessment incorrectly indicated that she had no falls since her prior assessment. The MDS Coordinator, responsible for coding the assessment, acknowledged the oversight, stating that she typically reviewed progress notes for such information. The fall occurred after the date of the resident's prior MDS assessment, and thus should have been included in the subsequent assessment. Interviews with the Director of Nursing and the Administrator confirmed that MDS assessments should accurately reflect the resident's status.
Failure to Implement Enhanced Barrier Precautions for Resident with Hemodialysis Catheter
Penalty
Summary
The facility failed to adhere to their infection control practices and procedures for Enhanced Barrier Precautions (EBP) during high contact care for a resident with a hemodialysis catheter. Nurse Aide (NA) #1 and NA #2 were observed providing a bed bath and dressing to Resident #103 without wearing gowns, despite the presence of signage indicating the requirement for gowns and gloves for high contact care. The resident had a hemodialysis catheter inserted in the right upper chest area, which necessitated EBP according to the facility's policy. Interviews with NA #1 and NA #2 revealed a misunderstanding of the EBP requirements, as they believed the precautions were meant for the resident's roommate and did not recognize a hemodialysis catheter as a reason for EBP. The Infection Preventionist confirmed that all residents with indwelling medical devices, including hemodialysis catheters, require EBP for high contact care. The Director of Nursing and Unit Manager #2 also demonstrated a lack of awareness regarding the necessity of EBP for residents with hemodialysis catheters, indicating a gap in understanding and implementation of the facility's infection control policy.
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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