Rocky Mount Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rocky Mount, North Carolina.
- Location
- 160 S Winstead Avenue, Rocky Mount, North Carolina 27804
- CMS Provider Number
- 345260
- Inspections on file
- 23
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Rocky Mount Rehabilitation Center during CMS and state inspections, most recent first.
Two residents were involved in a physical altercation in a common area, during which one resident was reportedly struck in the face by another while a third resident encouraged the aggression. CNAs observed the incident, separated the residents, and notified the nurse, but the RN on duty did not immediately notify the Administrator despite acknowledging she should have. The weekend Administrator on Duty learned that one resident may have hit another and that the alleged victim reported being hit by a man, yet the incident was still communicated to the Administrator as a non‑physical, verbal altercation. A written CNA statement describing the hitting was not reviewed by the Administrator for several days, the DON was not promptly informed, law enforcement was not notified within 24 hours, and key witnesses were not interviewed in a timely manner, resulting in delayed and incomplete implementation of the facility’s abuse reporting and investigation procedures.
The facility failed to maintain complete medical records related to an altercation between two residents and a subsequent clinical assessment. Staff witness statements described both residents hitting each other, and the assigned nurse reported she checked both residents and found no visible injuries but did not document the incident or her assessment in either record. Days later, a bruise below one resident’s eye was noted on a skin audit, and a PA evaluated the resident, confirming the eye was not painful, not shut, and without vision problems, and that the resident reported being hit in another room. The PA did not document this assessment in the medical record.
A staff member was employed and worked as an RN without a valid nursing license, as the facility failed to properly verify her credentials. Despite documentation showing competency and no performance issues, subsequent checks revealed she was only licensed as a CNA, not an RN, and her name did not match any active RN license in Maryland or North Carolina. The facility's HR process did not identify the discrepancy, and the staff member continued to work in the RN role until her departure.
Surveyors identified expired medications in the medication refrigerator and on a medication cart, as well as unopened insulin pens that were not refrigerated according to manufacturer instructions. The DON and nursing staff confirmed these findings, with staff interviews revealing inconsistent checks for expired medications and a lack of awareness regarding proper storage and discard timelines.
A resident's medical record was incomplete and inaccurate after a physician order for tracheostomy care was entered incorrectly in the electronic system, preventing the order from appearing on the TAR/MAR. As a result, nurses were unable to document the tracheostomy care provided, and some only realized the omission during the investigation. The DON confirmed the order was not entered properly, and the Administrator acknowledged the need to review the process.
Two residents with chronic pain conditions had narcotic pain medications go missing from the facility. The discrepancy was discovered during a routine narcotic count by nursing staff, and subsequent investigation confirmed that medication cards and countdown sheets for both residents were unaccounted for. The missing narcotics were reported to authorities, but the facility was unable to determine how the medications were removed or by whom.
A resident with a tracheostomy did not receive consistent or properly documented respiratory care due to missing orders on the TAR, leading to lapses in tracheostomy care and skin assessments. Nursing staff were unclear about care responsibilities and failed to inspect for moisture-associated skin damage in the neck folds, which was only discovered incidentally. Infection control practices were also breached when a nurse reattached oxygen tubing that had fallen on the floor.
A nurse did not remain at the bedside to confirm that a resident with renal dialysis dependence took all prescribed Lanthanum Carbonate tablets, resulting in a pill being left in a cup on the bedside table. The resident's care plan did not include self-administration, and no assessment for self-administration safety was documented. Staff interviews confirmed that the nurse was expected to observe medication administration but failed to do so.
A resident with an indwelling urinary catheter and significant cognitive and physical impairments was observed with her catheter collection bag touching the floor while in bed. Staff interviews confirmed awareness that the bag should not contact the floor, but adjustments to bed height had allowed this to occur, and the duration of the contact was unknown. Facility leadership acknowledged the bag should have been properly positioned to prevent floor contact.
A resident with severe cognitive impairment and multiple medical conditions did not receive enteral nutrition via g-tube as ordered, when staff failed to ensure the tube feeding pump was operating during a scheduled feeding period. Nursing staff were unaware of the interruption, and documentation did not reflect the actual administration of the feeding.
Nursing staff failed to demonstrate competency in tracheostomy care, as evidenced by improper handling of oxygen tubing and lack of facility-specific training or competency evaluation. Several nurses had not attended required training, and the facility could not provide documentation of tracheostomy care competencies for its staff. Leadership interviews revealed inconsistent protocols and missing records related to tracheostomy care education.
A nurse administered incorrect medications and dosages to a resident, including giving vitamin B12 instead of vitamin D3, providing double the ordered dose of a nasal spray, and administering levothyroxine while the resident was eating despite instructions to give it on an empty stomach. These actions resulted in a medication error rate of 12%, exceeding the acceptable threshold.
The facility did not consistently post daily nurse staffing sheets at the start of each shift, with instances of outdated or missing postings. The Scheduler was unclear about procedures for printing and posting staffing information for days other than the current day, and it was uncertain whether weekend staff had access to the required information.
The facility did not maintain an accurate facility-wide assessment, as it listed former administrative and clinical leaders rather than current staff. The assessment had not been updated to reflect recent changes in key positions, as confirmed by the interim Administrator, potentially affecting all residents.
Two residents and their responsible parties were not provided with required information about the facility's bed hold policy during hospital transfers. Medical records lacked documentation of this notification, and interviews with the responsible parties and the Admission Director confirmed that the policy was not discussed or provided at the time of transfer.
A resident with diabetes experienced a delay in treatment for hypoglycemia due to a nurse's failure to recognize symptoms and follow physician orders. The nurse, unaware of the resident's diabetes, did not check blood sugar levels or administer necessary medication, leading to a critical delay. EMS was called under the assumption of a stroke, and upon arrival, found the resident with a critically low blood glucose level. The lack of documentation and communication further exacerbated the situation.
A resident with Diabetes Mellitus Type 2 experienced a critically low blood glucose level, requiring EMS intervention. The primary nurse called EMS but failed to notify the physician of the incident. Subsequent staff notified the on-call physician for further orders, but the Physician Assistant and Medical Director were not informed of the EMS involvement. The DON was also unaware of the situation, highlighting a communication breakdown in the facility.
A resident with Diabetes Mellitus Type 2 experienced a critically low blood glucose level, prompting EMS intervention. Despite the resident's condition and subsequent treatment, the primary nurse failed to document the incident in the medical record, as confirmed by the DON.
A resident on anticoagulation medication experienced significant post-operative bleeding, but the LTC facility failed to ensure effective communication among staff and with the provider. The resident was not sent to the hospital promptly, and vital signs were not assessed. The on-call physician was not informed of the bleeding severity, leading to inappropriate treatment orders. The resident required a blood transfusion after being sent to the hospital.
A resident experienced significant post-operative bleeding while on an anticoagulant, but the facility failed to notify the physician appropriately. Despite the bleeding, the resident was administered Eliquis without consulting a physician. Miscommunication between nursing staff and the on-call physician led to inappropriate treatment orders, and the resident was eventually sent to the hospital after family intervention.
A resident with a history of blood clots and recent surgery experienced excessive bleeding while on Eliquis, an anticoagulant. Despite the bleeding, the medication was administered without proper monitoring or communication with the physician. The facility failed to document the administration and did not have a clear protocol for managing the situation, leading to a deficiency in care.
A resident in a LTC facility, who preferred showers and was dependent on staff for bathing, was not provided with a bariatric shower bed. The existing shower bed was deemed unsafe, and the resident only received bed baths. Despite approval to purchase a new bed, it was not yet available, leading to the resident not receiving showers as scheduled.
A resident's hearing assessment was inaccurately coded as adequate without hearing aids, despite multiple consultations indicating the need for hearing aids. Staff interviews revealed inconsistencies in awareness of the resident's hearing needs, with the resident expressing difficulty hearing and preferring a hearing amplifier over the hearing aid due to fit issues.
A resident with major depressive disorder and dementia was not referred for a PASRR after being diagnosed with an anxiety disorder. Despite having a care plan addressing cognitive impairment and using psychotropic medications, the facility failed to submit a new PASRR application. The Social Worker and Administrator acknowledged the oversight.
A resident's care plan was not updated to reflect their hearing impairment, despite multiple consultations indicating the need for hearing aids. Staff were unaware of the resident's hearing aids or alternative devices, and the care plan lacked necessary interventions. Interviews revealed a communication gap among staff regarding the resident's hearing needs.
A facility failed to obtain necessary orders for oxygen and respiratory therapy for a resident with acute respiratory failure and a tracheostomy. The resident's care plan included tracheostomy care and respiratory therapy but lacked interventions for oxygen use. Despite receiving oxygen at 2.5 liters per minute, there were no physician orders for oxygen in the records. Staff confirmed the resident had been on oxygen since admission, yet it was undocumented. Additionally, there was no physician order for respiratory therapy, although the resident received it regularly.
The facility did not have the Infection Preventionist (IP) present at one of the six Quality Assessment and Assurance (QAA) committee meetings, specifically the meeting held in June 2024. The absence was confirmed by the IP due to illness, and the Administrator noted a lack of documentation of her participation. This could potentially impact all 110 residents.
Failure to Timely Report and Thoroughly Investigate Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy and federal requirements for reporting and investigating alleged abuse following a resident‑to‑resident altercation. The facility’s Abuse and Neglect Prohibition policy, revised in 8/2023, stated that the center would investigate any alleged abuse, neglect, or misappropriation of resident property and report all allegations and substantiated occurrences to state/federal agencies and law enforcement. However, the policy did not specify that the Administrator must be notified immediately of alleged abuse, and it referenced reporting to the corporate office via “Risk Guide” without defining what that entailed. Surveyors found that after an altercation between Resident #1 and Resident #2, the facility did not report the incident to local law enforcement within 24 hours and did not initiate a timely, thorough investigation. The incident occurred in the activity room on the evening of 2/14/26, when Resident #1, Resident #2, and Resident #3 were watching television. NA #1, seated at the nursing desk with a direct view into the activity room, heard Resident #1 yelling, “Stop. Leave me alone,” and heard Resident #3 say, “Hit her again.” As NA #1 entered the room, she saw Resident #2 hit Resident #1 in the face with his fist and then swing again, with Resident #1 raising her arm to block the second blow. NA #1 reported that she did not see Resident #1 provoke or hit Resident #2. NA #2 entered with NA #1 and later stated she saw both residents hitting each other but did not know who started it or where the blows landed. That night, Resident #1 had no visible marks, but within a couple of days she developed a black eye. NA #1 wrote a statement on 2/14/26 describing the incident and placed it under the Administrator’s door as instructed, and later added that before bed Resident #1 said Resident #2 had hit her in the eye. Nurse #1, the 3–11 PM nurse on 2/14/26, reported that a NA told her the two residents were in an altercation and that Resident #1 had started hitting Resident #2, who eventually hit back. She assessed both residents and found no marks but did not notify the Administrator, acknowledging she knew she should have. The Scheduler, acting as Administrator on Duty that weekend, overheard NA #1 say that Resident #2 had hit Resident #1, confirmed with the nurse that the nurse was aware, and assessed Resident #1, finding no marks. Resident #1 told the Scheduler that a man had hit her and described a male resident; Resident #2 denied involvement. The Scheduler called the Administrator at home and reported that Resident #2 may have hit Resident #1 and that there were no injuries, and was told to have NA #1 write a statement and place it under the Administrator’s door. The Administrator later stated she understood this to be a verbal, non‑physical altercation and did not review NA #1’s statement until 2/17/26, did not speak with NA #1 until 3/4/26, and did not begin the investigation until 2/17/26. By 2/16/26, the DON had not been informed of any alleged abuse, learning only that Resident #1 had darkening under her eye after the Administrator had already noticed it. On 2/17/26, the Administrator observed discoloration under Resident #1’s eye and obtained differing accounts from Resident #1, who first attributed it to a branch hitting her on the way to dialysis and then to a male resident who pushed her, pointing to her right anterior shoulder. The Administrator also interviewed Resident #2, who denied hitting anyone, and Resident #3, who stated that Resident #1 started hitting Resident #2 and that Resident #2 only pushed her away defensively. The facility’s initial allegation report to the state agency, submitted on 2/17/26, incorrectly listed the incident date as 2/17/26, later corrected in the five‑day investigation report to 2/14/26 with acknowledgment that the facility became aware on 2/17/26. Local law enforcement confirmed they did not receive a report of the alleged assault until 2/17/26 at 12:17 PM, indicating the facility did not notify law enforcement within 24 hours of the 2/14/26 altercation. The Administrator acknowledged that the incident was not reported to her as abuse initially, that the investigation was delayed because details were not clearly communicated and she had not read NA #1’s statement promptly, and that not all witnesses, including NA #1, were interviewed in a timely manner. The facility’s investigative file contained conflicting witness accounts and documentation indicating that alleged abuse occurred on 2/14/26, while the initial report to the state agency cited 2/17/26 as the occurrence date. NA #1 reported that no one spoke with her about the incident after she submitted her statement until she was interviewed by the surveyor on 3/4/26, and the Administrator confirmed she did not interview NA #1 until that date. The DON reported that no one notified her of alleged abuse during the days immediately following the incident. These findings demonstrate that the facility failed to follow its own abuse policy and federal requirements by not ensuring immediate Administrator notification of alleged abuse, not reporting the alleged crime to law enforcement within 24 hours of the altercation, and not conducting a prompt and thorough investigation that included timely interviews of all witnesses.
Failure to Document Resident Altercation and Subsequent Clinical Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for two residents involved in an altercation. An investigation file regarding an alleged abuse incident on 2/14/26 documented witness statements from two nurse aides, one reporting that Resident #2 hit Resident #1, and another reporting that both residents were hitting each other. Nurse #1, who was assigned to both residents that day, stated she had been informed that Resident #1 hit Resident #2 and that Resident #2 hit Resident #1 back. She reported she checked both residents, saw no injuries or marks, but did not document the altercation or her assessment in either resident’s medical record. The Administrator stated that Nurse #1 should have made a notation in each resident’s record that they had been involved in an altercation. The deficiency also includes the lack of documentation by a Physician Assistant (PA #1) following an assessment of Resident #1 after the same altercation. On 2/17/26, Resident #1 was noted on a skin audit report to have bruising to the cheek area below the left eye. PA #1 reported that she assessed Resident #1 after staff reported the altercation and the bruise, recalling that the resident’s eye was not painful or shut, there were no vision problems, and the resident stated she had been hit in another room without giving details. PA #1 acknowledged that she did not document her assessment in Resident #1’s medical record. The Administrator reported that PA #1 should have made a notation in the record about this assessment following the bruised eye and altercation.
Failure to Verify RN Licensure for Nursing Staff
Penalty
Summary
A facility failed to verify that a staff member hired as a Registered Nurse (RN) possessed an active professional nursing license in accordance with state laws. The staff member, identified through employment records and licensure verification, worked as an RN for several months. The personnel file included a Maryland Board of Nursing (MBON) licensure verification with the same first and last name as the staff member, but the middle name was missing, and subsequent checks revealed discrepancies. The staff member's competencies were reviewed and no performance issues were documented during her employment. Further investigation revealed that the staff member did not have an active RN license but was registered as a Certified Nursing Assistant (CNA) in Maryland, with her middle name included in the registry. Attempts to verify her RN license in both Maryland and North Carolina were unsuccessful, and the North Carolina Board of Nursing did not have her listed. Interviews with facility staff and external parties, including a staffing agency and another facility, highlighted concerns about the staff member's credentials, particularly regarding inconsistencies in her name and the absence of a valid nursing license. Despite these concerns, the facility's Human Resources process failed to detect the lack of a valid RN license, relying instead on incomplete or mismatched documentation. The staff member continued to work as an RN until she left the facility, and no further investigation was conducted by facility staff when questions about her licensure arose. The deficiency was identified through a review of employment records, licensure verification, and staff interviews, confirming that the facility did not ensure all nursing staff were properly licensed as required by state regulations.
Expired and Improperly Stored Medications Identified During Survey
Penalty
Summary
Surveyors observed that expired medications were not removed from the medication refrigerator in the medication storage room at the nursing station. Specifically, a box containing five expired COVID-19 mRNA vaccine injections, an open bottle of cephalexin oral suspension, and an open bottle of vancomycin hydrochloride oral solution were found past their expiration dates. The DON confirmed these findings prior to removal and stated that the Unit Manager was responsible for checking and removing expired medications, but checks were only performed every few weeks. Additionally, on the Hall 100 medication cart, an open inhalation powder medication used for COPD and asthma was found to have exceeded the six-week discard period after opening, which Nurse #1 was unaware of. The DON, who was new to the facility, had not yet implemented a process for regular checks of medication carts for expired medications. Further observations revealed that unopened insulin lispro injector pens, which require refrigeration according to manufacturer recommendations, were stored at room temperature on the Hall 200 medication cart instead of in the refrigerator. Both Nurse #2 and the Pharmacist confirmed that the insulin pens should have been refrigerated until opened, as indicated by clear labeling on the packaging. The DON also acknowledged that the insulin pens should have been placed in the refrigerator upon delivery from the pharmacy.
Incomplete Medical Record for Tracheostomy Care Due to Documentation Error
Penalty
Summary
The facility failed to ensure that a resident's medical record was complete and accurate regarding tracheostomy care. Upon review, it was found that a physician order for tracheostomy care every shift and as needed was entered into the electronic medical record using an option that did not populate the Treatment Administration Record (TAR) or Medication Administration Record (MAR). As a result, the order was only visible in the orders section and not accessible for nurses to document the care provided. Multiple nurses who cared for the resident reported either forgetting to document tracheostomy care or being unable to do so because the order did not appear in the TAR/MAR. The Director of Nursing confirmed that the order was not entered properly, preventing appropriate documentation. The deficiency involved a resident who had been readmitted to the facility and required regular tracheostomy care. Despite the presence of a physician order, the improper entry into the electronic system led to a lack of documentation for tracheostomy care over several months. Staff interviews revealed that nurses performed the care but did not document it due to the missing order in the documentation system, and some only realized the omission during the investigation. The Administrator acknowledged the issue but did not provide an explanation for the failure.
Failure to Prevent Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to protect residents' rights to be free from misappropriation of narcotic medications for two residents. Both residents had physician orders for opioid pain medications, which were delivered to the facility and documented as administered according to their Medication Administration Records. However, it was later discovered that one medication card containing 30 tablets for each resident was missing and could not be located within the facility. The issue was identified when a nurse noticed a discrepancy in the narcotic medication card count during her shift. She recalled that the number of narcotic cards had decreased unexpectedly and questioned another nurse, who denied removing any narcotics. After further investigation and a search of the medication cart, it was confirmed that the medication packs and their corresponding countdown sheets for both residents were missing. The facility's pharmacist confirmed the delivery process and the expectation for the facility to notify the pharmacy of any discrepancies, which was done after the issue was identified. Interviews with staff involved in the medication administration and narcotic count process revealed that the missing narcotics were not accounted for by any of the nurses on duty. The nurse who was named in the investigation as potentially involved was placed on a do not return list, but attempts to interview her were unsuccessful. The facility was unable to substantiate the allegation internally, but the missing narcotics were confirmed as removed from the facility and reported to the appropriate authorities.
Failure to Ensure Safe and Documented Tracheostomy Care and Skin Assessment
Penalty
Summary
The facility failed to implement effective systems for entering and documenting tracheostomy care orders, resulting in the absence of tracheostomy care orders on the Treatment Administration Record (TAR) for several months. This led to inconsistent and undocumented tracheostomy care for a resident with a history of anoxic brain damage, tracheostomy status, and severe cognitive impairment. Multiple nurses reported that they did not document tracheostomy care because there was no order on the TAR, and some were unsure of the required frequency or specific procedures for tracheostomy care, such as changing the inner cannula or inspecting the skin under the collar. During direct observation, a nurse was seen picking up oxygen tubing from the floor and reattaching it to the resident's respiratory equipment, which was immediately corrected by another nurse due to infection control concerns. The nurse admitted that she typically reconnected tubing without replacing it when it became disconnected, not recognizing the need for sterility at the connection site. Additionally, the facility did not have effective systems in place to identify and assess avoidable moisture-associated skin damage (MASD) in the resident's neck folds. The MASD was only discovered incidentally during tracheostomy care, and prior skin assessments had not included the neck area unless staff were alerted to a problem. Interviews with nursing staff revealed a lack of clarity regarding responsibilities for tracheostomy care, with some nurses stating they had never performed the care or were unsure which shift was responsible for specific tasks. The wound nurse confirmed that skin folds, especially in heavier residents, should be assessed regularly, and that the MASD was found in a moist, sweaty area under the tracheostomy ties. The respiratory therapist and medical director both described appropriate tracheostomy care procedures and assessment expectations, but these were not consistently followed or documented by nursing staff due to the missing orders and lack of clear protocols.
Failure to Ensure Medication Administration at Bedside
Penalty
Summary
A deficiency occurred when a nurse failed to remain at the bedside to ensure a resident took all prescribed medications. The resident, who was cognitively intact and dependent on renal dialysis, had a physician's order for Lanthanum Carbonate 500 mg chewable tablets to be taken before meals. The resident's care plan did not include self-administration of medication, and there was no assessment in the medical record to determine if self-administration was safe for this resident. During observation, a large white pill was found in a cup on the resident's bedside table. The resident reported taking the medication before meals and stated she intended to take the pill but had forgotten. Interviews with the nurse, DON, and administrator confirmed that the nurse was expected to watch the resident take all medications before leaving the room, but this did not occur, resulting in the medication being left at the bedside.
Catheter Bag Found Touching Floor During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a history of urostomy, spina bifida, seizures, and chronic kidney disease, who had an indwelling urinary catheter, was observed with her catheter collection bag touching the floor while lying in bed. The resident's care plan included specific instructions regarding catheter care, and her assessment indicated she required substantial to maximal assistance with all activities of daily living due to severely impaired cognition. During the observation, approximately three inches of the catheter bag were in contact with the floor, which was confirmed by staff interviews. Nurse Aide #1, responsible for the resident's care, acknowledged that the catheter bag should not be touching the floor and explained that the bag could touch the floor if the bed was set too low. The aide was unsure how long the bag had been in contact with the floor, as she typically emptied it at the end of her shift. Both the interim DON and the interim Administrator confirmed in interviews that the catheter bag should not have been on the floor and should have been positioned to prevent such contact, regardless of bed height adjustments.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when staff failed to provide enteral nutrition via a gastrostomy tube as ordered by the physician for a resident with significant medical needs. The resident, who had diagnoses including anoxic brain damage, dysphagia, quadriplegia, and was severely cognitively impaired, was dependent on staff for all activities of daily living and received the majority of nutrition and hydration through tube feedings. The care plan and physician orders specified continuous tube feeding at a set rate for 22 hours daily, with a scheduled hold from 12:00 PM to 2:00 PM. However, during an observation period, the tube feeding pump was found not infusing between 11:08 AM and 11:48 AM, outside the scheduled hold time, with the pump screen off and the formula bottle nearly full. Nurse documentation indicated the feeding was administered as scheduled, but direct observation contradicted this. The nurse assigned to the resident was unaware that the feeding was not infusing during the observed period and suggested that a nurse aide may have turned off the pump and forgotten to restart it. The nurse aide interviewed stated she typically only placed the pump on hold during care and did not recall turning it off. Facility leadership confirmed that the feeding should not have been interrupted during this time and that physician orders were not followed.
Failure to Ensure Nursing Staff Competency in Tracheostomy Care
Penalty
Summary
Nursing staff at the facility were found to lack appropriate competencies in providing tracheostomy care, as evidenced by direct observation, record review, and staff interviews. One nurse was observed picking up oxygen tubing from the floor and reattaching it to equipment connected to a resident's tracheostomy humidifier, a practice that was immediately corrected by another nurse who instructed her to replace all tubing. The nurse admitted to routinely reconnecting tubing that had fallen on the floor without replacing it, and also stated she had not attended the facility's tracheostomy care training. Another nurse, who was an agency staff member, reported having prior tracheostomy care experience but had not received any facility-specific education or training on the procedure, despite having performed tracheostomy care for a resident during her shift. A third nurse, who had recently returned to the facility, stated that her performance in tracheostomy care had not been evaluated since her return and that she had not received any training or education on the subject in the past two months. The facility was unable to provide documentation of tracheostomy care competencies or training for any of the nursing staff reviewed. The only documented training was a skills fair conducted by a respiratory therapist, but attendance records showed that not all relevant staff participated, and there was no evidence that the nurses involved in the deficiency attended the session. Interviews with facility leadership revealed a lack of consistent protocols and documentation regarding tracheostomy care education and competency evaluation. The Staff Development Coordinator position had experienced high turnover, resulting in gaps in training oversight. Although orientation was supposed to include tracheostomy care skills evaluation, no documentation could be found to confirm that this had occurred for the nurses in question. The deficiency was identified for three of eight nursing staff reviewed for tracheostomy care competencies.
Medication Error Rate Exceeds 5% Due to Multiple Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by three medication errors out of 25 observed opportunities, resulting in a 12% error rate. During medication administration, a nurse gave a resident two vitamin B12 tablets instead of the prescribed cholecalciferol (vitamin D3) tablets for vitamin D deficiency. The nurse admitted to not verifying the medication against the physician's order and assumed vitamin B12 was correct. Additionally, the nurse administered two sprays per nostril of fluticasone propionate nasal spray for allergies, contrary to the physician's order of one spray per nostril, based on her belief that the full dose was not being delivered with a single spray. In another instance, the nurse administered levothyroxine sodium 50 mcg to the same resident while the resident was eating breakfast, despite the medication blister pack being labeled to give the medication on an empty stomach. The nurse acknowledged awareness of the administration instructions but did not check if any medications needed to be given before breakfast and proceeded to administer the medication after the resident had started eating. Interviews with the DON and pharmacist confirmed that the medications were not administered as ordered and that the nurse did not follow proper verification and administration procedures.
Failure to Consistently Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to consistently post daily nurse staffing sheets at the beginning of each shift, as required. On one of the five days surveyed, the posted staffing sheet in the lobby was outdated, displaying information from two days prior. Additionally, a review of records revealed that the staffing sheet for one day within a 31-day period was missing. Interviews with the Scheduler indicated a lack of understanding regarding the process for printing and posting staffing information for days other than the current day, and uncertainty about whether staffing information was posted during weekends or throughout the month. The interim Administrator confirmed that weekend nursing staff should have access to the necessary information to ensure timely and accurate posting.
Inaccurate Facility Assessment Due to Outdated Leadership Information
Penalty
Summary
The facility failed to maintain an accurate and up-to-date facility-wide assessment that reflected the current administrative and clinical leadership, including the Administrator, DON, Infection Preventionist, Rehabilitation Manager, Staff Development Coordinator, and Maintenance Director. The last recorded update of the facility assessment was on 10/31/24, and since that time, there had been multiple changes in leadership positions. During an interview, the interim Administrator confirmed that the assessment still listed former staff members and had not been updated to reflect the current personnel since he began his role on 9/9/25. This deficiency was identified through staff interviews and record review, and it had the potential to affect all 109 residents in the facility.
Failure to Provide Bed Hold Policy Notification During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation or notification regarding the bed hold policy to residents or their responsible parties during hospital transfers for two of four residents reviewed. For one resident, there were two separate hospital transfers, and in both instances, neither the resident nor the responsible party received information about the bed hold policy. Medical records lacked documentation of this notification, and both the resident and responsible party confirmed in interviews that they were not informed. The Admission Director, who was responsible for providing this information, acknowledged that she did not discuss the bed hold policy during these transfers unless she anticipated needing the room for another resident. The President of Operations confirmed that no documentation could be found regarding these notifications. Similarly, another resident was transferred to the hospital, and neither the resident nor the responsible party received information about the bed hold policy. The responsible party confirmed in a telephone interview that no notification was provided, and the Admission Director stated she did not contact the responsible party to discuss the bed hold policy for this transfer. The President of Operations again confirmed the absence of documentation regarding communication of the bed hold policy for this resident.
Failure to Implement Diabetes Care Orders Leads to Delay in Treatment
Penalty
Summary
The facility failed to implement physician orders for diabetes care for a resident diagnosed with diabetes, leading to a delay in treating hypoglycemia. On the morning of the incident, the resident exhibited symptoms such as slurred speech and a change in consciousness, which were not recognized by the attending nurse as signs of hypoglycemia. The nurse, unaware of the resident's diabetes diagnosis, did not check the resident's blood sugar or administer any medication to address the low blood sugar levels. This oversight resulted in a critical delay in treatment. The nurse called emergency medical services (EMS) under the assumption that the resident was experiencing a stroke, as she did not know the resident had diabetes. Upon arrival, EMS found the resident unresponsive with a critically low blood glucose level. After administering dextrose, the resident regained consciousness and began to speak. The nurse's failure to recognize the signs of hypoglycemia and her incorrect communication to EMS about the resident's diabetes status contributed to the delay in appropriate medical intervention. The medical record for the day of the incident lacked documentation, and the Director of Nursing was not informed of the resident's low blood glucose or the EMS call. The absence of documentation meant that the incident was not included in the 24-hour summary report, further highlighting the communication breakdown within the facility. Interviews with staff, including the Physician Assistant and Medical Director, confirmed that the nurse should have recognized the symptoms of hypoglycemia and taken appropriate action according to the existing physician orders.
Removal Plan
- Nurse #1 was given education on diabetic protocol and change in condition with MD notification by Director of Nursing.
- Education was initiated by the Director of Nursing to Licensed Nurses, including agency licensed nurses, related to the facility policy on hyperglycemia and hypoglycemia.
- Education included obtaining blood glucose levels as needed for signs and symptoms of hypo/hyperglycemia.
- Education included reviewing resident medication administration record and diagnosis list to determine residents with Diabetes Mellitus.
- Immediate action is required if signs and symptoms of hyperglycemic or hypoglycemic are identified.
- When EMS is called to the facility, it is vital that accurate information is communicated to EMS, including if the resident is Diabetic.
- Parameters for MD notification and follow-up for diabetic residents were established.
- Insulin hyperglycemic and hypoglycemic orders to include monitoring and when to obtain a re-check of blood glucose level per facility policy and/or physician order.
- Licensed staff and agency staff that don't receive the education will receive it prior to working the next scheduled shift.
- The Director of Nursing will track the training to ensure all staff are educated.
- Newly hired licensed staff will receive training during orientation by Director of Nursing.
Failure to Notify Physician of Critically Low Blood Glucose
Penalty
Summary
The facility failed to notify the physician of a critically low blood glucose level in a resident, which required Emergency Medical Services (EMS) intervention. The resident, who was admitted with a diagnosis of Diabetes Mellitus Type 2, experienced a significant drop in blood glucose to 46 mg/dL, well below the normal range of 70-100 mg/dL. EMS was called, and upon their arrival, they administered dextrose intravenously, which resulted in the resident regaining alertness and the ability to speak. Despite the critical nature of the situation, there was no documentation in the medical record indicating that the physician was notified of the incident on the day it occurred. Interviews with facility staff revealed that Nurse #1, who was responsible for the resident at the time, prioritized calling EMS over notifying the physician. Nurse #2, who worked the subsequent shift, did notify the on-call physician to obtain an order for more frequent blood glucose checks. However, the Physician Assistant and Medical Director confirmed that they were not made aware of the EMS intervention. The Director of Nursing also stated that she was not informed of the incident and emphasized that Nurse #1 should have notified the physician and followed up with her regarding the resident's condition.
Failure to Document Resident's Change in Condition and EMS Intervention
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who experienced a change in condition requiring Emergency Medical Services (EMS) intervention. The resident, who was admitted with a diagnosis of Diabetes Mellitus Type 2, had a critically low blood glucose level of 46, which is below the normal range of 70-100 mg/dL. On the day of the incident, EMS was contacted at 8:51 AM for a possible stroke, and upon arrival, they administered dextrose intravenously, which resulted in the resident becoming alert and communicative. Despite this significant medical event, there was no documentation in the resident's medical record regarding the low blood glucose level or the EMS intervention. The deficiency was further highlighted during an interview with Nurse #1, who was responsible for the resident's care on the day of the incident. Nurse #1 admitted to observing the resident's change in consciousness and calling 911 but failed to document the incident in the electronic medical record, citing being sidetracked and forgetting as the reason. The Director of Nursing confirmed the absence of documentation for the shift during which the incident occurred, acknowledging that Nurse #1 should have recorded the event in the nurse progress notes.
Failure in Communication and Care for Post-Operative Bleeding
Penalty
Summary
The facility failed to ensure effective communication among nursing staff and with the provider, resulting in a resident who was on anticoagulation medication not being sent to the hospital promptly when she experienced significant post-operative bleeding. The resident, who had a history of deep vein thrombosis, pulmonary embolism, anemia, and peripheral vascular disease, underwent Mohs surgery on her left lower extremity. Despite the resident's sheets being soaked with blood and the dressing on her leg saturated, the nursing staff did not immediately communicate the severity of the situation to the on-call physician, nor did they recognize the need for a higher level of care. The nursing staff also failed to assess vital signs and perform treatments as ordered. Nurse #3, who was not initially assigned to the resident, attempted to manage the bleeding by following wound care instructions and applying pressure, but the bleeding persisted. The on-call physician was contacted, but due to incomplete information provided by the nursing staff, the physician ordered Bumex for edema rather than addressing the bleeding issue. The resident expressed a desire to go to the emergency department, and only after a second call to the physician was she sent to the hospital, where she required a blood transfusion due to low hemoglobin levels. Additionally, there was a failure to follow wound care orders accurately due to a lack of supplies. Nurse #6, who performed wound care on previous days, did not have access to hydrogen peroxide as specified in the wound care instructions and used normal saline instead. This deviation from the prescribed wound care protocol was not communicated to the physician for alternative orders. The Director of Nursing confirmed the absence of documentation for vital signs prior to the arrival of emergency medical services, indicating a lapse in monitoring the resident's condition effectively.
Failure to Notify Physician of Post-Operative Bleeding
Penalty
Summary
The facility failed to notify the physician when a resident, who was prescribed an anticoagulant, experienced significant post-operative bleeding. The resident had a history of deep vein thrombosis, pulmonary embolism, anemia, and peripheral vascular disease, and had recently undergone surgery for non-melanoma skin cancer. On the evening of the incident, Nurse #3 discovered that the resident's dressing was saturated with blood and attempted to control the bleeding by applying pressure and changing the dressing. Despite these efforts, the bleeding continued, and the resident's request to go to the emergency department was eventually honored after the on-call physician was notified. Nurse #3, who was not initially assigned to the resident, administered the resident's prescribed Eliquis, a blood thinner, without consulting a physician, despite the ongoing bleeding. Nurse #3 communicated the situation to Nurse #4, who then spoke with the on-call physician. However, Nurse #4 did not inform the physician about the resident's recent surgery or the use of Eliquis, leading to an order for Bumex, which was not appropriate for the bleeding condition. The resident's family was involved in the decision to send her to the hospital. Interviews with the on-call physician and the resident's primary physician revealed a lack of communication and understanding of the resident's condition. The on-call physician stated that if she had been informed of the blood thinner and recent surgery, she would have recommended immediate hospital evaluation. The primary physician did not believe immediate notification was necessary, nor did he see a reason to stop Eliquis. This miscommunication and lack of appropriate action contributed to the deficiency in care provided to the resident.
Failure to Monitor Anticoagulant Use
Penalty
Summary
The facility failed to properly monitor and manage the administration of Eliquis, an anticoagulant, for a resident who was at high risk for bleeding. The resident, who had a history of deep vein thrombosis, pulmonary embolism, anemia, and peripheral vascular disease, underwent surgery for non-melanoma skin cancer on her left leg. Despite the known risks associated with Eliquis, the facility did not adequately monitor for signs of bleeding, as evidenced by the resident's bedsheet and dressing being saturated with blood. On the evening of the incident, Nurse #3 discovered the resident's dressing was soaked with blood and attempted to control the bleeding. Despite this, Nurse #3 administered Eliquis to the resident after explaining the potential for increased bleeding, as the resident agreed to take the medication. However, the bleeding continued, and the resident requested to be sent to the emergency department for further evaluation. The facility's Pharmacy Consultant later confirmed that the resident was at high risk for bleeding and should have been closely monitored. The physician for the resident indicated that Eliquis should not have been stopped before or after the surgery, as the wound was superficial. However, the lack of documentation on the Medication Administration Record and the failure to communicate the resident's bleeding condition to the on-call physician contributed to the deficiency. The facility did not have a clear protocol for managing such situations, leading to inadequate monitoring and communication regarding the resident's condition.
Failure to Provide Bariatric Shower Bed for Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident who preferred to take showers, as they did not provide a bariatric shower bed. The resident, who was moderately cognitively intact and dependent on staff for bathing, expressed that showers were very important to her. Despite being scheduled for showers twice a week, she was only provided with bed baths during the review period due to the unavailability of a suitable shower bed. Interviews with staff revealed that the existing shower bed was too narrow and unsafe for the resident, and the shower chair was not an option due to her limited mobility. The Central Supply had discussed the need for a bariatric shower bed with the Administrator, who approved the purchase. However, the dimensions of the new bed were not compatible with the current shower room, and no updates were provided on the progress of acquiring a suitable bed. The Director of Nursing and other staff confirmed that the resident had not received a shower since her hospitalization, and the issue of the shower bed remained unresolved. The resident's Power of Attorney also confirmed her preference for showers and the facility's failure to provide them. The facility's President of Operations eventually purchased a bariatric shower bed, but it was not yet available at the time of the report.
Inaccurate Hearing Assessment Coding
Penalty
Summary
The facility failed to accurately code the resident assessment for hearing in the case of one resident. The resident, who was cognitively intact, was coded as having adequate hearing without the use of hearing aids in the Minimum Data Set (MDS) quarterly assessment. However, multiple hearing consultation reports indicated that the resident had been seen for hearing aid services, including a fitting for a replacement hearing aid and regular maintenance. During an observation and interview, the resident expressed difficulty hearing and mentioned needing to keep the television volume high. The resident also indicated uncertainty about the possession of hearing aids. Interviews with staff revealed inconsistencies in the understanding of the resident's hearing needs. A nurse acknowledged the resident's hearing difficulties but was unaware of any hearing aids. The Medical Records Clerk confirmed the resident had a hearing aid and a hearing amplifier, which the resident preferred due to fit issues with the hearing aid. The MDS Nurse responsible for the assessment was unaware of the hearing aids and did not perceive any hearing difficulties during the assessment. The Administrator noted that the MDS Nurse could have reviewed the resident's hearing consultations in the paper records to ensure accurate coding.
Failure to Refer Resident for PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly identified mental health diagnosis for a Preadmission Screening and Resident Review (PASRR). Resident #40, who was admitted with major depressive disorder and dementia, was initially given a Level I PASRR upon admission. However, after an additional diagnosis of anxiety disorder was added to the resident's medical record, the facility did not complete a PASRR referral for the newly identified serious mental illness. This oversight was identified during a review of the resident's records and staff interviews. The resident's care plan included treatment for impaired cognitive function and the use of psychotropic medication for agitation, depression, and anxiety. Despite these interventions, the facility did not submit a new PASRR application following the new diagnosis. The Social Worker, responsible for submitting PASRR referrals, acknowledged the oversight and stated that a new application should have been submitted. The Administrator also confirmed that the new mental health diagnosis required a PASRR referral, which was not completed due to an oversight.
Failure to Revise Care Plan for Hearing Impairment
Penalty
Summary
The facility failed to revise the care plan for a resident with hearing difficulties, despite multiple assessments and consultations indicating the need for hearing aids. The resident was admitted to the facility and had a series of hearing consultations, which noted the need for a replacement hearing aid and subsequent fitting. However, the care plan last reviewed did not include interventions for the resident's hearing impairment. During an observation and interview, the resident expressed difficulty hearing and mentioned the need to keep the television volume high. The resident was not wearing hearing aids at the time, and staff were unaware of the resident's hearing aids or any alternative devices. Interviews with various staff members, including a nurse aide, a nurse, the medical records clerk, the MDS nurse, and the Director of Nursing, revealed a lack of awareness and communication regarding the resident's hearing aids and the need for care plan updates. The medical records clerk confirmed the resident had a hearing aid and a hearing amplifier, but the resident preferred the amplifier due to poor fit of the hearing aid. The MDS nurse and the Director of Nursing acknowledged that the care plan should have been updated to reflect the resident's hearing aid use, but this was not done, leading to the deficiency.
Failure to Obtain Orders for Oxygen and Respiratory Therapy
Penalty
Summary
The facility failed to obtain necessary orders for oxygen and respiratory therapy for a resident with acute respiratory failure and a tracheostomy. The resident's care plan, initiated in March 2022 and revised in June 2022, included interventions for tracheostomy care and respiratory therapy but did not include interventions for oxygen use. Despite the resident receiving oxygen at 2.5 liters per minute via a tracheostomy collar, there were no physician orders for oxygen use in the June and July 2024 records. Observations confirmed the resident was receiving oxygen, and staff interviews revealed that the resident had been on oxygen since admission, yet this was not documented or ordered. Additionally, the resident's care plan included respiratory therapy, but there was no corresponding physician order for this therapy in the records. The resident's MDS assessment indicated she received respiratory therapy, and staff interviews confirmed that a respiratory therapist visited the resident several times a month. However, the Director of Nursing acknowledged that an order for respiratory therapy should have been part of the physician's standing orders but was missing. This oversight resulted in a deficiency in providing appropriate respiratory care for the resident.
Infection Preventionist Absence at QAA Meeting
Penalty
Summary
The facility failed to ensure the presence of the Infection Preventionist (IP) at one of the six Quality Assessment and Assurance (QAA) committee meetings, specifically the meeting held on June 28, 2024. This deficiency was identified through a review of the facility's Monthly Meeting Agenda & Calendar QAA sign-in sheets from January through July 2024, which showed the absence of the IP at the specified meeting. The IP confirmed her absence due to illness during an interview on August 1, 2024. Additionally, the Administrator suggested that the IP might not have been in the facility or forgot to sign the attendance sheet, and there was no documentation of her participation as the committee was only reviewing existing plans at that time. This absence could potentially affect all 110 residents in the facility.
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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