Shoreland Health Care And Retirement Center Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Whiteville, North Carolina.
- Location
- 200 Flower-pridgen Drive, Whiteville, North Carolina 28472
- CMS Provider Number
- 345397
- Inspections on file
- 22
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Shoreland Health Care And Retirement Center Inc during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and severe cognitive impairment lost a lower denture and subsequently relied on a poorly fitting, painful temporary denture brought from home, which she often refused to wear. A grievance was filed by the family, and the Social Worker obtained consent paperwork and scheduled an in-house dental appointment for denture replacement several months later, without attempting to secure an earlier visit or contact an outside dentist, despite the resident’s swallowing difficulties and high choking risk identified by a FEES study. The resident’s care plan noted oral/dental problems and the need to coordinate dental care, and observations showed her eating soft bite-size foods without the lower denture, chewing slowly and with food smeared on her clothing, while staff and therapy providers acknowledged that having a full set of dentures was important for her eating and swallowing.
Surveyors found that staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy for two residents with indwelling devices. One resident with a urinary catheter and another with a feeding tube both had EBP signage posted and PPE carts with gowns and gloves available outside their rooms, yet in each case a nurse provided high-contact care—changing a catheter bag and administering meds and water flushes via feeding tube, then adjusting bedding—while wearing only gloves and not donning a gown. Both nurses reported they did not notice the EBP signage or know the reason for the precautions, despite having received infection control training, and later acknowledged that gowns should have been worn along with gloves during these care activities.
A resident with high-risk prostate cancer, cognitively intact and dependent on staff for ADLs, had a scheduled oncology appointment for labs and a Lupron injection that was missed when a transportation aide could not take him due to a CPR class and another aide could not accommodate the trip. The appointment was rescheduled about a month later without notifying the DON or clinical team, and there was no documentation in the medical record about the missed appointment. The resident reported receiving Lupron every six months for years, expressed concern about the delay in treatment, and oncology later documented he was slightly overdue for his next dose.
Surveyors found that the facility failed to keep its medication error rate below 5%, identifying three insulin administration errors out of 25 opportunities (an 8% error rate) involving two residents with diabetes. A temporary agency nurse was assigned to perform all blood glucose checks and insulin administration on two halls and, due to unfamiliarity with the residents and their insulin needs, administered Humalog insulin after breakfast rather than before meals as ordered. One resident with diabetes and diabetic retinopathy received both scheduled and sliding-scale insulin when no breakfast tray was present and later reported receiving insulin after eating, while another resident with diabetes and chronic kidney disease similarly had insulin given after finishing breakfast. The NP, physician, and DON all stated that insulin was expected to be administered prior to meals and in accordance with the prescribed orders.
A resident with moderate cognitive impairment and a history of dementia and epilepsy exited a facility unsupervised due to a Nursing Assistant Instructor silencing the wander guard alarm without checking for residents at risk of elopement. The resident was found outside in a parking lot and was assisted back into the building. A wander guard was placed on the resident, but a subsequent incident occurred when the resident again exited unsupervised, highlighting a failure in supervision and alarm system management.
Failure to Timely Arrange Dental Services for Replacement of Missing Denture in Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to arrange necessary dental services to replace a missing lower denture for a resident with dysphagia and dementia. The resident was admitted with diagnoses including dysphagia and dementia and had a physician’s order for a modified texture diet of soft bite-size food with mildly thick liquids. A quarterly MDS assessment documented severe cognitive impairment, moderately impaired vision, and a need for setup or cleanup assistance with eating and oral hygiene. At the time of that assessment, the resident had no documented dental issues and was receiving a mechanical and therapeutic diet. A grievance was filed by the resident’s Responsible Party (RP) reporting that the resident’s lower denture was missing. The Social Worker documented that the family brought in an extra pair of dentures and that paperwork was being completed so the resident could receive in-house dental care, with the grievance resolution stating that in-house dental would come at the beginning of the year as the earliest time to start replacing dentures. The Social Worker reported she did not receive the completed paperwork back until several weeks later, at which time she scheduled an in-house dental appointment for denture replacement, with the earliest available date several months away. She did not attempt to obtain an earlier appointment or contact an outside dentist, despite the resident’s dysphagia diagnosis. The RP reported that the temporary lower denture brought from home did not fit well, caused the resident pain, and that the resident did not like to wear it. Staff interviews confirmed that the resident had a lower denture in the room that she did not like to wear because it caused pain, and that she could indicate pain by grimacing or saying no. A care plan revision documented oral and dental health problems with risk for further decline and decline in nutritional intake related to wearing dentures, with an intervention to coordinate dental care as needed. Observation showed the resident eating soft bite-size foods without the lower denture, chewing slowly and with food smeared on a towel. Therapy staff and the Speech Therapist noted the resident’s high risk of choking and the importance of a full set of dentures, and the DON later acknowledged awareness of the missing denture but not of the long delay in scheduling replacement, and stated that an outside dentist should have been used if the in-house appointment was six months away.
Failure to Follow Enhanced Barrier Precautions for Residents With Indwelling Devices
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection control policy and procedures for Enhanced Barrier Precautions (EBP) during high-contact care for residents with indwelling medical devices. The facility’s Infection Control Policy dated 6/1/25 defined EBP as the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multi-drug resistant organisms, specifically including care of urinary catheters and feeding tubes. Surveyors observed that one resident with an indwelling urinary catheter had an EBP sign posted outside the room and a PPE cart with gowns and gloves available, yet the assigned nurse changed the urinary catheter bag while wearing only gloves and did not don a gown. The nurse reported not realizing the resident was on EBP, stated she did not see the sign, and acknowledged she should have worn a gown along with gloves when performing the catheter care. A second deficiency event occurred with a resident who had a feeding tube and an EBP sign posted outside the room, with a PPE cart containing gowns and gloves in the hallway. During medication administration and water flushes through the feeding tube, followed by repositioning the resident’s blankets, the nurse wore gloves but did not don a gown. This nurse also stated she did not see the EBP sign and did not know why the resident was on EBP, despite having received infection control training, and acknowledged she should have read the sign and worn a gown with gloves when providing feeding tube care. The Infection Preventionist and the DON both confirmed that staff had been trained on EBP and that staff were expected to wear gowns and gloves when providing direct care to residents on EBP, including urinary catheter and feeding tube care.
Failure to Ensure Timely Oncology Appointment and Lupron Injection
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received cancer-related care as ordered and scheduled. The resident was admitted with prostate cancer and had a care plan noting an ADL self-care deficit related to malignant prostate cancer. A quarterly MDS showed the resident was cognitively intact, did not reject care, and required staff assistance with ADLs. An after-visit summary from the cancer center documented a scheduled return appointment for labs and an oncology visit with a Lupron injection, which the resident had been receiving every six months for over five years. On the date of the scheduled oncology appointment and Lupron injection, the resident was not transported to the cancer center. The resident reported that the transportation aide told him she had a mandatory meeting and could not take him, and that the appointment would need to be rescheduled. The resident stated the appointment was ultimately rescheduled and occurred about one month later, and he expressed concern and dissatisfaction about the delay in his cancer treatment, stating he believed other arrangements could have been made to get him to the appointment. Record review from the date of the missed appointment through the later appointment showed no documentation in the medical record or progress notes regarding the missed oncology appointment. Transportation Aide #2 stated she did not take the resident to the appointment because she had a CPR class that day, and that she notified Transportation Aide #1 she was unable to transport him. Transportation Aide #1 stated she could not accommodate the appointment in her schedule and rescheduled it for a date four weeks later, without notifying the DON. The Medical Director confirmed the resident was followed by oncology for high-risk prostate cancer and Lupron therapy and noted the cancer center documented he was slightly overdue for his next dose. The DON stated she was not made aware that the cancer treatment appointment had been rescheduled with a four-week delay and that the transportation aides did not notify her when they could not take the resident to his cancer treatment appointment.
Failure to Administer Mealtime Insulin as Ordered Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 medication errors out of 25 opportunities, resulting in an 8% error rate. The errors occurred during a medication pass on the 200 and 300 halls, where Nurse #1, a temporary agency nurse, was responsible for all blood sugar checks and insulin administration. Breakfast meal trays for the 200 Hall were scheduled to be delivered at 7:30 AM and 7:40 AM, but insulin doses were observed being administered later, and not in accordance with physician orders specifying administration before meals. For Resident #29, who had diabetes, diabetic retinopathy, and long-term insulin use, physician orders directed administration of 10 units of Humalog insulin subcutaneously before meals, to be held if blood sugar was less than 100, along with a separate sliding-scale Humalog order before meals and at bedtime. During the observed medication pass at 9:15 AM, Nurse #1 obtained a blood sugar of 295 and administered a total of 14 units of Humalog (10 units scheduled plus 4 units sliding scale) when the resident’s breakfast tray was not present in the room. Resident #29 later reported that the insulin was administered after she finished her morning meal. The Nurse Practitioner, Physician, and DON each stated that insulin was expected to be administered prior to meals and in accordance with physician orders. For Resident #82, who had diabetes, chronic kidney disease, and long-term use of hypoglycemic drugs, a physician order directed sliding-scale Humalog insulin to be given subcutaneously before meals and at bedtime based on specific blood sugar ranges. During the same medication pass at 9:25 AM, Nurse #1 obtained a blood sugar of 256 and administered 4 units of Humalog insulin when the resident’s breakfast tray was not in the room. Resident #82 reported that nurses usually obtained his blood sugar before meals but that he typically received insulin after he finished eating, and on the observed date he ate breakfast and then received insulin afterward, later than usual. Nurse #1 stated she was unfamiliar with which residents required blood glucose monitoring or insulin, which caused delays and failure to administer insulin according to the physician’s orders.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a moderately cognitively impaired resident from exiting the building unsupervised. The resident, who had a history of dementia with behavioral disturbance, epilepsy, and falls, was found outside the facility in a parking lot, having positioned himself in an unlocked vehicle. This incident occurred after a Nursing Assistant Instructor entered the code on the wander guard system without ensuring that no residents with wander guard alarms had passed the threshold and exited the facility. The resident was able to propel himself independently in a wheelchair and had not previously exhibited wandering behavior. However, on the day of the incident, a family member alerted the facility that a resident was outside. Staff found the resident in the back passenger seat of a car, uninjured, and assisted him back into the building. Following this incident, a wander guard was placed on the resident, and it was checked to ensure it was functioning properly. A subsequent incident occurred when the resident again exited the facility unsupervised. The Nursing Assistant Instructor had silenced the wander guard alarm without checking for residents at risk of elopement. The resident was found outside by a staff member returning from a break and was brought back inside. The root cause was identified as the NA Instructor's failure to check the surroundings for residents at risk of wandering or elopement, allowing the resident to exit the building.
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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